HARINGEY HEALTH IN 1972 The Annual Report of the Medical Officer of Health & Principal School Medical Officer. HARINGEY HEALTH IN 1972 The Annual Report of the Medical Officer of Health & Principal School Medical Officer. To: The Worshipful the Mayor, Aldermen and Councillors of the London Borough of Haringey Ladies and Gentlemen, I have the honour to present the report on the health of the Borough of Haringey for the year ended 31 December 1972. The Report for 1972 is the eighth and last of the Annual Reports of the Medical Officers of Health for Haringey. It follows a long series of annual reports by the Medical Officers of Health of the former Boroughs of Tottenham, Hornsey and Wood Green (listed on following page) who, together with Drs. McAuley and Perkins of the Middlesex County Council, saw the evolution to the health services over a century. The office of Medical Officer of Health now joins the extinct occupations of the past such as the Barber Surgeons. Like a mediaeval dynasty our year finishes with a comet. The new Area Health Authority will be able to review the functions carried out at present by the Local Health Authority and bring to us the benefit of an overall approach taking account of the problems seen in the hospitals and general practice and, similarly, the quality of work in hospitals may derive benefit from constructive consumer criticism through the medium of the new Community Health Councils which must be seen as an evolution from the most successful of those frequently very successful bodies the Friends of the Hospitals. The future of the new National Health Service will depend not only on the enthusiasm, competence and skill of the staff in hospitals, general practice, clinics and domiciliary care but also on the capacity of the Service to keep aware of public needs and wants and in meeting this challenge lies the opportunity for a pioneering achievement that could be an example to the world. The Environmental Health Services which were the first product of the early years of Public Health and the basis upon which local government was built will remain as the responsibility of the Local Authorities. They will, however, have the advice and assistance of the Area Health Authority through the Specialist Community Physician designated as the Proper Officer. In conclusion, I should like to record my thanks to Councillor Mrs. Lipson, Chairman of the Health Committee during the year, and to the members of the Committee for their encouragement and support. My thanks are especially due to the staff of the Health Department for their loyal and efficient service during a year of exceptional difficulty and uncertainty in view of the anticipated changes. I have the honour to be your obedient servant. J.L. PATTON Medical Officer of Health MEDICAL OFFICERS OF HEALTH WHO HAVE SERVED HARINGEY AREA TOTTENHAM From February 1873 Dr. W. Tyndale Watson " March 1902 Dr. J.F. Butler Hogan " January 1913 Dr. D.C. Kirkhope April 1937 Dr. G. Hamilton Hogben WOOD GREEN From — 1888 Dr. Charles Hamilton Conolly October 1910 Dr. Thomas Slater Jones " July 1920 Dr. William E. Porter — 1928 Dr. Malcolm Manson " May 1952 Dr. W. Clunie Harvey — 1964 Dr. Janet K. Campbell HORNSEY From May 1879 Dr. Henry Clothier May 1904 Dr. Harold Coates March 1921 Dr. Austin Threlfall Nankivell " March 1925 Dr. William Wilson Jameson " January 1929 Dr. R.P. Garrow " September 1949 Dr. G. Hamilton Hogben HARINGEY From April 1965 Dr. J.L. Patton HEALTH COMMITTEE Councillor Fred Carnell, JP Councillor Mrs. Maureen F. Dewar, MCSP JP (Vice-Chairman) Councillor Bryan D. Lipson, LLM Councillor Mrs. L.H. Lipson, MCSP (Chairman) Councillor Jeffrey Lotery Councillor Peter Nicholls, JP Councillor Ulric Thompson Councillor Mrs. Sally Whitby Council Sir Robin Williams, Bt MA SENIOR STAFF OF THE DEPARTMENT Medical Officer of Health and Principal School Medical Officer J.L. PATTON, MB ChB MFCM(RCP) DPH Deputy Medical Officer of Health and DPSMO W.T. ORTON, MB BCh BAO MFCM(RCP) DPH Principal Medical Officers School Health Mary C. Douglas, MB ChB MFCM(RCP) DPH Maternity and Child Welfare Ruth Y. Golder, MB ChB DRCOG DPH Mental Health U.P. Seidel, MB BSc MFCM(RCP) DPH DPM Senior Medical Officers Joan F. Nicholls, MB BS DCH DPH (until 14.5.72) Z. Zubrzycki, Med Dipl MFCM DPH K. Vali Shah, MB BS(Bombay) MFCM DPH DIH (from 15.5.72) Departmental Medical Officers Manju Chakrabarti, MB BS MSc(Calcutta) Kyvelie Papas, Med Dip MD(Athens) LAH Avery B. Cooper, MRCS LRCP T.H. Elias, MB BS MRCS LRCP DPH W.G. Griffiths, MRCS LRCP S.R. Lund, MB BS(Parkistan) DPH Part-Time:— Marie H. Brockbank, MB ChB DPH Jean Dickson, MB ChB Eva M. Diamond, LRCS LRCP LRFPS Margaret Kirk, MB BS DCH Chief Dental Officer and Principal School Dental Officer G.C.H. Kramer, LDS RCS Dental Officers Gitanjali H. Abeyasinghe, LDS UBrist N. Ansbergs, DDD Aniela Kowalska, LDS RCS Rosemary Jackson, BDS Alison G. Little, LDS RCS A.H. Landsman, LDS RCS Part-Time:— Mrs. M.P. Antoniewicz, BDS Miss D. Saxon, LDS RCS 2 Orthodontists T.J. Combes, BDS DOrth RCS Joy Maclnerney, BDS LDS DOrth RCS Public Analyst W.B. Chapman, BSc FRIC Director of Nursing Services Mary Smith, SRN SCM HV Area Nursing Officer (Health Visiting and School Nursing) Priscilla Z.M.J. MacLaughlin, SRN SCM HV Nursing Officers (Health Visiting and School Nursing) Clarissa I. Johnson, SRN SCM HV Frances Prevett, SRN SCM HV Bridget V. Williams, SRN SCM QIDNS HV (Midwifery and Training) Mable Mountain, SRN SCM (District Nursing) Mary Evans, SRN Parsooram Luchmaya, SRN RMN Berthe F. Specht, SRN SCM ON Physiotherapists Nancy W. Allardice, MCSP SRN Eva Bower, MCSP SRP Liv Pedersen, DP Gudrun Trowbridge DP Occupational Therapist Jeanette D. Duncan, DOT (NSW) Senior Speech Therapist Eleanor R.P. McKeown, LCST Speech Therapists Joan D. Came, LCST Alison Courtice, LCST Sally D'Souza, LCST Jane C. Froud, LCST Ruby Sewell, LCST Orthoptists Lesley Bracket, DBO Senga Conn, DBO 3 Screening Technicians Hilda M. Bristow Frances M. Jenner Philomena C. Ward Health Education Officer Sheila M.P. Frost, SRN SCM HV DHE Veterinary Adviser P.G. Abdre, BVetMed MRCVS Chief Public Health Inspector W.J. Wilson, DPA MAPHI MRSH Deputy Chief Public Health Inspector E.S. Glegg, MAPHI AMIPHE Principal Public Health Inspector F.H. Canton, MAPHI Assistant Principal Public Health Inspectors A.E. Clarke, MAPHI AMIPHE W.E. Goodfellow, MAPHI E.S. Gray, MAPHI F. James, MAPHI E.A. Kottman, MAPHI R.C. Sanderson, MAPHI Senior Public Health Inspectors P.J. Barnes, MAPHI W.N. Brazil, MAPHI N.H. Briggs, MAPHI C.J. Cattell, MAPHI B.J. English, MAPHI W.P. Kent, MAPHI D.W. Martin, MAPHI H.G. Stephenson, MAPHI Senior Shops Inspector T.E. Goodwin 4 ADMINISTRATIVE STAFF Chief Administrative Officer D.B. Davies, DPA FHA MRSH Principal Assistants H.J. Dunham, BA A.W. Lawrence, MAPHI F.R. Reeve, DMA LHA MISW Sections Heads Domiciliary Care Hilda Battley Environmental Health H.P. Bradford Supplies, Buildings and Transport R. Newman Staffing K.J. Walker Accounts and Wages L.E. Wells Infectious Disease Control H.C.B. Wheal Child Health S.E. Woodroffe 5 VITAL STATISTICS 1971 1972 Area of District (in acres) 7,491 7,491 Population - Registrar General's Estimate at 30 June 238,200 235,490 Rateable Value at 1 April £13,816,991 £13,890,918 Product of penny rate (n.p.) £ 134,000 £ 134,500 Approximate number of separately rated dwellings 72,500 73,529 LIVE BIRTHS Total registered: Male 2,162 1,952 Female 2,043 1,848 Total 4,205 3,800 Birth Rate per 1,000 population 17.65 (16.0) 16.1 (14.8) Total illegitimate live births 597 581 Illegitimate as percentage of all live births 14.20% (8%) 15% (9%) STILL BIRTHS Total registered: Male 24 29 Female 23 20 Total 47 49 Still births rate per 1,000 live and still births 11.05 (12) 13 (12) Total illegitimate still births 10 8 Illegitimate still births as percentage of all still births 21.28% 16.33% DEATHS FROM ALL CAUSES Male 1,312 1.358 Female 1,425 1,421 Total 2,737 2,779 Death rate per 1,000 population 11.49 (11.6) 11.8 (12.1) MATERNAL MORTALITY: Number of deaths 2 3 Rate per 1,000 total live and still births 0.470 0.779 INFANT MORTALITY (Deaths of infants under 1 year of age) (a) Legitimate: Male 51 34 Female 36 16 Total 87 50 Rate per 1,000 legitimate live births 24.11 16(17) (b) Illegitimate: Male 9 12 Female 8 4 Total 17 16 Rate per 1,000 illegitimate live births 28.48 28 (21) (c) Totals: Male 60 46 Female 44 20 Total 104 66 Rate per 1,000 total live births 24.73 (18) 17 (17) NEO NATAL MORTALITY (Deaths of infants under 4 weeks) 67 44 Rate per 1,000 live births 15.93 (12) 12 (12) EARLY NEO-NATAL MORTALITY (Deaths of infants under 1 week) 57 35 Rate per 1,000 live births 13.56 (10) 9 (10) 6  1971 1972 PERI NATAL MORTALITY (Total still births and deaths under 1 week) 104 84 Rate per 1,000 live and still births 24.44 (22) 22 (22) NOTE: The figures in parenthesis indicate the rates for England and Wales. Comparability Factors To enable local vital statistics to be compared with other districts or with national figures, the Registrar General issues comparability factors for correcting crude birth and death rates. These factors make allowance for the way in which the sex and age distribution of the local population differs from England and Wales as a whole. The death rate comparability factor has been adjusted specifically to take account of the presence of residential institutions in the area. To compare the crude 1972 rates for Haringey with the national rates, Haringey's figures must be multiplied by the appropriate comparability factors, which are 0.86 for births and 1.02 for deaths. The adjusted birth rate for Haringey is 13.8 and the death rate 12.0, compared with national rates of 14.8 and 12.1. 8 DEATHS OF HARINGEY RESIDENTS SHEWING AGE GROUP AND SEX DISTRIBUTION 1972 DISEASE TOTAL Under 4 weeks 4 weeks & under 1 year 1 -4 5-14 15 - 24 25-34 35-44 45 - 54 55-64 65 - 74 75 and over M F M F M F M F M F M F M F M F M F M F M F M F B4 Enteritis and Other Diarrhoeal Diseases 2 3 - 1 1 1 1 - - - - - - - - - - - 1 - - B5 Tuberculosis of Respiratory System 6 2 - - - - - - - - - - - 1 - 1 1 2 - 1 - 1 1 B14 Measles - 1 - - - - - 1 - - - - - - - - - - - - - - - - B17 Syphilis and its sequelae 3 1 - - - - - - - - - - - - - 1 2 - 1 - - - - - B18 Other Infective and Parasitic Diseases 3 3 - - 1 - - - - - - - - - - - 1 2 - - - 1 1 - B19I1) Malignant Neoplasm, Buccal Cavity etc. 1 4 - - - - - - - - - - - - - - - - - 1 1 3 - - B19(2) Malignant Neoplasm Oesephagus 11 7 - - - - - - - - - - - - - - 1 - 2 1 3 1 5 5 B19(3) Malignant Neoplasm, Stomach 35 21 - - - - - - - - - - - - - 2 4 1 8 3 11 2 12 13 B19(4) Malignant Neoplasm, Intestine 38 54 - - - - - - - - - - 1 1 2 1 - 2 10 6 18 12 7 32 B19I5) Malignant Neoplasm, Larynx 2 1 - - - - - - - - - - - - - - - - 1 1 - - 1 - B19(6) Malignant Neoplasm, Lung, Bronchus 146 33 - - - - - - - - - - 1 - 1 2 10 2 45 12 61 12 28 5 B19(7) Malignant Neoplasm, 6reast - 50 - - - - - - - - - - - 1 - 3 - 6 - 12 - 10 - 18 B19(8) Malignant Neoplasm, Uterus - 17 - - - - - - ' - - - - - - - - - 1 - 6 - 5 - 5 B19(9) Malignant Neoplasm, Prostate 19 - - - - - - - - - - - - - - - - - 2 - 5 - 12 - 619(10) Leukaemia 3 7 - - - - - - 1 - - - - - - - - 1 2 - - 2 - 4 619(11) Other Malignant Neoplasms 85 98 - - - - — - 2 1 3 - 1 1 6 4 9 7 23 19 25 26 16 40 B20 Benign and Unspecified Neoplasms 4 - - - - - - - - - - - 1 - - - - - 2 — 1 - - - B21 Diabetes Mellitus 5 16 - - - - - - - - - - - - - 1 - 1 - 2 2 3 3 9 B22 Avitaminoses, etc. - 1 - - - - - - - - - - - - - - - - - - - - - - 846(1) Other Endocrine etc. Diseases 2 4 - - - - - — — - - 1 1 - - — — — 1 1 — 2 — — B23 Anaemias 3 10 - - - - - - - - - - - - - - - - - - - 2 3 8 B46(3) Mental Disorders 1 7 - - — - — — - - - 1 — — — — — — 1 1 - 1 - 4 B46(4) Multiple Sclerosis 1 2 - - - - - - - - - - - - - - - - 1 2 - - - - B46(5) Other Diseases of Nervous System, etc. 11 17 - - 1 - 1 - - - - - 1 - - - - 1 2 5 2 6 4 5 B26 Chronic Rheumatic Heart Disease 10 17 - - - - - - - - - - - - - 2 2 1 4 5 2 3 2 6 B27 Hypertensive Disease 24 27 - - - - - - - - - - - - 1 - 5 - 3 2 5 9 10 16 B28 Ischaemic Heart Disease 375 274 - - - - - - - - - - 1 - 8 - 32 3 85 20 133 67 116 184 B29 Other forms of Heart Disease 54 102 - - 1 - 1 - - - - - - - - 1 2 - 1 4 15 15 34 82 630 Cerebrovascular Disease 95 189 - - - - - - - 1 - 1 - 1 1 1 4 4 11 20 32 43 47 118 646(6) Other Diseases of Circulatory System 38 74 - - - - - - - - - - - - 1 - 5 2 5 2 11 13 16 57 B31 Influenza 3 3 - - - - - - - - - - 1 - - - - - - - - 2 2 1 B32 Pneumonia 91 170 - - 2 2 - - - 1 - - - - - - 1 - 5 10 21 21 62 136 B33(1) Bronchitis and Emphysema 118 36 - - - - - - - - - - - - - - 5 1 15 3 40 10 58 22 B33(2) Asthma 1 2 - - - - - - - - - - - - - - - 1 1 1 - - - - B46 Other Diseases of Respiratory System 8 12 - - 3 1 2 - - - - - - - - 1 - - - 1 - 3 3 6 B34 Peptic Ulcer 17 14 - - - - - - - - - - - - - - 1 - 3 2 7 5 6 7 B35 Appendicitis 1 1 - - - - - 1 - - - - - - 1 - - - - - - - - - B36 Intestinal Obstruction and Hernia 7 6 - - - - - - - - - - - - - - 1 1 3 - 1 1 2 4 B37 Cirrhosis of Liver 7 2 - - - - - - - - 1 - - - 1 - 1 - 3 1 1 1 - - B46(8) Other Diseases of Digestive System 11 23 - - - - - - - - - 1 - 1 - - 3 - 3 3 2 4 3 14 B38 Nephritis and Nephrosis 4 9 - - - - - - - - - - - - - 1 - 1 2 3 - 1 2 3 B39 Hyperplasia of Prostate 4 - - - - - - - - - - - - - - - - - 1 - - - 3 - B46(9) Other Diseases, Genito-Urinary System 8 11 - - - - - - - - - - - - - - - - 1 2 1 1 6 8 B40 Abortion - 1 - - - - - - - - - - - 1 - - - - - - - - - - B41 Other Complications of Pregnancy etc. - 2 - - - - - - - - - - - 1 - 1 - - - - - - - - B46( 10) Diseases of Skin, Subcutaneous Tissue - - - - - - - - - - - - - - - - - - - - - - - - B46( 11) Diseases of Musculo—Skeletal System 4 12 - - - - - - - - - - - - - - - - 1 2 1 1 2 9 B42 Congenital Anomalies 11 4 3 1 3 2 1 - - - 4 - - - - - - - - 1 - - - - B43 Birth Injury, Difficult Labour, etc. 15 6 15 6 - - - - - - - - - - - - - - - - - - - - B44 Other Causes of Fterinatal Mortality 13 6 13 6 - - - - - - - - - - - - - - - - - - - - B45 Symptoms and III Defined Conditions 3 10 - - 2 - - - - - - - - - - - - - 1 - - - - 10 BE47 Motor Vehicle Accidents 14 13 - - - - 1 1 2 3 - 2 - - 2 2 4 1 2 3 1 3 BE48 All Other Accidents 22 25 - - 1 1 1 - 1 - 3 1 1 - 2 2 4 - 1 3 4 5 4 13 BE49 Suicide and Self-inflicted Injuries 12 7 - - - - - - - - 1 - 4 , - 1 1 2 1 2 1 1 2 1 2 BE50 All Other External Causes 7 4 - - - - - - - - 1 1 3 - - 1 2 1 1 - - 1 - - TOTAL ALL CAUSES 1,358 1,421 31 13 15 7 8 3 5 5 16 6 16 9 26 25 100 43 259 159 409 300 473 851 6 01 HARINGEY STATISTICS SINCE THE CREATION OF THE LONDON BOROUGH IN 1965 Year Population (R.G. Est.) BIRTHS DEATHS COMPARABILITY FACTORS DEATH RATE OF INFANTS PER 1,000 LIVE BIRTHS Still Birth Rate per 1,000 live and still births Peri-Natal Mortality Rate per 1,000 live and still births Percentage of Births Illegitimate No. Rate per 1,000 Population No. Rate per 1,000 Population Births Deaths Under 1 year Under 4 week Under 1 week 1965 256,750 5,611 21.85 2,865 11.16 .92 .97 17.82 13.01 11.76 14.06 26.65 13.75 1966 254,650 5,604 22.00 2,913 11.44 .92 .97 17.67 11.78 10.89 14.07 24.81 11.96 1967 254,120 5,337 21.00 2,805 11.04 .92 .97 18.74 13.30 11.99 10.57 22.43 12.97 1968 245,270 5,120 20.87 2,967 12.10 .92 .96 22.27 15.62 13.87 16.52 30.16 13.75 1969 242,300 4,753 19.62 2,920 12.05 .92 .96 20.83 13.04 10.52 12.26 22.65 13.57 1970 238,410 4,342 18.21 2,784 11.68 .92 .95 23.05 16.58 13.36 11.61 24-81 14.07 1971 238,200 4,205 17.65 2,737 11.49 .92 .95 24.73 15.93 13.56 11.05 24.44 14.20 1972 235,490 3,800 16.1 2,779 11.80 .86 1.02 17.37 11.58 9.21 12.73 21.82 15.29 NOTIFICATIONS OF INFECTIOUS DISEASES DURING 1972 BY SEX AND AGE GROUPS Under 1 1 2 3 4 5-9 10-14 15-19 20-34 35-44 45-64 65 + UNK TOTAL. M F M F M F M F M F M F M F M F M F M F M F M F M F Scarlet Fever 22 1 - - 2 2 8 6 7 6 22 32 4 7 4 3 2 3 - - - - - - - - 111 Measles 16 11 27 23 19 21 22 14 27 24 97 89 17 8 4 4 4 6 - 1 - - - - 3 3 440 Whooping Cough 1 1 - 2 - - 1 21 - - - - - - - - - - - - - - - - - - 7 Food Poisoning 1 2 1 1 1 1 - - 1 1 4 1 1 - - - 6 4 - 1 - - - - - - 26 Ophthalmia Neonatorum 1 - - - - - - - - - - - - - - - - - - - - - - - - - 1 A. Encephalitis Infective - - - - - - - - - - - - - - - - - - - - - - - - - - - A. Encephalitis Post Infectious - - 1 - - - - - - - - - - - - - - - - - - - - - - - 1 Acute Poliomyelitis Paralytic - - - - - - - - - - - - - - - - - - - - - - - - - - - Acute Poliomyelitis Non-Paralytic - - - - - - - - - - - - - - - - - - - - - - - - - - - Acute Meningitis 1 - - - 1 - - - - - 2 1 - - - 2 2 1 1 - - - - - - - 11 Diphtheria - - - - - - - - - - - - - - - - - - - - - - - - - - - Typhoid - - - - - - - - - - - - - - - - - - - - - - - - - - 2 Para-Typhoid - - - - - - - - - - - - - - - - - - - - - - - - - - - Dysentery - 1 - - 1 - - 1 - 5 - 1 - 1 1 4 4 - - - 3 - - - - 22 Scabies 1 1 2 3 7 8 6 6 10 5 38 30 28 30 21 22 42 66 12 16 8 5 2 2 4 8 383 Tuberculosis — Respiratory - - - 1 - - 1 1 - 1 - 1 1 1 2 3 9 8 8 4 13 3 9 - - - 65 Tuberculosis — Meninges & C.N.S. - - - - - - - - - - - - - - - - - - - - - - - - - - - Tuberculosis — Other - - - - - - 1 - - - - - 1 - 1 - 4 5 1 2 2 2 - -1 - - 20 Smallpox - - - - - - - - - - - - - - - - - - - - - - - - - - - Malaria - - - - - - - - - - - - - 1 1 - 5 2 2 - - - - - - - 11 Infective Jaundice - - - - 1 - 1 - - 1 14 26 4 9 2 3 30 26 7 4 5 2 — 1 - 2 138 11 PART I ENVIRONMENTAL HEALTH W.J. Wilson, Chief Public Health Inspector Surface Water Pollution A continuous programme of investigation is carried out by a technical assistant who reports all contraventions to the Public Health Inspectors. There are two systems of sewerage operative in the Borough. Surface water is collected and conveyed to the water course, rivers, etc. Soil sewage is conveyed to the sewage treatment works. Occasionally it is found that water courses are being polluted particularly with detergent scum and soap solution. The practice of washing down cars in the roadway leads to oil washings entering the surface water drainage system. Close co-operation with the Greater London Council (Department of Public Engineering) is maintained. During the year 1,478 premises were inspected in this way and drainage corrections were requested in 301 instances. The Public Health Inspectors took any necessary action to ensure that the required works were carried out and, where appropriate, formal action was taken under the Public Health Act, 1936. Water Supplies A small area on the Borough boundary containing 106 premises between Great North Road and Aylmer Road, N2, is supplied with water by the Lee Valley Water Company and the remainder of the Borough receives its water from the Metropolitan Water Board. A full report on the water supplied by the Lee Valley Water Company was contained in the report of 1966. Dr. Windle Taylor, Director of Water Examination, Metropolitan Water Board has kindly supplied the following information regarding water supplied by the Board to Haringey during 1972:— 1. (a) The supply was satisfactory both as to (i) quality, and (ii) quantity throughout 1972. (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 your area, but the population supplied direct according to the Registrar-General's estimates at 30th June, 1972, was 234,874. (ii) No houses were permanently supplied by stand-pipe. (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:— The higher elevation around Muswell Hill is supplied with River Thames-derived water from the Thames Valley. The remainder of the Borough is supplied with New River-derived water. No new sources of supply were instituted and there were no changes to the general scheme of supply in your area. The number of samples collected and the bacteriological and chemical analyses of the supply from the above sources after treatment are shown on the attached sheets. (b) On account of their hardness content and alkaline reaction the Board's river and well water supplies are 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. Swimming Baths and Paddling Pools Public health control of the public and privately owned pools is maintained on behalf of the Public Health Department by regular sampling of water for bacteriological and chemical examination from the swimming pools in the Borough. By special arrangement between the Council and the Greater London Council the samples are collected and examined by specialist chemists on the staff of the Greater London Council Scientific Branch. Samples are similarly taken from paddling pools in the parks when these are in use during the summer months. 12 AVERAGE RESULTS OF THE CHEMICAL AND BACTERIOLOGICAL EXAMINATION OF THE WATER SUPPLIED TO THE LONDON BOROUGH OF HARINGEY FOR THE YEAR 1972 Average Chemical Results (Miligrams per litre (unless otherwise stated)) Description of the Sample No. of samples Ammoniacal Nitrogen Albuminoid Nitrogen Nitrate Nitrogen Chlorides as a Oxygen abs. from Permanganate 4 hrs at 27°C Turbidity Units Colour (Burgess Units) Hardness (Total) CaC03 Hardness (non carbonate) CaC03 PH Value Phosphate as PO4 Silicate as Si02 Sulphate SO4 Natural Fluoride as F Magnes ium as Mg Sodium as Na Potassium as K Surface Active Material as Manoxol OT Electrical Conductivity (micrompos) New River derived 104 0.014 0.050 7.9 42 0.70 0.1 9 308 80 7.8 2.1 10 52 0.15 5.5 28.8 5.1 0.02 640 Thames derived 364 0.031 0.069 6.9 35 1.06 0.1 13 274 82 7.9 2.8 10 58 0.15 5.0 24.5 5.5 0.02 570 Average Bacteriological Results Description of the Sample 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 Escherichia 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. New River derived 1.506 58.8 000 55.91 4.2 70.25 1.1 510 20.1 000 100.00 100.00 Thames derived 8,087 42.3 000 41.94 10.2 56.76 4.0 3.891 10.0 000 99.85 99.97 13 The filtration and chlorination equipment at the Borough Council's swimming baths is highly efficient and the analyses generally give very good results. The Baths Department is advised of the results of the tests in respect of the Council Controlled establishments and these results are supplementary to the tests undertaken by the staff of that Department. Chimney Heights Nine applications were received under Section 6 of the Clean Air Act 1968. In one instance the proposed height was not acceptable and revised proposals were agreed after discussion with the engineers. Of four cases not subject to specific control by Section 6 one chimney proposed was considered to be of insufficient height and the plans were subsequently modified to the satisfaction of the department. Furnace Installations The use of natural gas at six industrial furnaces came to the notice of the Department during the year. Control of Atmospheric Pollution Of 96 half-hour observations of industrial chimneys made during the year 6 emissions of smoke were found to be excessive and were halted following informal action. There were 4 contraventions arising from on-site burning where buildings were being demolished. Excessive smoke arising from two incinerators was observed. One of these was replaced by a modern appliance and in the other case, improved management of the appliances prevented the continuance of the nuisance. Smoke Control Orders In two cases it was found that householders in contravention of smoke control orders were causing the emission of smoke by burning bituminous coal which they had purchased locally and in third case a householder was found to be burning wood road blocks. Suitable warnings were given and the offences were terminated. Investigation of Atmospheric Pollution Up to the end of the year under review Haringey maintained three daily recording instruments for the collection of data regarding the smoke and sulphur dioxide content of the atmosphere. It was necessary to close down the Burghley Road station at the end of 1972 because a change of use of the site necessitated the removal of the measuring equipment. In addition to giving information on local trends, the data forms part of information collected by the Warren Spring Laboratory to show national distribution and trends in atmospheric pollution. The readings obtained depend to some extent on varying local meterorological conditions which at times may give rise to deviations from the general trend. 14 TABLE A AVERAGE DAILY READINGS OF SMOKE AND SULPHUR DIOXIDE IN THE ATMOSPHERE 1971/72 (Microgrammes per cubic metre) Classification Burghley Road N8 (1) Tottenham Town Hall N15 (2) Civic Centre N22 (3) A.1 A.2 D.2 (a) Smoke July 1971 24 26 27 August 21 24 23 September 44 48 49 October 44 45 49 November 49 46 45 December N N N January 1972 61 62 53 February N 62 64 March 73 69 68 April N N N May 20 24 20 June 18 17 17 (b) Sulphur Dioxide July 1971 71 80 88 August 52 65 71 September 104 128 107 October 115 146 133 November 123 146 131 December N N N January 1972 161 184 176 February N 192 189 March 204 198 209 April N N N May 63 78 73 June 52 66 63 NOTE: "N" indicates that number of readings insufficient to give accurate average Classification of Sites The following classification of sites indicates the neighbourhood in which the instruments are located as follows:— A.1 — residential area with high density housing or with medium density housing in multiple occupation, in either case surrounded by other built-up areas. A.2 — predominantly A.1 but interspersed with some industrial undertakings. D.2 — small town centre; limited commercial area mixed with old residential housing and possibly industry. 15 TABLE B MONTHLY DEPOSIT GAUGE READINGS 1972 Rainfall (litres) Hornsey Town Hall Site Rainfall (litres) Hampden Road N8 Site Deposits-mgs. per Deposits-mgs. per Dissolved Undissolved Total Dissolved Undissolved Total Jan. 4.9 280 95 375 4.8 256 64 320 Feb. 1.6 109 109 218 4.1 90 113 203 March 4.7 71 97 168 4.4 36 91 127 April 2.9 64 76 140 3.4 63 79 142 May 3.4 120 93 213 3.6 221 75 296 June 2.3 89 22 111 2.5 165 13 178 July 2.7 64 114 178 2.8 87 95 182 August 0.2 65 18 83 0.2 55 30 85 Sept. 2.4 90 68 158 2.3 113 65 178 Oct. 1.2 133 49 182 1.0 124 45 169 Nov. 7.3 206 52 258 8.3 162 66 228 Dec. 1.5 89 71 160 1.7 84 69 153 TOTAL 35.1 1,380 864 2,244 39.1 1,456 805 2,261 Rodent Control Details of the rodent control measures in the sewers are shown in the table. In addition to the sewer treatments control of rats and mice is carried out wherever these are found. This work is difficult because most of the mice in this area are of the type which is resistant to Warfarin poison, and the control work tends to be more difficult with so many houses being in multiple occupation, since access to some of the rooms in these houses cannot easily be obtained. Close co-operation is maintained with the Pest Control Unit, Ministry of Agriculture, Fisheries and Food and with the Pest Control Officers in adjoining boroughs. The services of the Council's rodent operatives are provided free of charge for the treatment of infestations by rats or mice in domestic premises but a charge to cover the cost of the operators' time and material used is made for the treatment of other premises. The following is a summary of treatments carried out during 1972:— 1. Dwelling houses —1,018 2. Factory premises — 38 3. Shops and Cafes — 98 4. Schools — 39 5. Miscellaneous — 36 6. Total charge of 2—5 above — £644 16 RODENT CONTROL IN PUBLIC SEWERS LONG TREATMENT AREA SODIUM FLUORACETAMIDE SODIUM FLUORACETAMIDE TOTAL MANHOLES BAITED MANHOLES 1ST REVISIT AFTER 7 DAYS 2ND REVISIT AFTER FURTHER 7 DAYS No Take Part Take Complete Take No Take Part Take Complete Take West 2,141 2,141 2,037 92 12 2,102 34 5 East 1.256 1.256 1.149 98 9 1.194 46 16 TOTAL 3,397 3,397 3,186 190 21 3,296 80 21 Percentage 93.78% 5.59% 0.63% 97.02% 2.35% 0.63% SHORT TREATMENT WEST 2,141 EAST 1,256 TOTAL 3,397 NOTE: The short treatment consisted of a single visit to each of the manhole points for the deposit of a poison bait. No follow-up visits were made to ascertain the amount of poison taken by rats. 17 Cleansing and Disinfecting Station The treatment of affected materials by cleansing, disinfection and/or disinfestation was carried out at the Department's Depot in Wightman Road, N8. In addition to routine disinfection work to infected bedding or soft furnishings, bundles of articles were disinfected prior to despatch abroad. Supervised bathing and treatment of verminous persons and scabies patients were also carried out at the Station. Laundry Service for the Incontinent During the year 2,202 bundles of soiled articles were cleaned and laundered at the Council's laundry in the Hamilton Hogben Training Centre. Care is taken to ensure that the laundry is treated separately from the normal work undertaken at the Centre. Collections and deliveries are made twice weekly by the Department's general assistants. Insect Pests Free assistance is given to householders to eradicate insect pests, and providing its use is not indiscriminate or over-generous, DDT continues to be the most effective insecticide in dealing with the majority of these insects. Other special formulations are available where this use appears to be preferable. Insect Pests Houses Other Premises Ants 23 7 Bees 1 - Beetles 57 3 Bluebottles 1 - Bugs 103 2 Cockroaches 97 27 Fleas 133 1 Flies 12 1 Lice 3 - Maggots 8 - Red mite 6 - Silver fish 13 - Wasps 58 1 Unspecified 38 2 Sprayed for other reasons (precaution etc.) 85 - TOTAL 638 44 Where requests for assistance are received in respect of non-domestic premises a charge is made to cover the cost of the service. During 1972 £44 was received in this connection. Mortuary The Public Mortuary is situated in Myddleton Road, Hornsey, N8 and is used for the reception of bodies from the whole of the Borough. Works to provide the Coroner's Court and offices within the same building as the Public Mortuary were completed early in 1972 and these were brought into operation in April. Since that date the Coroner has found it convenient to direct that bodies should be removed to the Haringey mortuary from the adjoining Borough of Enfield. During 1972 420 bodies were received into Hornsey Mortuary from Haringey and a further 139 bodies were removed to the mortuary from the London Borough of Enfield. A post-mortem examination was carried out in each case. Inspections and Reinspections carried out by Public Health Inspectors and Technical Assistants Statutory Nuisances 6,365 Drainage 1,285 Drain Tests 29 Surface water pollution 2,805 Vermin and Pests 283 Rodents 598 Accumulation of Refuse 959 Smoke Observations 91 Smoke Control 575 Noise 433 18 Disrepair Certificates 1 Housing Surveys 375 Multiple Occupation 11,357 Overcrowding 81 Other inspections under Housing Acts 2,875 Mortgage Advance 2 Improvement Grants 3,830 Infectious Disease (Not food borne) 405 Food Poisoning and food borne disease 234 Factories with Mechanical Power 354 Factories without Mechanical Power 20 Outworkers 38 Offices etc: General Inspection 236 Offices etc: Other visits 248 Shops Act 3,262 Employment of Young Persons 551 Bakehouses 203 Bakers and Flour Confectioners 147 Butchers 441 Canteens and Kitchens 141 Confectioners — Sugar 169 Fishmongers 46 Fried Fish Shops 175 Greengrocers and Fruiterers 424 Grocers 751 Hawkers of Food 88 Prepared Food Premises 128 Public Houses and Off Licences 124 Restaurants and Cafes 631 Slaughterhouses 129 Other Food Premises 73 Street Traders 971 Food and Drugs Sampling 817 Ice Cream Sampling 129 Milk Sampling 36 Imported Food Regulations 197 Surrender of Unsound Food 307 Investigation of Food Complaints 368 Bacteriological examination of Food 176 Hairdressers 46 Old People's Welfare 48 Pet Animals Act 117 Other Visits 2,175 No access 2,265 Defects remedied as a result of action by Distric Public Health Inspectors Drains repaired 23 W.C. cisterns repaired or renewed 58 W.C. pans renewed or cleansed 17 Flush pipes repaired 11 Waste pipes repaired or renewed 66 Rain water pipes repaired or renewed 40 Roofs repaired or renewed 227 Eaves gutters repaired or renewed 73 Water service pipes repaired 16 Yards repaired or reconstructed 15 Floors repaired or renewed 96 Dampness remedied 336 Window frames and sashes repaired, renewed or painted 223 Fire places, stoves and ovens repaired or renewed 1 Flues and chimney stacks repaired 4 Brickwork of walls repaired and walls rebuilt 30 Wallplaster repaired 187 Ceiling plaster repaired 136 Staircase, balconies and steps repaired or renewed 21 19 Noxious accumulations removed 128 Nuisances from animals abated 2 Miscellaneous defects remedied 136 Statutory Notices Served Housing Act 1957 Section 9 (Repair of Unfit Houses) 1 Section 78 (Overcrowding) 13 Housing Act 1961 (Houses in Multiple Occupation) Section 12 (Management Orders) 6 Section 14 (Neglect of Management) 6 Section 15 (Amenities) 52 Section 16 (Means of Escape in case of Fire) 58 Section 19 (Limitation of number of occupants) 2 Public Health Act 1936 Section 39 (Drainage) 56 Section 44 (W.C. provision) 1 Section 45 (Repair of W.C.'s) 10 Part III (Statutory nuisances) 268 Public Health Act 1961 Section 17 (Drainage) 25 Tottenham Corporation Act 1952 Section 43 (Urgent Repairs) 100 Work executed by the Council in default of or by agreement with the owners during 1972 Public Health Act 1936 Section 39 (Drainage) 3 Section 45 (W.C. repair) 1 Section 79 (Refuse accumulation) 1 Part III (Statutory nuisances) 1 Public Health Act 1971 Section 17 (Drain Clearance) 8 Tottenham Corporation Act 1952 Section 43 (Emergency Repairs) 37 Housing Act 1957 Section 9 1 Housing Act 1961 Section 15 (Houses in Multiple Occupation — Amenities) 7 Section 16 (Houses in Multiple Occupation — Fire Precautions) 9 Haringey Corporation Act 1971 Section 5 (Reinstatement of Electricity supply) 5 Rag Flock and Other Filling Materials Act 1951 No rag flock is manufactured in any premises in the Borough. 18 premises are registered for the use of filling materials in upholstery work or the stuffing of bedding, toys, etc., but the use of rag flock as a filler is not now very common. 20 District Public Health Inspection There has been a marked improvement in the general environment and in the housing stock in recent years but it is necessary for vigilance to be maintained to ensure that no matters which could be prejudicial to health or a nuisance are overlooked. Where the attention of the department, either by complaint or by the observance of a Public Health Inspector, is drawn to such a situation the person concerned is advised of the matter and is invited to take effective action to abate the nuisance. If action is not forthcoming in reasonable time then a statutory notice is sent specifying the works required and setting out a time limit for the work to be carried out. If the work is not then completed the matter is referred to the magistrates court. During 1972 6,365 visits were made to investigate complaints and 761 informal notices were sent requesting action to remedy unsatisfactory conditions. In 268 instances it was necessary for this informal approach to be followed by the service of statutory abatement notices. Legal proceedings were taken against defaulters on 14 occasions but 8 cases were subsequently withdrawn upon satisfactory completions of the works required before the dates of the intended Court hearings. The other 5 resulted in fines totalling £30.00 and costs £35.00. In 100 cases where the normal procedure for securing the abatement of statutory nuisances would have been unduly lengthy having regard to the defective conditions arising, urgent notices were served under the provisions of Section 43 of the Tottenham Corporation Act 1952 and repairs were carried out by the Council in the owner's default at 37 premises. The Council's expenses in these cases become official charges against the premises and are recorded in the register of Local Land Charges. Old People's Welfare Sometimes elderly people are found to be living in very distressing conditions. Frequently it is possible to improve these conditions by the removal of large quantities of unwanted materials and goods, by disinfection and deodorisation and by securing essential repairs thus making the work of other social services more effective. Noise Many complaints are received concerning noise and each is investigated. Usually the noise can be classified with one of two categories. Firstly noise emanating from business premises where informal approaches by the Public Health Inspector to the managements usually achieves the desired co-operation. Frequently a good deal of technical research and experiment is necessary to satisfy the legal requirements that the best practicable means shall be used to minimise the effect of the noise or vibration. The second category concerns noise in private homes usually caused by machinery or electrical equipment sometimes in conjunction with work carried out on the premises. If necessary the co-operation of the Town Planning Department is sought to ascertain whether the use is appropriate to domestic premises. Local Bye-laws concerning noisy instruments and also noisy animals are a great help in appropriate cases. Sometimes complainants are advised that the proper course of action would be to take legal advice with a view to taking a civil action in the Courts. Drain Stoppages Where complaints concerning obstructed drains are received the Public Health Department first investigates to see if the obstruction can be cleared by a simple action such as plunging. If so this is carried out by the Public Health General Assistants free of charge. In the event of a stoppage being more resistant the owner is notified that immediate action is necessary to clear the drain and is invited to sign a form requesting the Borough Engineers Department which has heavier equipment, to deal with the matter. In these cases the person responsible must undertake to meet the Council's charge. If agreement cannot be reached statutory action is taken under Section 17 of the Public health Act 1961 whereby the Council does any necessary works and recovers the cost thereof from the owners of the premises. During the year 1,150 drains were cleared by the Public Health Department and 545 jobs were passed to the Borough Engineer's Department. It was also necessary to serve 25 notices under Section 17, Public Health Act, 1961 and in 8 of these cases to carry out the clearance in the owners' default. House Drying Assistance is given when premises have been saturated, caused possibly by burst water pipes or tanks or major roof defects. Powerful hot air blowers and dehumidifiers are taken to the premises and greatly speed up the drying out process. 21 Accumulations of Refuse Once again there has been a good deal of dumping of refuse matter on open spaces throughout the Borough. This practice is conducive to the harbourage of vermin and causes a great deal of work for the inspectorate. Diseases of Animals Act 1950 The Council is the responsible local authority under this Act, but no local emergency arose during the year which required special action in this respect. Pet Animals All pet shops and animal boarding establishments are inspected with particular reference to cleanliness, temperature, ventilation and fire precautions. The Council's vetinerary advisor also visits these premises to ensure that the welfare of the animals or birds is reasonably safeguarded. HOUSING Unfit Housing The main task of the Section responsible for action under Parts II and III of the Housing Act 1957 has been the continuance of detailed examination of all houses in the Inspection Area Programme with reports on their condition and recommendations as to treatment. In the course of this work records of inspections were compiled, statements of principal grounds of unfitness were prepared where appropriate, details as known of ownerships and occupancies were listed and notices under Section 170 of the Housing Act 1957 were issued concerning all interests in each property which contained a dwelling. Findings on inspection of Areas, with observations, recommendations and relevant maps were circulated to all other Departments involved in order that joint submissions might be laid before the Area Renewal Panel. It had been anticipated that the last of the Areas in the Inspection Area Programme would be completed by the end of the year but staff limitation and the survey of two additional areas visualised for rehabilitation resulted in near completion of the Programme but with two areas to be carried forward for investigation in 1973. Buildings in seven Areas confirmed under Part III of the Housing Act 1957 were demolished during the year and the sites cleared for redevelopment. Ten areas which were confirmed before 1972 have not yet been cleared or are only partly cleared. Four areas submitted for approval were confirmed by the Department of the Environment. Three areas await Public Local Inquiries and/or confirmation. Eleven areas have been surveyed and reported upon during the year and are at various stages of consideration or statutory procedure. Public Local Inquiries were held in respect of three areas, two of which since have been confirmed. The following is a situation summary of progress in respect of clearance areas and related Compulsory Purchase Orders at the end of the year:— 1. Confirmed Areas demolished and sites cleared during 1972 High Cross Court, N15 Chesnut/Welbourne/Somerset Roads, N17 Craven Park Road, N15 Birkbeck/St. Joseph's Roads, N8 Russell Road/Victoria Crescent, N15 Beaufoy/Tenterden Roads, N17 Kings Road, N22 2. Areas confirmed before 1972 and not yet cleared Park Lane, N17 Paxton Road, N17 Eade/Vale Roads, N4 Westerfield Road, N15 Lealand Road, N15 Clarendon Road, N8 Summerhill Road, N15 Tebworth Road, N17 Boyton/Eastfield Roads, N8 Philip Lane, N15 22 3. Areas confirmed during 1972 Houses Estimated No. of Families Stonebridge/lpplepen Road, N15 176 250 Plevna Crescent, N15 58 76 Park Road, N8 (purchase by agreement) 13 10 Fortis Green Cottages, N10 4 4 Philip Lane, N15 16 18 267 358 4. Areas declared before 1972 and not yet confirmed Houses Families Blenheim Road, N22 30 35 5. Areas declared for clearance during 1972 Houses Families Fortis Green Cottages, N2 4 4 The Crescent, N15 26 40 Park Road, N15 5 5 Hartington Road, N17 149 175 Ascot/Cornwall Roads, N15 14 16 Pellatt Grove, N22 9 15 Paignton Road, N15 141 188 348 443 6. Areas surveyed in 1972 and awaiting report Dorset Road, N15 Antill/Hanover/Spondon Roads, N15 Rangemoor Road, N15 Area Woodstock/Ennis Roads 7. Other areas inspected during 1972 Carlton/Clyde Roads, N15 (For action under Education Act) 483/529 Seven Sisters Road, N15 (Deleted from Part III action) Albert Road, N4 (For rehabilitation) Middle Lane, N8 (For rehabilitation) Public Local Inquiries were held during the year in respect of three areas declared for clearance, namely: — Stonebridge/lpplepen Roads Area (confirmed) Plevna Crescent Area (confirmed) Blenheim Road Area Under-noted are houses or parts of houses upon which closing orders were made. These dwellings or parts of dwellings were unfit for human habitation and could not be made fit at reasonable cost. 30a Haringey Park, N8 15 Houghton Road, N15 64 Nightingale Road, N22 7 Queens Avenue, N10 545 Seven Sisters Road, N15 Closing orders on the following were determined during the year following substantial and satisfactory repair and improvement. 8 Beatrice Road, N4 26 Elizabeth Road, N15 1 Ennis Road, N4 67 Lothair Road, N4 68 Milton Park, N6 37 Stanley Road, N15 83 Victoria Road, N22 28 Woodstock Road, N4 General Improvement Areas During the year two further areas were surveyed and declared General Improvement Areas. These were Coleraine Park Area comprising 610 dwellings declared by the Council in April, and Middle Lane Area (68 dwellings) declared in October. The Department were able to undertake this work despite the continued shortage of staff because of the particular circumstances relating to these areas. 23 In the-Coleraine Park Area some 50% of the properties are owned by one property company which had been persuaded and encouraged by officers of this Department to embark on a comprehensive rehabilitation programme which had started prior to the survey. Over 90% of the properties are singly occupied and the various types and present condition of the properties were currently known to the Department. A sample survey only was therefore conducted. Admittedly this did not allow an officer to interview each household on the estate, but this was of less significance as 50% were already aware of their property owners' proposals. A 100% survey would have been preferable but this was not within the Department's capabilities and there were very good grounds, in view of the housing improvement activity, for declaring this area. The survey of the Middle Lane area was made simpler because a large part of the area had been inspected the same year under the inspection area programme to determine appropriate houses for Part III clearance action. The total of six areas is now operative. Durban Road 121 dwellings July 1970 Clonmell Road 351 dwellings November 1970 Noel Park 2,797 dwellings March 1971 Clarendon Road 264 dwellings July 1971 Coleraine Park 610 dwellings April 1972 Middle Lane 68 dwellings October 1972 In each of these areas the Council has either improved its own houses or had included them in a programme for improvement. The progress since declaration in the improvement of privately owned houses up to the end of the year is shown in the following table. It should be noted that some applications for grants had been received prior to declaration and this particularly applies to the Coleraine Park area. Improvement Grants for Dwellings in General Improvement Areas to 31 December 1972 Area Total No. of privately owned dwellings suitable for improvement Grant Applications Grant Approvals Improvement Completed Durban Road 105 (81) 26 20 12 Clonmell Road 1,349 ( 234) 16 13 10 Noel Park 823 (450) 28 21 15 Clarendon Road 263(210) 12 10 5 Coleraine Park 575 (467) 67 55 33 Middle Lane 46 (29) — _ — TOTAL 2,161 (1,471) 149 119 75 NOTE: The figures in brackets indicate the number of privately owned dwellings considered suitable for improvement with grant aid. In declaring 6 areas comprising some 1,800 private properties since the beginning of 1970 the Council has well exceeded its original proposed programme of some 400 properties per annum. Progress with both house and environmental improvements is constrained by availability of professional staff. The Council acknowledged towards the end of the year that because of other commitments insufficient effort was being directed towards securing the improvement of houses in declared areas. They therefore passed the following resolution: — "That work on the existing 5 GIAs and the 6th to be declared in October be consolidated and that consideration be given to the merits of area improvement in cases where it is decided not to proceed with clearance in inspection areas or to areas where spontaneous enthusiasm develops as a result of decision by owners such as occurred on the Coleraine estate." To secure the rehabilitation of 5 houses comprising 10 dwellings in Durban Road proved unexpectedly difficult. In-1969 the Council entered into a formal agreement with the owners to rehouse the existing tenants and have the right to nominate tenants to the improved dwellings. By September 1970 all the tenants had been rehoused but by the beginning of 1972 no positive steps had been taken by the owners to repair and improve the houses and they became an "eyesore" in the middle of the area. In March the Council made a compulsory purchase order on the properties; but by the end of the year the Borough Valuer and Estate Surveyor had managed to negotiate their purchase and the compulsory purchase order procedure was halted. A decision was taken later to demolish these houses and consideration is currently being given as to the most suitable future use of the cleared land. 24 London House Improvement Campaign This campaign was initiated by the Department of the Environment in association with the London Boroughs and the Greater London Council. It took place over a four week period commencing in the middle of April, and was backed by a special advertising promotion of improvement grants in the national and local newspapers and on television. This Council during the month had 4 demonstration houses open for 2 weeks each. These houses were continuously manned, and were open for 3 evenings until 8 pm and on Saturdays until 5 pm. A total of close on 4,000 persons visited them. As the result of this campaign the number of enquiries and applications for grant increased dramatically and the staff were under considerable pressure to deal with them. This upsurge in interest continued unabated up to the end of this report period. Repair and Improvement of Dwellings Owing to severe staff shortage systematic house to house inspections throughout the whole Borough to secure at least the full repair and improvement of tenanted property were not possible. However, a tenant may ask the Council to require his landlord to provide the basic amenities in his dwelling. In most cases this refers to an internal W.C. and bathroom. If this is in all respects reasonable, the Department can require the owner to carry these works out. Sometimes this can be arranged by negotiation, but if this fails notice may be served under the provisions of the Housing Act or if considered more appropriate compulsory purchase powers may be invoked. This latter action was taken during the year in respect of 4 properties, 3 of which are within the Durban Road improvement area. This procedure requires confirmation by the Department of the Environment and if objections are lodged a public enquiry is called. By the end of the year the outcome of these four cases was not known, and generally the Council's declared resolution to such compulsory acquisition spurs the owner into some more positive action. If a property is subsequently properly repaired and improved it would not be the Council's policy to pursue the acquisition, and indeed it is most unlikely that in such a case the Minister would confirm the order. Improvement Grants The rise in the number of applications for grants continued in 1972 but the rate of increase was less marked than in the previous year. 1970 1971 1972 Standard Grants 213 162 115 Improvement Grants 194 416 411 Conversion Grants 140 326 592 TOTAL 550 904 1,118 The applications for the conversion of the larger properties nearly doubled and this was a cause of concern to this Council because of the number of premises which were being acquired by developers for conversion and the subsequent sale of the resulting dwellings on long leases. This loss of accommodation for letting caused the Council to decide to consider early in 1973 whether grant approvals should be allowed only in those cases where the proposals for the disposal of the dwellings upon completion of the works were not prejudicial to the Council's overall housing policy. Improvements and Rents The Housing Finance Act 1972 replaced Part III of the Housing Act 1969 which made provision for the decontrol of dwellings which were provided with all the standard amenities and met the other qualifying conditions. Although the 1972 Act provides for the decontrol of all dwellings by the 1 July 1975, the particular date of decontrol depending upon the rateable value of the dwelling, provision is still made for earlier decontrol where the landlord is able to obtain a certificate from the Council that the dwelling meets all the qualifying conditions. In addition the 1972 act reduced the phasing of rent increases from 5 to 3 annual increments and permitted landlords immediately upon completion of grant aided improvements to increase the rent by 1 2Vi% of the cost of the improvements less the grant received, provided the rent did not exceed the registered fair rent. This led to special difficulty when the act came into operation as tenants who had given their consent on the understanding that the rent would rise gradually over a period of years to the fair rent found that the initial increase under the new provisions would result immediately in a rent almost up to the fair rent. The Council had discussions on this problem with a large property company which was undertaking improvements to an estate in the Borough and it was agreed by them that, notwithstanding the new legislation, the rent increases would be limited and phased over a period of years. 25 Applications for Qualification Certificates (a) Dwellings having amenities No. of Applications outstanding at 1.1.72 480 No. of Applications received in 1972 129 609 No. of Qualification Certificates Granted 83 No. of Qualification Certificates Refused 42 No. of Applications withdrawn 10 No. of Applications where owners notified of repairs needed 472 607 No. of Applications under investigation at 31 December 1972 2 (b) Missing Amenities to be provided No. of Applications outstanding at 1.1.72 110 No. of Applications received in 1972 151 261 No. of Certificates of Provisional Approved issued 169 No. of Certificates refused 19 188 No. of Applications under investigation or negotiation at 31 December 1972 73 Houses in Multiple Occupation By reason of staff limitations the majority of primary inspections of houses in multiple occupation were confined to those concerning which complaints were received or where the Public Health Inspectors saw evidence that an inspection was very necessary. A house to house survey of those areas where this is considered necessary cannot yet be commenced on a systematic basis. Staffing still proves the obstacle in our attempts to achieve the necessary goals but it is hoped the new structure of the Public Health Inspectorate will attract sufficient Inspectors of the right calibre and quality to fill the posts and enable this problem to be dealt with in the only way which would bring any real degree of success in this special area of Housing deprivation. Number of separately occupied parts of houses visited for first time 1,842 Number of revists to above 6,504 Number of houses completely inspected 762 Number of houses found satisfactory 93 Number of houses where informal notices relative to S 15/16 sent 598 Number of houses where specification given of work required for means of escape in case of fire 272 Number of houses inspected where multiple occupation would exist upon completion of mortgage advances being contemplated by this Council 13 Number of houses where items of management notified to owner 133 Number of cases of penal overcrowding 22 Number of cases of penal overcrowding abated 13 Number of cases of non-penal overcrowding 11 Number of cases of non-penal overcrowding abated 3 Number of formal S.12 Notices (Management Orders) 6 Number of formal S.14 Notices (Management Neglect) 6 Number of formal S.15 Notices (Amenities) 52 Number of formal S.16 Notices (Fire precautions) 58 Number of formal S.78 Notices 13 Number of houses where S.19 Direction made 9 Number of houses where S.19 Direction revoked 2 Number of houses where S.12 Management Order made 4 Other notices served 456 Other visits, including discussions with owners, builders etc. at premises 2,320 26 Completed Works W.C. provided 22 Baths/showers provided 42 Sinks/lavatory basins provided 39 Water Heaters provided 181 Cooking facilities provided 16 Food stores provided 20 Space Heating provided 22 Fire Precautions Work 207 Electricity restored 2 Repairs External 151 Internal 195 FOOD HYGIENE From time to time it is necessary to review the various duties for which we are responsible and among other things to ask ourselves whether we have our priorities in the right order. Such an exercise may very well result in less effort being given to certain aspects to allow more attention to be given to a facet of the work which appears to have evolved in such a way as to justify more attention and time being given to it. It may also serve the purpose of indicating that in certain aspects we are justified in continuing a method which is traditional. In the very wide field of Food Hygiene, efforts have been made to arrange exhibitions, series of lectures, seminars, Press campaigns etc. These may do some good if viewed over a long period, but experience shows that nothing can replace the frequent visits of the Public Health Inspector to all food premises in his capacity as friend and mentor. He can under favourable circumstances, advise and obtain standards far above those which he can enforce. As a result of the steadily improving standards in Food Hygiene, the recalcitrant trader is highlighted and firm measures have to be adopted with the result that more cases are being taken before the courts and more food being seized for condemnation than in the past. Special problems which have developed during the year are those in connection with the use of (a) micro-wave ovens which are coming into use in greater numbers, with the possible risk to users from radiation leakages and (b) the increasing use of deep freeze cabinets in domestic premises. This from time to time raises problems in dealing with complaints regarding unsatisfactory food-stuffs such as meat which was purchased weeks if not months before. The total number of food shops at the end of the year was as follows: — Trade No. of shops No. of inspections Bakers and Flour Confectioners 95 147 Butchers 105 441 Cafes and Restaurants 238 631 Confectioners, Sugar 371 169 Fishmongers 34 46 Fruiters and greengrocers 169 424 Grocers 399 751 Off Licences and Public Houses 202 124 Registered Food Premises At the end of the year the following premises were registered under Section 16 of the Food and Drugs Act 1955:- 27 Sale of ice cream 845 Manufacture and sale of ice cream 1 Cooking of hams and other meat 63 Fish frying 55 Fish curing (smoking) 3 Sausage manufacturer 90 Preparation of jellied eels 3 Shell fish 2 Prepared foods 28 Pickling meat 3 TOTAL 1,093 In addition the following classes of food hawkers and their storage premises are registered under Section 11 of the Middlesex County Council Act 1950: — Trade No. of Hawkers registered No. of storage premises Fruit and vegetables 83 55 Shell fish 10 6 Fish and/or meat 8 6 Fish and chips 1 - Ice cream 29 11 Light refreshments 23 13 Peanuts 4 2 Eggs 3 – Groceries 5 3 TOTAL 166 96 Milk and Dairies Regulations The number of distributors registered at the end of 1972 was 234. There are no dairies in the Borough where loose milk is bottled. Milk (Special Designation) Regulations At the end of the year the following licences to use special designations were valid for premises in the Borough: — Pasteurised Milk 181 Sterilised Milk 167 Untreated Milk 29 Ultra Heat Treated Milk 71 Imported Food Regulations 1968 The examination of imported food received in sealed containers at the cold stores and warehouses in the Borough is undertaken by the Public Health (Food) Inspectors. Details of the consignments received are set out in the following table: — 28 Consignments of Imported Food examined under Imported Food Regulations Type of Food No. of consignments Egg, Frozen or Dried 34 Cheese 31 Confectionery, Sugar 9 Meat and offal 7 Tinned milk or fruit juices 15 Frozen prawns and shrimps 26 Citrus Fruit 1 Gelatine 1 Tomatoes 5 TOTAL 129 Food Sampling The Department continues to sample a wide range of foodstuffs for chemical and bacteriological examination. From time to time the emphasis on articles to be sampled is shifted in the light of experience, and the advice given by Mr. W.B. Chapman, the Council's Public Analyst and Dr. Betty Hobbs, Director of the Food Hygiene Laboratory at the Central Public Health Laboratory. Food Samples Articles No. samples taken Unsatisfactory Label Analysis Alcoholic Beverages 12 3 1– Baby Foods 7 – – Beverages 2 – – Butter 1 – – Cheese products 21 – 2 Confectionery (flour) 17 2 1 Confectionery (sugar) 49 3 1 Cream 8 1 – Deodorant 8 — – Drugs 45 2 1 Fish and fish products 11 1 – Flour and flour products 13 – – Food (misc.) 12 – – Fruit Juice 14 2 – Fruit (fresh) 4 – – Jams and preserves 21 – 2 Meat and meat products 24 1 – Milk 177 – 7 Oils and fats 4 1 – Peanuts 1 – – Pickles 6 3 – Potatoe crisps 2 – – Prepared desserts 5 – – Prepared foods 23 1 – Soft drinks 12 3 1 Soup and soup mixes 2 – – Spices and condiments 23 4 – Tinned Fruit 36 3 – Tinned vegetables 12 4 – Toothpaste 1 – – Vegetables (fresh) 2 – – Yoghurt 3 – – TOTAL 578 35 15 29 Details of Unsatisfactory Samples Sample Irregularity Comment Cheese — Emmentaler Sample contained less than the minimum percentage of milk fat in the dry matter Manufacturer warned — Full fat hard cheese Contained insufficient milk fat in the dry matter In correspondence with the manufacturer Box of 6 jam tarts Contained a colouring matter which is not permitted by Regulations Colouring matter changed by manufacturer Kola Drops Contained a colouring matter which is not permitted by Regulations Letter sent to manufacturer — still awaiting reply Syrup of Blackcurrant B.P.C. Contained a colouring matter which is not permitted by Regulations In correspondence with manufacturers Honey and Apple Jam Sample contained less than the minimum percentage of soluble solids Manufacturer warned Mophisto Jelly Sample contained less than minimum percentage of soluble solids Still in correspondence with manufacturers Milk (7 samples) Deficient in non-fatty milk solids Deficiency due to the condition of the animals Lemon Squash This food contained Cyclamic Acid which is not permitted by the Regulations Found to be old stock — Vendor warned Labelling Irregularities Label inconspicuous 1 List of ingredients incomplete or absent 11 List of ingredients included generic terms 6 Alcoholic declaration incorrect or less than minimum height 3 No name or address given 9 Description of ingredients inaccurate 5 Food Complaints 142 complaints of unsound foodstuffs were investigated and, where appropriate, legal proceedings were instituted or warning letters sent. Details are shown in the following table:— 30 Commodity Foreign bodies Other reasons Warning letter Prosecution No formal action Cases referred elsewhere Baby food — 2 — — 2 _ Beer 2 – 2 – — — Bacon – 1 — – 1 — Bread 15 11 15 6 5 — Butter – 1 — — 1 — Cereal 1 – — — 1 — Cheese – 8 4 2 2 — Confectionery (flour) 10 6 8 5 3 — Confectionery (sugar) 9 – 6 3 – – Cream – 2 1 – 1 – Dates 1 – 1 — — — Fruit (fresh) — 1 — — 1 — Fruit (tinned) – 1 – – 1 — Fish 2 3 3 – 1 1 Lettuce – 1 1 – — — Jam 1 – 1 – – — Cooked meats 2 4 4 1 1 – Meat – 2 2 – – – Meat pies 1 6 2 4 1 – Meat (tinned) 1 1 2 – – – Milk 11 13 11 5 5 3 Peanuts 1 – – 1 — — Prepared foods 6 5 7 1 3 – Tinned soup 1 – 1 – – – Starch products 5 – 1 1 3 – Toothpaste – 1 – – 1 – Vegetables (tinned) 1 2 2 1 – – Yoghurt – 1 – 1 – — TOTAL 70 72 74 31 33 4 A number of these articles were submitted to the Public Analyst and his reports assisted when assessing what action should be taken in respect of offences. Prosecutions were instituted in thirty-one cases where it was judged that the circumstances warranted such action and the results are shown in the following table: —  Fine of Costs £ £ Steak and Kidney pie — mouldy 10 5 Pint bottle of milk in dirty condition 50 10 Sliced, wrapped loaf — mouldy 10 5 Pineapple cake — stale and mouldy 20 5 2 Cornish pasties 30 10 Remnants of apple pie — mouldy 20 10 Canned garden peas — mouldy 20 10 Mouldy pies 15 10 Dirty milk bottle 50 10 Foreign body in Florentine 15 10 Cheesecake — mouldy 50 5 Bakewell Tarts infested with ants 15 5 "Pasta Sirene" Macaroni 10 5 "Finger" roll — mouldy 10 5 Home baked loaf — mouldy 15 10 Pie, mash and liquor — abnormal odour and taste (mash) 5 5 Foreign matter in unopened pint of milk 50 10 Packet of jellies, one gum containing nail 25 15 Bar of chocolate with maggot 15 5 Foreign matter in a thin sliced white loaf 30 10 Soft cheese — mouldy 25 15 1,085 270 Surrender of Unsound Food 1,240 Certificates were issued in 1972 in respect of unsound foodstuffs which were surrendered by wholesale and retail distributors. Meat Inspection An authorised meat inspector assists in the inspection services which the Public Health Inspector is statutorily required to provide at the Markfield Road abattoir. The abattoir is constructed to deal with many types of animals where the flesh is intended for human consumption but the bulk of the work covers bovines and horses, the flesh of some of which is intended for export. The Company is approved by the Ministry of Agriculture, Fisheries and Food to export to countries within the European Economic Community and such an approval is only granted to an abattoir which complies with the requirements of the European Economic Community. The whole or parts of carcases which are rejected as unsuitable for human consumption are passed directly for processing, sterilization and manufacture into pet food within a separate building in the same complex. This arrangement is regarded by the Public Health Department as eminently satisfactory since the rejected meat is not removed from the direct supervision and control of this Department. Summary of Carcases Inspected 1972 Donkeys Bovines Horses Calves Sheep Cows Number killed 2 697 722 246 474 1,639 Number inspected 2 697 722 246 474 1,639 All diseases except Tuberculosis Whole carcase condemned – 26 13 19 11 101 Carcase of which some part or organ was condemned – 177 451 46 408 1,219 Percentage of number inspected affected with disease other than T.B. – 29 64.2 26.4 88.4 80.5 Cysticercosis only Carcases refrigerated – 5 – – – 35 Percentage of number inspected affected with cysticercosis – 0.7 – – – 2.1 32 The Food Hygiene (Markets, Stalls and Delivery Vehicles) Regulations 1966 The Middlesex County Council Act 1950 — Section 11 The position in respect of itinerant hawkers of hot dogs, hamburgers, etc. in the vicinity of the Tottenham Hotspur Football Club on match days, has steadily improved. It was not found necessary to ask for the assistance of the police on any occasion during this year and the general standard of hygiene of the food hawkers operating in the area was reasonably satisfactory. The occasional unregistered hawker who appears for the first and often the only time remains a problem. Offices, Shops and Railway Premises Act 1963 The difficulties mentioned in the last Annual Report with regard to the application of the offices, shops and railway premises (Hoists and Lifts) Regulations 1968 has been resolved after some discussion between the Factory Inspectorate and the Brewers Society. A considerable number of such hoists have since adapted successfully. Class of Premises No. of Premises Registered during 1972 No. of Registered premises at end of year No. of Registered premises receiving a general inspection 1972 Offices 6 492 16 Retail Shops 30 1,150 177 Catering establishments and canteens – 156 37 Wholesale shops and warehouses 1 75 4 Fuel Storage Depots 2 5 2 TOTAL 39 1,839 236 Analysis of Contraventions Found Section Type of contravention No. found Section Type of contravention No. found 4 Cleanliness 6 12 Clothing accommodation 3 5 Overcrowding 1 13 Sitting facilities 1 6 Temperature 31 16 Floors, Passages, Stairs 10 7 Ventilation 6 8 Lighting 4 17 9 Sanitary conveniences 22 19 10 Washing facilities 11 24 First Aid 25 Hoists and Lifts 18 Abstract 34 Persons employed in registered premises Class of workplace No. employed Office 7,121 Retail shops 6,899 Wholesale shops and warehouses 1,539 Catering establishments 1,095 Canteens 238 Fuel storage depots 42 TOTAL 16,934 Males 7,533 Females 9,401 33 Reported Accidents Workplace No. Reported Total No. investigated Prosecutions Formal warning Informal warning No action Offices 2 1 — — 1 — Shops, Retail 40 21 – 1 10 10 Wholesale Shops 10 1 – – – 1 Catering establishments 2 – – – – – Fuel Storage Depots – – – – – – TOTAL 54 23 – 1 11 11 Analysis of reported accidents Cause of accident Office Shop Warehouse Catering Estab. Fuel Storage Machinery — 3 — — — Transport – 2 2 – – Falls of persons 1 12 2 – – Stepping or striking against object or person 1 1 – – – Handling goods — 14 6 2 — Struck by falling object – 3 1 – – Fires and explosions – – – – – Electricity – – – – – Use of hand tools — 4 — — — TOTAL 2 39 11 2 – FACTORIES The local authority has responsibilities to inspect the sanitary accommodation and water supplies, in all factories and business premises. In factories where no mechanical power is used, the other welfare provisions of the Factories Acts are also the responsibility of the local authority. Frequent visits are made to factories for a variety of reasons and it is the usual practice to check all the conditions whilst on the premises. Premises No. on Register No. of Inspections Written Notices Prosecutions (1) Factories in which sections 1, 2, 3, 4 and 6 are enforced by the local authority 58 20 – – (2) Factories not included in (1) in which Section 7 is enforced by local authority 976 344 1 – (3) Other premises in which Section 7 is enforced by local authority excluding outworkers 17 – – – TOTAL 1,051 364 1 – 34 Summary of defects found in factories Particulars No. of cases in which defects were found Found Remedied Referred to Factories Inspector Referred by Factories Inspector Sanitary conveniences (S7) (a) Want of cleanliness 4 4 – – (b) Unsuitable or defective 5 5 – – (c) Not separate for sexes 2 2 – – (d) No intervening lobby 8 8 – – (e) W.C.'s not labelled – – – – Abstract 4 4 1 – TOTAL 23 23 1 – Hairdressers Section 21 of the Greater London Council (General Powers) Act 1967 was applied to Haringey with effect from 1 January 1968. This requires all persons carrying on business as hairdressers or barbers at premises in the Borough to be registered with the Council. Byelaws in respect of such establishments in Haringey prescribe standards of hygiene in relation to the premises, equipment and persons working on the premises. 179 premises were registered at the end of the year. All are inspected from time to time based on an assessment of conditions found at the time of previous inspection. Shops Acts 1950—1965 A total of 3,262 shops inspections were made during the year. The following contraventions were noted: — General Section 17(2) Assistants weekly half holiday notice not displayed 289 Section 32(2) Notice of hours of employment of young persons not displayed 81 Section 32(3) Abstract of provisions of employment of young persons not displayed 59 Section 32(1) Record of Hours worked 75 Closing Hours Section 2(1) Failed to close at prescribed hour 89 Section 1 (1) Failed to close at 1 pm on early closing day 74 Section 1 (2) Failed to exhibit early closing day notice 333 Section 13(1) Failed to exhibit exempted trade notice 198 Sunday Trading Section 22(3) Failed to keep record of hours of employment 40 Section 57 Failed to exhibit Sunday Trading Notices 140 Jewish Traders Section 53(1)(c) Notice not exhibited 17 Street Trading Although there is no street market in the Borough, 24 sites on the public highway are licensed for street trading. The majority of these are in side roads off the Tottenham and Wood Green High Roads and off West Green Road, N.15. The Council also license 16 small sites on the public footpath for trading. These are occupied mainly by news-vendors and are situated in the vicinity of British Rail and Underground Stations. 35 Outworkers Employers of outworkers in certain specified trades are required to make half-yearly returns showing the home addresses of such workers and the class of work upon which they are engaged so that any necessary steps can be taken to prevent work being undertaken in unwholesome premises, or to stop the spread of infectious disease. The following is a summary of outworkers employed in the Borough according to the 1972 summer returns: — Trades No. employed Wearing Apparel 233 Curtain and furniture hangings 92 Handbags 1 Sacks – Umbrellas 10 Artificial flowers 12 Cardboard boxes 19 Brushes 5 Button carding – Christmas Crackers 30 Manufacture of brass objects – Weaving of any textiles 1 TOTAL 403 Radioactive Substances Act 1960 During the year, the Council received from the Department of the Environment, details of Certificates issued under Section 1 of the above act in respect of three premises. These premises were visited by one of the Senior Public Health Inspectors, in order that the department may continue to be kept informed of the levels and uses of radioactive materials within the Borough. It is interesting to record that these materials are used in many ways, some uses being purely experimental and others of very practical application. An example of the latter is in the use of radioactive materials, in minute quantities, which form the basis of fire detectors. These can detect the presence of smoke and, in consequence, set off fire alarm systems within the buildings and operate relays so that doors, normally required to be left open in the course of business, can be closed automatically to prevent the spread of a fire; whilst at the same time leaving a safe exit route for those persons left within the building. Student Public Health Inspectors Until 1972 the Department had an establishment of eight student public health inspectors, with two pupils on each year of the four-year course. In order to secure a greater output of qualified inspectors and to assist in relieving the acute shortage of staff the Council has decided to increase the number of pupils so that there is an intake of three each year. Three were recruited for the start of the course in 1972. They attend the Education Board Diploma day-release course at the Tottenham Technical College. The in-service training is directly supervised by an Assistant Principal Public Health Inspector who has steadily expanded and developed their programme of practical work, to ensure that, when qualified, the officer will have a very full experience of the best methods of dealing with the problems he is likely to meet with as a public health inspector. Two students completed their training during the year and passed their final examination for the Public Health Inspector's Diploma. It is pleasing to record that the education standard of applicants for appointment is steadily improving. 36 PART II PERSONAL HEALTH SERVICES AND INFECTIOUS DISEASE CONTROL Co-ordination and co-operation with Hospital Services and Family Doctor Services The valuable links with the Hospital and Family Doctors Services, described in last year's Annual Report, have been continued. The attachment and liaison schemes between the domiciliary staff and family doctors have continued. Unfortunately there has been little progress with Health Centres. The scheme for notification of congenital defects apparent at birth continued as in previous years and a table is included in the report. The Department of Health asked for information about the Family Planning Service; Health Education; and action taken by the Council on contact tracing and the control of venereal disease, and reports are included. The Department of Health also asked for any action taken by the Council on the fluoridation of public water supplies but during the year there has been no action. Special investigations have been carried out into the gradual increase, between 1968-1971, in the number of infant deaths in the post natal period, and Dr. Golder's report is included. There is also a report about the five years experience in breast cancer screening organised by Mr. Abel, Consultant Surgeon at the Prince of Wales's and St. Ann's Hospitals. ANTE-NATAL SERVICES The attendance at the ante-natal clinics continues to decline and as a consequence of the closure of the Alexandra Maternity Home this decline was accelerated and the Health Committee has decided to reduce the number of ante-natal sessions at the various clinics. The Alexandra Maternity Home was closed on 31 December, 1972 because the modern policy is for hospital care to be given in larger units where the full facilities of a general hospital are available and this is now practicable because the length of stay in maternity hospitals has been considerably reduced in recent years. The Alexandra Maternity Home was established in 1943 by the former Borough of Hornsey, when the Council of that Borough purchased the Alexandra Park Nursing Home for the purpose of a municipal maternity home and thirty years of excellent service were provided to a large number of Hornsey and Haringey mothers in these premises under the care of Matrons, Howell, Ball and Davis. DEATHS IN THE POST-NATAL PERIOD Dr. R. Golder, Principal Medical Officer Maternal and Child Health In England and Wales deaths of infants between the ages of 1 week and 1 year have not declined in numbers in recent years. This is in contrast to the still birth and first week deaths which have shown a slow but steady decline both nationally and locally. The Haringey figures for 1 week to 1 year deaths have been higher than the national average and have been rising until 1972. The Department of Health has been concerned about this national problem and a number of studies have been made which have shown that social and environmental factors influence the numbers of deaths in this age group considerably. Over the past five years the actual numbers of babies between age 1 week and 1 year who have died in the Borough are as follows:— 37 1968 1969 1970 1971 1972 43 47 44 47 34 M25 F18 M22 F25 M28 F16 M23 F24 M23 F11 The number of births, however, has been steadily declining, as follows: — 1968 1969 1970 1971 1972 5,120 4,753 4,342 4,205 3,800 When the deaths are expressed as the rate per 1,000 births the rising trend from 1968-1971 is very clear — 1968 1969 1970 1971 1972 8.39 9.88 10.13 11.18 8.16 This trend prompted an investigation and a study has been made of several factors surrounding the deaths of these babies. The cause of death as stated on the death certificate was studied, also the birth weight, the place in the family, the social class according to the occupation of the father, and the nationality of the mother. The most interesting facts which have emerged from this are the differences in death rates according to the nationality of the mother. When each year is taken separately the numbers in each national group are small and may be misleading and so rates have been calculated covering the four years 1969-1972. 1968 has been omitted because the nationality was not routinely recorded in that year. The five main national groups in the Borough are as follows:— United Kingdom West Indian African Eire Cypriot Here are the number of births in each group, with the deaths written below: — Nationality 1969 1970 1971 1972 Totals United Kingdom 2,295 1,869 1,852 1,584 7,600 23 15 13 9 60 West Indian 721 577 564 494 2,456 3 9 12 11 35 African 229 186 182 149 746 6 3 6 3 18 Eire 406 390 365 279 1,440 6 3 3 4 16 Cypriot 415 431 355 381 1,582 1 5 4 3 13 From these figures the death rates of infants between 1 week and 1 year from 1969-1972 according to the nationality of the mother are: — United Kingdom 7.89 deaths per 1,000 births West Indian 14.85 ,, ,, ,, ,, African 24.12 ,, ,, ,, ,, Eire 11.11 ,, ,, ,, ,, Cypriot 8.21 ,, ,, ,, ,, These differences are striking. It would be interesting to know if other Boroughs have the same experience. The facts will be reported to local and national medical authorities and consideration given to what further investigation or other action should be taken. 38 Movement of Babies born in 1971 into and out of the Borough up to 30 June 1973 Ethnic Groups of Mother No. moving into Haringey No. moving out of Haringey U.K. 171 400 Eire 26 69 European 32 32 Cypriot 43 48 Indian 14 11 Pakistani 11 6 W. Indian 56 66 African 40 63 Not stated 335 185 Other 40 42 768 922 These figures show the high mobility of young families living in Haringey a practice which makes follow up of children difficult and can be a factor in depressing our statistics for immunisation. Births 1969/72 and Nationality of Mother Nationality of Mother 1969 Births 1970 Births 1971 Births 1972 Births *No. % No. % No. % No. % Not Stated 548 10.9 506 11.4 583 13.5 541 14.1 U.K. 2,295 45.4 1,869 42.2 1,852 42.9 1,584 41.1 Eire 406 8.0 390 8.8 365 8.5 279 7.3 European 161 3.2 162 3.7 168 3.9 163 4.2 Cypriot 415 8.2 431 9.8 355 8.2 381 9.9 Indian 94 1.9 97 2.2 65 1.5 85 2.2 Pakistani 35 0.7 32 0.7 21 .5 28 0.7 W. Indian 721 14.2 577 13.0 564 13.0 494 12.8 African 229 4.5 186 4.2 182 4.2 149 3.9 Other 151 3.0 176 4.0 164 3.8 144 3.7 Total *5,055 100.0 4,426 100.0 4,319 100.0 3,848 100.0 R.G's No. of Haringey Births 4,753 4,342 4,205 3,800 1969 Births include transfers into Haringey during 1969 CARE OF MOTHERS AND YOUNG CHILDREN Live Births (a) Domiciliary 170 (b) Hospital or Nursing Home 3,665 Still Births (a) Domiciliary 2 (b) Hospital or Nursing Home 43 Total 3,880 39 Ante-Natal Clinics Attendances during the year are shown in the following table:— Clinic Sessions held Ante-natal Total Attendances Post-natal Average Attendance per session Burgoyne Road 48 296 32 6.8 Chestnuts 61 637 31 10.9 Church Road 42 141 10 3.6 Fortis Green 47 496 15 10.9 Gordon Road 52 262 22 5.5 Lordship Lane 50 353 25 7.6 Mildura Court 51 471 19 9.6 Park Lane 52 464 49 9.9 Stroud Green 50 256 18 5.5 Weston Park 64 336 25 5.6 Stuart Crescent 50 155 16 3.4 Total 567 3,867 262 7.3 Distribution of Welfare Foods National Dried Milk (Packets) Orange Juice (Bottles) Vit C Tablets Vit A & D Tablets Vit A, C & D Tablets Vit Drops (Bottles) 6,233 12,298 320 * 1,053 Ø 608 † 10,750 Ø Discontinued and phased out during second half year * Temporary issue as supplement to Vit A & D tablets pending availability of Vit A, C & D tablets and phasing out of Vit A & D tablets † New issue phased in during second half year to replace Vit A & D tablets discontinued during second quarter of year. Child Health Clinics The following table of attendances during the year indicates the continuing need and use of the service: — Clinic Sessions Attendances Average Attendance per session Number of cases seen by M.O. Number of cases referred elsewhere Alexandra Park Road 52 1,596 30.7 429 16 Burgoyne Road 150 4,084 27.2 863 9 Chestnuts 198 4,788 24.2 2,019 82 Church Road 152 2,349 15.5 1,070 5 Fortis Green 98 3,246 34.1 1,219 18 Gordon Road 102 2,237 21.9 710 39 Lordship Lane 201 4,340 21.6 1,740 37 Mildura Court 100 2,549 25.5 987 65 Park Lane 152 3,868 25.4 1,716 31 Somerset Road 134 1,769 13.2 1,054 43 Stroud Green 104 3,706 35.6 ' 1,097 15 Weston Park 200 4,485 22.4 1,605 29 Stuart Crescent 149 4,832 32.2 1,722 30 Total 1,792 43,849 24.5 16,231 419 40 Mothercraft and Relaxation Classes These classes are considered to be one of the important branches of health education, health visitors and midwives co-operating together in the weekly courses of instruction and discussion. Attendances during the year: — Clinic Sessions Attendances Average attendance per session Burgoyne Road 40 159 4.0 Chestnuts 46 132 2.9 Church Road 27 109 4.0 Fortis Green 34 242 7.1 Gordon Road 32 86 2.7 Lordship Lane 47 152 3.2 Mildura Court 22 42 1.9 Park Lane 48 277 5.8 Stroud Green 39 262 6.7 Weston Park 41 197 4.8 Stuart Crescent 24 103 4.3 TOTAL 400 1,761 4.4 Toddlers' Clinics (2-5 years age group) Children attending toddlers sessions do so by special appointment at six to twelve month intervals. The following table gives details of attendance:— Clinic Sessions Attendances Average attendance per session No. of cases seen by M.O. No. of cases referred elsewhere Burgoyne Road 51 475 9.3 475 27 Chestnuts 96 905 9.4 905 75 Church Road 26 295 11.3 295 4 Fortis Green 48 526 11.0 526 31 Gordon Road 49 407 8.3 404 41 Lordship Lane 94 1,057 11.2 1,057 29 Mildura Court 50 771 15.4 633 46 Park Lane 98 943 9.6 943 61 Somerset Road 53 481 9.1 479 26 Stroud Green 51 494 7.0 478 38 Weston Park 86 776 9.0 769 44 Stuart Crescent 49 469 9.6 469 27 TOTAL 751 7,599 10.1 7,433 449 41 Congenital Malformations Details of children born with a convenital abnormality continued to be passed to the Registrar General. During the year 95 cases were notified, suffering from abnormalities as listed below: — Dianostic Group Congenital Malformation No. 0.1 Anencephalus 7 0.4 Hydrocephalus 3 0.8 Spina bifida 6 0.6 Other specified malformations of brain or spinal cord 1 1.9 Other specified malformations of ear 3 2.0 Unspecified malformations of alimentary system 1 2.1 Cleft lip 3 2.2 Cleft palate 3 2.4 Tracheo-oesophageal fistula 1 2.7 Rectal and anal stresia and stenosis 1 3.0 Unspecified malformations of heart and circulatory system 3 4.1 Malformed nose 1 5.3 Hydrocele 4 5.4 Malformations of male external genitalia 1 5.7 Hypospadias, epispadias 9 5.0 Unspecified malformations of urino-genital organs 3 6.0 Polydactyly 8 6.1 Syndactyly 1 6.4 Unspecified reduction deformity of limbs 1 6.5 Talipes 21 6.6 Congenital dislocation of hip 2 6.7 Other specified malformation of upper limb or shoulder 3 6.8 Other specified malformations of leg or pelvis 1 7.0 Other malformations of musculoskeletal system 3 7.2 Malformations of spine 1 8.1 Other malformations of face or neck 3 8.3 Pigmented naevus 2 8.4 Other specified malformations of skin including ichthyosis congenita 3 8.9 Exophthalmos 2 9.6 Down's syndrome (mongolism) 1 9.8 Other specified syndromes 1 9.9 Multiple congenital malformations not specified 2 9.0 Other and unspecified congenital malformations 3 TOTAL 108 Analysis of Pre-School children on Observation Register as at 31st December, 1972 Categories of Observation Deafness of genetic origin in parents or siblings 53 History of maternal rubella in the first four months of pregnancy 15 Gestation 36 weeks or less 218 Birth weight under 4 lbs. 45 Moderate or severe birth asphyxia 375 Difficulty in sucking or swallowing 5 Failure to thrive not explained by simple feeding problem 69 Convulsions 8 Cyanotic attacks or severe apnoeaic spells 27 Abnormal neurological signs in neo-natal period 39 Haemolytic disease of the newborn 248 Congenital abnormalities 200 "Late" or "Late intake" 201 Mother in care of mental health service 16 TOTAL 1,519 Number of children born during the year 3,880 Number placed on observation register 995 (25.6%) Where there is a particular risk of deafness, children are examined at the audiology unit as well as at the routine child health sessions. 170 such children young were seen at the unit during 1972. Analysis of Pre-School children on Handicapped Register at 31st December, 1972 Categories of Handicap Partially-sighted 4 Physically handicapped 50 Partially-hearing 2 Mental Handicap 45 Maladjusted 1 Speech Defect 2 TOTAL 110 Miscellaneous 6 42 Nursing Services Miss M. Smith — Director of Nursing Services Health Visiting The present establishment of health visitors is 36. This ratio of staff per population is far below the recommenda tion of the Jameson Report 1956 (an inquiry into Health Visiting). This report accepted by the Ministry of Health, recommended one health visitor per 4,300 population (50 posts). Circular 13/72 issued by the Department of Health February 1972 states: — "While subsequent experience confirms this estimate (1—4,300 population) as reasonable for some areas, a ratio of one health visitor to 3,000 population may be desirable in others, e.g. those with a highly developed system of attachment to group practice or those with a high immigrant population" (79 posts). Attachment of health visitors to group practice is not a practical proposition at the present time, nor will be in the foreseeable future due to shortage of staff. There were 12.4 unfilled posts at the 31 December, that is one third of the very low establishment of 36. A considerable inward and outward flow of residents, the complexity of present day problems, makes it impossible to give the kind of service to the public that is necessary and desirable with such a limited staff. Home visits made by health visitors during the year: — Expectant mothers 1,974 Children under 1 year 10,509 Children 1—5 years 21,189 Children 5—16 years 1,134 Adults 17—64 years 4,515 Over 65 years 1,524 Miscellaneous 874 TOTAL 41,719 Student Health Visitors Four sponsored student health visitors were successful in obtaining the Health Visitors Certificate and five commenced the year's training in September 1972. Unfortunately training students in such a limited number does not result in achieving a full establishment, but it does contribute towards filling some of the gaps resulting from retirement, staff moving from London and others starting their own families. Midwifery Service Domiciliary deliveries continue to show a decrease. 167 patients were delivered in their own home (229—1971). 22 patients who were considered suitable by the consultants for early discharge were delivered by the domiciliary midwives in hospital. A total of 847 patients were discharged early for nursing by the midwives. Of these 199 were planned early discharges, that is the homes had previously been assessed and considered suitable for early discharge within 48 hours following confinement. 616 were discharged between three to eight days, and 26 were self discharge against medical advice for a variety of reasons. Some of whom give cause for concern because of the poor home facilities. Student Midwives District training for students is arranged four times each year in association with the North Middlesex and Whittington Hospitals. The training lasts for three months, the student being under the supervision of a domiciliary teaching midwife, having spent nine months prior to this in the training hospital. During 1972 thirty eight students received district training. Obstetric Nurse Training Forty student nurses undergoing three months obstetric training at the City of London and Whittington hospitals were given an insight into the work of the domiciliary midwife. Guthrie Tests Infants born with phenylketonuria appear normal at birth but as they get older the features of untreated phenylketonuria becomes apparent. Severe mental retardation is seen. If the condition is diagnosed early the infant can be given a special diet. The prognosis is then excellent. The Guthrie Test detects a raised level of phenylaline in the blood. This can be due to causes other than phenylketonuria and if the test is repeated after a few days the raised level will have fallen to normal in most instances. Two babies required further investigation following the test but ultimately proved to be normal. First and repeat Guthrie tests carried out by midwives number 1,073 (955-1971), and all were found to be normal. 43 Home Nursing Service The demand for district nursing service shows a steady and continuing increase. It seems extremely unlikely that the increase will be abated in the foreseeable future because of the trend for earlier discharge of patients from hospital to the care of the general practitioner and district nurse. An increased establishment of nurses will need to be seriously considered in the future. The following table shows the work of the nurses:— 1970 1971 1972 Number of patients 2,364 2,318 2,573 Total number of visits 104,286 109,375 116,565 Number of visits over 1 hour duration 1,781 2,317 2,739 Number of patients on 31 December 1972 Under 5 5-64 65 & over Total 60 595 1,918 2,573 The following gives an indication of the type of treatment provided: — 1971 1972 Injections 27,079 26,415 Dressings 25,445 24,907 General nursing care 21,812 23,836 Blanket Baths 13,989 16,064 Enemeta/Bladder wash out 127 1,232 Scabies 245 180 Maternity complications 26 46 Marie Curie Foundation Full time day or night nursing for terminal cancer patients was provided during the year for 16 patients by this foundation. A service very much appreciated by relatives of the patient. Hoists A new type of hoist which is lighter, easier to manipulate and more acceptable by patients and relatives has proved to be very successful. Apart from assisting the nurse working alone and caring for incapacitated patients they help to reduce the incidence of back strain to the nurses (an occupational hazard). Other sophisticated aids and appliances are introduced whenever possible for the prevention of bed sores and the comfort of bed-ridden patients. Incontinence During the past year there has been an increase to the supply of disposable incontinent sheets and pads for incontinent patients of all ages. Requests are made by general practitioners, health visitors and social workers on behalf of individuals who do not require a nursing service but the availability of these items are of great help to the person concerned and the relatives. Family Planning During 1972 this service continued to be provided by the Family Planning Association, acting as the Council's agents, the Council paying the fees for consultation and advice in all cases, and in addition the cost of contraceptive supplies for cases in the socio-medical priority categories. From 1 April the free service was extended to cover nursing mothers. In spite of all these family planning facilities the percentage of illegitimate births continues to rise to a high figure of 15% of all births. Two additional weekly evening sessions were established — at Fortis Green Medical Centre in April and at Park Lane Medical Centre in June. At the end of the year 14 weekly and 1 fortnightly sessions were being held in the Borough. The number of cases paid for during the year was — priority 1,505; non-priority 5,028. The Council decided that as from 1 April 1973 family planning service will be completely free for all Haringey residents. The domiciliary scheme continued, 362 cases being dealt with during 1972. I am very grateful to Dr. E. Christopher for the following report on the work of the domiciliary service from 1968 to 1973: — 44 5 Years Domiciliary Family Planning in Haringey—February 1968—February 1973 Total number of referrals for 5 years =760 Number of referrals for 1972/73 =205 Carrying case load =447 17 per month The figures for 1972/1973 will be looked at and compared alongside those for the years 1968/1973 inclusive Out of 205 cases 1972/1973 Out of 760 cases 1968/1973 Male sterilisation 15 85 Female sterilisation 13 107 Those moved away 11 59 Own method (coitus interruptus) 5 33 (31 visited regularly) Transferred to clinic 2 8 Failure 5 20 Oral contraceptive 72 191 IUD 36 (of these two regularly visited; others attend clinic) 132 Sheath 29 84 Cap 3 7 Pregnant at present 9 18 Not settled on method 5 15 (+ 1 patient died — backstreet abortion) Thus out of 205 cases referred for year 1972/1973 154 continue to be visited and out of 760 cases referred for years 1968/1973 447 continue to be visited, of which 293 are from previous years. Characteristics of families referred Total number of children for 205 cases 603 for 706 cases 2,768 (including 56 children born to families during 5 years) that is 3.6 children per family Number of children dead 8 77 Number of still births 10 44 Number of spontaneous abortions 55 169 Number of terminations 26 79 99 369 Therefore total number of pregnancies=3,137—that is 4.1 pregnancies per family. Total number of children in care 63 Marital Status Married 134 566 Single 66 147 Divorced or separated 5 47 205 760 Thus there were 194 one parent families—that is over ¼ of the families. 45  1972/1973 1968/1973 Ages 13 years 2 3 14 years 2 2 15 years 7 12 16—20 years 46 98 21—25 years 50 207 26—30 years 33 205 31+years 65 233 205 760 Nationalities United Kingdom 325 \A/est Indian 277 Irish 82 Indian 25 Greek Cypriot 20 Italian 10 Nigerian 6 Turkish Cypriot 8 Chinese 3 Iraq i i 1 Ghanian 3 760 Number of Children Number of families 1972/1973 0 1 2 3 45 6 7 8910 6 42 55 37 22 20 10 6 3 4 0 205 Number of Children Number of families 1968/1973 0 1 2 3 4 5 6 7 89 10 8 81 142 167 144 99 56 32 20 9 2 760 Referring Agents 1972/1973 1968/1973 Welfare Clinics Park Lane 43 208 Lordship Lane 43 184 Chestnuts 21 62 Somerset Road 6 39 Stuart Crescent 8 29 Gordon Road 5 16 Weston Park 6 11 Fortis Green 1 4 Church Road 0 3 133 556 Assistant Medical Officer 0 16 Homeless Families Unit 6 34 Social Services 9 47 Hospitals—Whittington 4 000 North Middlesex 6 27 Royal Free 1 000 46  1972/1973 1968/1973 General Practitioners 4 14 District Midwife 2 3 Probation Officer 1 3 Health Visitor—Islington 1 1 Barnet Domiciliary 1 5 Enfield Domiciliary 1 0 Family Planning Clinic 1 4 Self referral 37 72 54 203 205 759 NSPCC 0 1 205 760 Choice of method of different nationalities Sterilisation OC IUD Sheath Cap Male Female United Kingdom 67 42 105 35 18 1 West Indian 8 53 63 64 39 3 Irish 7 7 12 15 15 — Greek Cypriot — 2 1 5 5 — Turkish Cypriot — — 3 2 1 — Italian 1 1 1 2 1 — Nigerian — — 3 1 2 — Chinese — — — — — 1 Iraqii — — — — — — Ghanian — — 2 — — — Indian 2 2 1 8 3 2 85 107 191 132 84 7 Failure to take advice=5 (1972/1973) Three mentioned in the last report as failures ended up accepting birth control, one being an unmarried mother with 7 children. Characteristics of 5 'failures' 2 English (one had 4 children one had 8, and felt birth control was 'against nature') 2 West Indians—unmarried mothers with one child each 1 Irish with 5 children The 5 women had a total of 19 children. Characteristics of those sterilised for year 1972/1973—this includes those referred to the service in previous years who chose to be sterilised in 1972/1973. Female=30 Nationality Ages English 14 21-25 10 West Indian 11 26-30 12 Irish 2 31+ 8 Indian 2 Italian 1 47 Total number of children=122 ??? 4 children per family 0 1 2 3 4 5 6 7 — 1 5 9 2 6 3 4 Male=24 Nationality Ages English 19 21-25 3 West Indian 1 26-30 9 Indian 1 31+ 12 Irish 1 Italian 1 Total number of children=89—3.7 children per family 0 1 2 3 4 5 6 7 — — 7 3 6 6 2 — Number of Pregnancies occuring after Domiciliary Visit for year 1972/1973=45 Going to term and having baby= 28 Planned and wanted 11 Result of method failure 6 (2 sheath 1 rhythm 1 'pill' failure to take OC properly 1 after IUD removed for menorrhagia 1 after termination waiting for reinsertion of IUD) Not established on method 3 Pregnant at time of referral 6 (this included 3 women referred for termination whose pregnancies were too advanced) 3 of these women were then sterilised. 1 husband had vasectomy. Termination requested because of method failure=17 (5 were single girls) Failure to take OC properly 7 Sheath failure 5 Pessaries+safe period 5 5 of these women were sterilised at time of termination. Referred to domiciliary service for termination=7(1 sterilised at same time). These were then followed up with contraceptive advice. No woman being visited by the domiciliary service had more than one abortion through the service. COMMENTS 1. The number of referrals has been slightly less than last year possibly as a result of the opening of a new family planning clinic at Park Lane, as the health visitors from this clinic have referred more cases than from any other. (It is closely followed by Lordship Lane). The Social Services have increased their number of referrals from 1 in 1971/1972 to 15 (including those from the Homeless Families Unit). The number of self-referrals have increased indicating that women have spoken to others (who are needy but reluctant to attend a clinic) about the service. 2. Mrs. Hinshelwood, the domiciliary nurse continues her good work and has now completed 3 years with the service. A second nurse, Mrs. Farnoudi, has been appointed to help ferry patients to the IUD clinic and to do occasional evening visits. Mrs. Battley continues to do the clerical work for the service and being at the Town Hall is easily accessible to answer queries about the service. 48 3. Student social workers from Hatfield Polytechnic have continued to come to work with the domiciliary service for a 3 month placement which forms part of their training. This has proved a successful and mutually satisfying venture—the students have learnt about contraception and the vital part it can play in helping to solve some families' problems and the domiciliary team have been able to learn more about social casework techniques. 4. General Practitioners have been as helpful and co-operative as in the past. Only one refused to allow his patient to be put on the pill (although there were no medical contraindications) because of personal anxieties about the side effects of oral contraceptives. 5. Medical Problems The domiciliary service (as mentioned in previous reports) continues to function as a pregnancy advisory service. The comment is often made that if contraception were used more there would be less need for abortion. This may occur eventually. However, there is a paradox that once a couple have accepted contraception they may be more likely to seek abortion if an unplanned pregnancy occurs as a result of method (or patient) failure and may after this accept and persevere with a more reliable method. A new consultant was appointed to the North Middlesex in January 1973 and patients requesting abortion have been referred to him. Several terminations have now been done in the North Middlesex. There have been 2 suspicious cervical smears, one from a woman who had 7 children, and which when repeated was negative; the other (a West Indian girl with one child) necessitated a biopsy that fortunately also proved negative. One woman developed hypertension with the pill; she is awaiting sterilisation. There has been another vasectomy failure resulting in the wife getting pregnant for the fifth time. Two vasectomies have had to be done under general anaesthetic because the vas deferens could not be identified with certainty under local anaesthetic. It is interesting to note that culture and background influence which method is chosen, for instance, more West Indian women chose sterilisation and IUD compared to English women who opted more for the pill (and their husbands for vasectomy) than other groups. It is important to be aware of these kinds of differences when offering contraceptive advice. REFLECTION ON 5 YEARS DOMICILIARY WORK What is domiciliary family planning? It means the free provision of contraceptive advice and supplies by a doctor or nurse in the privacy of a woman's own home and at her request after referral by a health visitor, social workers, GP etc. Why is it necessary? Recently there has been a great deal of discussion on the subject of family planning and it may be thought that this kind of work is unnecessary. There is, however, still much ignorance and embarrassment about contraception and other sexual matters that make it difficult for some women (mainly in social classes IV and V) to seek help. Added to this are feelings of disgust and shame that surround sex, many thinking that sex is permissible only for procreation. Attendance at a family planning clinic in a sense implies—sex for sex alone, and this may prove too embarrasing for some women. Although the impression is often given that sex education is widespread in schools this is in fact not the case. Sex education at home is often of the "don't" and "be careful" variety without any explicit instructions so that often women do not realise the connection between menstruation and being able to have a baby. They may assume (having been forbidden to explore their own bodies) that they have only one opening 'down below'. Many still have the feeling that birth control is 'unnatural' and that interfering with nature will produce ill health—"babies keep you young". One West Indian woman with 8 children was very anxious about birth control methods and was concerned that using them would make her ill and prevent her caring for her children—she always felt marvellous during pregnancy. She was eventually fitted with an IUD (as she did not want more children) and has happily remained well after 3 years. There is also a strong element of fatalism among women from poor homes—they feel that the future cannot be planned. One such woman said "I believe that if you are meant to have a certain number of children then even the pill will not stop you". Some women feel that children are 'grown up' by the age of 5 and thus they "do not need you any more". There is also the feeling among some families that where existing children have "failed" and have not achieved what has been expected of them, success may be achieved with a new baby. How does the Service function? Firstly and more importantly it depends on the referring agent and how well the referral has been made. The majority of health visitors are now aware of the kind of woman that needs this help: the young fertile mother with 3 children in as many years, the unmarried mother, the mother or her husband or cohabitee who has physical or mental ill-health, the mentally handicapped, the large family with multiple problems "well known to 49 the social services", the poor clinic attender. For the health visitor the introduction of discussions about birth control is comparatively easy. This is usually done at the first or second visit after a confinement. The importance of a 'good' referral cannot be overestimated—the purpose of family planning and the domiciliary service should be offered in a constructive way and the woman's consent is essential before referral is made, so that the visit from the doctor is not seen as threatening or frightening. When this has not been properly done the woman may refuse to open the door. Health visitors have recently had the opportunity to update their knowledge about contraception through the Health Visitors Appreciation Courses run by the Family Planning Association, sponsored by the Department of Health and Social Security. Hospital staff may find it more difficult to recognise the woman in need as they may only see her in her best nightdress in a hospital bed. The task of referral is more difficult for the social worker which may perhaps account for the few referrals from them despite the fact that many have 50 or more families to cope with—a large proportion being families with young children. Social workers have to create an opening where contraception can be discussed—they do not have the ready made situation of the health visitor of the visit after confinement. The social worker may feel unsure of himself because of lack of medical knowledge about contraception and may therefore feel it is not his place to discuss it. As there is as yet practically no information given about contraception in courses for social studies it is perhaps not surprising that many social workers feel ill at ease with the subject and fear they might be intruding or pushing their own views on a person who does not want it. It is unfortunate that contraception may be seen as incidental rather than central to a family's problems—for instance, the family with a history of a "battered child" is in urgent need of contraceptive advice; a woman who cannot cope with 4 or 5 children is unlikely to cope with 6 or 7. Having worked in Haringey for five years doing domiciliary work and three years before that working as parttime medical officer I am aware of and appreciate the many problems and large caseloads facing the social services and of the turnover in staff and of junior and inexperienced staff; nevertheless, it was disconcerting to find that two assistant social workers who attend the Haringey Health Visitors' Appreciation Course in February 1973 did not know of the existence of the domiciliary service or the times and places of the local family planning clinics. The social worker (especially now that the importance of community medicine is increasingly recognised) is in a vital position with regard to a family to deal with marital and sexual problems and related contraceptive difficulties. Once a woman has been referred, and after the consent of the GP has been obtained, the doctor usually makes the initial visit in which the methods of birth control are discussed together with their limitations and side effects including the risk of thrombosis with the pill. This is essential if there is to be trust between doctor and patient because of the adverse publicity surrounding the pill. Providing there are no medical contraindications, the choice is left with the woman and this is crucial to successful family planning. The woman has the doctor's and nurse's home telephone number and can contact them if they are worried or have a query. It is found in practice that only a few use this facility, and these tend to be individuals who have a variety of problems with which they cannot get other help. The nurse follows up the initial visit by frequent regular visits if the woman chooses the pill. Women choosing the pill will rarely transfer to clinics, perhaps because they need the reassurance of a doctor or nurses' visits. The woman.selecting the IUD will often go for check visits to the IUD clinic, finding confidence after making the initial visit with a nurse. G.P.'s and the referring agent are notified about the method selected. What is the role of the domiciliary service? Originally this was to give contraceptive advice and supplies and to give support to the women to persevere with the method. However, as a result of its unique position several other roles have evolved. Domiciliary family planning is essentially social and preventive medicine combining many skills. It stands between health and social welfare and shares much in common with public health and social services. As mentioned before it acts as a pregnancy advisory service. Another function is to help with marital and sexual problems and also in some cases advising about the upbringing of children. Many of the families visited have marital and sexual problems that they have been reluctant to discuss with anyone else. One woman said just as I was leaving "You might think I'm a sex maniac having had 6 kids but will the pill help me to enjoy it, my husband says I'm frigid". There is often concern about the sexual development of children and what to say about sex to children. Like the patient who regularly visits her doctor with minor ills or for repeat prescriptions, some of the women seen by the domiciliary service seem to be "contained" by being able to "off load" their worries and anxieties at routine regular visits, and perhaps this is why women who have managed to make such a relationship with the doctor or nurse are reluctant to be transferred subsequently to a clinic. It could be argued that this is creating a form ef dependence but it may well prevent the woman from troubling her GP or the social services unnecessarily. As mentioned in previous reports there is difficulty in referring such cases to the social services which because of the large caseloads cannot always undertake preventive work. Another vital function of the domiciliary service is to liaise with the GP, Hospital, Social Worker etc. That this is so often necessary may be a reflection on the lack of communication between these groups. 50 Is the Domiciliary Service still needed? In view of the fact that in 1974 birth control advice and supplies will be obtainable through the National Health Service on a doctor's prescription, it may be wondered whether domiciliary visiting will still be necessary. It seems likely that there will continue to be a group of women for whom contraception is a problem and who will not go to get advice and even if they do will not persevere with a method. Given that there are many complex emotional and social problems associated with the continued use of contraception then some couples will continue to need more time than can reasonably be spent by a general practitioner. While several methods of birth control certainly require medical aid, it is important to appreciate that this area of medicine differs in an essential way from usual medical practice. Perhaps the most important difference is that the choice of method (again provided there are no medical contraindications) should be left to the individual concerned. As contraception is closely linked to attitudes towards sex and sexual relationships and since these attitudes vary enormously (e.g. with different cultures and age groups) then acceptability to the couple is paramount—it is not what the doctor thinks but what the couple feel would be the best methods. Thus while it may be simpler for a doctor to write a prescription for the pill much more may be needed for couples with sexual and emotional difficulties. Haringey, in common with other London Boroughs, has a large immigrant population with different cultures and differing attitudes to fertility and contraception, and this has to be taken into account when giving advice. For instance a common view amongst West Indian women is that heavy menstruation is needed to clear our "bad blood" and if this does not happen that this blood will go to the head and cause headaches. This might explain why more West Indian women chose the IUD; they do not like the scanty periods that are usual with the pill. It also is relevant that one in seven babies born in Haringey is illegitimate. Of course the child may be the result of a stable union. However, as seen from the report over ¼ of the women referred are single or divorced. There is also a small but increasing number of unmarried mothers, mainly West Indian, who are in their early teens. As noted in previous reports these girls are very vulnerable, their relationships are often tenuous and so they need much support to persevere with contraception. This again may prove difficult for the general practitioner. Indeed, though some women will certainly be prepared to ask their GP for advice, others, especially the unmarried may be too embarrassed. In many cases the GP, health visitor or social worker will need to initiate discussions in a tactful non-critical way—not as one obstetric registrar offered advice standing at the bottom of one patient's bed by saying in front of 12 other women "As you're unmarried its about time you had birth control advice". She left the hospital very angry..As she was known to the domiciliary service for sometime before this it was possible to recover the situation. The registrar meant well but a tactful approach is essential. Conclusions 1. Success is difficult to quantify in this work. Several years are needed before the overall outcome can be assessed. A description of two individual cases may convey this better than statistical tables— Mrs. E. is an Irish woman (RC) in her late 20's who was referred to the service 5 years ago. She had had severe Pre eclamptic toxinemia with her 7th child and was advised to be sterilised. Her husband afraid she would die with an operation refused to sign the form. The couple had not previously used birth control. Just prior to my arrival the "method" used was sleeping in separate rooms. She had an IUD fitted and she has not become pregnant. She looks well and has been rehoused and her home is now clean and comfortable, her children are all at school; she works part-time to help with the family's income and is taking driving lessons. She says now that she wishes she had heard about us earlier. Mrs. S. a 30 year old West Indian with 5 children under 7 years was referred by Homeless Families Unit 5 years ago. Her husband worked sporadically and they had many debts. He also had another woman. She was fitted with an IUD and has not become pregnant. The marriage has been patched up though the family still get into debt. With the children at school she is able to work part-time to help the family. 2. Social Services Social Workers, particularly the younger ones, might perhaps be helped by occasional case discussions (with special reference to family planning) with the domiciliary team. 3. Young people are subjected to many pressures nowadays and are urged to grow up quickly—some indeed may speed this up by becoming pregnant in order to escape from an unhappy home situation. They need help at school through education for sexual responsibility. Health visitors can advise mothers on preparing their children for responsible sexual relationships; many parents do not know how to talk about sex to their children. Health visitors attending family planning appreciation courses have often expressed a wish to help with sex education. 4. Women should continue to have the option of obtaining birth control advice from a clinic, from a general practitioner or where a special need exists, from a domiciliary service. 51 BREAST CANCER CLINIC, ST. ANN'S HOSPITAL Introduction Mr. Abel, Consultant Surgeon at Prince of Wales's and St. Ann's Hospitals, asked Dr. Patton, Medical Officer of Health, London Borough of Haringey, to co-operate with him in a scheme to examine 1,000 women annually to try to achieve earlier detection of Breast Cancer. The examination was to be by palpation only. The scheme and its history and results over five years are described. In 1967 the cervical cytology scheme was also gaining momentum and so the first 1,000 women over 35 years who applied for cervical cytology, thereby showing their interest in taking advantage of cancer detection schemes, were invited to join the Breast Cancer Screening Clinic. General arrangements and clerical work In 1968 it was decided to hold sessions twice a week during July. A main session was held on Tuesdays attended by two doctors from the Local Authority and two from the hospital. Approximately 160 patients were appointed to these sessions. A further 40 patients were appointed to a Thursday morning clinic where they were seen by Mr. Abel's registrar and houseman together with some other types of outpatients. The same arrangements were made in 1969 but the Thursday session was never satisfactory and it was dropped from 1970. The appointments were in batches between 9.30 am and 11.30 am and as we became more practised in the organisation of the clinic it was not too difficult to cope with 200 patients (approximately) per session once a week. With so many women coming and going there was inevitably some waiting and queuing. Some complained but most were so appreciative of the opportunity to participate that they put up with minor inconvenience. The clerical work prior to the sessions was quite arduous. The work involved making all the appointments and giving information. One administrative officer was in charge of the work. She prepared the list of those expected at the session in readiness for the volunteer clerical staff who covered the actual sessions. None of the administrative work was done by the hospital. Patients were told on their appointment cards to contact the Town Hall if necessary. Staff and Premises The screening clinics were held at St. Ann's General Hospital, Tottenham, in an adapted ward where a reception area was set up near the door with two volunteer clerks in attendance. There were six curtained cubicles each with an examination couch in which all dressing and undressing, as well as the examinations, were done. Doctors All the patients were examined by a doctor and the aim was to have four doctors working at each session, two from the hospital and two from the Local Authority. The Consultant Surgeon (Mr. K. Abel) was present at (almost) all the sessions. Nurses The hospital Outpatient Sister was in charge and usually there were three nurses on duty. They organised the patients on and off the couches, helped at cyst aspirations, chaperoned and made outpatient appointments when necessary. There was one volunteer nurse from St. John's Ambulance Brigade who attended all the sessions. She was a member of the local Women's Cancer Control Campaign who provided all the volunteers. Clerks Two volunteers received the patients as they came in, accepted their appointment cards and looked out the record cards from the file. They checked off the names on the lists supplied by the Local Authority administrative staff. They helped to record non-attenders at the end of the session and generally kept the cards in order. They also distributed health education leaflets on breast self-examination and other information on cancer prevention. Attendances 1968—959 patients were sent appointments 814 attended 1969—1,021 patients were sent appointments 730 attended The 1,021 were made up of all the original 959 plus others who asked to join. In an attempt to cut down on the clerical work appointments were given to patients for the following year when they attended in 1969. 52 1970—Appointments were only sent by post to those who attended in 1968 but failed to attend in 1969 plus some others who asked to join for the first time. 837 patients thus had appointments 663 attended Giving the appointments a year ahead was not found satisfactory and so all were sent by post again in 1971. 968 appointments were sent out 705 patients attended 1972—843 appointments were sent out 610 patients attended Patients were withdrawn from the scheme for many reasons—moving away, letters returned marked 'House demolished', a few died (not of breast cancer that we know of). Those who did not attend in 1968 or 1969 were not reappointed. Table I—Attendances 1958 1969 1970 1971 1972 1968 starters 814 637 562 589 487 1969 starters — 93 65 61 56 1970 starters — — 36 23 17 1971 starters — — — 32 26 1972 starters — — — — 24 TOTAL 814 730 663 705 610 Patients did not miss a year, then drop out of the scheme for good. Many missed a year then returned. Some came back after two years' absence. Table II — Ages of Women Examined Of the 814 women examined in 1968 — Born 1939—34 Age 30—34 14 1933—29 35—39 167 1928—24 40—44 199 1923—19 45—49 193 1918—14 50—54 109 1913—09 55—59 89 1908—04 60—64 31 1903 or earlier 65 or over 8 Not known 14 Patients referred for Further Investigation When a lump in the breast was found the patient was referred to Mr. Abel, the Consultant Surgeon. If he was present in the clinic he gave an opinion then and there; if not, the patient was given an appointment to see him at his normal outpatient session within the next few days. Table III Lump not confirmed Cyst aspirated Biopsy Total Referred Total Non-mal. Malignant 1968 16 5 14 0 35 814 1969 11 0 3 1 15 730 1970 14 3 5 3 25 663 1971 9 0 6 1 16 705 1972 4 10 4 2 20 610 53 Admission to hospital for biopsy was arranged within a few days of examination either at the screening clinic or the outpatient clinic. Great importance was attached to arranging immediate investigation in an attempt to prevent unnecessary anxiety. Cysts were aspirated by Mr. Abel at the screening clinic as well as at outpatients. In every case the fluid was examined microscopically in the hospital pathology laboratory. The patients were followed up at the outpatients sessions. CASES OF CANCER 1. Patient born 1918 Attended 1968—a small tender lump was found at edge of breast tissue, laterally on right side. It was difficult to find and on re-examination it was not confirmed and the patient was reappointed for the following year's screening. In 1969 the lump was found again. It had not increased in size. The patient was admitted for biopsy and carcinoma was diagnosed. She refused mastectomy and at her request was referred to another hospital for radiotherapy. 2. Patient born 1924 Attended first in 1969—at the screening clinic a non-discrete mass was palpated in the upper outer quadrant of the left breast. She was re-examined at the outpatient clinic after a month, when there was still no discrete lump and she was discharged until the following year. In 1970 the lump was still present and she was admitted for biopsy. An invasive scirrhous duct carcinoma was found and left radical mastectomy was carried out. 3. Patient born 1919 Attended in 1968, 1969 and 1970 and no abnormality was discovered. She was referred back to Mr. Abel, however, by the general practitioner in February, 1971. A radical mastectomy was carried out at that time for breast carcinoma with gland involvement. 4. Patient born 1921 Attended in 1968 and 1969 and no abnormality was found. In 1970 a discrete mobile lump was found in the lower inner quadrant of the left breast. She was admitted for biopsy and an infiltrating scirrhous lobular and duct carcinoma was found. She was advised radical mastectomy but refused. 5. Patient born 1921 Attended in 1968 and a lump was found which was not confirmed at the follow-up clinic. No lumps were found in 1969 or 1970. In 1971, however, a lump, which proved on biopsy to be an invasive scirrhous carcinoma, was discovered. She had a left radical mastectomy. The lymph nodes were free from carcinoma. 6. Patient born 1928 Attended 1968, 1969, 1970 and 1971. Chronic mastitis was noted but she was not referred for further investigation. In 1972 a hard lump was found on the right outer edge of the right breast. She was admitted immediately for biopsy. A scirrhous carcinoma was found and radical mastectomy was carried out. 7. Patient born 1921 Attended 1968, 1969, 1970 and 1971 when no abnormality was found. In 1972 a lump was found almost under the nipple in the upper outer quadrant of the left breast. Biopsy revealed extensive intra-duct carcinoma and left radical mastectomy was done. An eighth patient who does not appear in the figures is known to have had carcinoma. She attended the screening clinic in 1968 when no abnormality was found. In 1969 a diffuse lump was found in the inner upper quadrant of the right breast. It was slightly tender. It was not thought to be significant and she was asked to come back to the screening clinic the following year. However, she sent a letter then to say she had had her breast removed in March 1970 atanother hospital. A report was obtained and she had had a fairly well differentiated-adenocarcinoma, for which she was treated by simple mastectomy and radiotherapy. Conclusion We are well aware that examination of the breasts by palpation only is not adequate, that cases will be missed, and that it is still presumption that earlier detection means more cures. We would rather use better methods such as mammography or thermography, but until we have the resources for these we feel convinced that it is worth using palpation backed up by education in self examination. We have found that by the expenditure of a little effort and almost no money, several very small cancers have been found and it should be appreciated that this is not a statistical random sample but a group of women who had already selected themselves for the cervical smear test. 1,000 women is a small number but we all agree it is enough for one team as we have described. Had we to do these sessions more than four or five times a year they would be exhausting and efficiency could fall off from monotony and fatigue. The technique of palpation definitely needs practice and skill increases with experience. 54 We have described our system in some detail because it has had a fair trial and seems to work quite well. Its great advantage is in being hospital based so that immediate consultation with a surgeon is possible and prompt treatment is easy to arrange. Cervical Cytology Routine screening for cancer of the neck of the womb continued as part of the normal work of the ante-natal clinics. The evening sessions at Mildura Court Clinic exclusively for cervical 'smears' also continued throughout the year. Attendances at clinic sessions were as follows:— Clinic Attendances Burgoyne Road 60 Chestnuts 147 Church Road 37 Fortis Green 86 Gordon Road 80 Lordship Lane 127 Mildura Court 124 Park Lane 115 Stroud Green 45 Stuart Crescent 63 Weston Park 107 TOTAL 991 In addition, a number of special sessions were held for members of the Council's staff, 157 of whom attended for screening under these arrangements. Since the beginning of 1972 we have been notified by the National Health Service Central Computer of all Haringey women who become due for retest after five years. A letter is sent to these women from this department inviting them to make an appointment for a retest at any Council clinic of their choice or, if they prefer, to make arrangements for retest privately:— Smears taken at our clinics as a result of this 88 Moved away, not known, etc. 441 Already had smear, Hysterectomy etc. 46 Gone to GP, hospital, FPA, etc. as a result of reminder 9 No response at all 343 527 Dental Care for the Priority Classes Mr. G.C.H. Kramer, Chief Dental Officer, reports as follows:— The number of sessions devoted to the treatment of pre-school children and expectant and nursing mothers at 287 was 7 more than in the previous year. The trend of recent years showing a reduction in demand by the adults was continued to a small extent, but the amount of treatment provided for them showed some increase for the most usual items—fillings, extractions and dentures. This can not be taken as anything more than the fact that, for the relatively few concerned, their needs were rather greater than during the previous year. There was, however, an increase of 13% in the number of pre-school children inspected, and of 6% requiring and receiving treatment. The amount of treatment provided showed an increase greater than could be attributed to the very small number of extra sessions, and it is encouraging that the greater output was in conservative work with a reduction in the numbers of teeth extracted and of general anaesthetics administered. Could it be that, albeit very slowly and only to a tiny minority, we are getting our message over to them? The statistics are as follows:— 55  Expectant and Nursing mothers Pre-School children Number examined 121 906 Requiring treatment 118 621 Attendances for treatment 351 1,756 Treatment completed 63 448 Number of fillings 248 1,489 Teeth filled 235 1,363 Number of extractions 58 235 General anaesthetics — 90 Number of prophylaxes 86 152 Teeth otherwise conserved — 74 Other operations 119 480 Number of radiographs 18 20 Total number of dentures 19 Number of treatment sessions 287 Geriatric Services Dr. W.T. Orton The Retirement Advice Clinics continued to perform within the confines of their very limited role, unable through lack of staff to exert their supportive and preventive capabilities in the field, and used by only a small minority of older people. An encouraging development at the end of the year, however, was the appointment of the Borough's first two Geriatric Visitors, fully qualified nurses who devote the whole of their working time to the promotion of the health of the elderly. It is intended that they shall take an increasingly important part in the running of these clinics, where their knowledge of the home backgrounds of the clients will be of considerable value. Another important advance during the year was the formation of a co-ordinating committee attended by the Consultant Geriatrician at St. Anns and North Middlesex Hospital, a senior medical social worker and representatives of the Health and Social Service Departments. A general practitioner has recently joined the Committee and invitations have been extended to two psychiatrists. The committee meets bi-monthly and discusses means of using the resources of the various agencies concerned to the maximum advantage. It has proved a valuable means of increasing mutual understanding of the problems encountered by each service and the extent of need. The members have together studied ideas on the future pattern of health and social services and their co-ordination, and are closely following the development of the role of the geriatric visitor as a link between home and hospital. As it seemed only right to give this committee the name of "Geriatric Co-ordinating Committee" it became necessary to qive another title to the other committee which had been using it for some years. It was decided to give it the description of "Committee for the Elderly at Risk", as being a more appropriate definition of its function, which is to support and guide older people who are in a state of crisis or on the verge of it. Implied in this is the committee's aim to increase the independence of the elderly individual by offering, through field workers, services which she is willing to accept, and the determination to do everything possible to avoid compulsory action. The situation of an elderly person alone and in some danger is liable to evoke an emotional response from outsiders. On the one hand we are told that we should intervene immediately and, ignoring the protests of the individual, place her in a home or a hospital where she will be more secure. But the piece of legislation under which we are required to perform this task-Section 47 of the National Assistance Act, 1948-sets out certain criteria which must be satisfied, yet leaves them obscure enough to cause difficulties of interpretation in individual cases. Occasionally we do it—though not in 1972, fortunately—and in such circumstances we could perhaps be described by some as "bureaucrats", a term sometimes applied to those who are required by society to carry out some unpleasant tasks which it would rather not know about. But perhaps it might be worthwhile reminding them that the act of depriving a helpless old person of some of her liberty is not without cost, emotional and spiritual, to those obliged to put it into effect; and no application is ever made to the court without great heartsearching. On the other hand people may be horrified to find elderly people known to us who are living in squalor or at possible risk from death by fire. But the problem.is that although we have offered to remedy such situations, the old folk themselves may think that we are being fussy. It is a fact that some not only tolerate but enjoy their squalor—and who are we to deprive them of their happiness? With such cases we could no doubt fill all the available old people's homes several times over; and perhaps a case could even be made for forcibly removing middle-aged and young people who live in equally dangerous circumstances. 56 The fact is that there exists, bound up within the liberty of the subject, the right, within very broad limits, to live dangerously; and if we interfere with too much zeal to protect an individual from a specific peril we may be putting at hazard the freedom of every citizen. Thus most of the time we feel obliged to take the calculated risk of leaving the old person where she is, hoping that eventually she can be persuaded to see reason. On the other hand there is the point of view that says that if any individual wishes to live, suffer and die in such surroundings, nobody has the right to interfere, even to save life. This attitude of course presupposes that such a person has clearly and dispassionately thought out her situation. This is rarely the case. They are usually confused and irrational. If they were not, they would probably have agreed to have help long before. Therefore we can never assume that because a person rejects all approaches and abuses those who make them, that she necessarily means what she says. She may well be appealing for help in the only way that she feels preserves her independence and self-respect. It is not unusual to find that the old lady who has resisted every offer tooth and nail, even to the point when she is lying helpless and defiant, will, when all the legal procedures have been completed and the doctor appears with the magistrate's order, accept the ministrations of the ambulance men who have come to fetch her gracefully and thankfully and allow herself to be carried down to the ambulance without protest. For, taken all in all, is this not for her the final proof that there are people who really care about her? Chiropody Demands on this service continue to increase and, as before, treatments are spaced to a minimum of 8 weeks apart except in special cases. Applicants for domiciliary chiropody have all been visited before being accepted and most have been found to be in genuine need for treatment at home. The number of new applications received were as follows:— 1971 1972 Clinic or Surgery New cases 852 1,084 Domiciliary New cases 383 384 Waiting for assessment 25 40 Number of Assessments made for Domiciliary treatment during 1971 1972 Domiciliary treatment all the year New cases 291 285 Transferred from clinics 6 38 Transferred from "winter only" — 23 Domiciliary treatment winter months New cases 15 19 Transferred from clinics — — Referred to Home Nursing Department for nail cutting New cases 37 62 Transferred from clinics — — Clinic treatment only New cases 20 26 Old cases — — Cases that could be dealt with by relatives or friends New cases 2 — Cases no action taken 18 32 389 485 1,599 clinic sessions were held during the year, including sessions for school children. Elderly patients receiving treatment at end of year at— 1971 1972 Clinics 1,886 1,746 Private Surgeries 1,424 1,520 Domiciliary treatment 1,290 1,250 Waiting for clinic appointments 76 200 New patients on waiting list—Clinic 150 260 Patients referred to Home Nursing for nail cutting 114 62 57  1971 1972 Number of elderly patients treated 4,760 4,878 Number of school children/Expectant/Nursing Mothers — 233 Number of treatments given at Clinics 10,251 10,096 At private surgeries 6,668 7,950 Domiciliary 5,570 6,117 School Children 1,135 1,177 TOTAL TREATMENTS 23,624 25,340 1971 1972 New patients treated At clinics 336 349 At private surgeries 366 475 At domiciliary 369 304 School children/Expectant/Nursing Mothers 171 183 TOTAL 1,242 1,311 Vaccination against Diphtheria, Whooping Cough, Tetanus, Poliomyelitis, Measles and Rubella The following tables record the number of persons under the age of 16 known to have received a primary course or a reinforcing dose during the year by general practitioners or clinic staff:— A. The number who completed a full course of primary immunisation— Age or date of Immunisation Triple Dip/WC Dip/Tet Dip WC Tet Sabin Measles Rubella Total 0—1 year 43 — 1 — — — 41 — — 85 1—2 years 1,635 — 259 — — — 1,890 1,050 — 4,834 2—4 years 906 — 193 — — 2 1,102 1,345 — 3,548 4—6 years 18 — 351 12 — 46 532 222 6 1,187 6 — 16 years 86 — 90 — — 611 675 97 2,518 4,077 TOTALS 2,688 — 894 12 — 659 4,240 2,714 2,524 13,731 B. The number who received a reinforcing dose Age or date of Immunisation Triple Dip/WC Dip/Tet Dip WC Tet Sabin Total 0—1 year — — — — — — — — 1—2 years 34 — 264 — — — 39 337 2— 4 years 110 — 114 — — 2 226 452 4— 6 years 67 — 1,541 30 — 90 1,691 3,429 6—16 years 8 — 55 7 14 1,050 1,039 2,160 TOTALS 219 — 1,974 37 1 1,142 2,995 6,368 Infectious Diseases W.T. Orton, Deputy Medical Officer of Health Measles During the year 440 cases were notified—less than half those for 1971. This is encouraging, but in view of the availability and effectiveness of measles vaccination, it indicates that there is still a considerable amount of unnecessary suffering from this cause. Dysentery and Food Poisoning Food poisoning organism isolated during the year included Salmonella enteritidis and typhimurium. Staphyloccal food poisoning was also reported. 58 At the end of the year there was an outbreak of sonnei dysentery in the children and staff of a Council day nursery which necessitated a number of exclusions until the infection subsided. Sporadic cases of flexner dysentery were also notified at various times. A chronic infection of amoebic dysentery was discovered in a young man who had worked among refugees in India. This is not surprising in view of the conditions which he experienced; but it is probable that it will begin to appear more frequently among returning tourists as holidays in the tropics become more popular. Rubella As stated in the 1971 Annual Report, the Haringey Council decided that year to revoke its earlier decision not to vaccinate girls aged 11 to 13 years against this disease. Owing to shortage of staff it was not possible to begin that autumn but the programme was undertaken in 1972 and completed by the middle of the year, mainly by using senior medical staff to give the injections. As this disease in mothers can cause congenital malformations in their unborn babies this should be a useful investment for the future. Later in the year vaccination was also offered to women of childbearing age employed by the Council and a small number availed themselves of it. A total of 2,524 individuals were vaccinated during the year. Enteric Fever A carrier of typhoid, who had infected several others and had been a source of anxiety during the previous year, eventually agreed to have an operation for removal of the gallbladder. Specimens since then have shown no evidence of the organism, so it would appear that the focus of the disease has been eradicated. Only two incidents of enteric infection occurred in 1972, though they involved a considerable amount of investigation. Both originated on the continent of Europe. The first began with the admission of a young woman to hospital suffering from a fever of three weeks duration. A diagnosis of typhoid was made and subsequently confirmed bacteriologically. She had been nursing a young baby who then was found to be a symptomless excreter of the same organism. The child, too, was admitted to hospital. The mother responded well to treatment and all trace of her infection disappeared. Unfortunately, the baby, although well, continued to excrete the germ and had to remain in hospital after the mother was discharged. When it became apparent that this might persist for some time, discussions were held with the parents regarding possible alterations to their house to reduce the chance of further spread should the child still be positive on coming home. These presented great difficulties and, even if they had been carried out, an element of risk would have remained. Fortunately, the baby's infection cleared up after four months in hospital and no further action was needed. Enquiries as to the cause of this infection centred on a visit of some friends from southern Italy just over a fortnight before the mother became ill. They had brought with them a local delicacy, a kind of shellfish, bought in Taranto on the same day as their flight to England. These were eaten that evening in the traditional manner— raw with lemon juice. There was, therefore, a strong presumption that these uncooked shellfish were infected with typhoid but it was impossible for us to investigate further as the shells had long since been thrown away. The Department of Health was then contacted to ask if co-operation with the Italian authorities could be arranged. We were reminded that enteric was not internationally notifiable and told that they themselves had not yet succeeded in getting a number of southern European countries, including future Common Market partners, to appreciate the seriousness with which we regarded this infection. It would, therefore, be a waste of time to try to communicate with them. Further enquiries were therefore reluctantly abandoned, but another case occurred a few months later which reopened the question and stimulated us to independent action. A man became very seriously ill five days after returning from a holiday in Juan-les-Pins on the French Mediterranean coast, and was found to have typhoid fever. Fortunately, he responded well to treatment and was able to give a very detailed history. He felt that he might have caught the infection while bathing in the sea and was able to give a detailed description of the surroundings of the part of the beach he used. He also named various restaurants in the town which he had visited. The possibility of infection from sea water heavily contaminated with sewage is not yet established but is becoming more and more likely as marine pollution increases, especially in enclosed waters like the Mediterranean. But although he described drains entering the sea in the locality of this beach we felt that the cause was more likely to be food. Another reason for anxiety emerged when it was learnt that there were three French families with children staying in the same block of holiday flats, and that two young children, one from Rouen the other from Evreux, had had attacks of diarrhoea at about the time when he may have become infected with typhoid. A brief attack of diarrhoea sometimes occurs a day or two after infection by typhoid. In young children, this is rarely followed by the development of the full blown disease, but as we know from our own experience, they can become symptomless carriers. The Medical Officer of Health of Alpes Maritimes, informed us that the drains at the beach which had been mentioned were for rainwater only and that it would not be possible to identify the source of the infection as the number of cases of typhoid notified in the area was very low and tended to be isolated. Reassuring replies were also received from Rouen and Evreux. It would appear, therefore, that although the cause of this particular incident could not be identified, there are at any rate the beginnings of co-operation between ourselves and public health authorities in Europe, which we hope will develop extensively in the years to come. 59 Sexually Transmitted Diseases Figures regarding new cases at the Prince of Wales's Hospital Clinic, the only one in the Borough, were substantially the same as in 1971, with a drop in cases of gonorrhoea below the 1968/70 levels. But the total constituted only 23.1 per cent of the total of Haringey patients known to have been treated in the London area, 7,078, which again is not significantly different from 1971 (7.149). If clinics in boroughs bordering on Haringey are included, 80.1 per cent were seen in Haringey or its environs. Perhaps because of good communications to the south and west, 1,344 (19 per cent) attended clinics in Westminster, the City of London and Tower Hamlets. Very few attended clinics south of the river (55). New Haringey Cases attending Prince of Wales's Hospital Clinic Year Totals of Veneral Conditions Syphilis Gonorrhea Other Veneral Conditions Primary and Secondary Other 1966 896 3 9 96 788 1967 1,101 5 15 216 865 1968 1,090 4 10 259 817 1969 1,316 4 8 255 1,049 1970 1,260 4 5 258 1,001 1971 1,671 6 13 310 1,342 1972 1,635 2 2 236 1,395 Lead Poisoning The Health Department is sometimes asked to investigate the environmental circumstances resulting in lead poisoning in children. In one case dealt with during the year a boy aged four years developed lead poisoning after chewing paintwork. The high lead paints in the house were identified. During the enquiry he started school and his habit of chewing paint ceased. Two other cases showed levels of lead in the blood only slightly above the maximum of normal. In one of these no possible cause could be discovered, but the other was found to have been given the present of a small flute which he liked to play, a souvenir which some friends of the family had bought when on holiday in Mamia in Rumania. The mouthpiece of the instrument consisted of metal containing 77 per cent lead. Interestingly enough, while it would be illegal to try to import these, there is nothing to prevent tourists buying them abroad and bringing them into this country. Details of the investigation and photographs of the instrument were sent to the Department of Health and Social Security and the Home Office. Home Renal Dialysis At present (November 1973) electrical generators for emergency use are being supplied to eleven homes in the Borough adapted for renal dialysis. The number of people using the renal dialysis might be reduced if the supply of fresh human kidneys were more readily available. At the present time a complex arrangement can be made to enable a donor to bequeath his kidneys but how much simpler it would be if kidneys could be taken without consent from the tragic victims of a road accident, as I understand happens in Austria. Community Mental Health Dr. U.P. Seidel, Principal Medical Officer for Mental Health and Community Psychiatrist, continued to advise the various departments of the Council on psychiatric matters relating to clients and establishments in the community. The reorganised National Health Service will come into operation on 1 April 1974 and with it all public health medical officers will become part of the new Health Authorities which will join all doctors whatever their specialisation under one authority. This new scheme presents opportunities especially in the field of community psychiatry which may well be turned to the advantage of patients in regard to their management, care and supervision as these shift from a community setting to a hospital and back to the community again. In order to facilitate a truly efficient, comprehensive and dynamically orientated community mental health service, the closest of links must be established between psychiatrists and psychiatric hospital workers on the one hand and the community social services departments on the other for only in this way can we render appropriate and maximal help to psychiatric patients in the community. Co-ordinated planning of services and facilities and shared responsibilities for clients in the community are of the utmost importance and should be started at the earliest possible moment and not await an already implemented reorganised health service. 60 As it is envisaged to gradually transfer most if not all, the functions of the present large, often distant, psychiatric hospitals to smaller psychiatric units attached to District General Hospitals which in the case of Haringey are situated at St. Ann's, prince of Wales's, and North Middlesex Hospitals, this will inevitably bring more and more psychiatric work into the midst of our area and must, therefore, throw an increasing burden on the already existing community psychiatric services and establishments. To meet this challenge, the closest of collaboration in the planning and implementation of services and facilities between the hospital and community sectors is of supreme urgency and importance if we want any future scheme to succeed. During 1973, the Council had started an experimental Youth Counselling Service with one evening session a month at the Tottenham Technical College. A social worker is in attendance and psychiatric advice by the Principal Medical Officer for Mental Health is available when required. Referrals come from various professional agencies and individuals and there is little doubt that the demand for such a service will increase as its existence becomes more widely known. Dr. Seidel has completed a study on a community problem of considerable interest namely that of Suicides in the Borough during 1971 and certain extracts from his survey are the subject of a separate article in this annual report. Suicides in Haringey During 1971 Dr. U.P. Seidel, Principal Medical Officer for Mental Health and Community Psychiatrist There has been increasing concern over the large and rising number of suicides presented to our local hospitals and clinics. It became essential therefore, to place the whole issue on a factual basis by studying the actual number of people so desperate as to make attempts at taking their own lives. I must begin by stating that Haringey has the unenviable distinction of being amongst one of the areas with the highest figures for both attempted and consummated suicides. More than one attempt a day has been recorded throughout the year and is still rising, presenting indeed an alarming picture. The total number of Haringey residents for the year 1971 who attempted to kill themselves were 379, 275 females and 104 males, giving a sex ratio of almost 2.7 to 1 in favour of the female sex. The ages most prone to make attempts on their lives, and there was no difference between the sexes proportionately except over 70, were in order of frequency:— 20—29, 14—19, 30—39, most commonly; then, 40—49, 50—59 and 60—69 After the age of 70, females greatly outnumbered males by 11 to 1. People who actually succeeded in killing themselves amounted to—41 during the same year, 21 males and 20 females which gives a ratio in relation to the total population of 17 per 100,000 compared with the average national ratio of 8 per 100,000. The ages for consummated suicides were, however, in sharp contrast to the sexes. Amongst males the largest number of deaths occurred between the ages of 20 and 29; then 40 to 49, and 60 and 69 were about equal, followed by a lower number between 30 and 39 and only one death after the age of 70. For females, the whole picture was completely reversed. The largest number of women who succeeded in killing themselves were seen after 70 years of age whilst the figures were equal for the following ages:— 20—29, 40—49, 50—59, all at half the number of the over 70's The lowest figures were found in the 60—69 and 30—39 age groups in that order. Figures for attempted suicides are generally calculated by a multiplication factor of 6 to 10 times that of consummated suicides which based on average national figures should have come to 190. Yet we actually counted 379 keeping in mind that a number of cases must have eluded our search so that the final figure may well have reached the over 400 mark. All figures demonstrate that the number of Haringey residents either attempting or succeeding in killing themselves were more than double the average national rates. Tables I and II give the overall number for attempted and consummated suicides in Haringey and Table III shows the total population of the Borough, divided into age groups, at the time of the study. The map depicts the distribution curiously U-shaped, of attempted and consummated suicides over the whole of Haringey and affords a visual presentation of the areas more commonly affected than others. Several factors prone to give rise to suicides may be deduced from it, namely: the density of the population, especially houses in multiple occupation with few recreational amenities; single, widowed or divorced people, a shifting population; and the young living in furnished rooms or the old and lonely who are more frequently of the female sex. Contrary to what was believed in former years social status did not appear to influence the picture very much and suicides were encountered right across all social strata. 61 It was an obvious conclusion that measures had to be taken, some of which have already been initiated, to combat this large wastage of human lives and relieve the misery and suffering which an attempt on one's life must entail. It is now a Department of Health ruling that every suicide admitted to hospital, and surviving, must be interviewed by a psychiatrist. This approach offers the patient urgently needed medical and psychiatric treatments where indicated and gives the psychiatrist, with the help of ancillary professional workers, an opportunity to possibly alleviate any social and environmental factors which may have contributed towards a patient taking so drastic a step as suicide. As prevention is always better than cure, how can this aim be fostered further? First and foremost, we should take anybody seriously who makes even the slightest reference to wanting to kill himself, whether this is mentioned in the context of a medical examination or the confines of a social interview. The person concerned should be referred immediately to the appropriate professional body and not be "managed" by lay and inexperienced people. Wider knowledge of the environmental circumstances and mental illnesses likely to give rise to suicide should be disseminated amongst professional workers by arranging seminars and meetings and holding case conferences. It is hoped that the envisaged establishment of a local branch of the Samaritans will greatly contribute towards helping people in distress and thereby possibly reduce the suicide rate. As to public attitudes on the whole a greater understanding for those people in need of help and support, especially at times of crises would further enhance our fight against suicides. Table 1 Attempted suicides in Haringey 1971 related to age and sex Age Group 15-19 20-29 30-39 40-49 50-59 60-69 70-79 80 + Total 86 124 68 37 29 11 20 4 379 Percentage of Total No. of age group 0.56 0.31 0.24 0.14 0.10 0.04 0.15 0.07 0.21 No. of Males 23 28 27 9 11 4 — 2 104 Percentage of Total No. of Males for age group 0.31 0.13 0.18 0.07 0.08 0.04 — 0.13 0.12 No. of Females 65 96 41 28 18 7 20 2 275 Percentage of Total No. of Females for age group 0.81 0.47 0.29 0.21 0.12 0.05 0.22 0.05 0.28 Table II Consummated suicides in Haringey 1971 related to age and sex Age Group 15-19 20-29 30-39 40-49 50-59 60-69 70-79 80+ Total No. — 11 2 7 9 4 8 _ 41 Percentage of Total No. of age group — 0.03 0.007 0.03 0.03 0.02 0.06 — 0.023 No. of Males — 7 2 3 5 3 1 — 21 Percentage of Total No. of Males for age group — 0.03 0.01 0.02 0.04 0.03 0.02 — 0.024 No. of Females — 4 — 4 4 1 7 — 20 Percentage of Total No. of Females for age group — 0.02 — 0.03 0.03 0.01 0.08 — 0.021 62 Table III Population of Haringey in 1971 related to age groups and sexes (Based on—Population Census and Survey Figures) (U.P. Seidel 1973) Age Group 15-19 20-29 30-39 40-49 50-59 60-69 70-79 80 + Total No. 15,365 40,580 28,655 26,820 27,925 25,025 13,785 5,705 183,860 Percentage of Total Population of Haringey 6.5 17.1 12.1 11.3 11.8 10.6 5.8 2.4 77.6 No. of Males 7,535 20,160 14,710 13,295 13,210 11,310 4,635 1,620 86,475 Male Percentage of Total Population of Haringey 3.2 8.4 6.2 5.6 5.8 4.8 1.9 0.7 36.6 No. of Females 7,830 20,425 13,945 13,525 14,715 13,715 9,145 4,085 97,385 Female Percentage of Total Population of Haringey 3.3 8.5 5.9 5.7 6.2 5.8 3.9 1.7 41.0 Total Population of Haringey in 1971—237,065. Adult Training Centre This centre for the training of the severely mentally subnormal, aged 16 or over, is in the charge of Social Services Department. However, Health Department, which originally established the Centre, still has a considerable responsibility for the health of the trainees. At first sight the Centre resembles a small factory but this is only one aspect of its function, which is to prepare the trainees, if possible, for independent life in the community, in which, of course, the industrial environment plays a large part. Many other basic skills are taught such as elementary hygiene, hairdressing, and how to cross the road or take a bus. Special stress has been laid on sport. This is partly because we have believed from the first that subnormals are entitled to enjoy the benefits it provides. There is no doubt that the trainees have gained great satisfaction and pleasure from this, particularly in the successes they have achieved in competitions with other adult training centres. But sport is also valuable in other ways: in the improvement in general health and co-ordination it brings. One tends to forget that mental subnormality usually involves an element of physical handicap as well. This is why so many have poor posture and clumsy movement. It was therefore decided in the early stages of the establishment of the centre to develop a small plot of land on the Bounds Green Industrial Estate close to the centre into an open-air recreation area for the trainees. It was triangular in shape and so small that it was obvious that only a limited range of activities would be possible. The Department approached the Eastern Region of the Central Council for British Naturism, which holds sessions at one of the Council's swimming pools, for advice based on their considerable experience of making the maximum recreational use of small areas. It was eventually decided to have a games court in the centre of the area with a greenhouse at one end and plots for horticulture at the other. The court was 21'x45', to be used for the game of Miniten, which is popular in the Naturist movement. The game is played by the rules of tennis, but instead of a racket the player uses a double-bladed bat known as a "thug", the handle being set internally between the blades. The ball therefore cannot be struck as forcefully and co-ordination is made easier by the fact that the total reach is only a little beyond arm's length. Members of the Naturist Movement kindly came to the Centre on a Saturday morning and showed the staff how to play the game. An interesting discovery was that at no time did the ball go over the top of the 9' fence. The instructors felt that it would be possible to teach the trainees and it was decided to concentrate on indoor instruction during the winter months to allow the grass of the court to become established. Experience showed that a number of the trainees were able to strike the ball with the thug under playing conditions. Consideration was then given to the question of whether they would be able to use the system of scoring used in tennis, or if a simpler system would be required. However, before this problem was resolved, it was learnt that the site was to be taken over shortly for housing. Further progress has therefore ceased. While the urgent need for housing is fully appreciated, it is hoped that the Council will be able to provide another small area of land close to the Centre where the trainees' need for physical recreation can be met. It is also hoped that it will be possible to continue this promising investigation into the game of Miniten, with its possibilities of reducing the problem of limited space for exercise encountered by Adult Training Centres throughout the country. 63 The Samaritans As a Health Department we are well aware that overt mental illness is only the tip of an iceberg which consists of so-far undetected disease or the great mass of suffering in its many forms involving ordinary people faced with the problems of living. We were therefore pleased to be able to assist a local group mainly representing the churches in setting up an Enfield/Haringey branch of the Samaritans. This organisation, consisting of laypeople skilled in the art of befriending, has proved to be of enormous value in this country and abroad in helping people who are in despair or on the verge of suicide. The Health Department was represented on the Initiating Committee by the Deputy Medical Officer of Health and the Principal Medical Officer, Mental Health, together with an Area Officer from the Social Services Department, and their opposite numbers from Enfield. The Initiating Committee undertook its task with great enthusiasm and stimulated considerable public interest; and the Mayors of both boroughs greatly encouraged it, each by their attendance at the inaugural public meetings. By the end of the year the first group of volunteers had completed their training, the basic organisation had been established and a permanent committee was being formed. HEALTH EDUCATION Miss Sheila M. Frost, Health Education Officer Since the formation of the Borough in 1965 close links have been forged between the Health Education Section, the various voluntary and Local Authority Services, and especially with the schools. Health Education is now being recognised as an essential part of general education. The Section has acted as a catalyst between the statutory and voluntary bodies within the Borough and has thus been able to further health education. It is hoped that when the Local Authority Personal Health Services become the responsibility of the new Area Health Authorities in April, 1974, these links will not be weakened but improved. Inter-Services Standing Committee on Youth and Working Party The Health Education section still plays an active part in the working party of this Committee and was responsible, together with assistance from the staff of the Teachers' Centre, for organising the Committee's third symposium "Young People and Drugs", held at the Teachers' Centre in November 1972. During the morning session Mr. T.D. Vaughan, Lecturer in Adolescent Development, University of London, lectured on "The Adolescent in Society To-day", Dr. Philip Boyd, Director-in-Charge, Simmons House Adolescent Unit, spoke on "The Problem and Management of Drug Abuse in Young People". At the afternoon session, Dr. Boyd joined a Forum of local speakers in an "Any Questions" discussion, followed by a screening of the film "Better Dead". The day's proceedings were chaired by Dr. James Hemming, Educational Psychologist. The symposium was attended by 102 participants representing local hospitals, Education, Health and Social Services, the Juvenile Bureau, Marriage Guidance Council and the Family Planning Association. A quarter of those attending were teachers, including representatives from Enfield. This type of inter-professional gathering is useful in making fresh contacts and leads to greater co-operation between the various organisations thus furthering health education. The Committee were also responsible for initiating a Youth Consultation Centre, which commenced in January 1973 at Tottenham College of Technology. "Welcome to Citizenship" Exhibition 1972 The main theme of the exhibition was "Man in his Environment" and the aim was to convey a forward looking concept with emphasis through the displays of future policies, plans, trends and ideas for creating the environment of tomorrow's citizen. The Department's display depicted some aspects of the Borough's Health Services, with specific reference to family planning facilities, maternal and child health, including school health relating to screening techniques for hearing, eyesight and dentistry. The environmental services depicted the continuous surveillance of housing conditions by the Public Health Inspectors with the programmes of clearance or rehabilitation of houses unfit for human habitation. 64 Publicity and Publications One of the functions of the Section is to publicise health education and the health services, making use of the mass media. In connection with the Audiology Course, Dr. Fisch and members of the Audiology team broadcast on Radio London about the detection and early assessment of deafness in children. A booklet on the Tottenham Hearing Clinic has been produced for circulation amongst doctors, health and social workers, to inform them of the work and facilities available at the clinic and to disseminate this information within the new Area Health Authority. Since the commencement of the Borough the Section has built up a sizeable amount of audio-visual aids and information on health education topics. Teachers, pupils and the public have increasingly used the section as a resources centre, and to assist this a new Health Education Catalogue has been produced. In November 1972, coinciding with the "Young People and Drugs" symposium, the Section co-operated with the Guild of Health Education Officers in a national campaign to launch a pop record "Drug Takers Beware". This record was distributed, together with statistics and literature to every secondary school and college of further education in the Borough. Wide coverage of this event was given in the local and national press. The day-to-day work of the Section includes the distribution of literature and posters on health topics to Local Authority establishments and the general public. The free family planning facilities commencing in April, 1973, were given widespread publicity in the press, tenants association newsheets, general practitioners' surgeries, as well as through the personal contact of health personnel and social workers. Cervical Cytology Publicity The Haringey Women's Cancer Control Committee continue to meet monthly at Stuart Crescent Health Centre where the work involves addressing envelopes and the sending of literature to women in the "at risk" group for cancer of the cervix, inviting them to make an appointment for a cervical cytology test. This small band of dedicated women have managed to work their way through four doctors' lists of patients. The section provides the literature and assists with the practical work involved. Cervical cytology sessions were arranged for the staff of the Local Authority in co-operation with the Staff Welfare Officer. Prior to these sessions, to encourage participation, talks and the screening of a film was shown during the lunchtime breaks. 65 Courses and Study Days In 1972 the Section assisted the Family Planning Association in running a Government sponsored two-day Family Planning Appreciation Course for health visitors, to which social workers were also invited. A two-day course on "The Detection of Hearing Defects in the Infant and Pre-School Child" was also held for health visitors. This is the third course of its kind to be organised by the Section under the direction of Dr. L. Fisch, the Consultant Otologist, at Tottenham Audiology Unit. Dr. Fisch, the staff of the Department and two peripatetic teachers gave lectures and demonstrations, held at Tottenham Town Hall, the Audiology Unit and the Blanche Nevile School for the Deaf. This Course which included health visitors from surrounding local authorities was financially self-supporting. Food Hygiene Courses In 1973 a series of talks on personal and food hygiene has been given to the domestic staff at the Prince of Wales's and St. Ann's Hospitals at the request of the domestic supervisor and in co-operation with the hospital pathologist. This series is similar to previous courses run in 1969 and 1970. Medical Receptionists' Course A two year course for medical receptionists has commenced at Tottenham College of Technology and, as part of the course, six lectures on the School Health Service were given by the Health Education Officer, who also gives lectures on the Health Services for the Medical Secretaries Course at the College. Health Education in Schools As a result of a questionnaire sent to all primary and secondary schools by the Education Service to assess the amount and nature of sex education being carried out in schools, a working party was set up to plan health education in-service training for teachers. The Principal School Medical Officer and the Health Education Officer acted in an advisory capacity to the working party consisting of head teachers, educational advisers, and lecturers from All Saints College of Education. A course of nine lectures entitled "Growing Up in Contemporary Society" was arranged at the Teachers' Centre for the Spring Term of 1973. Associated with the course was a one-day conference at which the section displayed the Health Services audio-visual aids. The section supplied statistics and other relevant information throughout the course. 78 teachers from 27 schools attended. The lecturers were from London University, All Saints College of Education, and the fields of medicine and health education. During and since the course teachers have increasingly used the section's facilities and sought advice on syllabuses and health education projects. It is hoped that the Education Service will continue to promote similar courses. The Health Education Officer and other members of the Department continue to give talks in schools. The number of talks has declined but this is a reflection of a deliberate policy to encourage teachers to plan their own health education into the curriculum and for the section to provide the knowledge and an occasional expert to supplement the teachers' programmes. This has been facilitated by the course previously mentioned. Subjects often used as vehicles for health education topics are home economics, human biology, the humanities and junior science. In the autumn of 1972 a health education project was commenced in Northumberland Park Comprehensive School. This new school, with then no equipment for practical work in home economics, decided to use some of the home economic periods for health education. A series of six talks related to home economics, included as topics, first aid, home safety, food hygiene, nutrition and human development. The school population consisted, at that time, of eight groups of 22-25 first year boys and girls of mixed ability. This involved the Health Education Officer in 48 talks spread over the school year. A PTA meeting was held explaining the syllabus, and from this followed a further talk on the misuse of drugs. A research fellow from Enfield College of Technology is monitoring the development of the school over the next four years, and has recorded some of the health education sessions together with both PTA meetings. Health education will be planned into the curriculum as these children progress through the school. The Health Education Council are interested in the series and arranged for Radio London to broadcast a part of the session on "Safety in the Kitchen". Other talks given in schools covered a variety of topics concerning dental health, drugs including alcoholism and smoking, first aid, food hygiene, sex education including child development, ante-natal and post-natal care, contraception, venereal diseases, Local Authority and National Health Services. 66 Rehousing—Assessment on Medical Grounds Dr. Z. Zubrzycki, Senior Medical Officer The new scheme for assessment of medical cases which was introduced in August 1971 resulted in a considerable increase of cases referred for assessment by the Housing Department, while the number of requests from hospitals and general practitioners slightly decreased. This was a natural outcome of the ease with which an applicant could make his own statement of his, or of any member of his family's medical condition on which he claimed his priority. This form of statement became open to some criticism, as the scheme continued to operate. It was felt that sometimes it was too difficult for a lay person to describe the nature of his illness or disability. In such cases a letter was usually sent to applicants general practitioner or a visit made by the medical officer to assess the degree of priority. 88 special cases referred to the Panel consist mainly of elderly often lonely people severely handicapped by crippling diseases of old age. The accommodation which they occupy is often too large for them and with stairs which they cannot manage. They are special in the sense that they have no chance of consideration on their housing points total even if the maximum (15) medical points are awarded. In this way a serious medical case may not be a special if the 1st degree of medical priority with 15 points will bring it up to the level of points necessary to be considered by the Panel as a non-medical case. Number of requests for transfer on medical grounds shows a welcome decrease as compared with the previous year. As almost all requests come from tenants living in flats this fall may well reflect decrease of cases of "block of flats" neurosis. Table 1 Housing Assessment on Medical Grounds Month No. of cases Source of request Housing Department Hospital, GP or Clinic Tenant, HV PHI, etc. January 110 92 5 13 February 182 157 15 10 March 174 149 10 15 April 90 73 11 6 May 89 73 5 11 June 113 87 7 19 July 116 90 5 21 August 147 120 11 16 September 56 41 3 12 October 80 61 6 13 November 116 88 9 19 December 85 62 10 13 TOTAL* 1,358 1,093 97 168 *These figures include second investigations carried out during the year. Table II Medical Priorities recommended during 1972 *No. of cases Special—refer to Panel 88 1st degree 357 2nd degree 214 3rd degree 277 Recommended for transfer 89 Recommended for hostel accommodation 4 Recommended for accommodation to be shared 7 Recommended for priority when Clearance Area is being rehoused 1 Recommended to be referred to other sections 14 103 cases were investigated where no medical recommendation was made. *These figures include second assessments made during the year. 67 Staff — Medical Assessment or Examination Assessments without examination Medical Examination For admission to service or superannuation 1,729 17 For extension of service 8 11 After long-term sickness 40 68 Not completed — returned to work or retired 55 - Teaching Staff Teacher Trainees 259 Teachers on first appointment 157 Hornsey College of Art — end of term teachers 72 On behalf of other local authorities 27 TOTAL DEALT WITH 1,832 611 Assessments shown by Services Service Medical Assessments Extension of Service Superannuation Fund Without Examination With Examination Without Examination With Examination Without Examination With Examination Architects 25 – – – – – Baths 2 – – – – – Catering 1 – – – – – Chief Executive 46 – – – – – Cleansing and Transport 12 1 – – 7 1 Comptroller and Treasurer 33 – – – – – Education 1,004 6 8 11 – – Engineer and Surveyor's 49 1 – – 16 – Health 76 2 – – – – Housing 52 1 – – – – Libraries 33 1 – – – – Parks 5 – – – – – Planning 37 – – – – – Public Control 2 – – – – – Rent Officer Service 3 – – – – – Social Services 287 3 – – – – Valuation 14 – – – – – Tottenham College of Technology Students 25 – – – – – TOTAL 1,706 15 8 11 23 2 PUBLISHED ARTICLES "Psoriatics and the Community" An article by Dr. W.T. Orton, Deputy Medical Officer of Health of Haringey, was published in the Health and Social Service Journal of June 23, 1973. Psoriasis is a chronic skin disease which can be very unsightly and distressing to the patient, though it is usually not disabling or likely to shorten life. The Psoriasis Association (22 Billing Road, Northampton, NN1 5AT) has been formed to promote research and the well being of patients. No permanent cure has yet been discovered. The article also described the experience of "climate therapy" as carried out by the Swedish Psoriasis Association and allied bodies, whereby groups of patients are flown to resorts, mostly in the Mediterranean area, for prolonged exposure to sunlight. This is usually beneficial, although as happens with ail other forms of therapy, the skin rash tends to recur in a month or so. The writer suggests that on the whole this approach is worth encouraging, providing it is regarded as a means of relieving the condition rather than as a form of treatment. Furthermore ways should be found of avoiding the segregation of these patients by reducing their self-consciousness and encouraging their acceptance by the community. 68 PART III SCHOOL HEALTH SERVICE REPORT OF THE PRINCIPAL SCHOOL MEDICAL OFFICER FOR THE YEAR 1972 EDUCATION COMMITTEE 1972/73 Councillor Mrs. S.A. Berkery Smith JP (Chairman) Councillor D.F.W. Billingsley (Vice-Chairman) Alderman C.C.H. Chalker BA Alderman V. Gellay BSc MlnstP ARIC Alderman Mrs. N. Harrison Councillor Mrs. L.A. Angell Councillor Mrs. G. Atkinson Councillor Miss R. Harris TD Councillor A.G. Hudson Councillor Miss S.A. Jones Councillor Mrs. E. Murphy Councillor G. Murphy Councillor G.W.C. Peacock Councillor G. Pollard ACA Councillor P.P. Rigby JP CC Co-opted Members Mr. J.G. Elkington BA Mr. R.E. Grout Mrs. H. Peston Fr. A. Pollet SJ Schools Sub-Committee Alderman Mrs. N. Harrison (Chairman) Councillor Mrs. G. Atkinson (Vice-Chairman) Alderman V. Gellay BSc MlnstP ARIC Councillor Mrs. L.A. Angell Councillor Mrs. S.A. Berkery Smith JP Councillor D.F.W. Billingsley Councillor Miss R. Harris TD Councillor Miss S.A. Jones Co-opted Members Mrs. C.P. Payne Mr. S. Edwards PRINCIPAL SCHOOL HEALTH STAFF J.L. Patton, MB ChB MFCM(RCP) DPH Medical Officer of Health and Principal School Medical Officer W.T. Orton, MB BCh BAO MFCM(RCP) DPH Deputy Medical Officer of Health and Deputy Principal School Medical Officer Mary C. Douglas, MB ChB MFCM(RCP) DPH Principal Medical Officer (School Health) G.C.H. Kramer, LDS RCS Chief DentalOfficer and Principal School Dental Officer 70 The Worshipful the Mayor, Aldermen and Councillors of Haringey I have the honour to present for your consideration, a report on the School Health Service for the year 1972. Last year, the future of the School Health Service was uncertain when it was debated as to whether it would remain as the responsibility of the Education Authority or if it would pass with the personal health services to the new Area Health Authority. It has now been decided that the School Health Service will pass to the new Area Health Authority and evolve in the future in close association with their hospital world. The Working Party on Collaboration between the N.H.S. and Local Government has recommended a review of the School Health Service. As a result of these changes we may see a new guidance offered by the hospital paediatricians and other consultants dependent on the health problems seen from hospital rather than those seen by the community. Whatever happens, interplay between school, community and hospital must be productive of a new approach to School Health. The hospital paediatricians, when they view the School Health Service from their vantage point, will almost certainly have some criticism about the ever-increasing number of obese children who are a product of the continued effects of over-eating and the sedentary pastime of television viewing. The approach of the hospital consultant to the issue of free school milk for children in the age range 7 — 11, which is now the Council's policy, may be different and in time there may be some lead to more clearly defined medical criteria for the recommendation for free school milk in the interests of health. There is always scope for progress and change and a visit to the opening ceremony of the new Moselle School made me realise that the long established IQ test, which is valuable for assessing the capacity of the child to relate to academic life, may have some deficiencies in its ability to estimate the child's capacity for the fuller life because it does not include some cultural qualities such as the ability to appreciate music, colour and rhythm, all of which have so much to contribute to living. The well established British system of special educational treatment for handicapped children has aroused admiration in many of the under-developed countries. In the course of time these countries will probably establish their own services for their handicapped children and their services are likely to improve and advance more rapidly if influential parents of handicapped children in those countries help to stimulate the evolution of special schools. Unfortunately, however, there is some evidence from the School Health Services that a number of people from the former Commonwealth countries are bringing their handicapped children to England to arrange for their admission to residential schools here. This action must delay the evolution of much needed services in their own countries and when a child is suffering from a hearing defect, the additional burden of a foreign language must be an added disadvantage. I am pleased to record my thanks to all those who have contributed to the work of the School Health Service, to the Chairman and Members of the Education Committee and to Mr. Slater and Mr. Groves and their staff, who have given us their usual efficient co-operation at all levels. My thanks also to the teachers on whose enthusiasm and interest we are always dependent. J.L. PATTON MB ChB MFCM DPH Principal School Medical Officer 71 SCHOOL HEALTH SERVICE Dr. Mary Douglas, Principal Medical Officer School Population The School population of the borough on 25 January 1973 was as shown in the following table:— Primary Schools and Nursery Classes 25,289 Nursery Schools 377 Secondary Comprehensive Schools 13,362 Other Secondary Schools 1,105 Special Schools — The Vale School (for Physically Handicapped) 92 Blanche Nevile School (for the Deaf) (including classes for partially-hearing) 150 The Moselle School (for Educationally Sub-normal) 73 William C. Harvey School (for severely Educationally Sub-normal) 105 Greenfields School (for Maladjusted) 17 Suntrap Residential Open-Air School) 88 TOTAL 40,658 Medical Examinations in the School Health Service In this Borough the majority of children rising 5 are already in school. The number of nursery school placements are rapidly increasing and many children will therefore be offered their entrant school medical examination in the "toddler" years. It follows it is necessary to have close co-operation between the staffs of the Child Health Clinics and of the School Health Service. Greater numbers of children will be examined in their "toddler" years than at present and as only small numbers of these children can be examined in any one session an increase in professional staff who are trained in developmental paediatrics is essential now and for the future. This examination will be a fairly detailed developmental assessment as well as a general medical examination. Doctors who are concerned with the welfare of children in the learning situation realise that it is impossible to separate their pre-school learning period from the school period and are aware that children's abilities to learn must be assessed from the earliest possible age and that where the possibility of handicap is elicited, skilled therapy and teaching from both disciplines must be made available for the child and the parent. Under the present system, the School Health Service is required to provide help for a child who is thought to be handicapped when he or she reaches the age of 2. It is now generally accepted that for many children this is far too late and the time lost is irretrievable. There is a comprehensive service for children with hearing loss however young the infant. There is need to establish such a service for children who may suffer from physical or mental handicaps and, as in the case of the Audiology service, this would combine medical (including Health Visitors and physiotherapists) and teaching personnel working together, both visiting families at home and giving advice or treatment in clinics under the over-all supervision of a consultant paediatrician with special knowledge of cerebral palsy and mental subnormality. After the National Health Service reorganisation it is to be hoped that there will be even closer co-operation with the general practitioner and hospital services, whose facilities should be more readily available for the support of doctors in the School Health Service. The medical examination of the school child is designed to prevent any handicap impeding the child's ability to learn. Particular attention is therefore directed to the supervision of the special senses. Routine Medical Inspection of school children is undertaken on entry to school and in the final year of school life. At other times, examination is by selection. Such children may have been found to have a difficulty at a routine medical inspection or they may be selected for examination at the request of the parent or head-teacher. The school doctors try to visit their schools at regular intervals so that they may be available for consultation with the head-teacher or staff. The schools for handicapped children receive visits from a medical officer at least once a week. Periodic Medical Inspection The following table shows the number of children inspected by years of birth and the classification of theii physical condition — 72 Year of Birth Number of Pupils inspected Physical Condition of Pupils inspected Satisfactory Unsatisfactory Number % Number % 1968 & later 386 386 100. 1967 1,948 1,944 99.8 4 0.2 1966 1,992 1,992 100. – – 1965 602 602 100. – – 1964 453 453 100. – – 1963 383 383 100. – – 1962 * * 627 627 99.8 1 0.2 1961 * * 845 842 99.6 3 0.4 1960 * * 503 503 100. – – 1959 390 390 100. – – 1958 244 244 100. – – 1957 & earlier 1,421 1,420 99.9 1 0.1 TOTAL 9,794 9,786 99.9 9 0.1 "Signifies Selective Medical Examinations In the Appendix to this report a table is included giving the number of children found at periodic medical inspections to require treatment. "U" Children 1972 9 children seen at routine medical examinations were classified by the examining doctor as "unsatisfactory" i.e. whose physical condition on general inspection appeared unsatisfactory. This included grossly obese (as well as undersized) children — a condition particularly difficult to treat, which must give rise to anxiety about the future health of such children. Obesity in the community should be regarded as at least as serious to health as smoking. Other Medical Inspections The following are the numbers of special inspections and reinspections carried out during 1972. A special inspection is one which is carried out at the special request of a parent, doctor, nurse or a teacher, usually at a school clinic. Number of special inspections 2,199 Number of reinspections 3,043 TOTAL 5,242 Medical Treatment Details are given in the Appendix of treatment (excluding uncleanliness and dental defects) of pupils attending maintained primary and secondary schools (including nursery and special schools), whether provided directly by the Council or arranged through other agencies. Handicapped Pupils The Education Act 1944 places upon local Education Authorities the duty of ascertaining handicapped pupils in their areas and of providing special educational treatment for such children. Although it is the duty of the local authority to ascertain these children from the age of 2 years, it is desirable, especially in the case of blind, deaf and cerebral palsied children, that the defects be discovered before this age so that steps may be taken to help the child to develop as normally as possible despite his handicap. Therapeutic education cannot start too early in the life of a child and his parents, whatever the handicap. The School Health Service and Handicapped Pupils Regulations 1953 defined the various categories of handicapped pupils as follows:— (a) Blind — pupils who have no sight or whose sight is likely to become so defective that they require education by methods not involving the use of sight. (b) Partially sighted — pupils who by reason of defective vision cannot follow the normal regime of ordinary schools without detriment to their sight or to their educational development, but can be educated by special methods involving the use of sight. 73 (c) Deaf — pupils who have no hearing or whose hearing is so defective that they require education by methods used by deaf pupils without naturally acquired speech or language. (d) Partially hearing - pupils who have some naturally acquired speech and language but whose hearing is so defective that they require for their education special arrangements or facilities though not necessarily all the educational methods used for deaf pupils. (e) Educationally subnormal — pupils who by reason of limited ability or other conditions resulting in educational retardation require some specialised form of education wholly or partly in substitution for the education normally given in ordinary schools. (f) Epileptic — pupils who by reason of epilepsy cannot be educated under the normal regime of ordinary schools without detriment to themselves or other pupils. (g) Maladjusted — pupils who show evidence of emotional instability or psychological disturbance and require special educational treatment in order to effect their personal, social or educational readjustment. (h) Physically handicapped — pupils not suffering solely from a defect of sight or hearing who by reason of disease or crippling defect cannot, without detriment to their health or educational development, be satisfactorily educated under the normal regime of ordinary schools. (i) Pupils suffering from speech defect — who on account of defect or lack of speech, not due to deafness, require special educational treatment. (j) Delicate — pupils not falling under any other category who by reason of impaired physical condition need a change of environment or cannot without risk to their health or educational development be educated under the normal regime of ordinary schools. The ideal situation is to keep as many children as possible within the ordinary school system, even the severely handicapped. Experiment is necessary, requiring close co-operation between the Education and Health Departments. Two such trials are already under way in Haringey. The first involves the integration of a number of pupils of secondary school age who were attending the Vale School for Physically Handicapped Children into the William Forster Comprehensive School. A full report by the School Medical Officer appears under the section "Medical Services at the Vale School" (Page 00). The second experiment has been conducted as part of a research, under the auspices of the Institute of Education (University of London) and the Ewing Foundation, into the education of deaf children in ordinary schools. Six children attending the Partially-Hearing Unit of Blanche Nevile School were returned to an ordinary school at the beginning of the Summer Term 1973 for an initial period of one year, with special arrangements to support them and the teachers, in order that they might have the benefit of education alongside children with normal hearing. The trial has been started on the understanding that any child who suffers from this arrangement will immediately be returned to the Partially-Hearing Unit but any child who benefits by the change will remain at the normal school and will not be deprived of special support even if it should be decided at some future date that the project will not continue. Pupils handicapped by severe blindness or deafness are normally educated in special schools. Children with handicaps in other categories may attend ordinary schools with special consideration where necessary. The vast majority of children with speech defects and most children suffering from epilepsy or diabetes are able to be educated in ordinary schools. Where appropriate arrangements cannot be made for handicapped children in ordinary schools, or where the child fails to maintain reasonable progress, or is unhappy because of his disability, arrangements are made for education in day or residential special schools. As the number of children with more than one disability who do not fall clearly in one category is increasing, there is special need for facilities to assess each child's total handicap and to provide the appropriate special educational treatment. Home tuition may be arranged on a temporary or permanent basis for children who are unfit for education at school. Children who are in hospital for prolonged periods are given help from the hospital school. In the Appendix will be found a table, for which I am indebted to the Chief Education Officer, showing the number of pupils newly ascertained as handicapped, and newly placed in special schools during the year; and the distribution of ascertained handicapped children and the number awaiting placement on 25 January 1973. Special School Provision (a) Day Special Schools The following are the day special schools in Haringey:— 74 Name of School Category of handicapped pupil Number on roll on 31 December 1972 Total Haringey Children Out-Borough Children The Vale School Physically handicapped 53 33 86 Blanche Nevile School (includes units at Risley Avenue Infant and Junior and Drayton Comprehensive Schools for partially-hearing children) Deaf and partially hearing 52 99 151 Greenfields School Maladjusted 16 1 17 The Moselle School Educationally subnormal 71 1 72 William C. Harvey School Educationally subnormal 103 1 104 The children attending the partially-hearing units require special teaching because of their hearing difficulty, but are otherwise fully integrated with ordinary school life. The absence of a day school for maladjusted pupils has in the past been a great handicap. A unit for 15 children, with Mr. A.H. Hicks as Headmaster, opened in September 1972 at the White Hart Lane (Old School) building and was transferred to the Page Green School premises in January 1973. This has greatly facilitated work with handicapped children in the Borough and we look forward to the opening of the new school for maladjusted pupils planned for 1974. The Moselle School for educationally sub-normal children, which began as a small unit in October 1970, continued successfully in 1972 under very difficult conditions in the former Downhills (East) School building, and in February 1973 was transferred to its own new building on the Broadwater Farm Estate. This school will have a special unit for the assessment of learning ability of children difficult to place. The Health Department greatly appreciates the close co-operation enjoyed with the Education Department in the care of the pupils of these schools. Partially-sighted pupils who require day special schooling are placed mainly in the Joseph Clarke School, Walthamstow, or the New River School, Islington, and delicate pupils mainly at Hazelbury Open Air School, Enfield. During the year two children of nursery school age attended a special class for children with difficulties of communication held at the Wolfson Centre, Mecklenbergh Square, London, WC1. We could with advantage provide a special class within the Borough for children of school age who have difficulties of communication. (b) Residential Special Schools The Borough's residential open air school, Suntrap School, Hayling Island, Hampshire, accepts delicate and physically handicapped children — boys of primary school age (5—11) and girls of all ages. The resident staff includes a night nurse, and a medical practitioner attends twice a week and a dental officer once a week. The number of children placed at Suntrap at the end of 1972 was 100, of whom 9 were Haringey children and 91 children from other Boroughs. It is increasingly evident that many of the children already placed in Suntrap School are there because of their social conditions and are long stay cases. There is a case for using the school for short stay cases — children who need convalescent holiday periods following illness or hardship at home, and whose schooling will not suffer by being on holiday. There are many Haringey children who would benefit from this type of placement and whose parents would accept short periods from home. Great distress was caused by the closure of the Acorn School. Seven severely handicapped children with marked autistic tendencies, for whom it had been almost impossible to find suitable placement, were returned home from this school which closed down within six weeks of opening. Intensive investigation to find alternative residential placement for them by the Authority failed for all but two children. Considerable stress was placed upon the parents of these very handicapped children. Praise cannot be too high for the Education Department and the Head Teachers concerned who have cared for these children in the Greenfields and William C. Harvey Schools throughout this year. Meantime, plans were put in motion to set up a special unit in the one time isolation block of Suntrap School, Hayling Island, for the care of such children. This unit has been adapted for 8 children and, while under the over-all control of the Headmistress of Suntrap, will be completely separate and its own staff has now been appointed. The unit will open on 18 June 1973 with 4 children.* Blind children are educated in residential special schools. Children with other handicaps who require residential education are placed in schools administered by other Local Authorities or by independent bodies, apart from children suffering from severe epilepsy, who are placed in hospital special schools. * NOTE: The Unit opened as planned. The four boys who were admitted seemed happy and quickly settled. Great praise is due to the staff and the other pupils of Suntrap, who have welcomed these pupils, and to all concerned at the Education Department. 75 Hospital Classes I am indebted to the Chief Education Officer for the following report: "During 1972. two teachers have continued to provide tuition for children of school age who have needed in-patient treatment at St. Ann's and Prince of Wales's General Hospitals. Because of the wide age range of the comparatively Iow number of children (approximately 30 at any one time) the teaching is mainly on an individual basis but occasionally children of roughly the same age can be taught in groups for some subjects. 14s far as possible each child's school curriculum is followed by close liaison with the day schools. This is particularly important with those children whose stay in hospital is lengthy. The teachers have a well equipped classroom established in one of the children's wards but bedside tuition is provided for those children unable to attend the classroom". THE SCHOOL CLINIC Medical Officer Sessions Sessions staffed by school medical officers are held to deal with minor day-to-day medical problems, the follow-up of defects found at periodic and other medical inspections and particular problems brought by parents. School Clinic sessions also afford opportunity for special work to be carried out by school medical officers, including weight watching and warts clinics. A medical examination is offered to all school children who are new entrants to the country, including any child who has been out of the country for a year or more and has returned. This provides an opportunity to have the childrens' immunisation and vaccination programmes brought into line with other children in the Borough and also enables parents to meet the school doctor and discuss their child's health with him. Under these arrangements 401 children were examined during the year. Home Tuition During the year 14 children received home tuition for varying periods under Section 56 of the Education Act 1944 because they were not well enough to attend school for a considerable period. Day Nurseries — Admission of Handicapped Children As in previous years, children in the following categories were admitted on a medical recommendation to the day nurseries administered by the Social Services Department without charge to the parents, the cost being borne by the Education Committee under Section 56 of the Education Act 1944, if the child was over two years old. (i) Deaf, partially-hearing, partially-sighted, physically handicapped, maladjusted (ii) Mentally handicapped children under five years of age (iii) Children over one year old of deaf or deaf/mute mothers During 1972 14 Haringey children were in attendance at day nurseries under these arrangements, and at the end of the year 8 of these children were still in attendance. Recuperative Holidays During 1972 5 boys and 8 girls were recommended for recuperative holidays in order to assist their recovery after illness, and 4 boys and 6 girls were placed in suitable homes for a period of two weeks in each case. Plantar Warts Weekly sessions continued to be held at Weston Park and Lordship Lane Clinics, to deal with Plantar warts, and Dr. K. Shah reports as follows on the work at these clinics:— "The wart clinics at Lordship Lane and Weston Park progressed satisfactorily during the past year. The figures below show the number of sessions at both these clinics and the number of cases treated during 1971 and 1972". Clinic Number of Sessions Total A ttendances New Cases Number treated with electrocautery 1971 1972 1971 1972 1971 1972 1971 1972 Lordship Lane 49 48 611 521 239 257 93 53 Weston Park 51 50 569 637 190 203 87 92 TOTAL 100 98 1180 1158 429 460 180 145 76 Weight Watching Clinics In the Boroughs of Islington and Camden holiday parties for obese girls were arranged in 1971 with considerable success, as reported in their Principal School Medical Officers' Annual Reports. Such an experiment would be of considerable value in this Borough if a suitable holiday home could be found. The planned Field Centre in Wales comes to mind but this is understood not to be practicable at present. The Weight Watching Clinics at Fortis Green and Burgoyne Road Medical Centres continued during the year. The following report has been received from the Medical Officer at Burgoyne Road:— "The "Obesity Clinic" Burgoyne Road developed considerably during the year, two sessions per month being devoted exclusively to overweight children. The number of patients has increased, and a special questionnaire — including an individual graph for each child — has been devised, and, apart from check-ups of weight and height, the Blood Pressure and the thickness of the skin fold are being recorded. A total of 90 children (35 boys and 55girls) have been seen, the number of visits amounting to 266 (86 for boys — mean 2.39 visits per child — and 180 for girls — mean 3.33 visits per child). The ages of patients ranged from 5 years 3/12 to 16 years 10/12 — mean 10 years 9/12 for the boys, and, from 5 years /12 to 16 years 4/12 — mean 10 years 1 /12 for the girls (age recorded during the 1st attendance). The overweight (= weight in excess of the ideal for age and height) during the first attendance was from 14lbs 8 ozs to 108lbs (boys) and from 78lbs 8ozs to 8lbs 3ozs (girls). Of the 19 boys who attended more than once, 9 lost weight (biggest loss: 16lbs 8ozs), 9 gained (biggest gain: 14lbs 8ozs) and one remained the same. The remainder were seen only once. Of the 42 girls who attended more than once, 26 lost weight (biggest loss: 15lbs 14ozs) and 16 gained (biggest gain : 9lbs 11ozs). The remainder were seen only once. It is of particular interest that the weight follow-up has been extended to the groups of toddlers and babies — even the very young ones. No figures can be given as check-up and advising take place during the baby and toddler clinics and for only a fraction of those a dossier has been made, but the general impression is that mothers respond much better during these age groups, and the younger the baby is the prompter the loss in weight achieved, to such an extent, that only few months following the initial warnings, the patient can be discharged. Only a minimal fraction of failures can be reported." The following is the report of the Medical Officer of Fortis Green Clinic:— "Twenty children attended the clinic at Fortis Green during the year — ten being new cases and ten children who had attended previously. The sexes were evenly distributed. The ages of the children attending ranged from 5 — 16 years, one-third of them being teenagers; and grossly obese children amounted to approximately one-third. Two children were discharged when their weights reduced to normal. A girl of 15 lost 42 lbs but the average loss was only about 2lbs. although many children achieved a more normal appearance by a gain in height." CONSULTANT SESSIONS Orthopaedic Clinics A fortnightly orthopaedic session is held at the Lordship Lane Clinic for children from the Tottenham and Wood Green parts of the Borough. I am indebted to Mr. J.P.S. England, FRCS, Consultant Orthopaedic Surgeon,for the following report of the year's work at the Lordship Lane Clinic:— "During the course of the year some 19 Consultant Sessions were held and there was a total of 276 attendances. Of these there were 128 new patients, being further broken down into 59 pre-school and 69 of school age. Of the remainder, 67 follow-up visits were of pre-school age and 81 of school age. A small proportion of these clinical attendances were referred to the Prince of Wales's General Hospital for further x-rays and other investigations and were treated, if necessary, at this hospital. Those with scoliosis, numbering some 4 or 5 during the year, were referred to Mr. Manning at the Royal National Orthopaedic Hospital for his opinion in the Scoliosis Clinic and where appropriate, were then followed up at Lordship Lane. It is felt that this School Clinic is a valuable complementary adjunct to child orthopaedic care. A physiotherapist is in constant attendance at the Clinics and runs her own sessions working together with the attending Consultant and a surgical appliance fitter also attends at each consultant session." The details of attendances at the physiotherapy clinic at Lordship Lane during the year are as follows: — Under 5 years Over 5 years Totals New cases 8 37 45 Attendances 32 134 166 77 Children from the Hornsey district of the borough are referred to a special session at the Whittington Hospital which deals mainly with minor orthopaedic defects. During the year 22 new cases under 5 and 34 over 5 were referred from the Council's pre school and school clinics. For most of the year two physiotherapy sessions were held weekly at the Weston Park Clinic, Hornsey, to which children were referred by Assistant Medical Officers, who assumed responsibility for these cases. The attendance figures were as follows:— Under 5 years Over 5 years Total New Cases 4 20 24 Attendances 8 69 77 Towards the end of the year attendances at this clinic decreased. At the same time, a number of cases occurred in the Wood Green part of the Borough of children with minor orthopaedic defects, and it was decided to hold two weekly physiotherapy sessions at the Stuart Crescent Health Centre instead of the Weston Park Clinic. Ophthalmic Clinics In the early part of 1972, 7 weekly ophthalmic clinic sessions were held — 3 at Lordship Lane Clinic, 2 at Weston Park Clinic, and 2 at Stuart Crescent Health Centre, Wood Green. The size of the waiting list at Weston Park led us to ask the Regional Hospital Board to authorise 3 weekly sessions but unfortunately late in the year the ophthalmic consultant reduced his weekly sessions at Weston Park to one and early in 1973 reduced his weekly sessions at Stuart Crescent to one. The Regional Hospital Board has been unable, so far, to appoint a consultant to take his place and, therefore, in Hornsey and Wood Green, ophthalmic consultant time has been reduced and the waiting lists continue to increase. The situation has now been slightly alleviated in that the consultant has found it possible to resume attendances at the second weekly session at Stuart Crescent. Dr. T.G. Kletz, consultant ophthalmologist to the Lordship Lane Clinic, reports as follows on the year's work:— "The work of this clinic is mainly refraction and orthoptic investigation and treatment of muscle imbalance and squints. The cases are referred from the school medical services and the local infant and child medical clinics. The ethnic survey of myopia has continued and the statistics show a maintenance of the highish incidence of myopia in West Indians: Total Cases Native 35.8% Immigrant origin 64.2% New Cases Native 27% Immigrant origin 73% Of the new immigrant cases West Indian 54.7% Cypriot 15.2% Irish 13.1% Indian 6.3% Others 10.7% Myopia Native 20.4% of new cases seen Immigrant 40.5% of new cases seen West Indian 53.7% of new cases of West Indian origin. The majority of these children were born in the U. K." Details of attendances at the Ophthalmic Clinics during 1972 are as follows: — Lordship Lane Weston Park Stuart Crescent Under 5 Over 5 Totals Under 5 Over 5 Totals Under 5 Over 5 Totals New Cases 96 939 1,035 81 835 916 26 464 490 Attendances 174 1,749 1,923 131 1,181 1,312 101 1,086 1,187 Medical Services at the Vale School for Physically Handicapped Children The medical team at the Vale School is under the direction of a visiting consultant and a school medical officer. During 1972 and 1973 the school was well staffed, acquiring a full complement of therapists and nursing staff, consisting of a full-time school nurse, a full-time physiotherapist, a part-time physiotherapist, a full-time occupational therapist, and a part-time speech therapist. There was a gap of 6 months when an occupational therapist left but a replacement has been appointed recently and the number of speech therapy sessions at the school have also recently been increased. Unfortunately, due to family commitments and illness the part-time physiotherapist has had to reduce her sessions and the full-time physiotherapist will be resigning in July, 1973 to return to her native Norway. The school will therefore be in difficulties in September 1973 unless a new appointment can be made meantime. The Principal Medical Officer for Mental Health visits the school once a week for staff discussions. 78 I am indebted to Dr. Z. Zubrzycki, school medical officer, for the following report: — "The year 1972 will go into the chronicles of the Vale School for Physically Handicapped children as that in which an important opening was made in the boundaries of this close and isolated community. This was brought about by implementation of the co-operative scheme between the Vale School and the William Forster comprehensive school. Discussion had been going on for some time and it was felt that the time was right for a small number of physically handicapped pupils from the Vale School, aged about 14, to be integrated into the 4th year of the William Forster School. Nine pupils were selected, who seemed both physically and intellectually able to cope with the demands of a comprehensive school and likely to benefit from the broader education and the opportunity for social integration. A teacher from the Vale School was seconded to the William Forster School for a half of each day and two experienced attendants (one male and one female) were attached full-time to the Unit. Amongst the nine selected pupils there were three wheel-chair cases and two severe limb deformities. No child was involved in the scheme without the consent of the parents. The Unit went into operation in September, 1972. Full-time attendance was expected and transport to and from school was provided as before. The children were treated as members of classes of the William Forster School and were encouraged to take full part in the activities of the school. By the end of the first term it became obvious that the scheme, which started on an experimental basis, was entirely successful and that the Unit will continue as a permanent feature of the William Forster School. The year 1972 had also seen great progress towards the completion of the school's therapeutic pool. 4s the building was taking shape both the children and the members of the staff peeped curiously through the large windows hoping that the glossy cavity of the pool would soon be filled with azurean water. In fact, the pool was ceremoniously opened in February 1973 and became a source of enormous enjoyment for the children and a great help in their treatment The cerebral palsy unit associated with the school is a centre to which mothers are referred for advice and children for treatment as soon as cerebral palsy is diagnosed. Dr. William Dunham, consultant in physical medicine, attends weekly and a full-time cerebral palsy therapist gives treatment to the children under his direction. A speech therapist and an educational psychologist are available to give advice and treatment in suitable cases. Dr. Dunham reports as follows on the work of the unit during 1972:— "The school has, during the year, cared for 92 children with handicaps of various kinds; the group with cerebral palsy was the largest, with 29 children. The group presents special problems, and demands a special approach. Perhaps the most obvious handicap imposed by cerebral palsy is the inability of affected children to do things other children do with ease and enjoyment, and the natural instinct of anyone witnessing the frustration of a child's efforts is to "lend a hand". Yet if this means doing for the child what he cannot do for himself, it also means that an opportunity of helping him to overcome his handicap has been wasted, for the well-meaning action has removed the child's incentive to make the effort himself. If, instead, it means helping the child to do for himself the things he cannot do on his own, this not only gives him a sense of achievement, but shows him how to set about the task himself and encourages him to try again. So the first principle for anyone looking after the child with cerebral palsy is to help him to do things rather than to do them for him. But the problem is more complicated than this. Left to himself — and especially if given encouragement — the child in most instances will eventually find a way of doing things. But the way in which he learns to do them is often inefficient and unsightly. This would not matter if, having succeeded, he would then turn his attention to improving the efficiency and appearance of his performance. But this is not what happens. In fact the child, having succeeded, proceeds to practise his newly-found skills however unsatisfactory, rather than attempting to improve on them, and well-intentioned encouragement is likely rather to hasten the establishment of the faulty habits of movement than to eliminate them. Good intentions on the part of those looking after the child are of course "a must", but an understanding of how the child's activity is likely to be affected by the operation of those good intentions is equally important. These are some of the "special problems" mentioned above, to be faced together by parents, teachers and medical (including therapy) staff. Their collaboration forms the "special approach"." Of the 9 new cases seen at the unit during 1972, 7 were Haringey children and 2 were from outside the Borough. 3 of these children were under 5 years of age and 6 over 5. Recommendations made for the new cases were as follows: — Recommended for admission to the Vale Special School 6 Recommended for ordinary school 2 Recommended for residential school 1 Medical Services at the William C. Harvey School Medical supervision for the children who attend this school for the more severely educationally sub-normal children, is provided by a team consisting of two visiting medical officers, a full-time school nurse and a fulltime physiotherapist. The school would benefit by the services of an occupational therapist at least part-time. The urgent need is for more intensive speech therapy within the school. There is work for a full-time speech therapist but the lack of accommodation would make her presence there full-time very difficult. Increased facilities are therefore an urgent need. 79 Audiology Unit The Audiology Unit is within the curtilage of Blanche Nevile School and there is excellent co operation between the medical and teaching staff. Three sessions are held each week. The medical team consists of a Consultant Otologist, medical officers, and three audiometricians. There is regular supervision of pre school children with hearing defects and school children with hearing loss who attend ordinary schools. Pre school children with hearing loss are admitted where possible to day nurseries, play groups and where necessary to the nursery class at the Blanche Nevile School. Many of these children wear hearing aids and those not attending Blanche Nevile School are supervised by two full-time peripatetic teachers who work in close co-operation with Dr. L. Fisch, the Consultant Otologist. Dr. Fisch reports as follows on the year's work at the unit: — "The past year was an extremely busy one. Strenuous efforts were made to keep the waiting list in manageable proportions. The investigation and assessment of children with hearing impairment is becoming more complex, a greater number of people with special skills are involved and investigations are more complicated. Consequently, the administration of the unit is also more difficult and extra help and additional resources are required on that side to cope with the work and maintain our high standing. In spite of the difficulties, we were able to maintain the high standard of the audiology service during the past year. We were fortunate to have a full complement of peripatetic teachers — 2 for Haringey, 1 for Enfield, 2 for Barnet. The teachers work with great enthusiasm and dedication. Training of children with hearing impairment, of pre-school age or who manage in normal schools, is intensive. Children who are in the School for the Deaf or the special units for the partially hearing are regularly assessed. During the past year it was almost always possible for the appropriate class-teacher to be present during the examination. This was a great advantage. Parent/Teacher meetings were held regularly at least once a term. At one meeting two former pupils of the School for the Deaf — girls in their late teens/early twenties, both in responsible jobs and one of whom is married — came to talk to the meeting about their work and experiences. A considerable amount of teaching has been carried out at the clinic during the year. Student teachers from the London University Course for training teachers of the deaf, student health visitors, speech therapists, doctors, student midwives, audiometricians and other personnel attended, either in small groups or individually. Important new equipment was acquired at the end of the year. Most outstanding is an impedence meter which enables us to measure the middle ear pressure and movements of the ear drum, and helps in the detection of middle ear disorders. / am very grateful that, also at the end of the year, work commenced on building a new waiting room and toilet and in the examination room a one-way viewing window was incorporated for better accommodation of visitors and consequent improved standard of audiological work. Our audiometricians attended a day course in advanced techniques at Manchester University. The work of the audiometricians is outstanding. The Instruction booklets prepared in co-operation with the Health Education Section have proved to be extremely successful. / am extremely grateful to Health Education Section. Several thousand copies have been sold and the booklets are used in many audiology centres throughout the country and even overseas. In July 1973, a very successful two-day course on "The Detection of Hearing Defects in the Infant and Preschool Child" was held for health visitors from Haringey and surrounding Boroughs, in co-operation with the Health Education Section of the Health Department and teaching staff of the Education Department." The following is an analysis of the cases seen during 1972: — Age -1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Total New Cases in year 114 23 25 19 19 8 5 8 6 2 3 5 1 2 5 3 3 251 Cases brought forward from previous year 2 22 34 38 27 33 42 28 36 30 26 14 19 16 13 23 403 Re-exams of old and new cases 2 2 6 2 9 7 5 5 5 3 11 2 4 1 3 67 Total Attendances 721 80 Pre-School Children 317 Attending Infant and Junior Schools 297 Attending Senior Schools 107 TOTAL 721 Reasons for referral of new cases: — For diagnosis 131 Known to be deaf, examination before admission to Blanche Nevile School 1 Immigrants to borough, known to be deaf 2 Partially hearing, advice as to placement 1 Auditory training 2 "At risk" 102 Transfer from hospital outpatients dept. 8 Advice as to placement where deafness might be the cause of backwardness 4 TOTAL 251 51 of these referrals were from other boroughs. Audiometric and Vision Screening Routine audiometric and vision screening is carried out by three full-time audiometrician testers. Vision testing in school by the Keystone apparatus is combined with audiometric screening in junior and secondary schools and an additional vision screening test is given to children in their fifth year at senior schools. Audiometry is carried out for any child who is referred by his family doctor and the result is sent to the doctor so that he may carry out any necessary further investigations unless he specifically asks for these to be carried out at the Audiology Unit. In infant schools vision testing is carried out by the school nurse at periodic inspections and the orthoptists carry out screening procedures for discovery of latent squints. A senior audiometrician/vision tester has supplied the following report: — "With the opening of more nursery schools and nursery classes, and the admission to school of most "rising 5's", many more children under 5, including those in day nurseries, are being given annual hearing tests. Audiometry in the special schools for handicapped children has been most successful and we appreciate the help and the co-operation of the school staffs concerned. The percentage of these children who fail the test is higher than in the other schools and a number of children have been issued with hearing aids. Routine hearing tests continue in all other schools of the children in the following age groups: in the first and last year in infant school; once in junior school; in the first year in secondary school. The standard for passing screening tests is set purposely high and a high proportion of those who fail are found to respond to simple corrective measures. At the Audiology Unit we have been fortunate to obtain an impedence meter for measuring middle ear pressures, which is used for diagnostic purposes. 373 ear mould impressions were taken at the Unit in 1972 with much improved results. Vision screening tests with Keystone equipment continued as in previous years for children in the age groups 9-10, 11-12 and 15-16 years." During 1972, the follow-up by orthoptists of Keystone screening "failures" gave the following results: — Junior Schools Senior Schools Number % (of Keystone "Failures") Number % (of Leystone "Failures") Keystone "Failures" referred to Orthoptist 521 _ 277 — Confirmed as failures by Orthoptist 390 74.8 242 87.3 Already receiving treatment 97 18.6 105 37.9 Minor defects not requiring treatment 127 24.4 87 31.4 Referred to ophthalmic clinic for investigation 166 31.9 50 18 81 Speech Therapy Mrs. E.R.P. McKeown, senior speech therapist, reports as follows:— "The establishment was increased in October by two posts so that the equivalent of six full-time therapists could have been employed by the end of the year. During the year one therapist obtained an appointment in an assessment unit, and neither replacement nor additional staff were recruited (there are difficulties of recruitment) so that at the end of the year the six therapists who were employed fill the equivalent of only three and a half posts. The number of Speech Therapy students attending clinics had increased and without their help children would have waited considerably longer than the average four months before being seen. In spite of the useful contribution of students there is no substitute for fully qualified staff. Sessions were held regularly at eight school clinics, at the Vale and the Moselle Schools. During the year resident therapists were established in two schools with long waiting lists and where suitable accommodation could be provided for treatment. Unfortunately it proved necessary to discontinue therapy at the William Harvey School because of the shortage of therapists and the lack of suitable accommodation in the school. Perhaps the provision of a speech therapy room could be considered in any future plans for extension of the school premises. In spite of these difficulties it is hoped to resume some service to the school in September 1973. Numbers attending in 1972 Under five years 621 Over five years 4,027 TOTAL 4,648 The service has become well established and known in the Borough and there is good liaison between therapists and their colleagues in the medical and educational fields. During the Autumn Term a special exercise was undertaken and 9,198 children, ages from nursery to school leaving, at twenty seven schools were screened and 319 children were identified as being in need of further investigation and placed on waiting lists. The 3%% requiring therapy was broadly in line with the National A verage. The problems of staff shortage and organisation of the profession reached such proportions that in 1969 a Committee was appointed by the Secretaries of State for Education and Science and Social Services, under the Chairmanship of Professor Randolph Quirk, to consider the need for and the role of Speech Therapy in the fields of education and medicine. The "Quirk Report" was published in November 1972. Briefly its recommendations were that the scope of the Speech Therapists responsibility could be better appreciated and their proper sphere of professional independence recognised — i.e. speech therapists are not auxiliaries to the medical profession, they have independence in their own right. Certain proposals were made for reorganising the speech therapy service, and these are currently under consideration." Child Guidance Service During 1972 the two Child Guidance Centres under the administration of the Chief Education Officer, at Lordship Lane, Tottenham and Tetherdown, Hornsey, continued as in previous years. The two consultant psychiatrists, who are seconded by the Regional Hospital Boards, act as medical directors — Dr. Nina Meyer carrying out 5 weekly sessions at the Tottenham Clinic and Dr. K. Graf holding two sessions at the Hornsey Clinic. In March, 1973, the new Child Guidance Clinic in Wood Green was established, two sessions a week being carried out by Dr. Stewart Britten at the Stuart Crescent Health Centre, with the prospect of the clinic moving into White Hart Lane (Old) School when these premises are ready. I regret to record that Dr. Nina Meyer retired in June 1973. Dr. Meyer has given the child guidance service in Tottenham a twelve year period of valuable work and her enthusiasm and experience with the younger children has provided a useful stimulus for many of her junior colleagues. We have been fortunate in obtaining the services of Dr. Stewart Britten to undertake the sessions at Lordship Lane meantime. The Education Committee has decided to ask the National Foundation for Educational Research to review the work of the Child Guidance Services. Dr. Meyer reports as follows on her year's work at Lordship Lane:— "This will be my final Annual Report, since by the time this appears, / will have retired from the Health Service; this terminates twelve years of service at this Clinic. During this year, 212 children were referred — 20 by their General Practitioners — of these 7 were re-referrals and 17 were not proceeded with. 136 cases were dosed — 60 improved with help; in 15 cases the parents reported improvement before the child had been seen, 20 were non-co-operative; 12 were over school leaving age; 7 moved away; 6 were under the care of the Social Services, and 4 were under the care of the Educational Psychologists. 82 The pattern of this year has been like those in the past — one of the increasing seriousness of referred cases. School refusals have increased, which may be related to the raising of the school leaving age and to environmental pressures on children of many cultures, who are ill-adapted to the educational demands made upon them. The need for greater flexibility in providing different kinds of schooling is agreed, for example, for children who come to join their families from abroad, and who have had a different background from the one they are expected to meet on attending school here. The Day Maladjusted Unit and "Opportunity Classes" have met some needs, and other solutions, such as the new Northumberland Park School, seem to be moving in the right direction, with smaller classes and greater personal contact. Here, in this school, apparently problems are markedly less. On the psychiatric side, depression undoubtedly plays an increasing part in the pathology of children referred to us. This takes many forms, from behaviour disorder to psychosomatic disturbance and retardation of development; finding the causation of the stress is often of itself of therapeutic help. We need greater amenities in the form of in-patient units and short-term hostels, at times of family crises. One of the initiations the Psychotherapist has brought to the Clinic has been to treat family groups - mothers, fathers and children together — and this has been extremely rewarding in suitable cases, particularly with adolescents, who are precocious physically, but immature emotionally, and who have difficulties of communication with their families; in their lives outside their families, their attempts at self-expression are seen as anti-social acts. With the growth of greater centralisation of Social Services, one may hope that the work of the Child Guidance Clinic will be able to give an increasingly significant service to this work in the field. / would like to thank my colleagues for the help they have given me over the years; this work succeeds only with the help and support of a devoted team." Dr. Graf reports as follows on the year's work at Tetherdown:— "As requested, / have pleasure in presenting my report on the function and organisation of the Tetherdown Child Guidance Clinic during 1972. This is my 11th Annual Report since / was seconded by the North-West Regional Hospital Board to serve in this area and my 8th report as the Medical Director of the Tetherdown Child Guidance Clinic, which was established in 1965. Since the time of my appointment the scope of work and the non-medical establishment of the Clinic have considerably expanded, which reflects to some extent in the opening of the Wood Green Child Guidance Clinic as an independent unit. However, the consultant psychiatrist at Tetherdown, who as Medical Director has the ultimate clinic responsibility for all the psychiatric assessments and psychotherapy conducted at this centre, remains as before, unassisted by a junior medical colleague and is expected to continue to carry a vast case-load and considerable managerial responsibility, as he and his predecessors have done for the past twenty-two years in their two weekly sessions. Consequently, he has to rely unduly and unfairly on the support, efficiency and loyalty of his non-medical colleagues and being inundated with work of a clinical nature he is completely unable to take his knowledge and his expertise into the community as much as he would wish to do in order to assist and advise the social care worker in the field, the hospital services or in other institutions dealing with children. He has to spend much of his time with routine work well within the scope of a less experienced psychiatrist and when called to emergencies elsewhere or requested to do a domiciliary visit in homes, his routine work at the clinic suffers and is interrupted unless he invokes the help of colleagues working in other centres. In spite of the fact that there are at present, four psychotherapists attached to the Clinic to assist him, who attend on a sessional basis, who have about 20 children in treatment, which may last for months, or even years, he is unable to help in the treatment of the almost equal number of children who are still on the treatment waiting list, some of whom he would see if he had more medical assistance and time at his disposal. However, fortunately, only a minority of the children referred to the Clinic really require the lengthy and extensive psychotherapy which has to be given to the more disturbed child and some can be helped by more limited and superficial supportive treatment, advice given to parents and teachers, or other less time consuming therapeutic measures which include also the placement in special day or boarding schools for maladjusted pupils. In fact, there are currently 63 children, ascertained as maladjusted and annually reviewed by the psychiatrist, who following his recommendation are attending boarding schools recognised by the Department of Education and Science according to the Education Act of 1944. During the past year 22 of these children were reviewed, while 5 children were sent to our new day school for maladjusted pupils which is not yet able to receive its full complement. The number of children referred for child guidance investigation at the Tetherdown Clinic in 1972 was 180, of which 140 were seen by the Consultant Psychiatrist in 72 diagnostic and 66 review sessions. The majority (58) were referred from schools through teachers, some came to us at the request of their parents (35) while the Chief Education Officer and the Educational Psychologist sent us 19 children. A large number of referrals came from Medical Officers (41), General Practitioners (11) and Hospital Specialists (10), while other cases reached us through Probation Officers and the Social Services Department. 83 As is always the case, the referrals were made for a multiplicity of symptoms rather than because of an isolated problem and the maladjustment of the individual children had usually a multi-factorial etiology. Naturally parents, teachers and others were worried about various degrees and intensities of behaviour problems, at home or in school, but not every child exasperating its teachers in school, suffers from a psychological disturbance. Very frequently the fault must be sought elsewhere, perhaps in a sphere of social disturbance into which the Clinic cannot intervene and fails to supply the suitable remedy. The Clinic's team are equally concerned about the violent or aggressive child, as they are about the very withdrawn pupil who is no trouble to his teachers but opts out in school and keeps unduly to himself at home, and because he is not really a nuisance tends to be overlooked. The diagnosis and the treatment of school refusal because of either school phobia or truancy remains a tricky problem while severe depression and suicidal threats which are not entirely uncommon among children, even if they are fortunately rare, must always be taken very seriously. Such contrasting and diverse symptoms as bed-wetting, stealing, nightmares or unreasonable compulsion, to name but a few, may be the expression in a child of the same personal problem, often the result of emotional disturbance which reflects a social difficulty within the home or an educational handicap at school. Fortunately, symptoms which would have been regarded as signs of a more ominous disturbance with very unfortunate prognosis, if they occurred in an adult, may express in children only a temporary emotional crisis which can even resolve itself spontaneously, even if it usually benefits from supportive treatment or therapeutic crisis intervention. In contrast, however, the very plasticity and impressionability of a young individual who is constantly growing in body and mind will make him deeply vulnerable to many dramatic impressions which would hardly touch an adult. As is almost universally the case in Child Guidance Clinics in this country and abroad boys (123) predominated this year again over girls (52). There was a fairly even distribution of referrals of children in the age range of 5 to 14 years. The now time-honoured team-approach of the Child Guidance Clinic, its methods and aims, its relationship with the schools psychological service, the role of the Child Psychiatrist in a non-medical educational setting, his relationship to the children's branch of the Social Services Department and the psychiatric aspects of the Child Health Service as it will follow the reorganisation of the National Health Service, are all at present under consideration and in a state of flux, so that it is difficult to make any pronouncement or to give explanations on these points which will be, of course of great interest to anybody concerned with the Child Guidance Service. Let us hope that the near future will bring a solution to all the outstanding issues in the interest of our young clients whose happiness, whatever the future brings us, must remain our principal concern." TABLE 1 Source of Referral Number of Children Teachers 56 Medical Officers 41 Parents 35 General Practitioners and Hospital Specialists 21 Educational Psychologists 12 Chief Education Officer 7 Education Welfare Officers 5 Probation Officers 3 TOTAL 180 TABLE II Referral Symptoms Number of Children Various problems including violent and aggressive behaviour 73 Irregular school attendance and school refusal 39 Learning difficulties or backwardness 38 Unhappiness, depression and immaturity 28 Stealing and telling lies 19 Enuresis/encopresis 14 Asthmas, headaches, nausea and other physical complaints 7 84 Referral Symptoms Number of Children Nervous habits and tics 6 Nightmares and sleep disturbances 6 Phobias and shyness 4 Suicidal attempts and drug taking (including alcohol) 3 Speech defects 3 N.B. Certain children were referred with more than one of these symptoms. TABLE III Ages at Time of Referral Number of Children One year 0 Two years 2 Three years 4 Four years 3 Five years 15 Six years 17 Seven years 14 Eight years 18 Nine years 24 Ten years 19 Eleven years 9 Twelve years 19 Thirteen years 14 Fourteen years 18 Fifteen years 3 Sixteen years 1 Total number of boys referred 123 Total number of girls referred 57 TABLE IV Recommendations made or action taken by Clinic Team Number of Children Support, advice given to parents 46 Help in school 29 Waiting list for psychotherapy 27 Placement in remedial class, tutorial group or opportunity class 25 Referred for further specialist investigation 17 Ascertain maladjusted or ESN 14 Sundry recommendations and action 13 Prevention of Tuberculosis by BCG vaccination BCG vaccination is offered to all school children over 13 years of age. No students of Further Education took advantage of the opportunity to have BCG vaccination during 1972. 85 The following table gives details of BCG vaccinations carried out by the Council during the year- School Children Number % Parents approached 3,093 — Parents accepted 2,450 79.2 Number skin tested 2,343 — Number found positive 193 8.2 Number found negative 2,005 85.6 Number failed to attend for Mantoux reading 145 6.2 Number vaccinated (% of those approached) 2,005 64.2 Cases of Tuberculosis occurring in Teachers or Pupils Investigations were carried out on the advice of the Chest Physician at a comprehensive school where a case of pulmonary tuberculosis had occurred amongst the pupils. 330 pupils and staff had chest x-rays, but no further cases were discovered. Ringworm of the Scalp Cases of ringworm of the scalp continue to occur sporadically. During the year 19 cases occurred in 3 schools throughout the Borough. I am grateful to St. John's Hospital for Diseases of the Skin for the screening procedure which they continue to carry out in these cases. No evidence of spread of infection was discovered. All doubtful cases were referred to the Consultant Dermatologist at the Prince of Wales's Hospital for further investigation. Hygiene Inspections School Nurses continued to carry out regular hygiene inspections in the schools, to guard against the spread of infection and contagion. The following are details of the hygiene inspections carried out during 1972:— Number of individual examinations of pupils in schools 74,495 Number of individual pupils found to have nits in the hair 606 MILK IN SCHOOLS As a result of the Education (Milk) Act 1971, from the beginning of the Autumn Term 1971 free milk has been supplied only to — (a) children in infant and nursery schools up to the end of the summer term next following the seventh birthday; (b) children in primary schools where the school medical officer certifies that a child should be provided with milk at school; (c) all children in special schools. In accordance with the Council's policy, medical examination continued of all children aged 7—11 who no longer automatically qualified for school milk. As in 1971 these examinations were carried out by general practitioners employed sessionally in the School Health Service. The parents were advised when these examinations would take place and those parents who did not wish their children to be considered for free school milk on health grounds were asked to reply in writing but only a small percentage did so. In accordance with the further wishes of the Education Committee, from April 1973 parents will be given written notification of the examining doctor's decision. The Department of Education and Science ruled that the certification of pupils for the supply of free school milk on the grounds of health is a question for the professional judgment of the School Medical Officer and emphasised that there was nothing in the Act which required the Medical Officer to wait until there was overt sign of malnutrition before giving a certificate. During 1972, 9,994 children were examined, of whom 6,725 (67%) were given a certificate leading to the issue of a free 1/3rd of a pint of milk a day. 86 Co-operation with the Prince of Wales's Hospital The Department's close link with the Prince of Wales's Hospital continues. Senior medical officers attend weekly sessions at the Rheumatism Supervisory Clinic held at the hospital under the direction of Dr. Ian M. Anderson, consultant paediatrician, and at a general paediatric clinic. I am grateful to Dr. Anderson for the following report on the year's work at the Rheumatism Clinic:— "During 1972 there were no new recorded cases of rheumatic fever. There were 39 new cases of congenital cardiac lesions seen by Dr. I.M. Anderson during 1972 in his Paediatric clinics at the Prince of Wales's Hospital. Total number of NEW CASES in 1972 (Male = 15 Female = 24) = 39 All 39 were from the Borough of Haringey. 67% were referred from Child Welfare Clinics. Cases classified as follows:— Total In Haringey From other areas Male Female Congenital cardiac lesions 39 39 – 15 24 Pulmonary stenosis 2 2 – – 2 Aortic stenosis 1 1 – 1 – Patent ductus arteriosus 1 1 – - 1 A trial septal defect 3 3 – 1 2 Possible atrial septal defect still under supervision 1 1 – – 1 Ventricular septal defect 3 3 – – 3 Possible ventricular septal defect still under supervision 2 2 – 7 1 Cardiomegaly with a soft murmur 1 1 – 7 – Venous hum 1 1 – 1 – Possible venous hum to be reviewed in one year 1 1 – 1 – Innocent murmur 22 22 – 8 14 Ejection murmur to be reviewed in one year 1 1 – 1 – Five of the new cases have been transferred to Westminster Hospital to attend Dr. I.M. Anderson's Cardiac Clinic there for further investigations and follow-up." A medical officer from the department, acting as Registrar, attends a weekly session at the hospital held by Mr. William McKenzie, Consultant Ear, Nose and Throat Surgeon. Deaths of School Children It is with regret that I include the following details of local school children who died during 1972: — Sex Age Cause of Death Years Months F 7 4 Road accident F 11 4 Malignant disease F 9 10 Road accident M 14 7 Malignant disease M 5 5 Road accident F 5 5 Congenital defect M 6 4 Malignant disease M 12 10 Malignant disease 87 Road Accidents to School Children I am indebted to the Accident Prevention Officer for the following details of road accidents involving school children during 1972: — Fatal Serious Slight Pedestrians 3 26 168 Passengers – 5 32 Cyclists – 7 34 TOTAL 3 38 234 LIST OF SCHOOL HEALTH CLINICS AS AT 31 DECEMBER 1972 a — School Advice b - Dental c — Ophthalmic d — Orthoptic e — Orthopaedic f — Physiotherapy g — Cerebral Palsy Unit h — Speech j — Audiology Unit k — Child Guidance I — Chiropody a All Saints' Church Hall, 11 Church Road N6 j Blanche Nevile School for the Deaf, Philip Lane N15 abh Burgoyne Road Clinic, 58 Burgoyne Road N4 b Chestnuts Clinic, 268 St. Ann's Road N15 k Child Guidance Centre, Tetherdown N10 abh School Clinic, 128 Cornwall Road N15 abh Medical Centre, 150 Fortis Green N10 ah Gordon Road Clinic, 1a Gordon Road N11 b Dental Clinic, 334 High Road N15 abcdefhki Medical Centre, 239 Lordship Lane N17 abh Medical Centre, 131 Park Lane N17 a Somerset Road Clinic, 370 High Road N17 abcdfh Health Centre, 8 Stuart Crescent N22 abcdhl Medical Centre, rear of Hornsey Town Hall, 23a Weston Park N8 fgh The Vale School for Physically Handicapped Children N4 h The Moselle School for Educationally Subnormal Children, The Green N15 f The William C. Harvey School for Educationally Subnormal Children, Adams Road N17 SCHOOL DENTAL SERVICE Mr. G.C.H. Kramer, Principal School Dental Officer, reports as follows:— "The total numbers on the school rolls at 40,658 was higher by 771 than for the previous year, which was a welcome slowing down in the annual rate of increase over the past few years. The number of sessions devoted to inspections in the schools was 179, an increase of 37 over the previous year, which resulted in a significant improvement as compared with the very disappointing results in the preceding year. The number of pupils who received a first inspection was 16,575 and, together with a further 5,170 first inspected in the clinics, made a total of 21,745 who were seen over the year, representing 53.5% of all the children in our schools. Although this falls far short of what we should like to achieve, it is of interest to note that with the same numbers of dental staff as in the past, this would have been the highest percentage during the life of the Borough if the numbers of children in the schools had remained static. In addition to first inspections, a further 3,944 were reinspected during the year, and of the total first and reinspections together at 25,689, treatment was found necessary for 14,824 or 57.7% — slightly better than the 61.2% found in 1971. Treatment sessions were 4,041, of which 716 were for our orthodontic service. These were respectively 17 more and 32 fewer than in the previous year, yet there was a substantial improvement in the "productivity" of the service far greater than could be attributed to any alteration in sessions worked. For example, an additional 1,298 fillings affecting 1,477 extra teeth, without commensurate reductions in other significant items of treatment, which must be attributed to greater effort on the part of the dental officers in the face of the overwhelming demands upon our service. / am sorry to say that there was also some small increase in the numbers of teeth extracted, the one item where a substantial reduction would be welcomed. 88 Blood Testing for Certain Ethnic Groups The value of this precautionary measure prior to administration of a general anaesthetic has again been demonstrated during the year under review. A further 439 tests were done, bringing to light two children (twins) whose lives would have been seriously at risk, a further 7 for whom an anaesthetic would have been an unjustifiable risk until after a period of medical treatment and further test, and 19 for whom special care was needed. / feel every justification for repeating what / have written before: although this routine imposes a considerable amount of work when there is no certainty that any findings of value will emerge, / consider it to be of great value and continue to feel that its pioneering introduction in Haringey represented a notable advance in Local Authority dental services. From the start of our testing procedure in March 1969 to the end of the year under review, we have performed a total of 1,827. Staffing As evidenced by the very close similarity of the numbers of sessions worked compared with the previous year, the staffing situation has remained so stable as not to require any detailed comment, other than to repeat that we still have too few to meet the demand. It is sufficient to record that on 31 December, the date used nationwide for counting staff in post, we had the Chief Dental Officer/Principal School Dental Officer, Orthodontists to a full-time equivalent of 1.6, Dental Officers 7.6 and Dental Surgery Assistants 12.8. It should be emphasised that of the total numbers given in this report of the School Dental Service, 7% of their work is actually for treatment of the Priority Classes reported upon separately elsewhere and is not reflected in the statistical details given below. If the whole of their time was for children in our schools, the "productivity" of the service would be even higher." Dental Inspection and Treatment Pupils first inspected in schools 16,575 Pupils first inspected in clinics 5,170 Pupils reinspected 3,944 Number found to require treatment 14,824 Number of fillings: Permanent teeth 11,434 Temporary teeth 9,930 Number of teeth filled: Permanent teeth 9,904 Temporary teeth 9,203 Extractions: Permanent teeth unsavable 398 Permanent teeth for orthodontia 381 Temporary teeth 3,831 General anaesthetics administered: Total 1,035 By dental officers 727 Number of dentures supplied 11 Number of crowns and inlays 42 Number of teeth root filled 27 Number of prophylaxes 2,063 Number of teeth otherwise conserved 424 Other operations 4,353 Orthodontic Treatment Cases remaining from previous year 178 Cases commenced during year 183 Cases completed 245 Number of appliances fitted: Removable 306 Fixed 48 Number of impressions, adjustments, etc. 3,985 Number of radiographs 2,764 89 APPENDIX SCHOOL HEALTH SERVICE STATISTICS FOR 1972 SCHOOL HEALTH SERVICE STATISTICS 1972 Pupils found to require treatment at Medical Inspections Number of Individual Pupils found at periodic medical inspections to require treatment (excluding dental diseases and infestation with vermin) Year of Birth For defective vision (excluding squint) For any of the other conditions recorded Total individual Pupils 1968 & later 8 31 34 1967 121 187 245 1966 88 160 205 1965 22 53 60 1964 30 52 68 1963 26 51 56 1962 59* 87 * 121* 1961 68* 65* 106* 1960 24* 50* 58* 1959 22 38 51 1958 17 19 30 1957 & earlier 94 82 141 TOTALS 579 875 1175 'Signifies "Selective" medical examinations 91 TREATMENT OF PUPILS ATTENDING MAINTAINED PRIMARY AND SECONDARY SCHOOLS (INCLUDING NURSERY AND SPECIAL SCHOOLS) GROUP 1 Eye Diseases (e.g. blepharitis, conjunctivitis) Defective vision and squint Number of cases known to have been treated (a) External and other, excluding errors of refraction and squint 207 (b) Errors of refraction, including squint 2,952 TOTAL 3,159 (c) Number of pupils for whom spectacles were prescribed 1,228 GROUP 2 Diseases and Defects of Ear, Nose and Throat Received operative treatment for:— (a) Diseases of the ear 5 (b) Adenoids and Chronic Tonsilitis 48 (c) Other nose and throat conditions 2 Received other forms of treatment 109 TOTAL 164 Total number of pupils still on the register of schools at 31 December 1972 provided with hearing aids: (a) During the current year 12 (b) In previous years (excluding any pupils shown at (a) above who were provided with an aid in a previous year) 48 GROUP 3 Orthopaedic and Postural Defects Number of pupils known to have been treated at clinics or at out-patients departments 352 GROUP 4 Diseases of the skin (excluding uncleanliness) Ringworm (i) Scalp 19 (ii) Body 2 Scabies 1 Impetigo 2 Other skin diseases 428 TOTAL 452 GROUP 5 Child Guidance Treatment Number of pupils treated at child guidance clinics (including cases sent to the Tavistock and other hospital clinics) 321 GROUP 6 Speech Therapy Number of pupils treated by speech therapists 360 GROUP 7 Other Treatment given (a) Number of miscellaneous minor ailments treated by the Council 359 (b) Pupils who received convalescent treatment under School Health Service arrangements 10 (c) Pupils who received BCG vaccination 2,005 (d) Treatment other than (a) (b) and (c) above 326 92 93 RETURN OF ASCERTAINED HANDICAPPED PUPILS REQUIRING SPECIAL EDUCATION FACILITIES CATEGORY IN THE CALENDAR YEAR DISTRIBUTION ON 25 JANUARY 1973 Number newly ascertained as requiring education in a Special School (other than hospital Special Schools) Number newly placed in Special Schools (other than hospital Special Schools) Number on register of — Number placed in Boarding Homes Number requiring places in Special Schools Number on register of hospital Special Schools Number being educated at home under arrangements made under Sec.56 Education Act 1944 Totals Maintained Special Schools Non-Maintained Special Schools Independent Schools Day Boarding Day Boarding Day Boarding Boys Girls Boys Girls B G B G B G B G B G B G B G B G B G B G B G Blind Pupils — — — — — — 2 1 — — 2 2 — — — — — — — — — — — — 4 3 PartiallySighted Pupils 1 2 1 2 7 9 — — — — — 1 — — — — — — — — — — — — 7 10 Deaf Pupils — 2 — 1 12 15 1 — — — 1 3 — — — — 1 — — 1 — — — — 15 19 Part iallyHearing Pupils 2 1 3 — 10 17 1 — — — — — — — — — — 1 — — — — — — 11 18 Physically Handicapped Pupils 8 11 3 8 31 29 1 1 — — 1 3 3 — — — 7 6 1 — — — — — 44 39 Delicate Pupils 8 6 12 4 26 19 10 7 — — — — — 1 — — 10 4 3 — — — — — 49 31 Maladjusted Pupils 28 3 29 5 18 4 11 — — — 23 9 32 5 — — 1 1 20 4 — — 3 — 108 23 Educationally Subnormal Pupils 38 26 38 25 189 133 11 1 3 7 3 5 14 8 — — 31 21 1 2 — — — — 252 177 Epileptic Pupils — — * 1 — — — — — 2 — 2 — 1 — — — — — — — — — — — 5 — Pupils with Speech Defects 7 1 5 — — — — — — — — — 4 1 — — — 1 — — — — — — 4 2 TOTALS 92 52 92 45 293 226 37 10 5 7 32 23 54 15 — — 50 34 25 7 — — 3 — 499 322 GRAND TOTALS 144 137 519 47 12 55 69 — 84 32 — 3 821 INDEX Page No. Adult Training Centres 63 Ante natal Services 37 Atmospheric Pollution 14 Audiology Unit 80 Audiometry 81 Babies, movement into and out of Borough 39 Births, Notification of 39 Births, and nationality of mother 39 Blood testing for certain ethnic groups 89 Breast cancer clinic 52 Care of Mothers and Young Children 39 Cervical Cytology 55 Child Guidance Service 82 Child Health Clinics 40 Chimney Heights 14 Chiropody Services 57 Cleansing and Disinfection 18 Clearance Areas 22 Comparability Factors 7 Congenital malformations 42 Deaths in the post-natal period 37 Deaths of Haringey Residents 8 Deaths of School Children 87 Defects remedied 19 Dental Care: Priority Classes 55 School 88 Diseases of Animals Act 1950 22 Domiciliary family planning 49 Drainage and Sewerage 12 Drain Stoppages 21 Education Committee 70 Enteric Fever 59 Environmental Health 12 Factories 34 Family Doctor, co-operation with 37 Family Planning 44 Food Complaints 30 Food Hawkers 33 Food Hygiene 27 Food Imported 28 Food Poisoning 58 Food Premises 27 Food Sampling 29 Furnace Installations 14 Geriatric Services 56 Guthrie Tests 43 Hairdressers 35 Handicapped Children, admission to day nurseries 76 Handicapped Pupils 73 Requiring special educational facilities 93 Handicapped Register, Children on 42 Health Committee 1 Health Education 64 Health Visiting 43 Page No. Home Nursing Service 44 Home Tuition 76 Hospital classes 76 Hospital Services, co-operation with 37 House Drying 21 Houses in Multiple Occupation 26 Houses, Unfit 22 Housing applications, assessment on medical grounds 67 Imported Food 28 Improvement Areas 23 Grants 25 of dwellings 24 Incontinence 44 Infectious Diseases 58 Infectious Diseases, Notification of 11 Insect Pests 18 Inspections carried out by Public Health Inspectors 18 Laundry services for the incontinent 18 Lead poisoning 60 London House Improvement Campaign 25 Marie Curie Foundation 44 Measles 58 Meat Inspection 32 Medical examinations in school health service 72 Mental Health, Community 60 Adult Training Centre 63 Midwifery Service 43 Milk in Schools 86 Mortuary 18 Mothercraft and Relaxation Classes 41 Multiple occupation, Houses in 26 Noise 21 Nursing Services 43 Observation Register, Children on 42 Offices, Shops and Railway Premises Act 1963 33 Ophthalmic Clinics 78 Orthopaedic Clinics 77 Outworkers 36 Pet Animals 22 Phenylketonuria 43 Prince of Wales's Hospital, co-operation with 87 Psittacosis 76 Published articles 68 Qualification Certificates 26 Radioactive Substances Act 1960 36 Rag Flock, etc 20 Recuperative Holidays 76 Refuse, Accumulations of 22 Renal Dialysis 60 Ringworm 86 Road accidents to School Children 88 Rodent Control 16 Rubella 59 Samaritans 64 Page No. School Clinic, The 76 School Dental Service 88 School Health Clinics, list of 88 School Health Service 72 School Health Service Statistics 91 School Population 72 Schools, Special 74 Sexually Transmitted Disease 60 Shops Act 1950-1966 35 Special Schools Provision 74 Speech Therapy 82 Staff 2,70 Staff Medical Assessments 68 Statistics, School Dental 89 School Health 91 Statistics, Vital 6 Statutory Notices Services 20 Street Trading 35 Surface Water Pollution 12 Swimming Baths and Paddling Pools 12 Suicides in Haringey 61 Toddlers'Clinics 41 Tuberculosis in Schools 86 Tuberculosis, Prevention by BCG vaccination 85 'U' Children 73 Unfit houses 22 Vaccination against Diphtheria, Whooping Cough, Tetanus, Poliomyelitis, Measles and Rubella 58 Vale School, Medical Services 78 Venereal Disease 60 Vision Screening 81 Vital Statistics 6 since 1965 10 Water Supplies 12 Weight Watching Clinics 77 Welfare Foods, Distribution of 40 William C. Harvey School, Medical Services 79