I HIL7 London Borough of Hillingdon THE HEALTH OF HILLINGDON 1971 ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and PRINCIPAL SCHOOL MEDICAL OFFICER 1971 DR. J. STUART HORNER, M.B., Ch.B., D.P.H., D.I.H. Health Department, Council Offices, Uxbridge, Middlesex. Contents page Introduction 3-7 Health Committee 8 Staff 9 SECTION I Statistics Infectious Diseases Health Control Unit London (Heathrow) Airport 13-30 SECTION II Personal Health Services 33-49 SECTION III Social Services 53-56 SECTION IV Environmental Health 59-101 SECTION V Other Services 105-112 APPENDIX TABLES 115-125 SECTION VI Report of the Principal School Medical Officer 129-172 Index 175-176 The Worshipful the Mayor, Aldermen and Councillors of the London Borough of Hillingdon. Mr. Mayor, Ladies and Gentlemen, I have the honour to present my second Annual Report which covers the work of the health department for the year 1971. The Report follows the revised pattern with an emphasis upon the review of services for which I am responsible within a wider context of the health needs of the area. Particular prominence has been given to the work of the School Health Service in view of its crucial importance, yet uncertain future, at the present time. The year under review has been one of progressive improvement as agreed policies have been implemented and key staff recruited. Significant advances in staffing levels have been recorded in most areas within the department and have enabled more appropriate services to be provided, and new ones to be introduced. The resultant increases in the output of the service are reflected in the improved statistics recorded in the report and require no further amplification. The year was also marked by the introduction of management concepts within the health department and by the application of specific management techniques. In July, management by objectives was extended to the health department and involved most senior professional officers. Contrary to expectation it was found that standards of performance could be accurately defined and could be quantified in over 70% of cases. The technique has already produced a clearer organisation pattern within the department and has helped to define more accurately the contribution which each manager is expected to make. At the same time the introduction of the technique within the management organisation of the department has in no way infringed the essential clinical freedom which each professional officer is expected to exercise during contact with individual patients. In the same month a research team from Birmingham University commenced an operational research study at the health control unit to determine what changes in existing practice or in staffing levels were necessary in the light of the changing patterns of aircraft movement at London (Heathrow) Airport. The present requirement upon the unit to have available at least one clerk/ receptionist at a moment's notice at any time of the day or night militated against any significant economies but the study did show that a modified shift system which would ensure that more staff were available when they were most likely to be needed would reduce the additional staff who would otherwise be necessary to meet the commitments imposed by the new pier. In November a detailed study of the work of the domiciliary nursing services was undertaken and each nurse provided details of the work undertaken during a two week period. It has been recognised that the number of home nurses employed in Hillingdon is less than the recommended level and, indeed, an interim addition to the establishment was agreed during the year. Nevertheless it was necessary to determine the current levels of work, the extent of unmet need in the existing case load and indeed the total need for nursing services within the community. It is certain that some of these needs can be met by staff other than state registered nurses and the results of this study will enable realistic decisions to be taken about future staffing levels. Vital Statistics The total number of births confirmed the continuing downward trend in birth rate which has been noted in London generally for some years. The number of deaths was similar to the previous year, and whilst annual fluctuations and relatively small numbers preclude precise statistical conclusions the trends of earlier years continued. The steady increase in the number of deaths from ischaemic heart disease and other cardiovascular manifestations was maintained together with the upward progression of deaths from malignant disease. Carcinoma of the bronchus remains the largest single cause of death in this latter group. The urgency of the need to persuade people to stop smoking is reinforced by the knowledge that 128 Hillingdon residents died from what may now reasonably be regarded as a potentially preventable disease. The infant mortality figures are, yet again, disappointing. The interruption in 1970 of the depressing trend in the mortality rate amongst young babies since the inception of the Borough has not been maintained, and the figure this year is worse than ever before. A more detailed analysis 3 has failed to identify specific aetiological factors. Both the still birth rate and the perinatal mortality rate show a significant and welcome improvement. There has been a substantial increase in the proportion of deaths occurring in the period from the 8th day to the end of the third month of life. Some 40% of all the deaths in the first year occurred during this period. If it is difficult to identify casual factors, solutions are easier to suggest. Significant improvements in the infant mortality rate have occurred during the present century in association with improvements in the child health services, and in the education of mothers in the health care of their children. It is essential therefore that the developments in these areas which have been commenced during 1971 should be maintained and improved. Infectious Disease The increase in the number of notified cases of tuberculosis is discussed in more detail in the appropriate section of the report. These figures are a timely reminder that whilst the trend towards the ultimate eradication of the disease in this country continues, renewed vigilance is necessary and control measures of proven value must be rigorously pursued. Difficulties sometimes arise in persuading patients to accept the need for continued treatment, and it was necessary to seek an order under the Public Health Act 1936 to ensure the compulsory detention of one patient in a local hospital because of the potential risk of infection to other members of the community. The exercise of these statutory powers is never welcome but the authority is sometimes presented with no other alternative. It is pleasing to record the decision of the Council during the year that all new employees whose work involves frequent contact with children will now be required to present evidence of a satisfactory chest X-ray examination every three years. The Department of Health and Social Security have requested comment to be made on the progress of schemes for contact tracing in the control of venereal disease. Following a meeting at the Department in July discussions were held with the consultant venereologist for the area. It was felt that the situation in Hillingdon showed important differences from the pattern in inner London and that the introduction of the contact tracing scheme would not be helpful. Arrangements were completed for more effective communications between the local clinic and the health visiting service. The number of cases of venereal disease continues to show an accelerating upward trend. The number of cases of smallpox reported to the World Health Organisation (52,098) showed a large increase compared with the previous year but over half the cases were reported from Ethiopia where a major eradication programme was introduced. In the rest of the world there was a further decline in the total number of cases reported and the number of countries reporting the disease was again reduced. These trends, to which reference was made in my previous report, led to a decision to discontinue the present programme of infant vaccination in this country and to concentrate upon a high level of protection amongst priority groups. Efforts were made to ensure that airport workers likely to come into contact with passengers from endemic areas were aware of the importance of protection and the facilities for its provision. Infant vaccination is no longer offered as a routine procedure but any child who, for particular reasons is thought to require vaccination may receive it providing no absolute medical contraindications exist. Co-ordination and Co-operation Although health centre development was not as rapid as had been hoped, arrangements were completed by the end of the year for 16 of the 91 family doctors who have surgery premises in Hillingdon to practise from accommodation provided by the Local Health Authority. The circulation of a weekly bulletin to family doctors ensures an interchange of information and discussions take place at an early stage when individual doctors are considering a new project even if this concerns matters such as the erection of surgery premises over which the department has no administrative control. Co-operation with the hospital services continues to improve and has been given fresh impetus by developments in the nursing services. Changes in nurse training have made it essential that community and hospital nursing services co-operate closely with one another and these developments have accelerated the trend to close integration of the nursing and midwifery services. It is usual for the community nurse to visit the hospital before the patient is discharged where further nursing in the community will be required. The introduction of the nursing management structure in the local authority service in November has facilitated this 4 process by creating a stronger link at first line manager level between the two services. The degree of co-operation which can obtain may be illustrated by the night nursing service which commenced on 1st December, 1971. A detailed description of this service appears elsewhere in the report. By providing care throughout the night in appropriate cases this service has already ensured that some patients who could otherwise receive adequate care from their family doctors do not have to be transferred to hospital merely because of their need of nursing attention during the night time hours. The service has been fully utilised from the moment of its commencement by family doctors whose patients it exists to serve. Nevertheless, the service itself is based in hospital premises made available to the staff of the local authority. This enables the community night nurse to benefit from the presence and support of her hospital nursing colleague and may also allow reciprocal support to be given to the hospital nursing services. Environmental Health Services Changes were made during the year in existing arrangements for pest control and concentrated responsibility for this service within the public health inspectorate. There was an impression that the rat population had increased and vigorous attempts at eradication were pursued. A report in the medical press gave further confirmation of the previously noted association between soft water and an increased mortality from certain causes. Enquiries from all of the local water companies revealed that the existing water supply in this area is relatively hard and apart from a limited degree of softening in one part of the supply, there are no plans to soften water supplies in the foreseeable future. Considerable interest was aroused later in the year by the discovery that one well in the area was producing a water supply containing 1 part per million of fluoride. Most waters in this area are deficient in this trace element which appears to be essential to the full protection of teeth from dental decay. Efforts to replace this deficiency by artificial means have foundered on the need for agreement amongst a variety of water companies and a number of different local authorities. The knowledge that a number of Hillingdon residents are enjoying the benefits of this satisfactory water supply was most encouraging and detailed plans were made to investigate the possible beneficial effect on children's teeth in the area of the supply. The Council continues to support the principle of fluoridation of water supplies in view of the obvious benefit to dental health that would result. Personal Health Services The Chief Nursing Officer, Miss J. Byatt, took up her duties in August and her report on the work of the community nursing services will be found on page 40. Reference has already been made to the major changes which have been introduced. At the beginning of the year a report on the dental service was received following a visit by a dental officer from the Department of Education and Science and the Department of Health and Social Security. The report gave impetus to changes which had already been foreseen and planned. The Chief Dental Officer describes the improvements which have occurred, elsewhere in this report. Circular 36/71 urged local health authorities to review their present family planning arrangements and meetings were held with hospital and family doctor representatives together with voluntary organisations working in the area. As part of the five year plan to develop health and social services in the area, it had been agreed in November 1970 that family planning facilities should be extended. The Council accelerated this programme in July 1971 and resolved to provide a medical advisory service free to all who might wish to use it with effect from 1st April, 1972, and to encourage the development of the service as quickly as possible. The appointment of Dr. Joan Marshall as consultant adviser in family planning matters enabled the Council's first directly administered clinic to receive her valuable professional guidance. Later in the year plans were completed to assume financial responsibility for Hillingdon residents attending the clinic at Mount Vernon Hospital operated by the International Planned Parenthood Federation. This clinic also provides valuable training facilities which enable local authority medical and nursing staff to obtain the additional training which will be necessary as the service expands. 5 Health Education The development of modern effective health education is one of the major priorities of the Health Committee. An appointment was made to the newly created post of Principal Health Education Officer and Mrs. P. Mahy, who took up her duties in September, describes some of the principles of the new service in her first report. Teaching the public about health has been practised in the department for many years, but it is necessary to review the effectiveness and the value of existing methods. New concepts have been developed in the teaching profession and these must be applied not only in schools but in every teaching situation presented to health personnel. Unfortunately it is not only the attitudes of those whom we seek to teach which need revision. The development of a coherent health education programme inevitably throws into prominence those sensitive subjects connected with personal relationships. For some years now the department has received requests for talks on venereal disease, biological aspects of sexual function and more recently, contraceptive advice. These requests underline the need to develop comprehensive community health syllabuses in schools in which these subjects may receive attention as a natural development of the child's understanding of its bodily functions. Although specialist visiting lectures may be required to give factual information on such emotive matters, the separation of these subjects from the normal education programme within the school can only emphasise their particular position, and make the promotion of healthier attitudes more difficult. If discussion about sexual matters is less inhibited among the young, their elders do feel that such very personal subjects should be considered in private. These attitudes may make it more difficult to introduce important screening techniques such as those for cancer of the womb. During the year a new card was introduced to make the scheme more widely known and to facilitate requests for testing, whether by the family doctor or by one of the local cytology clinics. A national scheme for reexamination was introduced at the end of the year in place of the previous local arrangements. The decision of the Health Committee to prohibit smoking at its meetings provided further welcome evidence of a changing public attitude to this potentially lethal habit. It was disappointing that this excellent example was not followed by any other Committee for, as a government report entitled "The Young Smoker" which was published during the year, made clear the adult population cannot escape its responsibility for the education of the young in these matters. The example of those in contact with young people whether as parents or as professional workers is considered to be a far more effective deterrent in this field than more formal health education. Social Services The Local Authority (Social Services) Act 1970 was implemented on 1st April, 1971, and the new social services department was brought into operation. The necessary close co-operation between the new department and the health department was facilitated by a joint administrative support section and by a single chief officer guiding the initial development of the two separate services. Shortages of staff inevitably added to the difficulties presented by the new organisational pattern but indications of an interruption in the previously close inter-relationships in the work of the two departments had given some cause for concern by the turn of the year. Reorganisation of the National Health Service The consultative document published during the year confirmed the intention to reorganise the health services outside local government but left almost all of the important questions for London unanswered. The emphasis upon a two tier system raised doubts concerning a growth in bureaucracy without real improvement in the service to patients and careful precision in the nature of decisions to be taken at regional and area level will be necessary. The emphasis upon management was welcome confirmation of the policies which the Council has already applied to its health services and to whose effectiveness the following pages bear witness. It is my pleasure to thank the Town Clerk and Chief Officers for their unfailing support and help throughout the year. I am particularly grateful to the staff of the former health and welfare department and to those of the present health department for their ready assistance during this 6 period of great change and upheaval. The early publication of this Annual Report imposes many pressures and difficulties on the staff, and the help which I have received in their solution is particularly appreciated. Finally, my thanks are due to all members of the Council for their constant encouragement in our efforts to provide services worthy of the citizens we seek to serve. I am, Yours faithfully, J. Stuart Horner Director of Health Services March 1972 7 8 HEALTH COMMITTEE (as at 31 st December, 1971) Ex-officio: The Mayor (Councillor 0. Garvin, M.B.E., J.P.) The Leader of the Council (Alderman A. J. C. Beck, O.B.E., J.P.) The Leader of the Opposition (Alderman W. D. Charles, J.P.) Chairman: Councillor J. Rowe Vice-Chairman: Councillor J. E. E. Walters Aldermen: J. C. Bartlett M. C. Wheeler, J.P. Councillors: Mrs. E. G. Boff N. H. Butler, F.lnst.L.Ex. R. H. Collman Dr. C. H. Nemeth, M.A., L.R.C.P., M.R.C.S., M.R.C.G.P. A. J. Potts L. Sherman F. E. Walsh, F.A.P.H.I. Advisory: Mr. E. S. Saywell (representing Harefield & Northwood Group Hospital Management Committee) Councillor G. P. Buttrum (representing Hillingdon Group Hospital Management Committee) Mrs. B. H. Brandes Mr. T. Cluny (representing Hillingdon Council of Social Services) Mrs. E. Paine J Mrs. W. Hobday (representing Hillingdon Federation of Residents and Tenants Associations) Dr. P. Knight (representing Middlesex Local Medical Committee) Mr. G. W. Horsley (representing Pharmaceutical Society of Great Britain) STAFF Senior Staff and Approved Establishments: Director of Health Services and Principal School Medical Officer: Dr. J. Stuart Horner, M.B., Ch.B., M.F.C.M., D.P.H., D.I.H. Deputy Medical Officer of Health and Deputy Principal School Medical Officer: Dr. C. Lydon, M.B., B.Ch., B.A.O., D.P.H., D.C.H. Principal Medical Officers: Dr. V. M. D. N. Shaw, M.B., Ch.B., D.R.C.O.G., D.P.H. Dr. J. W. E. Bridger, L.R.C.P., M.R.C.S. Dr. B. Westworth, M.B., Ch.B., D.Obst., R.C.O.G., D.P.H. Dr. P. R. Cooper, M.A., B.M., B.Ch., D.T.M., D.P.H. Dr. E. W. Jones (Assistant), M.B., B.S., D.I.H., D.P.H., D.T.M. & H. (Medical Officers in Department - 9) (Airport Medical Officers - 10) Chief Dental Officer: Mrs. B. Fox, B.D.S. (Dental Officers - 13) (Dental Auxiliary - 1) (Dental Surgery Assistants - 18) Chief Public Health Inspector: A. Makin, M.R.S.H., F.A.P.H.I. (Public Health Inspectors - 21) (Technical Assistants - 8) Chief Nursing Officer: Miss J. Byatt, S.R.N., S.C.M., M.T.D., Q.N., H.V.Cert. Liaison and Administrative Officer: W. H. Knapton Principal Health Education Officer: Mrs. P. Mahy, S.R.N., C.M.B.(Pt. I), H.V.Cert., Community Care Cert., F.E. Teacher's Cert. Principal Nursing Officer: Miss A. D. Mogford, S.R.N., C.M.B.(Pt. I), H.V.Cert. (Health Visitors, Clinic Nurses and Health Assistants - 55) Principal Nursing Officer: Miss A. L. Drossou, S.R.N., S.C.M., Q.N. (Home Nurses — 41) (Auxiliaries — 2) (Midwives - 19) Senior Nursing Officers: Miss G. M. Austin, S.R.N., S.C.M., H.V.Cert. Miss J. Fielding, S.R.N., S.C.M., H.V.Cert., Q.N. Mrs. P. Fisher, S.R.N., N.D.N.Cert. Mrs. M. Gow, S.R.N., S.C.M., Q.N. Mr. D. B. McBain, S.R.N., B.T.A., Q.N. Mrs. D. N. Philcox, S.R.N., C.M.B.(Pt. I), H.V.Cert. Mrs. A. M. Read, S.R.N., S.C.M., H.V.Cert. 9 SECTION I Statistics Infectious Diseases Health Control Unit London (Heathrow) Airport "Venienti occurrite morbo."—Plautus (Go out to meet the approaching disease) General Statistics Area—square miles 42.5 Population—Registrar General's Census for mid-year 1971 236,020 Number of dwellings 76,821 Rateable Value as at 1st April, 1971 £18,512,633 Product of Penny Rate—1971/72 (Estimated) £184,830 Vital Statistics Total Live Births: Male Female Total Legitimate ... 1,646 1,563 3,209 Illegitimate ... 106 88 194 1,752 1,651 3,403 Birth Rate per 1,000 population: Hillingdon —Crude 14.4 —Corrected 13.8 England and Wales 16.0 Area comparability Factor: 0.96 Illegitimate Live Births: Male Female Total 106 88 194 Percentage of total live births: 6 Still Births: Male Female Total Legitimate 19 15 34 Illegitimate 3 2 5 22 17 39 Rate per thousand live and still births: Hillingdon 11 England and Wales 12 Total Live and Still Births: Male Female Total Legitimate 1,665 1,578 3,243 Illegitimate 109 90 199 1,774 1,668 3,442 These births occurred as under: Live Births Still Births At home 694 3 In hospitals, nursing homes or other maternity establishments 2,709 36 3,403 39 13 Infant Deaths (under 1 year of age):  Male Female Total Legitimate 35 24 59 Illegitimate 2 1 3 37 25 62 Legitimate—rate per 1,000 legitimate live births 18 Illegitimate—rate per 1,000 illegitimate live births 15 Infant Death Rate per 1,000 total live births: Hillingdon 18 England and Wales 18 Neo-natal Deaths (under 4 weeks of age): Male Female Total Legitimate 24 19 43 Illegitimate 1 1 2 25 20 45 Rate per 1,000 total live births: Hillingdon 9 England and Wales 12 Early Neo-natal Deaths (under 1 week of age): Male Female Total Legitimate 21 12 33 Illegitimate - - - 21 12 33 Rate per 1,000 total live births: Hillingdon 10 England and Wales 10 Perinatal Deaths (Still Births and deaths under 1 week combined): Male Female Total Legitimate 40 27 67 Illegitimate 3 2 5 43 29 72 Rate per 1,000 live and still births: Hillingdon 21 England and Wales 22 Maternal Deaths: Total NIL Deaths from All Causes: Male Female Total 1,148 1,105 2,253 Death Rate per 1,000 population: Hillingdon —Crude 9.5 —Corrected Area comparability Factor: 1.24 11.8 14 Infectious Diseases Dr. C. Lydon—Deputy Medical Officer of Health The following tables show the number of cases of infectious diseases notified to the department during 1971: DISEASES Ages of Cases Notified Totals Deaths Under One Year 1 to 2 3 to 4 5 to 9 10 to 14 15 to 24 25 and Over 1971 1970 1971 1970 Scarlet Fever 9 20 43 6 7 1 91 69 Diphtheria Whooping Cough 22 26 20 55 7 5 135 49 Measles 33 282 357 507 19 4 6 1,208 1,256 Meningococcal Infection 1 2 2 5 3 Poliomyelitis (Paralytic) (Non-Paralytic) Acute Encephalitis Infective 1 2 3 6 9 Post Infective 2 Smallpox Tetanus 1 1 Typhoid 3 Paratyphoid 1 1 2 2 Dysentery 5 4 3 1 5 20 38 68 Food Poisoning 1 1 1 1 16 5 25 49 Malaria 1 2 3 Infective Jaundice 6 3 23 21 53 68 Ages of Cases Notified Total Under One Year One Year 2 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and Over Tuberculosis Pulmonary 2 4 2 2 2 5 9 4 3 12 7 1 53 Non-Pulmonary 1 2 4 3 1 5 3 19 For the twenty-second consecutive year, no case of diphtheria has developed in this area and it is now eleven years since a case of poliomyelitis was notified. 15 MEASLES 1971 was a "measles year". At any rate taking into account the bi-annual outbreaks of measles which has been the accepted pattern of the disease for some time (see table below), it should have been a measles year and at 1,208 notifications the incidence of the disease in the Borough was certainly higher than one would have wished in the fourth year of a measles vaccination programme. No doubt the accumulation of non-immune children during 1969 referred to in my last Report has continued to contribute to a higher incidence of the disease. The number of cases notified during 1971, however, is only one-third what one would have expected if the bi-annual pattern had continued and with noticeably few complications occurring amongst those children who developed the disease, the practice of routine visits by Health Visitors of all cases of measles occurring in the under 5 year old group was discontinued in 1971, thereby releasing these hard pressed officers for other more essential duties. It is confidently expected that the incidence of measles in the community in future years will be considerably reduced and the pattern of the disease will continue to be reviewed with interest. Year 7 965 1966 7 967 1968 1969 1970 1971 Measles Notifications 3,569 832 3,481 471 1,204 1,256 1,208 CHOLERA SURVEILLANCE As from 18th September, 1970, a valid international certificate of vaccination against cholera was required of every traveller who at any time during the five days immediately prior to his arrival in the United Kingdom had been in any country, any part of which had been notified to the World Health Organisation as currently infected with cholera. A single injection of vaccine given not less than six days and not more than six months previously is accepted as evidence of validity. Travellers arriving in this country who have visited an infected area within the previous five days and are unable to produce a valid certificate of vaccination are placed under surveillance for the remainder of the incubation period. The Medical Officer of Health of the district of destination is informed of each traveller arriving in the U.K. who requires surveillance and the Principal Medical Officer (Port Health) comments on page 26 on the problems presented to the Unit by this requirement. During 1971, two hundred and three (203) persons arrived in Hillingdon from areas in which cholera was currently present and were placed under surveillance. Most of those placed under surveillance were persons arriving home following holiday trips abroad, chiefly from Spain and Portugal although a few were travellers from Africa and India. Two of those placed under surveillance developed gastro intestinal symptoms while still within the cholera incubation period but none of these proved to be a case of cholera although organisms of the salmonella group were isolated in one instance. DYSENTERY Of the 38 cases of dysentery notified, the majority referred to persons infected with Sh. sonnei organisms although one case of infection due to Sh. flexneri type 6 was reported. There was also one case of amoebic dysentery notified. This was a lady from overseas who although symptom free, was found to be a symptomless excreter of this organism during a routine investigation. Her condition was treated at the Hospital for Tropical Diseases. 16 ENTERIC FEVER No case of typhoid occurred within the Borough although a number of residents had to be investigated because of contact with cases in neighbouring authorities. There were two cases of paratyphoid fever. One, a 15 year old girl was a member of a family who spend part of each year abroad. This girl developed symptoms one week after returning from Beirut and subsequently paratyphoid B infection was confirmed. The other was a 26 year old man who became ill one week following return from holiday in Turkey. In both cases the infection cleared up quickly and investigation of contacts did not bring any secondary case to light. The elderly gentleman found to be a symptomless excreter of paratyphoid organisms and mentioned in the 1970 Annual Report continues to excrete the germs and remains under observation. He has no disability due to the infection but because of his age and cardiac condition, he is housebound and is not considered to be a source of danger to others. FOOD POISONING There was no serious incident of food poisoning in Hillingdon during 1971. No general or family outbreak occurred but 25 sporadic cases were notified, in 9 of which the causative organism was not discovered. There was one death associated with food poisoning—a 75 year old lady who had been in poor health for some time and who developed pneumonia and a stroke while in hospital being treated for salmonella infection. The types of salmonella organisms identified during the year were as follows Salmonella typhimurium 8 Salmonella enteritidis 2 Salmonella senftenberg 2 Salmonella infantis 1 Salmonella newport 1 Infectious diseases cases admitted to St. John's Hospital direct from Heathrow Airport (not notified on weekly return): Gastro enteritis 13 Dysentery 6 (2 amoebic, 1 boydii type 8, 1 flexneri type 2b, 2 other bacilli) Salmonella 2 (1 senftenberg) Typhoid 1 Paratyphoid 1 (Paratyphoid A) Infective Jaundice 6 Meningitis 1 (Meningococcal) Tuberculosis 7 17 INFECTIVE JAUNDICE All notified cases of infective jaundice continued to be visited. During the year, the details concerning nine cases were notified to the Blood Transfusion Centre because of family contacts who were on the list of blood donors. MALARIA During the year, three cases of malaria occurred amongst residents in the Borough. The patients were all members of the same family and the disease had been contracted naturally abroad. The family consisted of mother and father and a son aged 3 years 9 months, all of whom developed an "influenza" type illness ten to twelve days following return to this country. None of the patients was reported to have been taking suppressive drugs during the preceding two years and blood investigation showed Falciparium Malarial infestation. All three persons were admitted to the Hospital for Tropical Diseases for treatment. TETANUS One case of tetanus was notified during 1971. This was in a 29 year old man who had a history of having lacerated his knee while playing football some ten days before the onset of symptoms. The treatment received for his knee injury had not included the administration of tetanus toxoid or antiserum although the patient's immunisation history indicated that he had received a primary course of tetanus toxoid previously. The patient was acutely ill for approximately two weeks but eventually made a satisfactory recovery. TUBERCULOSIS A total of 72 cases of tuberculosis affecting Hillingdon residents came to the attention of the department during 1971—an increase of 17 over each of the two preceding years. Eighteen other cases of tuberculosis diagnosed outside the Borough in people who moved into this area during the year were also notified to this Authority making a total of ninety cases to be followed up for the first time during the year. The incidence of tuberculosis in this country has decreased dramatically over the past twentyfive years, particularly in young adults among whom the highest notification rates used to occur. There has been an apparent slowing-down in the rate of decline in notifications of tuberculosis in young adults which some have suggested is associated with the reported high notification rates in young immigrants. From the age distribution of cases shown in the table on page 15, and from the nationality distribution shown below, it would not appear that infected young immigrants make a major contribution to the notified cases of tuberculosis in this area. Nationality No. of cases notified 1971 1970 English 44 37 Indian 12 9 Pakistani 5 3 Irish 5 4 Chinese 2 1 African 1 Austrian 1 Falkland Islands 1 Welsh 1 Scottish — 1 Total 72 55 18 The following table indicates the incidence of pulmonary and non-pulmonary tuberculosis in those over and under twenty-five years of age over the past five years: Tuberculosis Notifications 1967-71 Year Under 25 years Over 25 years Total 1967 P 14 37 51 NP 5 9 14 1968 P 16 32 48 NP 1 13 14 1969 P 8 32 40 NP 3 12 15 1970 P 10 32 42 NP 4 9 13 1971 P 17 36 53 NP 7 12 19 P = Pulmonary. NP = Non-pulmonary. Of the nineteen non-pulmonary cases of infection notified during 1971 cervical glands were affected in thirteen cases, five more than in 1970 (11 of the non-pulmonary cases were born outside the United Kingdom). There was one case of tuberculous meningitis and the other five non-pulmonary cases affected kidney, knee, epididymis, intestine and one case of ischiorectal abscess. No fewer than ten of the fifty-three (53) cases where lungs were infected were primary complexes in young children. This represents an increase of six on the number of primary cases notified last year and all of them were discovered as a result of investigations carried out among contacts of other notified cases. Four of the primary complex cases resulted from investigations carried out when a teacher in one of the Council's junior schools was found to have an infectious form of the disease. In this particular episode, three hundred and five (305) children were tuberculin tested and all members of the staff offered chest X-ray examination. On page 110 reference is made to the Council's decision to make routine chest X-ray examination a condition of service for all persons whose work involves close and continuous contact with children and this incident highlights the risks to which young children can be exposed when in contact with infectious cases of tuberculosis. Of the 43 adult cases of pulmonary tuberculosis, no fewer than 20 were in the over 55 year old group and 13 of these had positive sputa confirming the widely accepted view that it is the older people who continue to form a reservoir of infection within the community. Several chest physicians believe that the reduction in tuberculosis in England and Wales over the past quarter of a century has given rise to dangerous misconceptions about the present level of the disease in the community, some physicians now regarding tuberculosis as rare. The increase in the number of notifications received by this Department during 1971 is due chiefly to the greater number of non-infectious glandular cases notified and to the success of tuberculin surveys carried out among contacts which brought to light 10 primary cases of infection. Clearly 19 however, tuberculosis is not a rare disease and with such a high percentage of sputum positive cases continuing to be discovered in the community, the time is far from opportune when one can be complacent about this disease which in 1970 caused 1,465 deaths in England, more than the total of deaths attributed to all other notifiable infectious diseases. As well as the investigation in the junior school referred to above, one-hundred-and-twelve students in a college for further education (Bible College) were also investigated when an infectious case of tuberculosis was discovered amongst one of the students. No other active cases were discovered. PUBLIC HEALTH ACT 1936—SECTION 169 An Order pursuant to the above Act was obtained from the Justices in relation to one patient who, although a sputum positive infectious case, was continually absenting himself from hospital and knowingly exposing other persons to the risk of infection. The patient was detained in hospital until it was considered that his disease was arrested and that he was no longer a danger to others. TUBERCULIN TEST AND BCG VACCINATIONS FOR YEAR ENDING 31st DECEMBER 1971 Number of persons vaccinated through the Authority's approved arrangements under Section 28 of the National Health Service Act. Contacts: Skin tested 722 Found Positive 84 Found Negative 233 Vaccinated 233 Babies vaccinated at birth — School children and students excluding those known to have received BCG vaccination already : Skin tested 2,259 Found Positive 89 Found Negative 2,170 Vaccinated 2,170 VENEREAL DISEASE The problem of sexually transmitted disease is considered to be less acute in this country than in other parts of the world. The effects of screening, etc., in ante-natal clinics and of contact tracing in helping to contain syphilis is recognised. Gonorrhoea, however, is not under control, and although the rate of increase is not at anything like the same level as in other countries, the problem, especially in the London area is becoming particularly serious. About half of the total new cases attending clinics in England for gonorrhoea are now being recorded in the London area. In July 1971, a conference on contact tracing was convened at the Department of Health and Social Security by the Chief Medical Officer, Sir George Godber, at which representatives from the Health Departments of all the London Boroughs attended. Venereologists and welfare officers representing all of the special clinics in the London area as well as representatives from the Metropolitan Regional Hospital Boards, general practitioners and the Department of Health and Social Security, also attended. The conference recommended that contact tracing in the Greater London area should be better organised and intensified. Physicians in charge of special clinics agreed to consider in consultation with local health authorities whether the present provision of "welfare officers" was adequate and each Medical Officer of Health was requested to designate one or more health visitors for liaison duties with these special clinics. As well as providing local information and on occasions, assistance with visiting of contacts, the function of the liaison officer would include acting as a point of reference for contact tracing staff at the clinics outside the authority's area. 20 Discussions have taken place between the staff of this department and the local Consultant Venereologist. There is no welfare officer at local clinics but it has been agreed that a senior nursing officer should be the appropriate point of contact in this area. The following are the returns made to this department in respect of residents of the Borough by physicians in charge of centres for the treatment of venereal disease in the Greater London area: Hospitals NUMBER OF NEW CASES Totals all Venereal Conditions Syphilis Gonorrhoea Other Genital Infections Other Conditions Primary and Secondary Other Hillingdon 1.170 1 7 111 706 345 Central Middlesex 31 1 4 10 16 Middlesex 128 1 6 74 47 St. Bartholomew's 10 1 4 5 St. Thomas' 11 6 5 Seamen's 1 1 Westminster 6 3 3 Whitechapel Clinic 14 3 9 2 Totals: 1971 1,371 2 9 124 813 423 1970 1,011 3 3 108 897 1969 992 2 4 109 807 WHOOPING COUGH There was a sharp rise in the number of notified cases of whooping cough (pertussis) during 1971. The 135 notifications represent a notification rate for the Borough of 56 per 100,000 compared with a rate of just over 20/100,000 last year and a national rate of 34/100,000. In two neighbouring authorities, the rates are 22 and 10/100,000. How much the increase in notifications in Hillingdon represents a true increase in actual cases of whooping cough as distinct from cases of paroxysmal cough is not clear. Since 1969 this department along with a number of other health departments throughout the country has been co-operating with the Public Health Laboratory Service in carrying out a survey into the efficacy of the whooping cough vaccines at present in use. The surveillance is based on the attack rates of immunised children in home contact with a notified case of pertussis. As bacteriological confirmation is essential, a health visitor visits each notified case and takes a pernasal swab from the case and any contacts who subsequently develop symptoms will also be similarly swabbed. On occasions throughout the year, the department's weekly bulletin to family doctors has included a reminder of the need for prompt notification of all whooping cough cases in an attempt to increase the chance of isolating the organism and bearing in mind how difficult clinically it can be to diagnose whooping cough from other, particularly viral, causes of paroxysmal cough, it is possible that general practitioners in their desire to co-operate, notify "suspected" cases which have helped to boost the returns for 1971. Of 268 children from whom pernasal-swabs were 21 taken during 1971, in only five cases was Bordetella pertussis (the organism which causes whooping cough) isolated. In 1968 the immunisation/vaccination schedule was altered and since that date, vaccination against whooping cough has been delayed in most cases to the age of six months and has not been completed until about fourteen months of age. It has been noticed nationally that the case rates of pertussis in the under one year old relative to those in the 1-4 year old age group, have increased since the change of schedule and at 22 (16.3%) the number of notifications of whooping cough in the under one year age group in this area for 1971 is the highest to date. Paroxysmal cough can be more distressing in the very young than in the older child and undoubtedly, many such cases are brought to the attention of family doctors by anxious parents resulting in a more realistic notification rate for this group. The Bordetella pertussis isolation rate has been found to be higher in this age group also and of the five pernasal-swabs found to be positive which were mentioned above, three of them were in the under one year of age group and two of these were in the pre-vaccination age group—one being only six weeks old. It is clear that throughout the country there is a wide range in the notification rates for whooping cough which is difficult to explain on epidemiological grounds and undoubtedly, local factors play an important part in deciding what the rate for a particular health area will be. Any clinically recognisable difference between whooping cough due to Bordetella pertussis and other agents would be of great importance as an aid to more positive diagnosis. Also the introduction of a serological test to confirm a diagnosis of whooping cough would be very valuable and it is likely that studies on these lines to be undertaken by the P.H.L.S. in the future, may be helpful to bring about more realistic notification rates. It seems probable that in the light of current investigations, information may be forthcoming which will be of value in influencing the immunisation policy of the future. Health Control Unit, London (Heathrow) Airport Dr. P. R. Cooper—Principal Medical Officer (Port Health) The year under review saw the completion of Heathrow's first twenty-five years of life and the event was duly celebrated on 27th May. The Airport has gone a long way since 1946 when the terminal accommodation was provided by tents and Nissen huts. During the same period, changes occurred also in Health Control. In 1946 the responsible authority was the Urban District Council of Yiewsley and West Drayton; later in that year, there was a take-over by the Ministry of Health which for a short time exercised direct control before transferring the responsibility to the Middlesex County Council, which in 1965 passed it to the Borough of Hillingdon. In the last twenty-five years, the event which had the greatest impact on the Unit was the introduction in 1962 of the Commonwealth Immigrants Act. The resulting work-load stemming from this increased annually. On the other side, there is the general world wide improvement in the smallpox situation. Not since the winter of 1961/62, when the United Kingdom had its last major outbreak, has attention been focussed so much upon the Unit and its activities singled out for so much publicity. By way of digression, it is interesting to speculate what will be required of a port's Health Control Unit in the next five years—let alone twenty-five. The World Health Organisation's eradication campaigns against smallpox have been so successful that it is probable that this condition will be sufficiently under control for relaxation to be permitted of measures now imposed at ports of arrival. On cholera, it may well be that within much sooner than five years passengers will no longer be required to present certificates of inoculation on arrival. The effect of other changes upon the Health Control Unit cannot yet be foreseen. The United Kingdom's entry into the European Community will have some effect upon the present medical 22 provision of the Commonwealth Immigrants Act and the Aliens Order. The free movement of manpower within the Community is to be encouraged but it is not yet clear whether this will be accompanied by a relaxation of Port Health Controls between constituent members. Similarly the Immigration Act 1971 is likely to affect the work load of the Unit. Finally, the re-organisation of the National Health Service scheduled for 1974 is bound to have repercussions upon the Unit. The need for the service will remain, and re-organisation must provide a satisfactory framework within which the Unit can operate effectively. To return however to the present, an interesting development during the year was a closer identification of the Borough's Health Services with the Health Control Unit at Heathrow. One consequence of this was to introduce into the Unit a system of Management by Objectives, which was being applied to all departments of the Council under the advice and guidance of Messrs. Urwick Orr and Partners—a firm of consultants specialising in this field. Considerable time and thought was given in preparation for this project. As yet it is too early to assess how valuable the exercise has been but preliminary indications are that it is proving to be something that was required. In an endeavour to improve the Unit's efficiency, plans were drawn up towards the end of the year to introduce a properly organised staff training programme. Hitherto, the training of receptionists has been somewhat haphazard, and it was not until shift-leaders were appointed in 1970 that this important subject received any real attention. With the appointment of the Council's first Principal Health Education Officer, it became possible to arrange a course of inservice training. The first such course is due to be held early in 1972. It is hoped that not only will it prove of benefit to all who attend it but also that the interest which it arouses will in some way counter the rate of staff turnover, which in recent years has been such a disturbing factor at Heathrow. STAFF Medical Officers Early in the year, Dr. E. W. Jones was transferred to other duties in the Health Services of the Borough. In his place, Dr. M. J. James was appointed and he took up duty on 21st May. At the end of the year, there was one vacancy on the establishment. Receptionists At the end of 1970, the authorised establishment was one Senior Clerk/Receptionist, six Shift Leaders and fifty-eight receptionists—a total of sixty-five. In post, in addition to the Senior Clerk/Receptionist, there were five Shift Leaders and fifty-three receptionists. The outstanding vacancy for Shift Leader was filled in January. As far back as 1969, in anticipation of the introduction of Boeing "747's" on African and Asian routes, application had been made to increase the number of receptionists by 43%. In view of the fact, however, that at the start the "747's" were confining their operations to the North Atlantic route, and that, in the event, they were carrying only 50%-60% capacity, the increase in the establishment became less urgent. Before any agreement was reached upon the final increase, it was decided to carry out a research study at Heathrow and the terms of reference were "to review the existing methods of work of clerk/receptionists in the light of the introduction of Boeing 747 aircraft on routes subject to health control, and to make recommendations concerning any changes in methods of work or in staff establishment which may be necessary in the light of these changes, either now or in the future". This study was undertaken by the Operational Research Unit of the Department of Engineering Production, University of Birmingham, and the recommendations included one to the effect that the staff should be increased by 23% as from April 1st, 1972, and another effecting a change of shift system. Before the Research unit's report was completed, however, approval had been received from the Department of Health and Social Security that a further twelve receptionists could be 23 engaged. By the end of the year, approval had been given for the establishment to be increased by an additional ten receptionists, effective from 1st April, 1972, on the lines suggested in the Birmingham report. During the year the high rate of turnover of staff continued. Twenty-six receptionists resigned and thirty-three were appointed, leaving fifteen vacancies to be filled on 31st December. It seems that the main reasons for leaving are either marriage or the attraction of an airline. A closer study of the reasons is being undertaken and to this end a fairly detailed questionnaire is being issued to those who resign, in the hope of gaining an insight into staff problems, and thereby reducing the rate of turnover. Much time was lost to the Unit as a result of sickness. There is no doubt that some of the uncertificated absences were due to genuine illness, but it was noticeable that certain members of the staff were absent for the odd shift on far too many occasions and these were often receptionists whose work and efficiency was below standard in other respects. ACCOMMODATION Terminals 1 and 2 There were no changes to record. Terminal 3 (Arrivals Building) Piers 5 and 6 and North Coach Station Despite ups and downs in the number of available receptionists, the Unit maintained a service for flight clearance of health-controlled flights on Piers 5 and 6 and at the North Coach Station without causing too much complaint. Improvements in regard to heating and lighting of the desks on Piers 5 and 6 which had been scheduled to start at the end of 1970 were halted owing to controversy over the central desk at each "finger". This related to the use of these desks by the airlines for security purposes when their staff were checking outgoing passengers. By the end of the year, no definite decision had been reached on this contentious matter, although it was agreed to delay no further the work required on the two side desks of the fourteen "fingers". A cold spell during November rendered the North Coach Station almost untenable, due to failure of the ceiling heaters and also to the fact that airline staff escorting flights through Health Control failed to close the outside doors. Improvements occurred when the Airport Management and their engineers eventually repaired the heaters and agreed to erect anti-draught screens between the check desks and the outside doors. Pier 7 This Pier, designed primarily for use by the "Jumbo" jets received its first health-controlled flight when Air India started Far East operations in May. Thereafter this airline brought in three flights per week. As a special concession, the staff agreed to clear their passengers at the Gate rooms on Pier 7, despite the fact that there were no facilities. During November and December, BOAC started "747" operations to and from the Far East and South Africa, likewise Qantas from the Far East, South African Airways from South Africa and Pan American Airways from the East. All these flights, which were subject to health control, were cleared on Pier 7 despite the shortage of staff. Desks were loaned by the British Airports Authority and passengers requiring revaccination had to be escorted back to base in the Terminal Arrivals Building. At the end of the year the position was that the tenancy agreement between the British Airports Authority and the Borough had been signed, as also had repayment forms for minor works to be carried out by the British Airports Authority in the immunisation accommodation. The work was scheduled to be completed early in 1972. 24 HEALTH CONTROL—GENERAL On 1st July, the Aircraft General Declaration, containing the health declaration section, was discontinued by agreement between the airlines and the Home Office, the Treasury and Excise and the Department of Health and Social Security. The details which were provided on this Form and which were of interest to the Health Control Unit, included the route of the flight, the names of the last change of aircrew, the numbers of passengers disembarking and the numbers in transit, together with reports of illness, other than airsickness or the effects of accidents. At the time that this proposal was discussed, certain disadvantages were pointed out to the Department of Health and Social Security, but it was agreed that if airline captains had anything positive to report regarding illness on board they would pass such information by radio. One effect has been that it is no longer possible to classify the origin of flights and of passengers into various areas, e.g. Asia, Africa, Central and South America, etc. This has been accepted by the authorities. Some of the other information formerly supplied could be obtained, should need arise, from alternative sources. COMMUNICABLE DISEASES Admissions to St. John's Hospital, Uxbridge included: Gastro-enteritis 12 Infective Hepatitis 5 Salmonellosis 3 Varicella 2 Bacillary dysentery Rubella 2 1 Infective mononucleosis 1 Tonsillitis, upper respiratory tract infection, pharyngitis, septic throats and bronchopneumonia were the causes of other admissions. Smallpox No cases of smallpox were reported in the United Kingdom during 1971, although on five occasions at Heathrow it was necessary to call upon the services of a Smallpox Consultant for examination of a suspect passenger. In two instances the suspect condition was recognised during flight. It was therefore possible to record the names and addresses of all passengers and crew before they disembarked. In the other three instances, suspicion was aroused respectively during certificate presentation at the check point, at the immunisation room when a doubtful certificate was being examined by the Medical Officer, and in the cubicle area during routine immigrant examination. Only in the first of these was it possible to obtain names and addresses of potential contacts and then by no means all of them. Routine inspection of vaccination certificates was carried out of persons arriving at Heathrow from or beyond countries of Asia and from most countries of Africa. In addition, spot checks were made of passengers from Asia who had transferred to London-bound flights at Frankfurt and who had not been subject to health control at that port. As was the case in 1970, the number of such passengers who failed to present valid certificates was insignificant. During the year, the USA announced a modification of the smallpox vaccination requirements for entry to that country. The presentation of vaccination certificates is now only in regard to persons who have within the previous 14 days been in countries reporting smallpox. This does not, however, represent an elimination of the requirement for proof of immunisation against smallpox. Retention of the requirement allows for flexibility by the United States Public Health Service. By this modification, the United States falls in certain respects into line with the United Kingdom, which normally does not require passengers from either the United States or Canada to present smallpox vaccination certificates on arrival. The number of passengers placed under surveillance for smallpox during the year was 2,603; the number of passengers who were isolated in hospital was 92. 25 Malaria Two cases of malaria were recorded. One patient was admitted to the Hospital for Tropical Diseases where parasites of Plasmodium malariae were found in the blood films. The second case, admitted to St. John's Hospital, Uxbridge, was one of malignant tertian malaria. Cholera The year past saw the extension of cholera into Spain and Portugal from the North African countries. Barcelona and Valencia Provinces and the suburbs of Lisbon became infected areas and from these areas cases were imported into Sweden and France. The United Kingdom reported one case imported from Tunisia. Passengers coming from infected local areas in such countries were placed under surveillance unless their international certificates of vaccination against cholera were valid, and all passengers arriving on flights from these areas were given a Council of Europe (Partial Agreement) Yellow Warning Card. Since so many British holiday-makers visit Spain and Portugal each year, the decision to subject flights to health control placed a considerable burden upon the Unit's staff, as well as causing nuisance to the travelling public. There is a certain confusion of thought at present regarding policy on cholera and what measures should be taken to prevent its importation. Even the efficacy of cholera immunisation itself is in dispute. Towards the end of 1970, the USA decided that cholera vaccination certificates would no longer be required from travellers arriving there, even when they came from infected areas. There are many in the United Kingdom who support this action, but owing to the Government's obligations under the Administrative Arrangements of the Council of Europe (Partial Agreement) and its inability to act unilaterally, similar action cannot yet be taken in the United Kingdom, although it must be recognised that within the countries signatory to the Council of Europe (Partial Agreement) there may be considerable variation in standards of hygiene, of water supplies and of sewage disposal. Until cholera spread from the Far East to the Middle East, North and West Africa in 1970, it was not the practice at ports of arrival in the United Kingdom to require a cholera vaccination certificate and it is encouraging to note that the whole question is to be reviewed by the Council of Europe Public Health Committee and the Group of Experts in 1972. The number of passengers placed under surveillance was 4,928. MEDICAL EXAMINATION OF COMMONWEALTH IMMIGRANTS The total number of Commonwealth Immigrants referred to the Medical Inspectors over the last five years was: 1971 39,961 1970 44,611 1969 44,575 1968 46,828 1967 16,061 The number of Forms Port 23 completed in 1971 was 62 (69 in 1970). The categories of those immigrants seen in 1971 was: (a) Voucher-holders or entitled dependants 28,976 (b) Non-entitled dependants 10,880 (c) Those appearing to be mentally or physically abnormal 19 (d) Those appearing not to be in good health 32 (e) Those mentioning health as a reason for their visit 54 The number of refusals following medical recommendation was 12. Mental instability 7 Pulmonary tuberculosis 2 Drug addiction 1 Congenital lung disease 1 Senile degeneration 1 26 MEDICAL INSPECTION OF ALIENS The total number of aliens referred to the Medical Inspectors during the last five years was: 1971 9,432 1970 8,488 1969 6,203 1968 5,351 1967 5,314 The number of Forms Port 12 in 1971 was 103 (81 in 1970). The categories of aliens seen in 1971 was: (a) Those appearing to be mentally or physically abnormal 93 (b) Those appearing not to be in good health 43 (c) Those appearing to be bodily dirty 2 (d) Those mentioning health as a reason for their visit 90 (e) Those intending to make their home in this country or to remain for more than six months 9,204 There were 73 refusals on medical recommendation (68 in 1970). The reasons for recommendation were: Mental instability 55 Cholera 1 Pulmonary tuberculosis 7* Pregnancy 1 Drug addiction 5 Non-medical 1 Venereal disease 3 * Two of these cases were not X-rayed at Heathrow, hence the apparent discrepancy in the section on tuberculosis. X-RAY UNIT When the Ministry of Health installed the Odelca Camera in the Oceanic Building (now Terminal 3) in 1965, it was intended primarily for the X-ray of chests of immigrants arriving in that terminal to exclude pulmonary tuberculosis. It was considered at the time that there were so few immigrants arriving in the Europa Terminal that the installation of a second unit was not justified. Should any immigrant be suspected, on clinical examination, of suffering from this condition then arrangements would be made to transport the passenger over to Terminal 3 for X-ray. It was, however, felt that there were too many practical difficulties for routine X-ray examination to be carried out of all immigrants arriving in the Europa Building (now Terminal 2) and in Terminal 1. Since 1965, the number of immigrants arriving in Terminals 1 and 2 has steadily increased. In the middle of August 1971 it was decided to keep records of those immigrants—both Commonwealth and alien—who arrived in Terminals 1 and 2 and who would in the normal way have been X-rayed had there been on-the-spot facilities for this to be done. These records show that between 15th August and 31st December 2,133 aliens out of a total of 2,576 would have been X-rayed; for Commonwealth immigrants the figures were 1,149 out of 2,436. Pro-rated for the year these figures become: Aliens - 5,688 Commonwealth - 3,064 Total - 8,752 It is a matter for consideration whether these figures now merit the installation of a second X-ray unit. The total number of immigrants X-rayed during 1971 was 9,383, and of these 8,576 were from Commonwealth countries and 807 were alien or stateless. The usual monthly trend was again followed in that there was a steady increase in the number of X-rays taken from 674 in January up to a peak of 1,257 in September—nearing the start of the academic year—and then falling off again to 639 in December. There is no doubt that this latter figure would have been considerably higher, but for the Indo-Pakistani war which interrupted all flights. During the year the Radiographer trained 15 clerk/receptionists to operate the plant in her absence. 27 Pulmonary Tuberculosis Thirty-three persons were discovered to have active pulmonary tuberculosis during the year. The figure for 1970 was 40. The country of origin was as follows: Pakistan 11 Kenya 3 Egypt 1 Philippines 1 Yemen 1 India 1 Uganda 2 Morocco 1 Solomon Islands 1 Turkey 1 Hongkong 4 Nepal 1 Tanzania 1 Seven persons were refused landing on account of the condition, one each from the Philippines, Egypt, Turkey, Yemen, Morocco, Pakistan and Kenya. One hundred and thirty immigrants were landed subject to conditional entry from the following countries: Pakistan 60 Uganda 9 Burma 1 Solomon Islands 1 India 33 Hongkong 3 Ceylon 1 Trinidad 1 Kenya 17 Tanzania 3 Guyana 1 Of these, 12 immigrants were reported as confirmed cases; 20 were reported upon as clear. At the end of the year there were still a number upon whom no follow-up had been received from destination health departments. OTHER ACTIVITIES An international airport as large and as busy as Heathrow is a fascinating place and Heathrow is within easy reach of London. Those responsible for receiving W.H.O. Fellows and other overseas visitors take advantage of these facts and often include a trip to the Airport, especially when the visitor has an interest in international health and control procedures. During the year distinguished medical visitors were received from Malaysia, Singapore, India and Ceylon. W.H.O. Fellows from Botswana, Gambia, New Zealand, Poland and Sudan, visited the Unit during the year together with two Immigration Officers from Afghanistan. The Annual Conference of the Association of Sea and Air Port Health Authorities was held in Southwark on 30th June, 1st and 2nd July, and was attended by the Chairman of the Health Committee, the Director of Health Services and the Principal Medical Officer. 1967 1968 1969 1970 1971 Total aircraft movements: 236,376 247,417 293,745 270,169 282,432 ** Total passenger flow: 12,635,996 13,355,906 14,314,882 15,606,719 16,332,442 * * Provisional figure. ** There were no fatal aircraft accidents. IMMUNISATIONS Vaccinations against Smallpox Vaccinations against Cholera 1971 6,413 1971 2,008 1970 8,998 1970 1,515 1969 10,254 1969 611 1968 10,293 1968 327 1967 9,158 1967 261 28 Port Health Control—The arrival of passengers from a Boeing 747 aircraft Number of Passengers Isolated 1971 92 1970 137 1969 88 1968 46 1967 20 Vaccinations against Yellow Fever 1971 225 1970 131 1969 103 1968 73 1967 47 STATISTICS Total number of Aircraft issued with Disinsectization Certificates 572 No. of cases for which Mental Welfare Officer was called 34 No. of Aliens inspected under Aliens Order 9,432 No. of Forms Port 12 issued 103 No. of Aliens refused entry 73 No. of Commonwealth Immigrants examined 39,961 No. of Forms Port 23 issued 62 No. of Commonwealth Immigrants refused entry 12 No. of Immigrants X-rayed 9,383 No. of Long-Stay Immigrants Notifications sent to Medical Officers of Health 29,202 No. of Conditional Landing Forms sent to Medical Officers of Health 180 No. of Surveillance Notifications sent to Medical Officers of Health 7,531 No. of Smallpox Vaccinations carried out 6,413 No. of Cholera Vaccinations carried out 2,008 No. of Yellow Fever Vaccinations carried out 225 No. of Unvaccinated Passengers Isolated 92 OPERATIONAL RESEARCH STUDY Professor K. B. Haley of the Department of Engineering Production at Birmingham University was commissioned to undertake an operational research study at the health control unit, and the detailed investigations were conducted from July to September, 1971. I am grateful to Miss Susan Blessed, one of the members of the research team based at the airport during this period for the following report: An Operational Research team from the University of Birmingham was requested to undertake a three-month study to investigate the optimum number of clerk/receptionists necessary, and to examine the methods of work in the health control unit at London (Heathrow) Airport. It was foreseen by members of the unit that additional receptionists would be required to cope with the work generated by the proposed increase in Boeing "747" aircraft (jumbo-jets) requiring health control. In 1971 there were almost 200 plane arrivals per week whose passengers were subject to control by the unit, and 4 of these were jumbo-jets. However, in 1972/3 there are expected to be 300 arrivals per week, 48 of which will be jumbos. The early stages of the study entailed close observation of the existing system and discussions with members of the health department, in order that the problem area could be identified. It soon became evident that the uncertainty of aircraft arrivals caused difficulties in the unit and resulted in slack and busy periods. Since little could be done to even out the work-load throughout the day and night it was decided, as an alternative, that if a twenty-four hour shift system could be designed to cater for these extremes, the work-load would at least be handled more easily. To develop this it was necessary to obtain additional information from other organisations at the airport, in particular the airlines themselves. Consultation with British Airports Authority and careful examination of past records revealed that the aircraft stands (disembarkation points) most frequently used were those closest to the health control unit itself. However, since some of the stands are situated at least fifteen minutes' walking time from the unit, enquiries had to be made regarding the length of time airline staff would hold passengers on an aircraft before releasing 29 them without health clearance, should a receptionist not be readily available. The answer given was one or two minutes, and it was thus clear that the shift system must be designed to permit sufficient girls to be available at all times. It was noted that, should the need have arisen, the health control unit were entitled to hold an aircraft for up to two hours, although this was not considered desirable. The unit was not informed in advance of the approximate passenger load of each aircraft. It was not therefore possible to determine how many receptionists should be sent to clear a flight. The usual practice was to send two receptionists to a conventional aircraft and four to a jumbo, but this was not always satisfactory. Designing a shift system to meet the needs of the years ahead required complete schedules for that period. Requests for the proposed 1972/3 timetables were made to the airlines concerned, however British Overseas Airways Corporation ultimately provided the majority of these. From the information collected it was possible to construct a mathematical model and subsequently a computer programme, which could be applied to a specific timetable. This formed the basis for developing a suitable shift system and for determining the number of receptionists required to meet flights. The assumption was made that two receptionists meet a conventional aircraft and four a jumbo, and the efficiency of the model was measured in terms of the percentage of aircraft inadequately served, i.e. where fewer than the specified number of receptionists were available. The model was applied to specific timetables and, for each hour, an estimate obtained of the number of girls required to meet flights. The fluctuations in work-load were thus highlighted and a shift system built around these. After applying the model to the 1971 schedule the conclusion was made that the health control unit appeared to have sufficient staff to cope with the work-load generated. However, using the same method for 1972/3 it was evident that additional staff would be reouired. A possible shift system for 1972/3 was: 0900 hours 2100 hours 0700 hours 1300 hours 0900 hours 2100 hours 1300 hours 2200 hours as opposed to the current system: 0830 hours 2030 hours 0730 hours 1930 hours 0830 hours 2030 hours It was decided that a total of 80 receptionists would probably be sufficient for the suggested system. This included staff to deal with the work in the other sections of the unit but it did not include shift leaders. It was concluded that the existing level of staff in 1971 appeared to be adequate to cope with the current volume of traffic. However, more receptionists would be required for 1972/3. The recommended shift system would permit the new jumbo pier to be manned as necessary. Finally, it seemed that the flow of work in the health control unit would be facilitated if there were more co-operation from the airlines. It would be most helpful if the unit were informed well in advance of the aircraft passenger load, and if the airline staff were to hold a flight for at least five minutes, should an emergency ever arise when receptionists were not available. 30 SECTION II Personal Health Services "Surely every medicine is an innovation, and he that will not apply new remedies, must expect new evils."—Francis Bacon 1561-1626 Personal Health Services ANTE AND POST-NATAL CLINICS Existing arrangements were continued during the year at 15 clinics. A total of 738 sessions were held attended by a total of 970 patients. The majority of sessions were conducted by the midwives but there was a significant decrease in the number of such sessions compared with the previous year. Four midwives now undertake ante-natal clinics in the surgeries of family doctors, and it is hoped that this trend will be accelerated in future years. As ante-natal care is transferred to the community health team led by the family doctor, the need for the local health authority to run separate clinics should gradually disappear. Number of women in attendance Number of sessions held by Total number of Sessions For ante-natal examination For post-natal examination Medical Officers Midwives 952 18 31 707 738 The numbers attending the Relaxation and Mothercraft classes were 1,017, representing a further increase of 3.4% compared with 1970. Classes were held at 14 clinics, and the total number of attendances during the year was 5,855. The proportion of mothers attending these classes who were booked for hospital delivery (89%) was similar to the proportion of all babies born in hospital in the area (75%) and indicated that this valuable introduction to the skills of parentcraft was welcomed by mothers as an addition to the assistance which they received from hospitals and family doctors. Arrangements were made to provide training for health visitors in the techniques of psycho-prophylaxis and mothercraft teaching during September, and a member of the Society of Obstetric Physiotherapists supervised the instruction given. The course was intensely practical and although numbers were limited it was possible to include some of the domiciliary midwives and one midwifery sister from Hillingdon Hospital in the class. Training in these techniques of so-called "natural" child birth is most important, particularly for younger health visitors who may not previously have had experience in this aspect of maternal care. The techniques undoubtedly give confidence to the young expectant mother, and enable her to look forward to the experience of child birth with anticipation rather than with fear. MIDWIVES ACT 1902-1951 The number of midwives who notified their intention to practice as midwives within the Borough (including those in hospitals) and who were practising at the end of the year was 102. All held the certificate of the Central Midwives Board. One of the principal nursing officers is also non-medical supervisor of midwives and undertakes the necessary visiting and investigation appropriate to the Council's statutory responsibilities in this area. CONGENITAL MALFORMATIONS The Registrar General requires information concerning children who are discovered at the time of their birth to have an obvious congenital malformation. Regular returns are forwarded to the Registrar General based upon information received from local midwives at the time that the birth is notified to this department in accordance with the Notification of Births Act 1907. A total of 77 with congenital conditions were notified in 1971. CONGENITAL ERRORS OF METABOLISM There are a number of rare diseases caused by metabolic defects which can now be identified shortly after birth. Principal amongst these is phenylketonuria which, if untreated, leads to irreversible brain damage, and mental subnormality. A blood test (Guthrie test) has been developed 33 and the technical difficulties experienced in the previous year when the test was introduced have been resolved as the nursing staff have had greater opportunity to become skilled in obtaining samples. The test is carried out on the sixth day of life by the midwife, and involves pricking the baby's foot to obtain drops of blood of a specified size. These are collected on a special filter paper which is posted to the regional centre for processing. The regional laboratory has now extended its screening facilities and since July 1971 tests for the diseases of histidinaemia and homocystinuria have been carried out on the specimen collected for the detection of phenylketonuria. It is anticipated that further rare diseases may ultimately be included in this single screening procedure. There were no cases of phenylketonuria or of similar metabolic errors detected in the Borough during the year. CHILD HEALTH CENTRES Dr. V. M. D. N. Shaw—Principal Medical Officer (Personal Health) The modern concept of a child health centre was outlined on page 28 of the annual report for 1970. The gradual change in emphasis so that developmental screening received major priority has continued but was limited by the reduction in the number of medical sessions allocated to this important work some years ago. Arrangements were completed by the end of the year to restore the medical supervision to previously agreed levels, and the work received added impetus through the introduction of management by objectives which required the explicit statement of the standard of service required. The aim of the child health service is to diagnose major handicaps as early as possible and to provide services which will enable the handicapped child to live as normal a life as possible. The major handicaps are significant defects of hearing, vision, motor control and mental development. In the child health centres screening tests should be applied to all children at least four times during the first two years of life. This is estimated to involve approximately 2,200 examinations per month, each examination taking at least ten to fifteen minutes. Current resources do not allow this standard to be achieved for all children in the Borough, and some attempt must be made to select a group most likely to show handicap. Although many have criticised the concept of the "at risk" register, there is some evidence that when resources do not allow the satisfactory screening of all children, priority should be given to those considered to be "at risk". Accordingly attempts are being made to ensure that children on this register receive adequate developmental screening. There are a number of children whose mothers do not recognise the need for the service which the child health centre provides, and therefore choose not to avail themselves of the facilities offered. Until more family doctors become interested and skilled in the developmental assessment of children, the observation of this group will largely depend upon the health visitor. She is the member of the child health team who has most to contribute concerning the home background of the child, and it is important that she should be skilled particularly in testing vision and hearing in the young child. Methods of screening have been especially devised so that a standard procedure is applied throughout the Borough. The health visitors have received special training in the techniques of screening of hearing and vision in babies and young children, and the initial screening of babies between the seventh and tenth month has been entrusted to them. Although it is not yet possible for such tests to be carried out on all children it is hoped to develop a total screening programme in this age group at the earliest possible date. Where the results of screening tests are doubtful the child is examined by one of the medical officers who may if necessary, refer the child to the hearing clinic at Heston for a specialist opinion. Recent research has suggested that some cases of deafness in children are caused by previously unsuspected cases of rubella (German measles) in pregnancy. As a result of this observation arrangements were completed for blood samples to be taken from all children referred for specialist hearing screening, and from their mothers. These samples were forwarded to the Institute of 34 Child Health for determination of rubella anti-body titre, and thus assist in the diagnosis of cases of rubella syndrome. It has been the practice for some years to examine babies at birth to exclude the possibility of a congenital dislocation of the hip. This examination may have been repeated at four to six weeks, but after this age no further attention has normally been given to the condition. During the year a report by an orthopaedic surgeon suggested that dislocation of the hip may occur at any time up to two years of age, so that continued screening for the condition is necessary in the child health centres. The necessary further tests were introduced to ensure a regular screening programme until the child is walking satisfactorily. The widespread introduction of developmental screening is a relatively new concept, and there has been a natural desire on the part of the doctors employed in the child health centres to receive specialist training in this work. A planned programme of training was therefore devised to assist with the work, and to provide equivalent facilities for local authority medical officers to those which their hospital and general practitioner colleagues currently enjoy. One doctor received specialised training in the assessment of infants and small children, and has subsequently been able to apply her new skills. One of the Principal Medical Officers attended a course in the assessment of hearing loss in young children, and he was subsequently able to organise the training courses for health visitors. Specialist week-end courses in paediatrics, gynaecology and dermatology have provided valuable post-graduate training but much longer periods of study will be necessary for those wishing to specialise in developmental paediatrics. Preliminary arrangements were made for one medical officer to be seconded for six weeks specialist training, and for another to be seconded for a full academic year. Co-ordination and Co-operation The child health services provided by the department do not exist in isolation but are organised in conjunction with those provided by local hospitals and by family doctors. Efforts continue to be made to promote closer co-ordination and co-operation between the three separate parts of the service. Co-operation must, of course, be a two-way process, and although every effort is made to promote such concepts, the department's efforts are not always reciprocated. Circular HM(71) 22 concerning hospital facilities for children instructed Regional Hospital Boards to ensure that as far as possible "firm arrangements are made for the transfer of information on child patients from hospital staff to . . . the Medical Officer of Health". Although such information is almost always available when specifically requested and consultants provide most helpful reports, it has proved impossible to secure the firm arrangements suggested by the circular for every child. The local authority may not be aware of its likely responsibilities for a particular child without prior warning from the hospital service, and it is to be hoped that the concept of a team approach with professional workers from different services and even different disciplines bringing their joint skills and responsibilities to the assistance of the patient will not have to wait until 1974 to find its complete expression in the area. Welfare Foods The welfare foods provided through the local health authorities were modified during the year. Vitamin "C" as well as Vitamins "A" and "D" being added to National Dried Milk. Orange juice and cod liver oil were replaced by multi-vitamin drops and tablets. In addition it is the practice in this area to permit the sale of certain specified proprietary foods at a cost slightly less than that available in local shops. The primary objectives of a child health centre are to promote health, to advise on the developmental progress of children and to provide health education. The sale of welfare foods is unlikely to assist these objectives, and existing policies must be kept closely under review in the light of local circumstances. The distribution of welfare foods has been aided for many years by a stalwart band of voluntary helpers. Their personalities have added an extra friendliness to the session, and their assistance is much valued in the department. The retirement of one of these ladies is always a moment of particular sadness and it is disappointing to note a declining number of volunteers available for this work. The child health centre can provide a fruitful area for voluntary effort, and it is to be hoped that others will come forward to assist on a voluntary basis in this valuable work. 35 HANDICAPPED CHILDREN IN DAY NURSERIES Fifteen handicapped children were placed in the day nurseries during 1971; the categories are shown in the accompanying table. Costs in respect of the 4 mentally handicapped children were charged to the Social Services Committee and the remainder were the responsibility of the Education Committee. It is important to ensure that the ratio of handicapped to normal children in the day nurseries remains low. In the case of most of the handicapped children there are additional factors in the home backgrounds which make day nursery attendance of great therapeutic value. For those with communication difficulties it is important that the children should be surrounded by speech to stimulate the desire to communicate before training in a special school is commenced. Category (handicap) Number Deaf or partially hearing 4 Delicate 5 Mentally handicapped 4 Speech defect 1 Epileptic 1 The Principal Medical Officer visits the nurseries from time to time to assess handicapped children and to discuss their problems and progress with the staff; she is available for consultation by the matrons at any time. In addition medical officers from the health department visit each day nursery quarterly to examine all the children. 23 such visits were made during 1971. FAMILY PLANNING The subject of family planning remains a popular topic of public discussion and local health authorities are exhorted to introduce schemes for the communities which they serve. The services which are provided by two voluntary associations within the Borough were continued during the year. Those provided by the Family Planning Association are largely based in local authority premises and so receive indirect financial support. The Association also operates a clinic at Hillingdon Hospital. The International Planned Parenthood Federation provides a comprehensive service at Mount Vernon Hospital. If further pregnancy is contra-indicated because of factors affecting the health of the family financial responsibility for the provision of family planning is assumed by the Health Committee. During the year the Council extended the categories of patients for whom it accepted full financial responsibility to include women who have four or more children, and to those receiving state benefits. The further development of the service was encouraged early in the year by the appointment of Dr. Joan Marshall as consultant adviser in family planning matters. In June the Council opened its first directly operated clinic at Laurel Lodge and the additional facilities provided were welcomed. A total of 109 women attended the new clinic in 1971 and with a progressive increase in the number of women attending, the individual service which the clinic provides clearly satisfied a real need in the area. A proportion of those most in need of family planning advice seem unable to keep ordinary clinic appointments. A domiciliary service is available, but it is usually possible to make special arrangements by the use of transport and temporary supervision of other children in the family, for attendance at the clinic itself where the doctor has available any special facilities which may be necessary. During 1971 a total of 173 women received free advice, 93 being new cases and 80 renewals. The number referred since 1965 are shown in the table on page 37. During 1971, 730 abortions were conducted at hospitals in Hillingdon. The aim of a public health service should be to prevent such unwanted pregnancies and so avoid the need for treatment which can be so traumatic to the personality and which is itself not without risk. 36  Medical Social Total 1965 (April/December only) 2 2 1966 15 15 1967 20 6 26 1968 41 36 77 1969 41 53 94 1970 69 68 137 1971 82 91 173 Family Planning Service—(general enquiries—not appointments), Uxbridge 38290. Laurel Lodge Clinic, Harlington Road, Tuesday 9.30 a.m. to 11.30 a.m. Hillingdon (appointments only) Family Planning Association Clinics Hillingdon Hospital By appointment only Tel: Uxbridge 38282 Ickenham Clinic, Long Lane, Ickenham Monday 7.00-8.00 p.m. Minet Clinic, Wednesday 1.45-3.15 p.m. Coldharbour Lane, Hayes 5.30-7.00 p.m. Northwood Clinic, Ryefield Court, Tuesday 7.00-8.00 p.m. Northwood Hills (appointments only) West Mead Clinic, Friday 1.45-2.45 p.m. West Mead, Ruislip 6.30-8.00 p.m. Uxbridge Clinic, Council Offices, Thursday 1.45-3.15 p.m. High Street, Uxbridge 5.30-7.00 p.m. International Planned Parenthood Federation Clinic Mount Vernon Hospital, Thursday 2.00-5.00 p.m. Northwood (by appointment only) WELL WOMEN'S CLINICS The number of women seen at these clinics was similar to previous years but a large proportion were those attending for a re-examination. The routine recall of those seen four years previously was continued, and by the end of the year almost all women who first attended in 1967 had been offered re-examination. Difficulties were experienced in the Yiewsley area due to the demolition of the previous clinic premises to allow the erection of a health centre on the same site. The temporary premises were quite unsuitable for cytology and at first Yiewsley residents were seen at Laurel Lodge Clinic. This was unsatisfactory as it was too far for most people to travel. Finally, the mobile clinic was parked near the shopping centre and this has proved successful. Although facilities were limited 37 and there was no waiting space under shelter, the failure rate for appointments was very low and the service was obviously much appreciated. In addition sessions were arranged at any clinic in the area where there was sufficient demand. Previous experience suggests that the demand will later decline and the sessions will then be discontinued or transferred elsewhere, thus making optimum use of available resources. It is known that certain women are more at risk of developing carcinoma of the cervix than others, and a screening programme must give particular attention to such women. In the final quarter of 1971, as part of the management by objectives procedure a study was made of the proportion of women attending cytology clinics who were included in the group most at risk. Although there was considerable variation between individual clinics (from 22% to 52%) the average of all clinics showed that over 40% of women seen were in these higher risk groups. Recently published studies have shown that women who start their sexual activity early are also at greater risk, and efforts were made to identify those in this group. There were six cases of malignancy found during 1971. Of these cases, 1 was under 30 years of age, 1 had two children but had been married twice, and the others had three or more children. All were referred to hospital gynaecologists for confirmation of the diagnosis and for treatment. It is pleasing to record the grateful thanks of the department to the teams of cytologists and technicians who provide so much assistance with this work, and especially to those at Hillingdon Hospital who were under considerable pressure during the middle of the year. Elers Road Laurel Lodge Minet North wood Ruislip Yiewsley Industry No. of women seen 136 514 353 247 235 188 46 "At risk" 52% 40% 50% 44-6% 22% 50% 35% Healthy 67 207 171 150 103 115 35 Abnormalities found: Pelvic: Malignancy 3 1 1 1 Cervical 19 123 9 31 70 42 4 Infection 24 65 18 22 36 13 4 Fibroids 8 28 9 11 3 7 Ovarian 5 2 4 1 2 Prolapse 2 1 3 1 Other 6 2 17 16 11 23 Breasts 4 43 10 1 10 8 4 Hypertension 6 12 6 8 1 3 3 Urine 9 Referred to G.P. 13 59 29 39 14 16 5 Previous cytology 31 319 55 78 50 36 22 CHIROPODY The known difficulties surrounding the existing chiropody service were thrown into greater prominence by the management by objectives procedure. At present the service is provided by 9 part-time chiropodists who work on a sessional basis in Council clinics and old people's homes, carry out domiciliary treatment, or work on an agency basis for old people's welfare groups. The pay and conditions of service are determined by national agreements and the number of patients who may be treated in each session is controlled by the recommendations of appropriate professional organisations. However, the demand for the services of fully qualified and state registered chiropodists far exceeds the supply. The waiting time for a first appointment is twelve weeks, and the average time between appointments is also about twelve weeks. 38 The situation has not been improved by the provisions of the Chronic Sick and Disabled Persons Act which offer chiropody services to an even wider section of the community. The survey completed by the social services department during the year has identified an additional 600 requests for chiropody treatment. Practically all the people treated are elderly, and many are brought to clinics by ambulance. The service is available for school children and other priority groups, but the major condition in children is that of plantar warts, and in order to relieve the pressure on the service arrangements were made for alternative facilities for the treatment of this condition during the year. Details will be found on page 136. Initially, new applicants for the chiropody service are assessed by home nurses since simple procedures like toe-nail cutting can be done by the nursing staff. A decision is also made concerning the patient's ability to travel to the chiropodist by public transport or by ambulance. If neither is practicable domiciliary treatment is provided. As the condition of the feet improve a former domiciliary patient may, of course, become a clinic attender. If the demand for the service is to be met radical decisions concerning future staffing arrangements will be necessary. During the year various alternative proposals were considered. Chiropody facilities are available at the following clinics: Minet, Coldharbour Lane, Hayes Laurel Lodge, Harlington Road, Hillingdon Uxbridge, High Street, Uxbridge West Mead, West Mead, South Ruislip In addition, sessions are held at Elm Park Club, Park Way, Ruislip. Arrangements are also made in co-operation with voluntary organisations as follows: Ruislip/Northwood Old Folks' Association: Sessions at Brackenbridge House Aged Persons' Home, domiciliary visits and at Chiropodists' surgeries. The British Red Cross Society: Sessions at Dawlish Drive, Ruislip Manor. The number of persons treated during the year was 3,140. This shows a further increase compared with the figure for the previous year (2,801). Number of Persons Treated By local Authorities By voluntary organisations Total Persons aged 65 and over 2,112 811 2,923 Expectant mothers 14 14 Physically handicapped or otherwise disabled persons under age 65 4 4 Others 182 17 199 Total 2,312 828 3,140 Number of Treatments In clinics 5,178 1,210 6,388 In patients' homes 2,871 632 3,503 In old people's homes 1,629 189 1,818 In chiropodists' surgeries 2,116 2,116 Total 9,678 4,147 13,825 39 THE WORK OF THE COMMUNITY NURSING SERVICE Miss J. Byatt, S.R.N., S.C.M., M.T.D., Q.N., H.V., Chief Nursing Officer The new nursing management structure agreed during 1970 was implemented during 1971. A chief nursing officer took up her duties in August and by 22nd November two principal nursing officers and seven senior nursing officers were in post. All posts in the new structure except that of the chief nursing officer were filled by promotion of existing staff. The management structure now gives three clearly defined levels of responsibility as is shown by the organisation chart on page 42. Nursing staff at field level are now in teams of 12-15 nurses, each team having its own first line manager who co-ordinates the work of the team and gives support and help where necessary. The first line managers are responsible to the principal nursing officers who, at middle management level, see that their own services are running smoothly. At top level the chief nursing officer co-ordinates the work of the various services—home nursing, midwifery and health visiting. Most of the community nursing staff at field level are highly qualified and therefore are not in need of supervision from nursing management staff. Newly qualified staff, however, need support and guidance as do the many nurses in training who now spend time in the community. IMight Nursing Service A night nursing service commenced on 1st December, staffed by state registered nurses and nursing auxiliaries. At first the service was a limited one, but it is planned that a state registered nurse and two nursing auxiliaries will be on duty every night from 10 p.m. to 6 a.m. The state registered night nurse visits seriously ill patients and those in need of specialised nursing care, and supervises the work of the nursing auxiliaries who stay all night with patients needing continuous care. Patients are referred from the day district nurses, from general practitioners or from hospitals. It is not possible to accept night nursing requests directly from the general public. At first the service was based at Brookfield old people's home but has now been transferred to St. John's Hospital, Hillingdon, where the night nurse has an office equipped with a telephone answering device—this allows messages to be recorded during her absence. It has been possible through the appointment of state registered night nurses to relieve the day nurses of some of their late night visits to seriously ill patients and to allow these patients to be settled for the night at a more realistic time. Attachment and Liaison Schemes It is important that the implementation of attachment schemes should take place under optimum conditions with adequate staff available to deal with what is known to be an increased work load. For this reason new attachment schemes have been delayed during 1971, the difficulty in recruiting health visiting staff being the main problem. However, various general practitioners have shown enthusiasm and interest and it is hoped to start new attachments early in 1972. The liaison and attachment schemes described in earlier reports continue successfully. It is notable that when community nursing staff are working closely with general practitioners their field of work expands, adding to their interest and job satisfaction. Liaison between Hospital and Local Authority Nursing Service The very good relationships between hospital and community nursing staff which has built up during the past years continues. During the year plans have been finalised with both Mount Vernon and Hillingdon Hospitals for the "community care" training of their student nurses. Nurses in general training now have the option of doing from 6-10 weeks community care and it is expected that up to 30 students each year will take up this option. In addition all nurse students spend a short time with community nurses and receive lectures during training from the community nursing officers. The liaison schemes formerly at Hillingdon Hospital and the Duchess of Kent Maternity Wing have been extended to include Mount Vernon Hospital and continue to function well to the benefit of both patients and nurses. 40 The Night Nursing Service—Sister briefs the staff for the night's work Training Scheme Increasing numbers of students of various categories are coming into the community for training and although this adds interest to the community nurses' work and is gladly undertaken, it is a heavy commitment when staff are under pressure. In addition to the student nurses' training described above student midwives spend three months on what is now a community care course rather than domiciliary midwifery experience. Newly approved by the Central Midwives Board this course aims to give the student a broad picture of community services as a whole and involves time spent with the health visitor and district nurse as well as with the district midwife and visits to various local authority establishments. Other students are those doing health visitor and district nurse training and students taking integrated nurse training. In addition, student midwife teachers and student tutors come for community experience, as do foreign visitors on scholarship study tours. The chief nursing officer was herself on a Florence Nightingale Memorial Committee scholarship to Scandinavia for the months of September/October and is therefore well aware of the needs of these visitors. The community nursing staff also need in-service training which is given in the form of lectures and study days and use is also made of study days arranged by other organisations such as the Queen's Institute of District Nursing. During 1971 special courses were given in hearing testing of babies and in ante-natal psycho-prophylaxis instruction. A comprehensive plan of training is being prepared for 1972. Domiciliary Midwifery Service There has been a marked change in the pattern of midwifery work during 1971 reflecting the national trend. Fewer women have had their babies at home—560 as against 796 in 1970, while the number of early discharges after hospital confinement has increased from 148 to 313, the most noticeable increase being in the last quarter of the year. The number of mothers delivered by domiciliary midwives in the unit at the Duchess of Kent Maternity Wing has increased from 68 in 1970 to 98 in 1971. For some years the actual number of midwives in post has been less than the establishment and the establishment has therefore been changed to a rather more realistic figure of 19 having taken into account the factors described above. It is, however, difficult to maintain this establishment at the desired level and the recruitment of suitably qualified midwives remains a problem. Domiciliary Nursing Service The number of patients nursed throughout the year has again risen and the district nurses have been working at a continuously high pressure. In order to assess the exact nursing staff needs a work study was carried out in November and the results should be known early in 1972. It is thought that much of the work at present done by state registered nurses could be done by less qualified staff thus leaving the state registered nurse free to do the highly skilled tasks which only she can do. For example, bed baths of chronically ill patients could well be delegated to a well trained nursing auxiliary with a state registered nurse giving supervision and guidance. An assessment has also been made of the nurses' equipment and sterilisation methods. Boiling as a method of sterilisation is no longer considered to be bacteriologically safe and therefore an increased use of pre-sterilised disposable equipment is planned. Preliminary negotiations have taken place with Hillingdon Hospital into the possibility of using central sterile supply department equipment for domiciliary nursing and midwifery services. The nursing establishment has been increased during 1971 and on 31st December it was 43 (including staffing of the night service). Health Visiting Service The difficulty in recruiting qualified health visitors has continued and increasing use has been made of clinic nurses and health assistants so that health visitors can concentrate on essential health visiting duties. The outlook for future staffing is, however, improving—nine students commenced training in September 1971 and will come onto the staff in 1972. Health visitors have been greatly helped in their work by the appointment during 1971 of the Principal Health Education Officer. Health visiting statistics are on page 124. 41 42 Top Management Chief Nursing Officer Middle Management Principal Nursing Officer (Health Visitors) Principal Nursing Officer (Nurses and Midwives) First-Line Senior Management Nursing Officer (West) Senior Nursing Officer (East) Senior Nursing Officer (North) Senior Nursing Officer (post to be implemented later) Senior Nursing Officer (Midwives) Senior Nursing Officer (Nurses) (North) Senior Nursing Officer (Nurses) (East) Senior Nursing Officer (Nurses) (West) Field Level Health Visitors Clinic Nurses Health Assistants Health Visitors Clinic Nurses Health Assistants Health Visitors Clinic Nurses Health Assistants Midwives Pupil Midwives District Nurses Nursing Auxiliaries District Nurses Nursing Auxiliaries I District Nurses Nursing Auxiliaries Dental care for the pre-school child DENTAL SERVICE (MATERNITY AND CHILD HEALTH) Mrs. B. Fox, B.D.S.—Chief Dental Officer Examination of school entrants suggests that many more young children would benefit from dental care before they reach school age, than at present receive it. Parents may not be aware that pre-school children are eligible for treatment under the priority services. Efforts have been made to inform them of the services which exist in the Borough. The numbers of pre-school children examined and offered treatment has increased but the type of treatment given is often of a preventive nature, e.g. topical fluoride applications to the teeth. At Cavendish Pavilion, a child health centre where there is no dental surgery, a dental surgeon has visited once a month to examine children attending toddler clinics and to give advice to mothers if requested. Arrangements were made to extend this service to Ruislip Gardens clinic in the Autumn. The services of two anaesthetists have been secured and regular general anaesthetic sessions have been established throughout the Borough. Many young children who were previously referred to the hospital service for extractions under a general anaesthetic, are now treated within the local authority service. Children on the observation register who may be "at risk" with dental disease or who, because of some physical reason may find difficulty in accepting dental treatment are invited to begin regular dental inspections after their third birthday. In this way, it is hoped to give preventive dental treatment and dietary advice preventing extraction of teeth, which often requires lengthy visits to hospital in these children. Arrangements have been made to examine handicapped children who attend a playgroup, if the parents wish. This should reduce the amount of travelling, which parents find difficult. Routine dental treatment is provided in the Borough by dental surgeons experienced in working with handicapped children. Children attending day nurseries are similarly examined at the nursery, and may be brought to the clinic for treatment by nursery staff. This is particularly helpful for single working parents. During the latter half of the year regular contact has been maintained with many health visitors conducting ante natal relaxation classes. A number of talks on dental health have been given to expectant mothers. Guidance has been offered on their own dental health, the establishment of sensible dietary habits and the restriction of sugar intake for young children. The number of expectant and nursing mothers seen by the priority service has risen but the majority still attend general dental practitioners. This is encouraged so that regular attendance for treatment is maintained after the period of entitlement to treatment under the priority services. Dental statistics are recorded on page 123. HOME DIALYSIS Under the provisions of Section 28 of the National Health Service Act 1946, local health authorities are empowered to make any arrangements necessary for the installation of equipment for intermittent haemodialysis and during 1971 requests for assistance in installing artificial kidney machines in their home were received from a further three Borough residents who had developed renal failure. During the year, also, the Council resolved no longer to make any assessment of patients financial means but to provide any necessary adaptations or provision of other facilities free of charge. The assistance given to two of the new patients during 1971 consisted in the provision of portable Portakabin units as the existing accommodation did not lend itself to suitable adaptations being carried out. In the third case, a house owner, neither adaptations nor the provision of a portable unit proved to be possible so, with the consent of the Housing Commitee, the patient was rehoused in Council accommodation having sold his house to the former tenant of the Council house. There are now seven persons living within the Borough who received assistance from the Council when artificial kidney machines were installed. In four cases, room adaptations were possible while in the remaining three cases, portable units of accommodation had to be provided. 43 HEALTH EDUCATION Mrs. P. Mahy, S.R.N., C.M.B. (Part I), H.V.Cert., Community Care Cert., F.E. Teachers Cert., M.I.H.E., M.R.S.H.—Principal Health Education Officer "If one were to offer men to choose out of all the customs of the world such as seemed to them best, they would examine the whole number and end by preferring their own". —Herodotus The general aim of health education within the community is to encourage people to value their health and to regard good health of mind and body as being an asset. Persuading an individual to alter an established pattern of behaviour, or to change an attitude, is no easy task. History and Legislation affecting Health Education The Public Health Act 1936, Section 179 gave local authorities power "to spend money on health education". National Health Services Act 1946, Section 21, provided for the "Publication of information on questions relating to health or disease, for the delivery of lectures and the display of pictures and films dealing with such questions". Under Section 28 of the 1946 Act, the Minister decreed "that there would be more scope for the exercise of these powers in relation to health education" (Min. Health circular 118/47). Health Education is needed from the "cradle to the grave". Indeed mothercraft classes are arranged to educate for the next generation whilst "in utero". An early health educator was Bishop de Marisco, 1220, Bishop of Durham. He "directs that women be admonished to bring up their off-spring carefully and not to place them when very young too near at night lest the babes be smothered; not to leave them alone in an house near the fire nor in a place near water. This duty is to be declared to them every Lord's Day". In their day to day work the medical team of health educators—doctors, dentists, health visitors, midwives and community nurses are encouraging people to value their health and to prevent man-made epidemics caused by abuse of body function and misuse of various agents such as drugs, tobacco, etc. Since the personality and habits are mainly developed in the first three years of life, health education is especially aimed towards those caring for young children. Mothercraft classes have been established for many years; involvement of the Father is being encouraged. It is felt desirable that a standard syllabus for these classes is necessary; this is being processed. The Principal Health Education Officer will act in a supportive and advisory role to those participating in mothercraft classes, namely health visitors, midwives and dentists. In order to give advice regarding content of talks, visual aids, equipment and literature available, it is necessary continually to search for and assess new material and knowledge, together with developments in communication technique. Statistical data at both national and local level must be studied. Added to this, precis of reports relating to numerous health topics must be made. "Handouts" and relative specialist information is circulated to staff. The concept of "team work" prevails; this involves in-service training later to be extended to multi-disciplinary groups. Invitations will be extended to youth leaders, school teachers, nurses from industry to name but a few. During a recent training weekend on psychoprophylaxis relaxation, midwives from both hospital and the community joined the health visitors. Development of health education in child health centres is planned. Home Accidents.—Statistics are alarming and the prevention of accidents in the home, all age groups being concerned, but primarily the young and elderly, is being studied closely. Several projects regarding this subject are being considered; clearly this subject must be included in mothercraft teaching. From the young to the elderly. A "Pre-retirement course" was arranged at Uxbridge Technical College. The health aspect of the course was organised by the principal health education officer; other members of the team to join her were Dr. Westworth, Principal Medical Officer, and Mrs. Gilboy, physiotherapist. The course was a success and our team contri- 44 Successful health education depends upon active participation bution was much appreciated. Several successful courses in "First Aid" were arranged for the Hillingdon Emergency Force and Venture Scout/Rangers by Dr. E. W. Jones, Assistant Principal Medical Officer; more courses are planned. Courses for the training of all sections of the Hillingdon Borough staff drawn from the education department, engineers and parks departments to name but three, have been organised by Dr. E. W. Jones. Those participating in the course are required to pass an examination; the long term aim being that all employees have adequate knowledge to render first aid. During these courses all members of the health education team assisted Dr. Jones, both by giving lectures and by acting as examiners. Requests from the British Red Cross Society, young wives groups, church groups, etc. are increasing. All requests are met; the Director of Health Services, and other medical officers participate in order to spread the load and broaden the team. HEALTH EDUCATION 1971 Talks given by Number of talks given Audience reached Total persons reached Medical Officers 16 First Aid Groups Voluntary Bodies 425 Dental Officers 1 Health visitors 45 17 Antenatal classes 204 16 Mothers at toddlers clinics 148 approx. Principal Health Education 6 Health Department Staff 60 Officer Pre-retirement group 12 October-December 1971 Church Fellowship 30 British Red Cross Society 12 Public Health Inspectors 8 Voluntary Groups 160 Industrial Groups Passive Health Education.—Another method of informing the public is by displays and through the media of the press. An annual programme of displays with a correlating news column in Civic Affairs has been planned. During the "Welcome to Citizenship" week the health department provided an audio-visual display, showing slides with commentary of the whole of the health department's work; this included health visiting, midwifery, home nursing and environmental health. It is intended to extend the health department's contribution by showing the work of the dental service, dental health education and the work of the health education unit. An appropriate text was provided in the "Welcome to Citizenship" booklet. The Hillingdon Show was again an opportunity to demonstrate to the general public by audio-visual media, the work of the health department. Plans are being processed to increase the health education content of future displays; a suitable script is being prepared. The health control unit at London (Heathrow) Airport have welcomed the services of the health education unit; a programme for training clerk receptionists has been processed and commenced. Enquiries and visitors to the health education unit have come from as far afield as Scandinavia, Alaska and the Bahamas. All enquiries from both this country and others have been dealt with to the satisfaction of all concerned. With the anticipated unification of the health services in mind, close liaison now exists between the health education unit, the maternity wing and tutorial staff of Hillingdon Hospital. Lectures are planned within the community for hospital staff and the principal health education officer is to join in the training programme of pupil nurses at the hospital. Doctors from Hillingdon Hospital have a programme processed and commenced, in preparation for the Diploma in Child Health. 45 The concept of an overall plan to promote health as a community ideal and to provide solutions for immediate national and local health problems will not bear fruition immediately. However, an important contribution to effective preventive medicine can be made by the broadly based education service outlined. Expansion is expected and 1972 should prove to be an exciting year for health education in the London Borough of Hillingdon. The continuing world-wide decline in the number of cases of smallpox except in countries where eradication programmes are being pursued resulted in a decision to discontinue the policy of infant vaccination in the United Kingdom. The risk of importation of the disease to this country has been progressively reduced and it is almost ten years since the last major outbreak of the disease. Smallpox vaccination carries a small risk of complication which is now considered to be greater than the risk of contracting the disease for most members of the community. There remain specialist groups within the community who are more likely to come into contact with the disease imported from abroad, and it is most important that the vaccination levels amongst these staff should remain high. Doctors, nurses and ambulance drivers constitute such special groups, but because of the presence of the busiest international airport in the world within the Borough's boundaries others resident in the area also fall into this category. Employees of airlines and those involved in passenger handling duties must also be included, and the facilities of the department have been offered to all airlines operating at London (Heathrow) Airport who have employees involved in receiving passengers or baggage from countries in which smallpox is endemic. The smallpox vaccination rate in this area has been disappointing for many years and was far too low to provide reliable community protection against a major importation of the disease. This rationalisation of policy is therefore welcome. Feasibility studies continued throughout the year to determine whether existing vaccination and immunisation records could be transferred to computer processing. Investigations appeared to show that such a transfer would offer relatively little advantage compared with the existing system in relation to the children who are currently immunised by the department's own medical staff. Approximately half of the children are, however, immunised by family doctors and for these groups computer processing seems likely to bring readily identifiable advantages. The situation was complicated by the transfer of existing Council computer services from the present Leo III computer to an "On-line" system, and by the transfer of vaccination and immunisation records to the Area Health Authority in 1974. It became clear to the working party that any computer system introduced would almost certainly remain in operation for at least five years and with over two-thirds of family doctors in the area anxious to participate in the scheme, its value in promoting co-ordination within the National Health Service could not be under-estimated. Arrangements were therefore made for all immunisation records for children born after 1st January 1971 to be transferred to computer processing. BCG Vaccination—Production of acquired resistance to tuberculosis BCG vaccination is offered to all children in the second year of the secondary schools. The vaccination is carried out in the schools by specialist teams of doctors and nurses. 2,766 children were eligible for BCG vaccination this year; 2,259 children were heaf tested and of this number 2,170 children were vaccinated. IMMUNISATION This gives an acceptance figure of 81.7% which though high is less than last year (83.6% 1970). The figures for 1971 and the preceding three years are as follows in the table. Year Children Eligible Children Tested Children Vaccinated Children not Vaccinated (Heaf positive) Percentages 1968 3,027 2,327 2,255 126 76.8 1969 3,247 2,519 2,401 118 77.6 1970 3,435 2,873 2,752 121 83.6 1971 2,766 2,259 2,170 89 81.7 46 Rabies Vaccination For several years now prophylactic inoculation against rabies has been offered to the staff at the R.S.P.C.A. kennels at London (Heathrow) Airport, where animals from many parts of the world are housed while in transit or awaiting transport to quarantine kennels. Similar facilities have been offered to the staff of a local kennels which is approved by the Ministry of Agriculture, Fisheries and Food for quarantine purposes. The vaccine used is a suspension of embryonic duck tissue infected with virus to which virucidal agent has been added. The recommended schedule for vaccination is two subcutaneous inoculations six weeks apart followed by a booster dose six months later and annually thereafter. Serum for anti body estimation is taken three weeks after the booster doses. In March 1970, a Committee of Enquiry (Waterhouse Committee) was set up to enquire into the precautions against rabies being taken in Great Britain. One of the recommendations of this Committee is that all persons who are considered to be at particular risk of contact with a rabid animal by nature of their employment, should be offered facilities for prophylactic vaccination against the disease. During 1971, local health authorities were requested by the Department of Health and Social Security to make available under Section 26 of the National Health Service Act 1946, facilities for vaccination against rabies and lists of approved establishments and of carrying agents authorised under the Importation of Dogs and Cats Orders 1928-1970 were issued to all local authorities. In addition to the personnel to whom such prophylaxis was already being offered it was considered that certain personnel involved in cargo handling duties at the London (Heathrow) Airport might be particularly at risk and facilities for vaccination was also offered to these groups. Immunisation Statistics are recorded on pages 121-122. MENTAL HEALTH SERVICES Dr. B. P. Westworth—Principal Medical Officer Approval of Medical Practitioners The Director of Health Services and two Principal Medical Officers are approved under the Mental Health Act 1959 as having special experience in the diagnosis of mental subnormality. No applications for approval were received from medical practitioners during the year. Psychiatric Services The work in this field has continued throughout the year although methods and organisation have varied as a result of the separation of the social service function. Weekly meetings held with mental welfare officers after 1st April became discussions with mental health social workers. In spite of changes there still remained a regular opportunity for the exchange of knowledge and discussion not only about individual problems but also topics more generally based on the prevention of mental ill health. Regular support was given to the staff and residents at Hayes Park Hostel and advice on mental health problems was always available. The Psychiatric Day Unit opened at Hillingdon Hospital and a very warm welcome was extended to members of the department by both clerical and administrative staff. It was so worthwhile to take advantage of these opportunities that it is now possible to see in retrospect the foundations that were laid for a comprehensive community mental health service. The opening of the psychiatric in-patient facilities at Hillingdon Hospital under the supervision of Dr. S. Wiseberg, the consultant psychiatrist, was delayed, but closer co-ordination was promoted during the latter months of the year by the attendance of the principal medical officer at the out-patient clinic. This has provided further opportunity for exchange of ideas so that the very best service can be provided for the patients within the catchment area. It is disappointing that barely half of the population of the Borough live within the area which will benefit from these improved facilities. 47 Mental Sub-normality Health visitors have continued to help and counsel parents of children under 16 years of age, and, where necessary, have called for additional help from the social services department. The aim has been to provide co-ordinated help by team work but liaison between differing disciplines has naturally proved quite difficult in the early stages. Role definition was often puzzling in its early interpretation. Regular meetings with staff from Leavesden Hospital have proved useful on both sides, and the appointment of Dr. C. Finn and Dr. Grace Woods for domiciliary and local consultations have been most helpful when difficult problems have arisen. This combination of local and consultant opinion has been invaluable when advice has been sought by the social services department. Future Developments A Command Paper issued during the year outlined the better services for the mentally handicapped proposed by Central Government and confirmed that the imaginative proposals already adopted by the Council were entirely in accordance with national policies. The emphasis upon community care for the mentally handicapped demands a close partnership between the hospital services which currently assume responsibility for many of these patients, the social services department which will now be responsible for the residential accommodation provided and the community physician and his staff. The development of the hospital psychiatric facilities in the area underlines the need for a similar development in the community services, and it is to be hoped that the 5-year programme to which the social services committee agreed during the year will be successfully implemented. The Command Paper stresses the need for hospital authorities and local authorities to agree a date beyond which further residential provision will be the primary responsibility of the social services department, and this unusual provision underlines the need for an energetic building programme if parents and relatives are to be spared the intolerable burdens that some of the more severely mentally handicapped sometimes present. Drug Abuse A Drugs Advisory Panel composed of professional workers from various council departments and other medical and social agencies in the area was convened to review the changing patterns of drug abuse in the area at six monthly intervals. The panel met on two occasions and concluded that whilst the Borough is certainly not exempt from what appears to be a national trend, there is no evidence of a specific local problem demanding urgent attention. Attention was drawn to the problem of alcohol abuse, particularly amongst young people in the age group 15 to 20 years. These observations were disquieting since the abuse of alcohol at these younger ages seems to be associated with a much shorter period in the development of alcoholic addiction amongst those patients who prove ultimately to be susceptible. Alcohol is a drug of addiction, and it is important to recognise the importance of reviewing abuse of all addictive drugs and not to consider particular drugs in isolation. In January 1971 a study day was organised by the Director of Health Services to help teachers and social workers to recognise drug abuse within the community, and among school children. Eminent speakers discussed the prevalence of drug addiction. The large audience was finally given a display by police dogs trained to detect cannabis in suspected premises. Following upon this many teachers expressed a wish to learn more of the nature of drug abuse and to recognise the evidence of drug taking in young people. Two further talks were arranged with officers from the Metropolitan Police to groups of teachers at Swakeleys School. Although the audiences were small the response was enthusiastic and facilitated the group discussion which is so essential to a full understanding of this problem. RECUPERATIVE HOLIDAYS With a view to preventing illness or to aid recovery from recent illness, recuperative holidays were arranged for 29 adults and 8 children during 1971. In fifteen other cases, patients were unable to receive recuperative holidays either because of deterioration in their physical condition or difficulties experienced in finding accommodation suitable to their requirements. 48 Patients placed on a recuperative holiday pay a maximum of £8.40 per week although the cost of the accommodation is usually much more. In cases of hardship, however, a reduction in the cost will be made down to a minimum accommodation charge of £2 per week. It has been the Council's policy for all persons placed on recuperative holiday to make their own transport arrangements, which in the majority of cases meant paying rail and bus fares. In November 1971, however, the Council agreed that transport costs should be included in the total sum which would be the subject of reduction when financial assessments were made in cases of hardship. During 1971 ten persons paid the maximum charge for a holiday while 16 were assessed to pay £2. The following table gives details of persons placed on recuperative holidays during 1971 and the preceding four years. Adults School Children Arranged Taken 1967 51 32 17 1968 65 53 15 1969 44 26 2 Arranged Taken 1970 48 29 12 10 1971 43 29 9 8 49 SECTION III Social Services "Physical ills are taxes laid upon this wretched life; some are taxed higher, and some lower, but all pay something."—Lord Chesterfield 1694-1773 Social Services The Local Authority Social Services Act 1970 provided for the appointment of a separate Social Services Committee, and the appointment of a Director of Social Services with responsibility for all of the work previously undertaken by the children's department together with many duties formerly undertaken by the health and welfare department. All of the welfare services not undertaken by Doctors or by nurses were transferred to the new department, together with the mental health services, the home help service, day nurseries and child minding. A working party under the chairmanship of the Town Clerk formulated proposals for the organisation of the new department based on the concepts enunciated in the Seebohm Report, and with particular emphasis upon the development of the generic social worker. On 1 st April 1971 the new organisation was brought into operation with the Director of Health Services undertaking the additional duties of Acting Director of Social Services. Every effort was made to ensure that the services to the public were maintained, and changes were introduced gradually. In spite of serious staffing difficulties and the absence of key members of the new organisation it was possible to commence the rapid development of services which were considered necessary, and to initiate a survey involving every household in the Borough to determine the extent of unmet need. The organisational separation of Health and Social Services which will be completed in 1974 by the re-organisation of the National Health Service emphasises the need for "working links" at all levels in the two organisations if the essential harmony of care which the patient should receive in the community is to be maintained. Every effort is being made to encourage such links although staff shortages in both services have presented difficulties. On 1st October 1971 Mr. G. P. D. Marsh took up his duties as Director of Social Services in Hillingdon, and I am indebted to him for the following description of the new department. I am most grateful for the opportunity of briefly describing some of the services that are undertaken by my department, and underlining the importance I place on ensuring close links between our two services. The department is organised into four divisions—Social Work, Residential Services, Day Services and Research. SOCIAL WORK The social work services of the department is the responsibility of Mr. W. N. Ritchie, assistant director. The Borough has been divided into three areas, each covered by one area team. The north team covers Ickenham, Ruislip, Eastcote, Northwood and Harefield and is at present based at Old Bank House in Uxbridge until August of 1972, when it is hoped that a new office will be ready in Ickenham. The west team is in its permanent base at Old Bank House in Uxbridge and covers Uxbridge, Cowley, Yiewsley and West Drayton. The east team is at present in Dragonfield, in the Council Offices, 259 High Street, Uxbridge, until April 1972, when it will be moving to an office in Golden Crescent, Hayes. The siting of the area offices reflects the spirit of the Seebohm Committee whose report was implemented in the Social Services Act 1970, which recommended a community based service and it is the intention of the Borough Council to ensure that they are situated in the community which they serve. It would be true to say that a tremendous amount of upheaval followed the establishment of the new department but it is gratifying to note that unlike some other local authorities, the organisation is already operating remarkably well. Since April 1971 there has been a large increase in the referral rate of cases to our department and up to 31st December, 1,800 cases have been referred. It seems that members of the public are already using the new service available to them. 53 In accordance with the Chronically Sick and Disabled Persons Act, 1971, a survey was carried out in the Borough, on a house to house basis. The survey revealed a great deal of unmet need and provided the new department with much useful information in forward planning. Hillingdon was one of the very first local authorities in the country to carry out this type of survey and as a result of the information obtained, the Council immediately increased its social work staff to follow up those cases which had been identified as needing help. Approximately 500 handicapped persons have indicated need and just under 1,700 elderly persons have been identified as requiring supportive help in their own homes. This important piece of legislation has focussed the attention of society on the needs of the elderly and the handicapped and for the first time for many years it should be possible to improve the services to those in most need. The Act has meant an increase in support services and more home helps are being employed, together with additional occupational therapists to extend the services to those who need them. The past twelve months have seen many advances in the field of social services and during the coming year further expansion of services to meet the needs of members of the community is envisaged. RESIDENTIAL SERVICES The residential services division is headed by Mr. L. A. Dotson, assistant director, who is responsible for the management of the 24 residential establishments of the social services. The 24 comprises—9 old persons homes, a hostel for the mentally ill, a hostel for mentally sub-normal adults, a weekly boarding unit for mentally sub-normal children, 7 children's homes, a residential nursery, an approved school, a remand home classifying centre and 2 hostels for homeless families. No new establishments have been opened during the year but new premises to replace the existing approved school and the residential nursery are now being built. Proposals have been approved for the replacement of the weekly boarding unit by a purpose-built unit which will provide permanent boarding facilities and not weekly as at present; for the provision of a new residential home for the elderly mentally confused; another old persons' home and a further hostel for mentally sub-normal adults. The Command Paper "Better Services for the Mentally Handicapped" envisages that many more mentally handicapped will be cared for within the community and this will undoubtedly mean an expansion of residential accommodation for the care of both children and adults who do not need treatment or nursing care in hospital. Facilities exist throughout the year for temporary admissions to residential old people's homes for short stay care to provide relief to relatives who normally care for their aged folk. During the summer months, 27 beds are available for this service and they are always fully booked. DAY SERVICES The day services division is controlled by Mr. J. L. Stoker, assistant director, who is responsible for the administration of: Day Nurseries Adult Training Centres Work Centres Home Help Service Meals on Wheels Concessionary fares for the elderly Aids and Adaptations for physically handicapped ** Registration and supervision of private day nurseries and child minders. ** (At the present time this service is kindly being undertaken by staff from the health department on our behalf). Expansion took place in a number of these sections during 1971 and plans are in hand for the expansion of others during the coming year. 54 The Chronically Sick and Disabled Persons Act 1970 The effects of the implementation of this Act have been reflected in the level of service provided to the physically handicapped during 1971. During the course of the year, 70 telephone installations were carried out in the homes of handicapped persons and the Council accepted the responsibility for the rental charges of 25 other cases. The number of adaptations carried out in the homes of disabled people increased from 53 in 1970 to 89 in 1971. To assist in coping with this demand the Council approved the appointment of additional occupational therapists. Concessionary Fares for the Elderly In April 1971 the Council adopted the scheme of granting concessionary fare permits to elderly people of pensionable age who were in receipt of supplementary benefit or a rate rebate. Permits were distributed from five centres within the Borough and up to 31st December 1971—• 3,740 were issued. The Home Help Service For some years now it has been very difficult to recruit women who are willing to work as home helps. Although there has been an approved establishment of 100 full time home helps it has not been possible to recruit more than the equivalent of 75 full-time home helps (on average). The general employment situation during 1971, however, changed the situation as far as recruitment was concerned and by December there was almost a full establishment. The home help service will be expanded further during 1972 and organising and clerical staff, along with the social work staff, will move out into offices in the area which they serve. The Meals Service The meals on wheels service is at present provided through a number of voluntary organisations. The Social Services Committee decided, however, to set up a working party to look into the whole question of the provision of meals both to the elderly and the disabled. Meetings have taken place with the voluntary organisations concerned and more are planned. It is the wish of the Council to provide a number of dining centres throughout the Borough, in addition to increasing the meals on wheels service. Day Nurseries The responsibility for day nurseries is one of the functions which passed from the Health Committee to the Social Services Committee in April 1971. The first of the Council's war time nursery buildings in Uxbridge is to be replaced and building commenced on the Park Road, Uxbridge site during 1971 and is due for completion in April 1972. Private Day Nurseries and Child Minders Responsibility for the supervision of these nurseries also passed to the Social Services Committee in April 1971, but at present the inspection and supervision is continuing to be carried out by the principal nursing officer and health visitors. RESEARCH The research division of the department is the responsibility of Mr. M. D. Tidball, assistant director, and is concerned to identify the needs, both present and future, for social services in the Borough by organising surveys and studies to analyse these. By continually examining the work of the department it is planned that the services provided for clients will continue to improve 55 and expand. Following the survey to identify the handicapped and elderly in need last autumn, the division is currently involved in a study of access facilities in public buildings and other establishments. Later studies will include the need for meals at dining centres or on wheels in the Borough, and the problems faced by the mentally handicapped in the community. Many challenging tasks face the new department in the coming year and if 1971 is any indication of the ability of staff to adjust to a new situation and to face the demands which have been placed upon them, then it is evident that with additional resources being made available to us, we will confidently approach the many areas of need which have been identified. The willing co-operation and assistance which is so evident in our relationship with other departments makes the task that much easier to undertake. 56 SECTION IV Environmental Health "If on inspection he finds the patch on the walls consists of greenish or reddish depressions, apparently going deeper than the surface, he shall go out of the house and, standing at the entrance, shall put it in quarantine for seven days."— Leviticus 14 v. 37 (New English Bible) Environmental Health GENERAL CIRCUMSTANCES Hillingdon is one of 32 London Boroughs created by the London Government Act, 1963 and the administrative Borough came into being on 1st April, 1965. The Borough is situated on the north west border of the Greater London area, and has a total area of 42.5 square miles. There is extensive urban development but approximately half of the Borough is designated Green Belt with a predominantly rural character. The Borough is 12 miles from north to south and 4 miles from east to west. It contains almost the whole of London (Heathrow) Airport as well as Northolt aerodrome. The area is bisected by the M.4 motorway and the A.40 major arterial road as well as a number of major rail links. In addition to providing housing for those who work in Central London the area provides significant local industrial development, particularly in Hayes and Uxbridge. Land in the southern part of the Borough, especially associated with the canal network is being reclaimed and imaginatively developed. WATER SUPPLY The Borough is supplied with water from three water companies: Rickmansworth and Uxbridge Valley Water Company, who supply the major part of the Borough, Colne Valley Water Company, and South West Suburban Water Company, who supply part of Harlington. The results of chemical analysis of water from these three supplies are as follows: Colne Valley Water Co. Rickmansworth and Uxbridge Valley Water Co. South West Suburban Water Co. Appearance Clear and bright Clear and bright Clear and bright Reaction (pH) 7.3 7.5 7.6 Parts per million Dissolved solids 393.2 334.0 478.8 Suspended solids — — 0.1 Chlorion 34.0 20.0 39.6 Free and Saline Nitrogen — — — Albuminoid Nitrogen 0.05 0.10 0.10 Nitrate nitrogen 1.20 0.40 0.75 Nitrite nitrogen — — — Oxygen demand 0.1 1.90 1.05 Biochemical oxygen demand 0.12 0.24 0.23 Total Alkalinity (CaCO3) 180.00 238.00 218.00 Lead (PB) Not detected Not detected Not detected Zinc (ZN) Not detected Not detected Not detected Copper (CU) 0.15 Not detected Not detected Fluoride content of water supplies: South West Suburban Water Company 0.262 p.p.m. Colne Valley Water Company 0.075 p.p.m. Rickmansworth and Uxbridge Valley Water Company 0.25.1.4 p.p.m. The variation in fluoride content of the water supplied by the Rickmansworth and Uxbridge Valley Water Company is due to the fact that one of the wells supplying water to the Borough has a naturally high fluoride content. 59 The results of the bacteriological tests carried out on the various sources of water supply are given in the following table: Source of Supply Satisfactory Unsatisfactory Total Direct from mains supply 116 9 125 From mains supply via storage tanks, etc. 28 28 Private supply 15 8 23 Drinking water dispensers 12 1 13 The nine failures on public water supply were found to be isolated results, repeat samples being satisfactory. PRIVATE SUPPLIES There now remains only one house in the Borough without a mains water supply, water being drawn from a shallow well which, while having a high coliform count, was found to be free from type 1 coliforms. A number of industrial premises draw water from deep wells for manufacturing purposes. Unsatisfactory results were obtained from a private supply to a food factory, the water is used as a coolant only but, as a precautionary measure, chlorination was introduced. A well supplying a small factory with drinking water was found to be unreliable, mains water was not available and the company installed a bacteriological filter. Subsequent samples have been found to be satisfactory. SEWAGE DISPOSAL I am indebted to the Director of Engineering, Mr. Basil D. Steele, for the following information: DESCRIPTION OF SYSTEM The London Borough of Hillingdon is drained on separate sewerage systems. The foul sewage is treated at the Mogden sewage treatment works of the Greater London Council and the surface water is discharged into the drainage areas of the Thames Conservancy or the Greater London Council. The Borough is divided into natural geographical areas served by district foul sewers which discharge into the Council's main sewers and thence to outfalls on the Greater London Council's trunk sewers. The responsibility of the Borough for the disposal of foul sewage ceases at the point where it discharges into the Greater London Council's trunk sewers which convey the sewage to Mogden. The disposal of the surface water is through the Council's main surface water sewers which discharge at a number of places into the rivers flowing in the Borough. The rivers of the Thames Conservancy Board are the Pinn, the Frays and the Colne and those of the Greater London Council are the Yeading Brook which flows into the River Crane. In addition, through the co-operation of the British Waterways Board, a number of surface water sewers discharge into the Grand Union Canal. Considerable development and redevelopment has taken place in this Borough since the sewerage systems were designed and this together with the increased use of water both for domestic and industrial use, has caused some local flooding. There are a number of areas in which the sewers are over-loaded to an extent that the addition of a comparatively small number of connections from new properties may result in local flooding. The Council is undertaking a detailed examination of the sewerage systems of the whole of the Borough to ascertain the adequacy of the systems, both for present needs and those of the foreseeable future. PROGRESS OF RESEWERAGE WORKS I stated in my last report that it was intended, where inadequacies were found in the system, to carry out such works as are required immediately and allow in the design of those works for possible future development. 60 Considerable progress has been made in the last year in basic survey work and the design of schemes which are referred to in the next paragraph. In addition schemes to the value of some million have not only been designed but the construction work has been carried out. North wood/Eastcote Road/Joel Street areas This area extends from the boundary with Harrow in the East through Northwood Hills to the London Transport Railway Piccadilly/Metropolitan lines at Eastcote in the South. To the West the area includes Ruislip together with Breakspear Road and Ducks Hill Road. In the North the area is from Mount Vernon Hospital along the boundary with the Rickmansworth Urban District and Watford Rural District. The Southern boundary is the London Transport Executive Piccadilly/Metropolitan railway line. A survey has been completed in this area in respect of the foul drainage and of the surface water sewers. A scheme for re-sewerage valued at some £900,000 has been designed and subject to approval by the Department of the Environment a contract should be let early in 1972. A study has been completed in the Ickenham and North Hillingdon area where flooding has occurred due to the inadequacy of both the foul and surface water systems. A scheme, some £380,000 in value, covering about 512 hectares (1,260 acres) practically divided equally north and south of Western Avenue at Hillingdon Circus has been designed, and approved by the Department of the Environment. This is the first stage of an overall scheme and provides in the main for new district sewers and new outfalls for both foul and surface water drainage. This work is programmed to commence very shortly. A second stage of surface water sewerage is being investigated. The foul and surface water drainage systems of Harefield have been examined and a complete survey made of the areas where flooding occurs. A scheme, some £300,000 in value has been designed and submitted to the Department of the Environment for approval and subject to this approval it is programmed to let a contract to allow work to commence towards the middle of 1972. Further schemes which can be associated with new highway works, as for example new sewers in George Street, Uxbridge, and as part of the next stage of the Uxbridge Relief Road have been designed and will be executed in the ensuing year. It will be seen that considerable progress is being made in the execution of the Council's large drainage programme. Design on further schemes is in hand in order to ensure that the momentum now created will be kept up in order to maintain the necessary progress. 61 ANNUAL REPORT OF THE CHIEF PUBLIC HEALTH INSPECTOR Mr. A. Makin, M.R.S.H... F.A.P.H.L It is impossible to comment in detail on more than a few of the matters dealt with but it will be seen that the inspectorate cover a wide range of environmental problems. Staff shortages both on the professional and administrative side have given rise to many difficulties but the staff have been most co-operative in an endeavour to maintain a satisfactory environment. It is hoped that it will not again be necessary to report staff problems as the Career Development Scheme and the Student Training Programme should be proving effective. In various parts of the report reference is made to work carried out by other departments and agencies, particularly the Public Health Laboratory Service and the Scientific Department of the Greater London Council, and their help is greatly appreciated. The report is in the same form as that for 1970 and is divided into sections as follows: 1. Air 6. Noise 2. Water 7. Consumer Protection 3. Food 8. Pest Control 4. Housing 9. Airport Sanitary Administration 5. Working Environment 10. Other Services 63 AIR The Clean Air Acts 1956-65 give authority to control pollution of the atmosphere from a number of specific sources: (1) Smoke from domestic chimneys by making Smoke Control Orders. (2) Dark smoke from industrial chimneys. (3) Dark smoke from industrial bonfires. (4) Smoke other than from the previous three sources which is a nuisance. (5) Emission of dust and grit from industrial chimneys. Local authorities are also authorised to undertake research into atmospheric pollution and to undertake publicity. In addition local authorities have general powers under other Public Health Legislation to control emissions of dust and offensive effluvia from industrial processes. Details of the efforts made to improve the atmosphere in this Borough are set out under various headings. SMOKE CONTROL PROGRAMME The smoke control programme made little progress in 1971. Although two Orders suspended from 1970 became operative during the year the shortage of solid smokeless fuel made it impossible to declare any further Orders to become operative in 1971. It was not necessary, however, to suspend any of the earlier Orders as had been the situation in 1970. Late in 1971 information was received from the Solid Smokeless Fuel Foundation, the Southern Electricity Board and the North Thames Gas Board that fuel supplies were adequate for the making of further Smoke Control Orders and five Orders were made to become operative in 1972. Details of these Orders are: Date of Smoke Control Area Operation Location 7 1.10.72 Hillingdon Heath -Abbotsfield School 14 1.8.72 Hillingdon Hill — Moorcroft Green 13 Not yet Woodland Avenue, Eastcote and surrounding area confirmed 16 do. Area around Cavendish Sports Ground 17 do. Ruislip Gardens - Torrington Road area Measurement of Smoke and Sulphur Dioxide in the Atmosphere The routine monitoring of the daily smoke and sulphur dioxide in micro-grammes per cubic metre in the atmosphere has continued at the 7 stations already established in the Borough. The monthly averages for both smoke and sulphur dioxide are set out in the table. The stations are designed to operate for 7 days without attention. When breakdowns occur the monthly average is not calculated because the results obtained from the lesser number of days could be inaccurate. This is the reason for some monthly results not being shown. The results achieved by the smoke control programme can be seen from the following table, however, the increased winter sunshine and the absence of dense fog are more readily appreciated and understood advantages. Apart from the long term health advantages these benefits must have made the combined smoke control programmes of the London Authorities one of the outstanding improvements in the environment and at relatively small cost. 64 Monthly Averages for Smoke and Sulphur Dioxide in Microgrammes per Cubic Metre for 1971 Month 76 High St., Northwood West Mead Clinic, South Ruislip Coldharbour Lane, Hayes Grange Park School, Lansbury Dr., Hayes Dragonfield, High Street, Uxbridge Oak Farm School, Long Lane, Hillingdon on Hall, Station Rd. West Drayton Smoke SO2 Smoke SO2 Smoke SO2 Smoke SO2 Smoke SO2 Smoke SO2 Smoke SO2 January 64 105 64 195 49 175 49 176 62 126 53 167 72 220 February 42 103 57 65 38 86 40 107 54 62 45 105 51 105 March 34 76 20 109 16 99 20 120 31 76 20 117 27 112 April 25 23 136 28 136 21 139 35 112 25 160 38 165 May 64 70 15 110 19 114 45 106 21 76 17 129 35 128 June 12 50 12 75 12 64 14 80 16 57 13 77 July 10 48 13 73 13 76 12 61 17 53 14 62 August 13 35 14 50 10 57 15 44 65 44 September 30 51 37 86 17 79 35 88 34 75 118 October 31 85 21 127 13 88 31 113 37 88 33 114 58 155 November 47 80 35 118 37 124 31 75 35 101 75 146 December 56 70 42 125 54 128 40 106 48 74 44 77 151 65 STATION Date in operative Smoke Control Area Smoke January 1971 June 1971 Ratio January Grange Park School, Hayes 1960 49 14 3.5:1 1965* 71 Drayton Hall, West Drayton 1962 72 1967* 51 Oak Farm School, Hillingdon 1968 53 13 4.1:1 1967* 53 West Mead Clinic, Ruislip 1968 64 12 5.3:1 1965* 85 Coldharbour Lane, Hayes 1971** 49 12 4.1:1 1965* 97 High Street, Uxbridge 62 16 3.9:1 1967* 66 High Street, Northwood 64 12 5.3:1 1965* 92 * The Years shown are the first available from records kept by this Borough. ** The Smoke Control Order affecting this area was delayed to coincide with the completion of the modernisation of the southern portion of the Council's Botwell Housing Estate, but the area is already surrounded by operative smoke control areas. INDUSTRIAL CHIMNEYS The control of emissions of smoke and other gaseous pollutants from industrial chimneys is achieved by the following methods. The Clean Air Act requires that the intention to install any industrial furnace, or any domestic furnace with a rating 55,000 Btu hour or more shall be notified to the local authority. During 1971 notification of the intention to install 39 furnaces were received. Of these notifications 19 related to gas furnaces, 16 to furnaces burning liquid fuel which has a sulphur content less than that of solid fuel, 3 to furnaces burning heavy fuel oil which has a sulphur content greater than that of solid fuel and one to an incinerator. 104 inspections were made in connection with boiler installations and chimneys and no contraventions were recorded. If the notification relates to an installation with a rating of 1,250,000 or more British thermal units per hour, then approval has to be given to the chimney height. This control is to ensure that the ground level concentration of sulphur dioxide is kept to a minimum. Nine applications for approval were received. Prior consultation as to the height of the chimney required had taken place before the applications were submitted and it was not necessary to refuse any application. Meetings were attended with representatives of the Central Electricity Generating Board, the Greater London Council and Ealing Borough Council concerning the proposed Generating Station at Bulls Bridge, Hayes, and provisional chimney heights have been agreed. A complication in this issue is the proximity of London Heathrow Airport, and if the agreed height is not acceptable to the Airport Authority further consultations will take place to consider the use of alternative fuel with a lower sulphur content. 66 INDUSTRIAL BONFIRES Legal proceedings were instituted against two car breakers for causing the emission of dark smoke in contravention of Section 1 of the Clean Air Act 1968, and for similar offences one was fined £15 without any costs, and in the second £10 with £10 costs. Further summonses in respect of a demolition contractor and commercial refuse tip resulted in fines of £20 with £5 costs, and £20 with £10 costs, respectively. SMOKE NUISANCES 165 complaints of smoke nuisance were received during 1971 and 561 visits were made in an attempt to control or to educate the persons concerned with the object of preventing a recurrence, and where necessary, enforcement action was taken. An application for a Nuisance Order to prevent a recurrence of the emission of a smoke nuisance was made to the local magistrates in respect of a manufacturing company whose premises are situated in Harefield. Evidence on behalf of the company was given by a representative of the National Industrial Fuel Efficiency Service and for the Council by a public health inspector. The defence first asked the Court to dismiss the case on the ground that the action was improperly brought because if a nuisance was as severe as alleged then the emission of smoke would be dark and therefore the action was improperly brought under this section. The bench did not accept this argument, but did accept the legal defence that the company had taken the best practical means to prevent the nuisance and therefore did not make the Order. However, they expressed the view that the action was properly brought and did not award costs against the Council. DUST AND GRIT The Clean Air (Measurement of Grit and Dust from furnaces) Regulations 1971 came into operation during 1971 and define for furnaces having a heat input of 1¼—5¾ million British thermal units per hour, the maximum permitted quantities of grit and dust in lbs per hour that can be emitted, and authorise the local authority to require measurements of emissions. 147 visits were made to premises in connection with the inspection and maintenance of plant installed to contain dust and grit emissions and 11 complaints of nuisance from dust were investigated. It was not necessary to take legal action in respect of any of these nuisances but one person did agree to cease operating the plant responsible following failure to comply with a statutory notice requiring works of maintenance and improvement to the dust suppression plant. Measurement of Dust and Grit Because of vandalism one of the standard deposit gauges in operation in the vicinity of the Uxbridge Industrial Estate was withdrawn. The other in the locality of an establishment manufacturing asbestos products has remained on site. One of the tests that has been carried out on the materials deposited in this gauge has been to check for the presence of asbestos dust. No such dust was detected by the infra-red method which is capable of detecting limits of 2.5% of the weight of the sample. Industrial and other odours 245 inspections were made in connection with emission of industrial fumes and 892 inspections in connection with offensive odours from all sources. Equipment for the detection of some specific gases including Perchloroethylene fume which is the gas emitted from do-it-yourself dry-cleaning establishments is maintained in the department. No major defects were noted at this type of establishment. Information concerning some of the more difficult problems in connection with odours from industrial and commercial processes is set out below: (a) Fumes from aircraft.—In 1970 reference was made to the nuisance from kerosene odours in the vicinity of Heathrow Airport and to the fact that it was hoped that the Warren Spring Laboratory would undertake measurements. No progress has been made on this, largely due to the technical difficulties in measurement. Equipment cannot detect or record smell other than by its chemical constituents. Although it is possible for the human sensory system to 67 distinguish readily between kerosene or paraffin, diesel oil and light fuel such as used in domestic central heating appliances, chemically these three liquid fuels are indistinguishable. Because of this it has not been possible to make an investigation at Heathrow. It is understood that the laboratory are considering the possibility of making an investigation at another airport where there is less likelihood of emissions of diesel or light fuel oil interfering with the results. (b) Odours from a coffee manufacturing process.—It was hoped that this problem would be solved late in 1971 by which date an entirely new process and method of dealing with the odours was to have been installed in the factory. The new method would have resulted on a number of identical pieces of equipment being installed. Unfortunately, in the first two of these to be installed there were quite serious fires and it was necessary to discover and rectify the cause before continuing with the operation. This has now been done and the remainder of the work will proceed. (c) Odours from a Caramel manufacturing process.—Investigation has been made into the possibility of reducing the effluvia caused by a caramel manufacturing process. The manufacturers are experimenting with the possibilities of masking the odour by the use of deodorants. Preliminary trials have taken place and the method appears to offer a degree of success at a reasonable cost. (d) Odours from a refuse tip.—A persistent obnoxious odour affecting a portion of the southern part of the Borough was traced to the area of stagnant water adjacent to a refuse tip. This nuisance was eliminated by the use of chemicals after agreement with Thames Conservancy. WATER SWIMMING POOLS There are 22 swimming pools in the Borough, varying in size from the large public baths to the small hotel pools. They may be divided as follows: Covered Pools Open Pools Public 2 3 Private schools 3 Local authority schools 2 5 Clubs 1 2 Hospitals 1 Hotels 1 2 Many of them are unheated and are only used for short periods during the summer season. Regular tests are carried out on the pool waters to ensure the efficiency of the water purification processes. The chlorine content and pH value of pool waters are checked by the use of a colour comparator and pH meter and when necessary bacteriological examination is also carried out. An area of Ruislip Lido is chlorinated and used for bathing purposes. Swimming Pool Samples Satisfactory Unsatisfactory Total Bacteriological 13 3 16 Chlorine determination 54 20 74 Unsatisfactory samples were due to failure on the part of the pool operators to maintain satisfactory dosage rates. During the year a new pool was brought into use employing Bromine for water purification. Bacteriological tests showed this method of treatment to be satisfactory. 68 FOOD The protection of the food supplied to the inhabitants of the Borough remains one of the most important tasks with which the Public Health Inspector is charged. This control is applied at all stages from import, in the cases of food brought into the Borough in sealed containers not examined at the port of entry, through all the numerous preparation and distribution processes which exist to the final point of supply. This protection extends not only to the inhabitants of the Borough but to the millions who use London Airport or who work in or visit the district. MILK AND MILK PRODUCTS The safety and quality of milk is rigidly controlled by the various statutory requirements designed to ensure that milk is only sold, handled or distributed by persons licensed for that purpose and the milk itself is processed in accordance with the requirements relating to the specific description under which it is sold. Dairy Farms The control of any food supply begins at the source of production. There are 15 dairy farms within the Borough, the milk from which, with 2 exceptions is sent for processing. Milk is supplied direct to the consumer without any form of heat treatment from 2 of these farms, in one case the supply being to members of the Jewish faith. Untreated milk from a farm outside the Borough is also retailed. Hygiene on the farm is the responsibility of the Ministry of Agriculture, Fisheries and Food who grant a licence for the production of milk. Samples are obtained by this department and examined for milk fat and non-fat solids in this department's own laboratory where tests may also be carried out to determine the presence or absence of added water. Examinations are carried out by the Public Health Laboratory service for the presence of antibiotics (T.T.C. test) and Brucella abortus. Both these tests are of considerable importance to the consumer. Antibiotics are increasingly used on the farm and, while strict precautions are issued regarding their use, the possibility of a human error resulting in failure to reject contaminated milk is ever present. Brucella abortus is destroyed by heat treatment and the chief danger to health lies in its presence in milk consumed by farm workers and their families before heat treatment or through its presence in milk of "untreated" designation. Any milks found to be positive following the milk ring screening test are submitted to further check by guinea-pig inoculation. In the case of a positive reaction the farmer is advised accordingly and if necessary steps are taken to ensure that all the milk is subjected to heat treatment. The following table gives details of the number of samples of raw milk taken and the results: Brucella Ring Test Guinea Pig Inoculation T.T.C. Test Negative Positive Negative Positive Negative Positive 83 15 8 0 24 0 The positive ring tests were possibly from cows which had been inoculated against Brucellosis. Processing Plants Milk is pasteurized and bottled at two plants within the Borough. 69 Both are regularly inspected and samples of milk and washed bottles together with churn rinses are taken and submitted to the Public Health Laboratory for examination, as a check of the effectiveness of the process and the efficiency of the cleaning methods. Bottles Churns Satisfactory Unsatisfactory Satisfactory Unsatisfactory 41 1 15 0 Catering Sales Milk is susceptible to post-treatment contamination due to failure to clean dippers, dispensers, etc. The use of disposable packs is increasing and has done much to reduce the hygiene failures from this source. Churns and Dippers Dispensers Milk Packs Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory 4 1 5 1 9 1 Premises registered and licensed Premises registered and licensed in accordance with the Milk and Dairies (General) Regulations, 1959 and the Milk (Special Designation) Regulations are as follows: Registered Milk Distributors 122 Registered Dairies 3 Licences to use special designations: (a) pasteurised 111 (b) sterilised 69 (c) ultra heat treatment 86 (d) untreated 16 (e) Dealers licence (pasteurised) 2 The results of all milk samples taken for the statutory tests are set out in the following table. Pasteurised— Phosphatase test Sterilised— Turbidity test UHT— Colony Count Untreated— Methylene Blue test Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory 84 0 4 0 1 0 9 3 Cream The production and sale of cream is not subject to the same strict control applying to milk. A licence is not necessary for its production and it is not required to undergo any tests. Cream is extremely favourable for the growth of bacteria, it has a limited life even under the most favourable conditions, and is one of the first foods to suffer as a result of incorrect storage, faulty stock rotation, etc. The Methylene Blue test is carried out by the Public Health Laboratory Service as a screening test, any failure of this test indicating the need for a closer enquiry into the methods of handling and storage. 70 The results of cream samples submitted for Methylene Blue test are as follows: Satisfactory Unsatisfactory Major Dairy Companies 31 12 Farm Produce 4 3 Catering Sales 20 5 Ice Cream Results of ice cream samples: Vehicles Premises Grade 1 2 3 4 1 2 3 4 Soft ice cream 4 1 4 3 4 2 0 1 Hard ice cream 12 3 1 1 70 9 4 4 Results of all samples taken: Grade No. Taken Percentage 1 90 73 (52) 2 15 12 (20) 3 9 7.5 (17) 4 9 7.5 (11) Percentages in brackets 1970. The reduction in the proportion of samples failing to satisfy the Grade I test is worthy of notice. This test is used for the provisional assessment of the bacterial cleanliness of ice cream. The majority of failures were due to faults in the storage and handling of the products. MEAT Slaughtering continues to be carried out at the one privately owned slaughterhouse in the Borough. Slaughtering is regularly carried out on Mondays, Tuesdays and Wednesdays and all carcases are inspected in accordance with the Meat Inspection Regulations 1963-1966. 71 Details of the animals slaughtered and inspected together with the quantities of meat condemned and reasons for condemnation are set out in the following tables: Number of carcasses Inspected and Condemned Cattle excluding Cows Cows Calves Sheep and Lambs Pigs Number killed Number not inspected 294 25 35 222 3,746 All diseases except Tuberculosis and Cysticerci Whole carcasses condemned Carcasses of which some part or organ was condemned 87 11 1 9 1 20 8 840 Tuberculosis only Whole carcasses condemned Carcasses of which some part or organ was condemned 1 Cysticerci Carcasses of which some part was condemned Carcasses submitted to refrigeration Generalised and totally condemned 1 Condemnation (All Causes)—Quantities pound weight: Cattle Calves Sheep Pigs Carcass Offal Carcass Offal Carcass Offal Carcass Offal Abscess 1 145 2 801 Arthritis 37 Ascaris 452½ Bruising 41 3 5 C. bovis 3 Emaciation 17 240 Fascioliasis 185 28 2 2 Haemorrhagic 28 40 Parasitic 144 12 29i 54 139 Pericarditis 6½ 59¾ Peritonitis 16½ 6 50 24½ Pleurisy 74 6 81 Pneumonia 3 17 158 908½ Pyaemia 308 Telangiectasis 62 Tuberculosis 91 Other conditions 118 50 1½ 196 60½ Total 42 788 50 63 17 41 744 2881¾ Total amount of meat condemned=2 tons 1 cwt 34¾ lbs 72 POULTRY INSPECTION There is one poultry processing establishment operating in the Borough dealing mainly with birds which have been slaughtered and plucked outside the district. Birds are eviscerated and either packed and frozen or sold fresh. The slaughter of poultry is also carried out on an occasional basis at a number of farms within the Borough. Such slaughter is concentrated into the Christmas period when visits are made to supervise and advise on hygienic practices. period when visits are made to supervise and advise on hygienic practices. At the processing establishment birds which show evidence of disease on evisceration are retained for examination by the Public Health Inspector, in accordance with the recommendation of the Ministry of Agriculture, Fisheries and Food. Details of the poultry processed are given in the following table: Chickens Hens Ducks Pheasants Turkeys Geese Total 84,605 2,157 97 26 2,697 24 89,606 INSPECTION OF OTHER FOOD Considerable time is spent in the examination of food at the request of the trade. Food which is found to be unfit is surrendered for destruction by way of tipping and burial at a refuse tip. Details of the food surrendered for destruction during the year are set out in the following table: Unfit Food Surrendered Class of Food Weight (lbs) Fresh Meat 3,742 Fresh fish 345 Fresh fruit 1,085 Fresh vegetables 1,059 Frozen meat 5,634 Frozen fish 2,526 Frozen fruit 164 Frozen vegetables 2,345 Canned meat 1,991 Canned fish 220 Canned fruit 4,226 Canned vegetables 2,433 Canned soup 448 Canned dairy produce (milk, cream and evaporated) 806 Canned meals Poultry 623 Cereals 582 Flour confectionery 465 Sugar confectionery 488 Fruit juice 319 Cheese 703 Other foods 665 Total 30,869 lbs Totals 1968 53,264 lbs 1969 39,494 lbs 1970 57,941 lbs Refrigerator breakdown remains the major single cause for food condemnation. 73 Food and Drugs Act, 1955 Details of Food examined in accordance with the requirements of the Food and Drugs Act 1955 are set out in the following table: Examined by Public Analyst PRODUCT PROCURED Adulterated, below standard or otherwise not complying with prescribed requirements PRODUCT PROCURED Adulterated, below standard or otherwise not complying with prescribed requirements Formally taken Informally taken Formally taken Informally taken Formally taken Informally taken Formally taken Informally taken Biscuits 6 Drugs 6 Bread roll 1 1 Essences 7 Buttered bread 3 1 Evaporated milk 1 Cake & pudding mix 7 1 Fish products 8 Fruit drinks & juices 7 Canned fish 5 Canned fruit 1 Fruit pies 1 Canned meat 5 Gelatine 1 Canned & packet meals 6 Indian food 8 Instant mashed potato 3 1 Canned puddings 9 Canned vegetables 3 Martini 1 Cereals 11 Mayonnaise 1 Cheese & cheese products 7 1 Meat & meat products 27 4 Chicken 2 Minerals 2 Chinese foods 3 Mustard 4 Coffee 1 Nutrament 2 Cooking oil 2 2 Pat6 6 Chocolate confectionery 2 1 Pickles 4 Preserves 5 Confectionery 5 Rice products 1 Crisps 1 1 Salad cream 1 Curry & curry powder 4 Sauces & sauce mix 11 2 Dessicated coconut 3 Sausages 5 38 3 Spices & savoury spread 8 Diabetic bread 1 Diabetic confect. 1 Soups canned & packet 7 1 Diabetic canned fruit 1 Suet 3 Diabetic preserve 1 Dried fruit 2 Total: 9 250 1 18 74 Samples Examined in the Departmental Laboratory Food Departmental (Chemical) Total Satisfactory Unsatisfactory Milk 72 2 74 Fresh cream 15 15 Ice cream 5 5 Buttered rolls and bread 43 7 50 Spirits 39 39 Meat pies 6 6 Sausage rolls 14 14 Minced meat 33 33 Cream cakes 10 10 Butter 5 5 Nutmegs 1 1 Ice lollies 2 2 Fresh fruit 1 1 Total 245 10 255 A further 24 samples of milk were examined by the Public Health Laboratory for the presence of antibiotics and all were found to be satisfactory. A total of 561 food and drug samples were examined, of which 30 or 5-3% were classed as unsatisfactory. examined, of which 30 or 5-3% were classed as unsatisfactory. Details of the action taken regarding these samples are set out in the following tabie. Product No. Contravention Action Beef croquette 1 Incorrectly described Isolated incident due to the error on part of shopkeeper—repeat samples satisfactory. Buttered rolls, Buttered bread 8 Incorrectly described Description amended—warning letters sent. Bread roll 1 Contained foreign body Warning letter. Cooking oil 2 Incorrectly labelled Labels being redesigned. Mashed potato mix 2 Incorrectly described New descriptions agreed. Nut chocolate 1 False description Absence of nuts due to manufacturing fault—warning letter. Milk 2 Low fat content Farm sample—advice given regarding bulk mixing of supplies. Cake mix 1 Incorrectly described Result of repeat formal sample awaited. Meat pasties 3 Incorrectly described Description amended. Sauce mixes 2 Incorrectly described Manufacturers re-designing label. Canned sausages 3 Deficient in meat One prosecution pending. Investigations continuing in remaining cases. Processed cheese 1 Incorrectly described Label amended. Soup 1 Incorrectly described Company to revise label. Fresh fruit 1 Incorrectly described Warning letter. Potato crisps 1 Foreign matter Warning letter. 75 Food Complaints Following a reduction in 1970 the number of food complaints resumed its upward trend during the year, being 192 as against 175 for 1970, 181 for 1969, 155 for 1968 and 114 for 1967. The complaints received are classified in the following tables: Food Foreign matter Mould Other Type of foreign body Milk 4 3 3 Metal spring; dirty bottles Butter 1 1 Cheese 2 5 2 Glass; fly Bread 13 21 4 Mice droppings; wasp; maggot; grease dough; deposits; beetle Bacon 1 1 Maggots Canned meat 4 4 Cooked meat and meat products 3 9 20 Nylon thread; bristle; fly Meat pies 1 1 Insect Fruit canned 1 1 2 Insect Fish 6 8 Worms; fly; matchstick Vegetables 2 3 3 Snail; plant cells Cereals 3 1 Wood lice; rodent droppings; insect Confectionery 7 4 4 Beetle; staple; mosquito; hair; spider Other foods 13 6 15 Rubber tube; ants; staples; rubber bands; maggots; flies; tin; nails; glass; dirt; grit Total 56 57 79 Total: 192 food complaints. Details of six prosecutions taken as a result of food complaints are set out in the following table. Further prosecutions are awaiting court hearings at the time of writing the report. Offence Statute Trade of Defendant Fine Costs Total 1. Use of a dirty milk bottle Milk and Dairies (General) Regulations, 1959, Regulation 27 Wholesale Dairyman £20 £9 £29 2. Use of a dirty milk bottle do. do. £25 £7 £32 3. Foreign matter in milk Section 2, Food and Drugs Act, 1955 do. £10 £5 £15 4. Foreign matter in milk do. do. £50 £10 £60 5. Selling mouldy cake do. Grocer £30 £6 £36 6. Selling bread containing wood splinters do. Bakers £15 £15 7. Selling sour cream do. Wholesale Dairyman £20 £5 £25 8. Selling a mouldy cream dessert Section 8, Food and Drugs Act, 1955 do. £40 £5 £45 76 It is interesting to note that there was a considerable reduction in the number of complaints concerning bottled milk but that bread retained its pride of place as the main subject of food complaints. The fact that 57% of complaints related to mould growths is cause for serious concern since it indicates quite clearly that insufficient care is being given to proper stock rotation. FOOD HYGIENE It is disappointing to report yet again that there is a great difficulty in maintaining a satisfactory standard of hygiene in food premises and at every routine visit it is necessary for the inspector to draw attention to failures in practices about which the occupiers have been repeatedly advised. These failures are reported verbally to the occupiers at the time of the inspection and confirmed in writing. As a result improvements are effected but unfortunately they are short-lived. It has not been the custom to prosecute when proprietors have been willing to co-operate, but the time appears rapidly to be approaching when prosecutions will have to be taken if co-operation is only forthcoming after the service of a notice and the resulting improvement is not maintained. Later in the report are details of the 14 prosecutions taken during the year—these were extremely serious cases with no redeeming features. If the policy is changed by taking a hard line it will have several repercussions, viz.: work load preparing evidence, work load on legal section and additional cases in a much overworked police court where at the present time it takes not less than an average of 4 months to obtain a hearing for a food hygiene offence. The following extract from an Inspector's report concerning a restaurant illustrates the type of conditions found. The proprietor in this case was subsequently prosecuted and convicted for contravening the requirements of the Food Hygiene Regulations. 1. A galvanised iron bath containing a dry greasy residue was stored on the bottom shelf of the gas range. The shelf itself was covered with a layer of greasy dirt and particles of carbonised grease and food scraps. 2. The fluorescent light fittings were heavily coated with dirt. 3. The extractor fan was heavily coated with grease. 4. The gas range had a coating of carbonised grease on the regulo controls and around the burners, gas pipes, oven shelves and doors. 5. The water pipes to the double bowl stainless sink were covered with grease and dirt. Metal supports to these sinks were dirty. 6. The external surfaces of the potator peeler were dirty as were the door runners and side of the bain-marie. 7. Raw meat was present in the wash hand basin. 8. A circular wooden chopping block was present on the central work table. It was resting on a layer of paper and there was a large film of mould between the surface of the block and the surface of the paper. A metal band was nailed around the block and there was a collection of stale food debris between the block and the band. 9. The clamp of a bench mounted can opener was screwed to the central working surface. The clamp was very dirty and the main body of the can opener which was lying on the floor was similarly dirty being covered with grease and dirt. 10. A large refrigerator contained cooked chicken and cooked meat in cardboard mushroom boxes. These boxes were dirty and the cardboard by its very nature was not capable of being thoroughly cleaned. 11. The walls of the kitchen were partly panelled with hardboard and partly tiled. The hardboard panelling behind the gas range was coated with grease and the tiles by the double bowl stainless steel sink unit were splashed with grease and dirt. The hardboard panelling behind the bain-marie was dirty and gaps between the wall and the glazed wash-up sink contained mould and dirt. 77 The various classes of food premises and businesses within the Borough are shown in the following table: Type of Business Total number BAKEHOUSES 23 BAKERS SHOPS 58 BUTCHERS SHOPS 134 CATERING PREMISES 1. Aircraft catering 10 2. Factory canteens 79 3. Hospital kitchens 10 4. Hotels, restaurants, cafes, Public Houses, clubs 323 5. School kitchens and dining canteens 84 6. Old People's/Children's Homes, Day Nurseries, etc. 37 7. Other catering premises (office canteens, etc.) 151 8. Confectioners 100 DAIRIES 2 FISHMONGERS AND POULTERERS 50 FOOD FACTORIES 1. Bakery and confectionery 4 2. Biscuit manufacture 1 3. Butter blending 1 4. Caramel production 1 5. Coffee and chocolate manufacture 1 6. Confectionery manufacture 1 7. Fat rendering 1 8. Manufacture of pharmaceutical products 2 9. Meat products 2 10. Soft drink and mineral manufacture 1 GREENGROCERS SHOPS 109 GROCERS SHOPS 238 HAWKERS OF FOOD 100 POULTRY PROCESSORS 1 POULTRY SLAUGHTERHOUSES—CASUAL 11 VENDING MACHINE SITES (NOT ON FOOD PREMISES) 57 TOTAL 1,592 78 Other conditions found at food premises included infestations of mice and cockroaches, blocked drains flooding the kitchen area with foul water, accumulations of filth and debris, and absence of effective equipment for washing. The larger the premises the more acute the problem and the criticisms apply equally to the whole of the food trade including the larger undertakings whose management and systems should be such as to ensure the maintenance of hygienic standards at all times. Viewed against this background the enforcement of satisfactory conditions in the 1,500 food premises within the Borough is a matter of serious concern. During the year conditions were found to be particularly bad at a large food factory and but for the fact that the company concerned took immediate remedial action it would have been necessary to consider the institution of legal proceedings. The Food Hygiene (General) Regulations 1970 came into operation on the 1st March, 1971, replacing the Food Hygiene (General) Regulations 1960 and 1962 which they consolidated and amended. Minor changes in the regulations were welcomed, particularly the requirement regarding the need for persons handling open food to wear clean washable overclothing. The visual inspection of premises alone is not sufficient to determine whether or not the hygiene standards are adequate. Faults in storage, stock rotation and other procedures are not always evident and in this respect, bacteriological assays are extremely useful. These detailed examinations are carried out by the Central Food Hygiene Laboratory, Colindale, 138 samples being examined during the year of which 30 were regarded as unsatisfactory and a further 17 as suspicious. Unsatisfactory or suspicious samples are carefully investigated in an effort to determine the cause for the failure. Details of the food sampled and the results obtained are set out in the following table: Bacteriological Examination Type of Food Satisfactory Suspicious Unsatisfactory Total Brawn 1 1 2 Shellfish 2 2 Cooked rice 11 2 13 Cooked chicken 10 6 16 Raw chicken 1 1 Cooked meat (excluding ham) 6 2 8 Cooked ham 9 4 9 22 Cream cakes 3 2 5 Fresh minced meat (including sausages) 38 9 5 52 Meat products 14 4 18 Chicken products 1 2 3 Total 95 17 30 142 A further assessment of hygiene standards is made possible by swabbing food equipment, food containers, working surfaces, etc. 217 such examinations were made and of these 92 were unsatisfactory requiring further investigation into cleaning methods and procedures. Legal Proceedings Of the 14 prosecutions for hygiene offences referred to earlier, 11 were taken for contraventions of the Food Hygiene (General) Regulations and 3 for contraventions of the Food Hygiene (Markets, Stalls and Delivery Vehicles) Regulations, and at the end of 1971 three further summonses were 79 awaiting hearing, two for contraventions under the General Regulations and one under the Markets, Stalls and Delivery Vehicles Regulations. Details of the prosecutions in 1971 are summarised below: Statute Nature of Business/ Occupation of Defendant Fine and costs Remarks The Food Hygiene (General) Regulations, 1960/70 Restaurant £600 Hygiene offences Bakehouse £390 Hygiene offences Bakery £195 Hygiene offences Grocers £35 Hygiene offences Kitchen worker £10 Smoking Restaurant proprietor £15 Permitting an employee to smoke Restaurant proprietor £10 Permitting an employee to smoke Company director £25 Smoking Restaurant proprietor £15 Permitting an employee to smoke Kitchen worker £13 Smoking Butchers £98 Hygiene offences The Food Hygiene (Markets, Stalls and Delivery Vehicles) Regulations, 1966 Ice cream delivery vehicle operator £90 Hygiene offences Grocery stall £41 Hygiene offences Fruit stall £7 Hygiene offences The Liquid Egg (Pasteurizing) Regulation, 1963 The regulation requires the pasteurization of liquid egg which is to be used in food intended for human consumption. 15 samples were submitted for the Alpha-amylase test for adequate pasteurization and found to be satisfactory. Imported Food Regulations, 1968 The number of food containers delivered to firms in the Borough which had not been examined at the port of entry increased rapidly during the year. at the port of entry increased rapidly during the year. Details of the imports examined and their country of origin are given below: Product No. of Containers Tons Cwt Stones Lbs Country of Origin Quarters of beef 9 116 16 France Cherry nutrient 1 87 9 6 5 Canada Fruit juice 3 46 14 5 10 Israel Canned tomatoes 3 20 7 10 14 Spain Mandarins 3 37 15 2 Spain Canned apricots 2 24 17 7 Spain Pineapple 1 9 9 5 Malaya Instant potatoes 3 86 15 7 Canada Confectionery 7 82 5 4 12 Dublin Total 32 612 12 8 3 80 Food Hygiene Lectures During the year new food premises in the Uxbridge Redevelopment Area were opened and some of the companies concerned accepted offers of food hygiene lectures to their newly recruited staffs. These lectures varied from an informal chat round a table to formal talks accompanied by colour slides. Lectures were also given to "0" level domestic science pupils, to all the school meals supervisors and to several organisations in the Borough. Statistical details are recorded on pages 45 and 148. OUTDOOR CATERING A Borough such as Hillingdon with so many open spaces lends itself to the organisation of outdoor fetes, annual shows, etc. Most of these are annual events such as the Borough Show, Hayes Town Fete and various private fetes. The problem of food hygiene enforcement at these events is simplified by having advance knowledge of dates. The organisers are asked to supply names and addresses of stall holders and great care is taken to ensure that these people are informed of their responsibilities. They are requested to submit details of how they intend to comply with the Food Hygiene Regulations and wherever possible the caterers and food stalls are visited during the event. Samples of food and swabs of work surfaces are taken for bacteriological examination and warning letters issued for unsatisfactory conditions found. The practice of co-operating with organisers and advising caterers has resulted in high standards of food hygiene at the open air events in the Borough. DISEASES OF ANIMALS ACT, 1950 The Local Authority's duties under the Act and the Regulations made thereunder are enforced by the public health inspectors assisted by a part-time veterinary officer. The regulations of principal concern are: (a) The Disease of Animals Waste Food Order, 1957: The requirements of this Order are particularly important as they ensure that all waste food comprising meat, bones and offal, etc., are boiled and handled in such a way as to safeguard against the spread of animal diseases. Untreated food waste is suspected of carrying the viruses of foot and mouth disease, swine fever and fowl pest. There are 29 licensed swill-boiling plants in the Borough. (b) The Movement of Animals (Records) Orders, 1960 and 1961. Under these Orders stock holders are required to keep records in the prescribed manner giving details of all stock brought into or removed from the premises. During the year it was necessary to issue three summonses against a farmer for failing to produce the required records. Fines totalling £15 were imposed together with £3 costs. THE SLAUGHTER OF ANIMALS ACT, 1958 During the year 3 licences to slaughter were issued. FERTILIZERS AND FEEDING STUFFS ACT, 1926 FERTILIZERS AND FEEDING STUFFS REGULATIONS 12 samples of fertilisers and 3 samples of animal feeding stuffs were taken during the year. 4 samples of fertilisers (2 dried blood, 1 basic slag and 1 hoof and horn meal) did not comply with the written guarantees, warning letters were given in two cases, investigations are still in progress in connection with the two other samples. HOUSING Two of the main tasks of Local Authorities in the field of housing are: (1) Eradication of slums; (2) The repair and improvement of existing houses. This part of the report gives details of the department's efforts to carry out these duties. 81 SLUM CLEARANCE During 1971 the Council declared one clearance area comprising 2 houses and made 2 Demolition Orders. Inspections of similar type properties will be made during 1972 and representations will be submitted in order to deal with any further unfit property. The number to be dealt with is small as most of the older houses in the Borough are capable of being dealt with by repair and mprovement. It is appropriate to mention that the operation of the Improvement Grant provisions of the Housing Act, 1969 has resulted in the repair and improvement of many houses already, which, if that action had not been taken the houses would be being considered for clearance procedure. REPAIR AND IMPROVEMENT The repair and improvement of houses is achieved by various means: (a) By the operation of the qualification certificate procedure where the landlord applies for a Qualification Certificate to enable him to ask the rent office to fix a fair rent for his properties. Before issuing a Qualification Certificate the local authority must be satisfied that the house is in good repair and possesses the standard amenities. 82 The action taken during the year is reported below in the following tables: Unfit Houses (not capable of repair at reasonable expense) (Housing Act, 1957) 1. Undertakings received (Section 16) — 2. Closing Orders made (Section 17) ... — 3. Demolition Orders made (Section 17) 3 4. Closing Orders made (rooms) (Section 18) 1 5. Closing Orders determined (Section 27) 1 6. Closing Orders revoked and Demolition Orders substituted (Section 28) — 7. Houses demolished following Demolition Order 4 8. Houses demolished following Closing Orders — 9. Number of persons displaced: (a) individuals — (b) families — Clearance Areas and Individual Unfit Dwellings Since the 1st April, 1965 the Council have made 49 Demolition Orders, 33 Closing Orders and declared 43 Clearance Areas. (1) Clearance Areas represented during the year: (a) Number of areas 1 (b) Houses unfit for human habitation 2 (c) Houses included by reason of bad arrangement, etc. (d) Houses on land acquired under Section 43(2) — (e) Number of people to be displaced: (i) individuals 3 (ii) families 1 (2) Action taken during the year relating to Clearance Areas: (a) Houses demolished by Local Authorities or owners: (i) unfit 13 (ii) others — (b) Number of people displaced: (i) individuals 23 (ii) families 7 (b) By the implementation of the Improvement Grant Scheme. (c) By the use of the repair sections of the Housing Act, 1957 as amended by the Housing Act, 1969. (d) By the use of the nuisance provisions of the Public Health Act, 1936. Details of the action taken to secure the repair and improvement of houses are as follows: (a) Qualification Certificates As reported in 1969 and 1970 there were 2,214 applications for Qualification Certificates of which it was only possible to survey 1,422, leaving 792 to be inspected in 1971. In addition, further applications were received in 1971. Although the rush of applications has stopped there is a steady stream of new applications. To date, from the inception of this procedure 1,352 certificates have been issued. These houses are not of a type for which the normal repair provisions of the Housing Act or the Public Health Act would be used but nevertheless the average cost of bringing them to the standard of good repair necessary for the issue of a Qualification Certificate has averaged at £250 per dwelling. Thus it will be seen that repairs to date have cost approximately £271,250. From the foregoing it can be seen that this scheme has not dealt with the hardcore of the problem, i.e. property which is older in more serious disrepair and lacking in amenities. Until November 1971 the department was only responsible for the technical work involved in the qualification certificate procedure but since that time both the administrative and technical matters have become the responsibility of the department. Applications for Qualification Certificates received during 1971: Number of applications for Qualification Certificates received 265 Number of houses inspected 800 Number of applications for Qualification Certificates cancelled 14 Number of Qualification Certificates refused 19 Number of Qualification Certificates granted 836 Number of combined applications received (Improvement Grant and Qualification Certificate) 61 Number of houses inspected 78 Number of Certificates of Provisional Approval issued 29 Number of combined applications granted 28 Number of combined applications refused — Improvement Areas When the Housing Act, 1969 came into operation no provisions were retained for the continued Declaration of improvement areas, and the powers given to local authorities in the Housing Act, 1964 to compel landlords of tenanted houses to provide standard amenities were discontinued. This is considered to be a retrograde step since it will now be more difficult to secure the provision of these amenities in all dwellings. In 1965 it was estimated that over 2,700 houses were lacking in one or more standard amenities and a target was set to include all these in improvement areas over a period of 10 years. Although the Housing Act, 1969 made provisions for action to continue in respect of any area declared under the 1964 Housing Act, it created many difficulties. Whilst under the 1964 Act an owner could increase the rent by 12½% of his share of the cost of providing standard amenities, under the 1969 Act he can obtain a certificate of fair rent which ultimately, after phasing, produces a rent in excess of 12½%. Tenants in the improvement areas who had signed their willingness to have the standard amenities for a 12½% increase of half the cost of their provision, have been reluctant to agree to the fair rent which was higher. Owners on the other hand were interested not only in providing the amenities, but also in carrying out repairs to a good standard in order to obtain the double benefit of the £1,000 discretionary grant and a "fair rent". 83 When an improvement notice is served on a landlord of a tenanted house he may instead of carrying out the work, serve a purchase notice on the Council requiring it to purchase the house. Six such notices have been served on this Council. The properties acquired have been taken into the housing pool and the Housing Department is carrying out full improvement and repair. The position at the end of 1971 in respect of the four Improvement Areas declared by the Borough is shown below: Area No. No. of Houses lacking amenities in the area No. improved No. still to be improved Remarks owner/ occupier tenants willing tenants unwilling Suspended Notice 1 108 75 22 — 7 4 houses demolished 2 159 38 48 25 22 21 dwellings (flats) are already provided with baths in the kitchens and it is physically impossible to re-arrange the dwelling to give separate bathroom. 4 other houses have been demolished. 1 house is owned by the Borough Council and is being comprehensively improved by the housing dept. No default action is being taken as there are redevelopment proposals. 3 189 49 115 15 8 1 purchase notice 4 158 47 60 22 24 5 purchase notices Number of: 1. Preliminary Notices served — 2. Undertakings accepted — 3. Immediate Improvement Notices served 1 4. Suspended Notices served — 5. Final Notices served — 6. Dwellings improved (a) full standard 15 (b) reduced standard — 7. Dwellings improved by Local Authority in default: (a) full standard — (b) reduced standard — General Improvement Areas As an alternative to the declaration of improvement areas the 1969 Act introduced the concept of a general improvement area concept. The intention of declaring such an area is not only to improve individual houses lacking modern amenities, but also to improve their environment. In fact, before declaring a general improvement area the local authority must be satisfied that 84 living conditions in the area ought to be improved, and that by using the powers available to them they will be able to secure or assist with such an improvement whether by improving the dwellings in the area or carrying out environmental work to improve the amenities of the area, or both. Local authorities are expected to find potential general improvement areas from those areas predominantly residential but in which the houses are lacking in basic amenities, need repair and have not yet reached the end of their useful life. Officers of the Department of the Environment visited eleven areas in Hillingdon which were suggested by the Redevelopment Working Party; of these only two were considered to be possible general improvement areas. One is in Yiewsley comprising Tavistock Road, Bentinck Road, Winnock Road, Wimpole Road, Padcroft Road and High Street, making a total of 134 houses. The other is in Uxbridge and comprises Cowley Mill Road, Waterloo Road and the Bridge Road area. This latter area had already been declared an improvement area under the Housing Act, 1964 (Improvement Area No. 3) and progress is shown in the table on page 84. Of the 134 houses in the suggested Yiewsley area, 94 already have the basic amenities and 40 require improvement. In this latter group only 10 owner occupiers and 4 tenants are interested in improvements at the present time. Thus, unless there is a necessity on planning grounds for the environmental improvement of these areas, existing powers and the improvement grants available are sufficient to deal with the repair and improvement of individual properties. These are: (i) The right of a tenant to make a representation to the Council to require a landlord to provide standard amenities. (ii) The right of a landlord to appeal to the County Court to require a tenant to have standard amenities. (iii) The agreement of landlord and tenant voluntarily to have improvements carried out with the assistance of an Improvement Grant. (iv) The right of the local authority to serve appropriate notices to secure the repair of a dwelling house. Dwellings outside Improvement Areas, Section 19, Housing Act, 1964 Comment was made earlier that the authority to declare improvement areas under the 1964 Housing Act, together with the power of compulsion to require the provision of standard amenities were withdrawn. However, there was retained in the 1969 Housing Act the opportunity for the tenant of a dwelling house to make representation to the Council with a view to the exercise by the Council of their power under Section 19 of the Housing Act, 1964 to require a landlord to provide any missing standard amenity. If the landlord does not choose to provide these amenities after service of notice by the Council he may serve a purchase notice on the Council to buy his interest in the house. There has been one purchase notice served on the Council after the service of a Section 19 notice, but this was subsequently withdrawn as the house was sold to the occupier who is taking advantage of an improvement grant to improve the house himself. Although public health inspectors explain to tenants the details of action that can be taken under this section, tenants are reluctant to make representations. This is probably due to the fear of having to pay a new "fair rent" for the improvements effected. Old people in particular do not wish to trouble with the inconvenience of building alterations. Dwellings outside Improvement Areas (Section 19 Applications) 1. Number of representations made by tenants 2 2. Number of Preliminary Notices served (full standard) 3 3. Number of Immediate Improvement Notices served (full standard) 3 4. Number of dwellings improved: (a) full standard 5 (b) reduced standard — 85 The position with the 2 representations is as follows: Applications for grants by owners 1 Houses found to be unfit and dealt with by Closing Orders — Representations cancelled — Immediate Notices served on owners — Negotiations with owners in progress 1 Improvement Grants There has been a change in the type of application for grants this year the greater number being for the improvement grant rather than the standard grant. In accordance with the Act, assistance by public health inspectors has been given to both owners and builders in the somewhat complex form filling and other submissions that are required for grant purposes. The scheme has worked well in this Borough and few applications have been refused. The reason for such refusals has been that the work proposed was outside the scope of the grant scheme. There are still some 1,800 houses lacking in basic amenities and these houses are the most likely to need substantial repair as they are the oldest. It is to these houses that attention will have to be directed in the immediate future. Before the improvement and rent provisions of the Housing Act, 1969 were operative the majority of applications for improvement grant applications were from owner occupiers but since that date the majority of applications are being submitted by owners of tenanted property. This will speed up as it becomes possible with staff availability to inspect houses and serve on the owners notices requiring substantial repair. In fact when notices for this purpose have been served during 1971 on owners of properties lacking in amenity the owner has immediately applied for an improvement grant. This is the purpose of the scheme and will result, it is hoped, in a great improvement in the older houses. 86 Details of Improvement Grant Applications received and given Grants in 1971 are as follows: Standard Grants Owner/Occupier Tenanted 1. Number of applications received 16 17 2. Number of applications approved 9 11 3. Number of applications refused — — 4. Number of dwellings improved 10 22 5. Works carried out in default — — 6. Number of applications cancelled or changed to Improvement Grants 4 2 The total number of applications for Standard Grant in 1970 was 159. Amount paid in grants £3,956 00 Average grant per house £123 00 Amenities Provided (a) fixed bath 11 (b) shower — (c) wash hand basin 23 (d) hot water supply (to any fittings) 29 (e) water closet: (i) within dwelling 17 (ii) accessible from dwelling — (f) food store — (g) sink 3 The total number of applications in 1970 was 106. Amount paid in grants £39,033 Average grant per house £520 Improvement Grants—Publicity Information on improvement is sent out with all correspondence concerning housing emanating from this department in order to create interest in improvement. The public notice boards, the Borough Show and "Welcome to Citizenship" Exhibition are all used to publicise improvement grants. Repair (Housing and Public Health Acts) Little action is ever shown in the following table relating to the Housing Act, 1957. This is by no means uncommon as most authorities secure the repair of dwelling houses by use of the nuisance provisions of the Public Health Act, 1936 and by use of the new section 9(1A) of the Housing Act 1957 which empowers a local authority to serve notice on an owner where a dwelling is not unfit for habitation but in need of substantial repair. This section is now used fairly extensively, especially with the increased value of all types of property and the trend of increasing rents, it is becoming more and more difficult to use the old provisions of the Housing Act, 1957 relating to "reasonable expense". Not to be overlooked in this connection is the amount of repair work carried out to dwelling houses after public health inspectors visit a house in connection with an improvement grant. Almost invariably an owner making his application for a grant is not in a competent position to inspect a dwelling house to ascertain how far short of good repair it falls. Many houses therefore that are improved in this area nowadays are also repaired to a good standard as a result of inspections carried out by public health inspectors bringing to the notice of the owners matters requiring attention for the essential good maintenance and preservation of property. Unfit Houses made Fit After informal action by Local Authority by owner After formal notice under Section 9(1) and 16(1), Housing Act, 1957: (a) by owner (b) by local authority After formal notice under Public Health Acts Previously included in a clearance order which has been or will be modified or revoked under Section 24, Housing Act, 1961 Previously included in a demolition order which has or will be revoked under Section 24, Housing Act, 1957 Previously included in a closing order which has or will be determined under Section 27, Housing Act, 1957 2 87 Improvement Grants (Discretionary) Owner/Occupier Tenanted Number of applications received 41 117 Number of applications approved 34 92 Number of applications refused — — Number of dwellings improved 36 39 Number cancelled 5 4 Other Houses in which Defects were Remedied After formal notice under Public Health Acts 32 After formal action under Section 9(1 A), Housing Act, 1957: (a) by owner 5 (b) by local authority After informal action by local authority 1060 MULTIPLE OCCUPATION Although multiple occupation continues to increase in the Borough, the exact extent is not known. An extensive survey would be necessary to ascertain the complete situation although it is not considered that the type of multiple occupation taking place in the Borough is in any way as serious as in adjacent Boroughs. As reported previously control has been exercised by the use of direction order procedure. Regular supervision is undertaken of houses on which there are direction orders. When contraventions are discovered action is taken to reduce the number dwelling in the house, but complete control is impossible because of the general shortage of single family accommodation in the area. It is disturbing to find in connection with new house and flat development that there is often immediate letting to several single people after completion when the units were specifically designed for single family occupation. The only control appears to be by use of the direction order procedure of the Housing Act. During the year 36 new cases of multiple occupation were discovered. 47 notices of "Intentions to serve directions" and 50 directions were served. In addition 34 notices of intention and direction were re-served as a result of changes brought about by the Housing Act, 1969. Satisfactory means of escape in case of fire were required in 8 cases. Fifteen prosecutions were taken for the contravention of Directions and convictions were obtained in each case. Common Lodging Houses There is no common lodging house in the Borough at the present time. CERTIFICATE OF DISREPAIR—RENT ACT, 1957 It was noted in last year's annual report that as landlords of controlled dwelling houses obtained fair rent certificates, there will be a reduction in the number of tenants who will avail themselves of the powers in the above Act to obtain certificates of disrepair. In fact, no applications for these certificates have been received, neither was any other action necessary under the Rent Act, 1957 to revoke any existing certificates. In future if a tenant who has agreed to a fair rent subsequently becomes dissatisfied with the state of disrepair of a dwellinghouse and the defects cannot be remedied by any action from this department, he may apply to the Rent Officer for a rent adjustment. 88 CONTROL OF CARAVAN SITES Caravan Sites and Control of Development Act, 1960 The following table shows the number of licenced sites in the Borough. One new licence was issued during 1971. Both the temporary and permanent site conditions are based on the Department of the Environment's model standards. Licensed Sites in the Borough Temporary Licenses Permanent Licenses 19 13 Gypsies and other Itinerants There has been a considerable reduction in the number of parking places in the Borough used by gypsies but there have been major problems from a site adjacent to the Colnbrook By-Pass. This site was formerly an experimental road used by the Road Research Laboratory. The road has been used for several months by itinerants and is in a most disgusting condition, littered with refuse, human and animal excreta and infested by rats. As the site is owned by a government department it is not possible to institute proceedings for the abatement of the nuisance as would be possible if it were in the ownership of anyone other than the Crown. In these days when there is so much talk of preventing pollution and improving the environment it is indeed strange that the Department of the Environment should condone such intolerable conditions on one of the major routes into London on a site under its control. Representations by the Council to the Department have so far been unsuccessful. WORKING ENVIRONMENT The working environment is one of the largest fields in which the public health inspector carries out his work. The specific enactments controlling places and conditions of employment are the Factories Act, 1961, the Offices, Shops and Railway Premises Act, the various Shops Acts, and the Agriculture (Safety, Health and Welfare Provisions) Act. As far as the Factory Act is concerned the major provisions are administered by the factory inspectorate. In addition to the specific legislation there are other enactments dealing with particular matters of public health and all types of premises including factories, shops and work places, viz. Public Health Acts, 1936 and 1961, the Prevention of Damage by Pests Act, 1949 and the Food and Drugs Act, 1955. When public health irspectors are carrying out general inspections of all types of work place in addition to ascertaining the facts required by the specific legislation the following matters are also investigated and if necessary action to ensure compliance with requirements taken. (a) Nuisances—(e.g. dampness). (b) Drainage—e.g. leaking gutter, storm and foul drainage with particular reference to chemicals or oils in the effluent. (c) Refuse storage and disposal—in this connection the type of waste is noted, and if noxious wastes are produced the method of disposal is investigated to ensure proper disposal to avoid risk of pollution. (d) Rodent infestation. (e) Food hygiene—with special reference to canteens and vending machines. A serious omission in connection with a large number of workers is the lack of specific legislation dealing with the conditions of employment, in particular for prescribing safety precautions —examples are teaching and caretaking in schools. 89 OFFICES, SHOPS AND RAILWAY PREMISES ACT, 1963 There are 3,049 registered premises in the Borough employing 32,704 persons. The following table shows the various types of premises and numbers employed. Class of Premises No. of Registered Premises No. of Registered Premises receiving one or more general inspections during the year No. of Persons Employed Offices 882 489 19,841 Retail shops ... 1,814 1,814 8,061 Wholesale shops, warehouses 83 50 1,869 Catering establishments open to the public, canteens 260 260 2,860 Fuel storage depots 10 4 73 Totals 3,049 2,617 32,704 4,929 visits were made to this class of premises during 1971 and 580 Notices requiring various works as shown in the table below were served. various works as shown in the table below were served. Except where referred to in the paragraph on the legal proceeding the defects were remedied by informal action. Defect Number of Premises Cleanliness 245 Overcrowding 3 Temperature 135 Ventilation 72 Lighting 94 Sanitary convenience 84 Washing facilities 247 Supply of drinking water 5 Accommodation for outdoor clothing 44 Seats or sitting facilities 7 Facilities for meals 6 Disrepair 168 Fencing exposed parts of machinery 52 First Aid Equipment 190 Other matters 377 It was necessary to take legal action in respect of defective flooring at a shop and a defective W.C. at a wholesale premises and fines of £5 with costs and £10 with £5 costs, respectively, were imposed. No action was necessary in respect of: (a) The protection of young persons from dangerous machinery. (b) The training of young persons working at dangerous machinery. (c) The prohibition of heavy work. It was not necessary to make any application to the local Magistrates Court for an Order preventing either work being carried on in premises that were considered to be dangerous or to prevent any dangerous practices in those premises. After a report from the Fire Brigade of a young child having her dress set on fire, a portable paraffin heater of an unsuitable type was found to be in use in a shop. The occupier was informed that unless the use of the heater was discontinued it would be necessary to apply to the Courts for an Order but the use was discontinued without the necessity of court action. 90 64 accidents were investigated at premises registered under the Offices, Shops and Railway Premises Act during the course of the year, none of which was fatal. Table 2 sets out the type of premises where the accidents occurred and the causes of the accidents. The accident due to an explosion occurred in an office when for photographic purposes an attempt was being made to create with chemicals the fog conditions so prevalent in the London Area before the advent of smoke control. Type of premises No. Reported Action Recommended Fatal Non-Fatal Prosecution Formal Warning Informal Advice Offices 18 18 Retail Shops 19 19 Wholesale Warehouses 12 1 11 Catering Establishments 15 15 Totals 64 1 63 Cause Offices Retail Shops Wholesale Warehouses Catering Establishments Fata/ NonFatal Fatal NonFatal Fatal NonFatal Fatal NonFatal Machinery 3 3 Transport 1 Falls 7 3 1 5 Stepping or striking against object or person 4 2 1 Handling 4 4 6 5 Struck by falling object 1 Fires & explosions 1 Hand tools 8 1 Not otherwise classified 2 2 2 Total 18 21 12 15 91 Lifts and Hoists Lifts and hoists have to be examined by a competent engineer every six months. If the appliance is not in good repair then the engineer must report to the local authority details of the repair requirements. Sixteen such reports were received during the year. The defects were not of a serious nature and in every case immediate action was taken by the occupiers to remedy the defect. FACTORIES The public health inspector's function under the Factories Acts varies according to whether the factory is a power or non-power factory. In addition to the general provisions for all places of employment, in a power factory the public health inspector is concerned with: (1) The purity of the drinking water. (2) The adequacy and suitability of the sanitary accommodation. (3) The display of the abstract of the Factories Act. (4) The abatement of nuisances. (5) Rodent control. (6) The enforcement of the Food Hygiene (General) Regulations in connection with food sales from canteens and vending machines. In non-power factories the public health inspector is concerned with all of the above matters together with the following: (1) Cleanliness (4) Ventilation (2) Overcrowding (5) Drainage of Floors (3) Temperature There are 973 power factories and 24 non-power factories in the Borough and during 1971 820 visits were made to the factories and 65 notices requiring works to be done were served. Tables giving details of the inspections and defects are set out below: Inspections Premises Number on register Number of Inspections Written notices Occupiers prosecuted (1) (2) (3) (4) (5) (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 24 58 7 (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 973 725 39 (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) 16 37 9 Total 1,013 820 55 92 Defects Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector (1) (2) (3) (4) (5) (6) Want of cleanliness (S.1) Overcrowding (S.2) Unreasonable temperature (S.3) Inadequate ventilation (S.4) Ineffective drainage of floors (S.6) Sanitary Conveniences (S.7) (a) Insufficient 9 9 (b) Unsuitable or defective 46 46 1 (c) Not separate for sexes Other offences against the Act (not including offences relating to Outwork) 3 3 3 Total 58 58 3 1 OUTWORKERS If a factory employs persons to carry out certain specified works in their own homes the details must be notified by the factory to the local authority in whose area the factory is situated. That local authority must in turn notify any other local authority in whose area the employed person resides. This type of work is generally referred to as home work but the persons so employed are known as out-workers. No notifications were received from factories situated in this Borough but notifications of 178 persons employed as out-workers by factories outside the Borough were received. 175 homes at which this work is carried out were inspected, no contraventions of the Act or other matters needing attention were recorded. Details of the number of persons employed as out-workers and the types of place at which they are employed is set out below: Type of work No. of out-workers Alterations or finishing wearing apparel 30 Making curtains 1 Making Christmas crackers 145 Making lampshades 2 Total 178 93 AGRICULTURE (SAFETY, HEALTH AND WELFARE PROVISIONS) ACT, 1965 There are 81 agricultural units in the Borough and all were inspected during the year. It was not necessary to take statutory action in respect of any of these premises. SHOPS ACT, 1950 TO 1965 EMPLOYMENT OF YOUNG PERSONS ACT, 1938 TO 1964 This legislation controls the hours of employment of young persons and includes restrictions on night-work, regulates the opening hours and half-day closing of shops, Sunday opening and compensatory leave and provides for rest and meal breaks for employees. The Shops (Airports) Act, 1962 exempts the shops at Heathrow and other Airports from the half-day closing provisions, but there has been no approach to the Council for the introduction of six day trading in any other part of the Borough. Individual traders have asked if six day trading is permitted but if a formal application for six day trading was received it would be necessary to obtain the views of all persons engaged in that particular trade and there is no indication that the majority of traders in this Borough would require this facility. There is a restriction against carrying on certain trades on a Sunday and this has caused considerable difficulty during the year. Undoubtedly there is a customer demand for the sale of prohibited goods but as the law stands the Council is required to enforce the Sunday Closing provisions. A Sunday market was opened on the car park at the Hayes Football Club and whilst there was obvious consumer support there was also great objection from local shopkeepers and residents. 118 prosecutions have been instituted against persons for infringement of the Sunday Trading restrictions. Nineteen of these were against shopkeepers and 99 were against stall holders in the Hayes Market. Of these prosecutions 21 are still awaiting to be heard and 83 were successful and fines totalling £73 were imposed on the shopkeepers and £204 on the stall holders and the Council was awarded costs totalling £16 and £61 respectively. NOISE Noise complaints have increased and 124 complaints were received during the year. Noise does seem to create maximum disturbance to people and any noise which is faintly discernible if caused by a commercial enterprise in a mainly residential area has the ability to annoy any local resident who objects to that commercial development. This statement is not intended to be an attempt to justify one complainant as against another but to indicate the serious personal anxieties that can be caused to individuals. The question of what is considered to be nuisance varies widely and complaint has arisen from the use at 8.10 a.m. of commercial transport in a mainly residential area. Any attempt to assess noise as a nuisance solely on the basis of a sound pressure level recorded on an instrument, no matter how this pressure is weighted to calculate a level of annoyance to "the average man" can never be totally successful. Although it was reported in the 1970 annual report that because of the noise levels, houses in the immediate vicinity of the extension to number 1 runway at Heathrow Airport were unsuitable for residential use, it is still not possible to report that this matter has been resolved. Jet aircraft have been banned between 1st April—31 st October, 1972 from taking off from Heathrow between the hours of 23.30 and 06.00, but no reference has yet been made to aircraft landing at Heathrow. The measurements taken at Longford did not indicate any appreciable difference between the noise level due to landing or take off. During 1971 two other potential and serious sources of noise have had to be considered. In both cases it was considered that the criteria of noise level inside a dwelling house which was established by the Wilson Committee in their report of 1963 was the most appropriate. These levels are 55 dBA during the day and 35 dBA at night. Both levels, it is considered, refer to houses with the windows open to the degree that would be normal without any consideration of noise. The first source of potential noise was the Ringway 3 road which will affect many parts of the Borough and the second was the establishment of a power station by the Central Electricity Generating Board in the southern part of the Borough. Recommendations 94 have been made that the sound be contained below a non-nuisance level. There is ample proof that this is practicable in the second case because following a complaint from a local resident of noise nuisance due to the testing of gas turbine engines a statutory notice was served on the company responsible and the nuisance abated. The noise levels measured were: inside the test cell—127 dBA, immediately outside the cell—114 dBA. It should be noted that continuous exposure to a level of 90 dBA would necessitate personal protection from noise and this has been provided for the employees. The noise level outside the complainant's house was 75 dBA. After completion of the sound reduction work which included fitting silenced air intakes, sand filled expansion boxes to silence exhausts, the level outside the complainant's house was 53 dBA. The proposed power station at Bulls Bridge, Hayes, which will operate on gas turbine engines should be planned and designed to minimise noise and a non-nuisance level should be readily obtainable. Discussions in an effort to achieve this have taken place with officials of the Central Electricity Generating Board and agreement is awaited. LONDON (HEATHROW) AIRPORT NOISE INSULATION GRANTS SCHEME Unless the British Airports Authority decides to extend this scheme, 1972 will be the last year during which applications for a grant can be made to provide sound insulation for houses in the defined area. The present grant of 60% or a maximum of £150 of the reasonable cost of sound insulation works carried out remained the same, and so did the cost yardstick set by the British Airports Authority. Few applications were made during the year and no problems have been encountered. Details of applications dealt with are as follows: No. of applications received 22 No. of applications granted 22 No. of applications dealt with since the start of the scheme on 1st January, 1966 654 No. of private dwellings in the area 6,000 CONSUMER PROTECTION The Consumer Protection Acts 1961/1971 authorised the Secretary of State by Regulations to impose on the sale of certain classes of goods conditions designed for the safety of the purchaser. Details of the work carried out in enforcement of some of these regulations is set out below: (1) The Heating Appliances (Fireguards) Regulations 1953 lay down the design of guards to be fitted to gas and electric fires and oil heaters. The Regulations are intended to protect from risk of fire any persons brushing against this type of appliance. The guard would not prevent a young child from deliberately touching the flame or heating element and should not therefore be regarded as a replacement or substitute for the type of guard used to protect a young child from fire as is required under the Children's and Young Persons' Act of 1933. The guards provided to these types of appliances are inspected during routine inspections of shops; no contravention of the regulations was observed during 1971. (2) The Oil Heaters Regulations 1962 lay down standards for the construction of oil heaters and for the display of a suitable warning notice concerning the use of incorrect fuel, over-filling and standing in draughts, etc. Leaflets explaining the dangers of using this type of appliance incorrectly are distributed by the inspectorate where considered appropriate and are available printed in Bengali, Hindi or Urdu. It would simplify distribution of these leaflets if they could be obtained printed in multi languages. No contravention of the Oil Heater Regulations was observed during 1971. (3) The Night Dresses (Safety) Regulations, 1967 define the meaning of "Nightdress" and lay down for children that nightdresses must be flame proof and that for women nightdresses must be either flame proof or conspicuously labelled to the effect that the garment must be kept away from fire. During 1971 equipment for testing the flammability of materials was installed in the laboratory at Drayton Hall. All of the nightdresses tested, including those purchased from market traders were found to be flameproof. 95 (4) The Toys (Safety) Regulations, 1967 prescribe standards for toys. Toy outlets in the Borough are visited periodically and suspect toys are purchased and submitted to the Public Analyst for examination to determine whether or not they comply with the requirements of the regulations. Twelve toys were purchased during 1971 of which 3 were found to contain lead in excess of the 5,000 parts in 1 million parts of the dry paint film permitted. Publicity was given to the unsatisfactory toys and as a result numerous enquiries were received from the public regarding toys which had been purchased or received as gifts. In some cases it was possible to give this information immediately, but in other cases it was necessary to submit the toy for examination. The regulations came into operation on 1st November, 1967 and the fact that toys continue to be sold in contravention of these regulations is a matter for serious concern. The toys in question are all of foreign manufacture and urgent steps are necessary to ensure that all toy importations comply with the regulations. Details of toys sampled are given in the following table: Satisfactory Toys Unsatisfactory Toys Article Country of Origin Article Country of Origin Reason Toy aeroplane Hong Kong Building bricks China 34,800 parts per million Pb Spinning bricks on wheels Foreign House blocks China 63,500 parts per million Pb Skipping ropes(2) Wooden beads Metal sports car Piano book Xylophone Building bricks England Czechoslovakia Japan Japan Hong Kong Foreign Tomahawk Taiwan 55,930 parts per million Pb The Consumer Protection Act, 1971 which became operative on 30th April, 1971 provided that where an offence was due to the act of default of some other person, that person might, subject to certain defences, be charged with the offence. At the time of writing this report these contraventions are still under investigations. PEST CONTROL Rats and Mice The Council's obligations under the Prevention of Damage by Pests Act, 1949 were, until the 1st January, 1971, carried out partly by direct labour and partly by the employment of specialist contractors. From that date it became possible to recruit the full establishment of manual staff and for the first time since the formation of the Borough rodent control was carried out entirely by direct labour. Because of this it was possible to direct more time to the location of infestations of rats and mice and to introduce systematic surveys and treatments of premises and sewers. All routine inspections of premises include a check for the presence of rats and mice and as a precaution against the spread of infestation all premises due for demolition are poison baited before the work commences. The number of premises found to be infested with mice further increased during the year and this is a matter for concern. The problem of rodents was given publicity by the display on notice boards throughout the Borough of posters printed by the Local Government Information Office emphasizing the need 96 to notify rodent infestations and the importance of properly containing waste food which might prove an attraction. Section 3 of the Prevention of Damage by Pests Act, 1949 places an obligation on certain occupiers of land (not including agricultural land) to notify the local authority in writing of the presence of rats and mice. This provision would be invaluable if occupiers fulfilled their obligations as it would enable the authority to ensure that effective action was taken, not only in respect of that property but also adjacent properties which might be involved. It was necessary to draw the attention of a number of firms to this requirement as, although they had arranged for rodent control specialists to treat their premises, their failure to notify the fact meant that this was carried out in isolation. Mice Infestations—Schools and Hospitals Repeated complaints were received concerning mice infestation in certain schools. The mice were found in some classrooms, domestic science rooms and school meals kitchens. Treatment was carried out by poisoning and trapping. The poisoning campaign had to be modified for various reasons such as: (1) Risk of contamination of food. (2) Non-effectiveness of certain types of poison at temperatures of 65°F. (3) Apparent resistance by the mice. A serious infestation of mice and cockroaches occurred in one of the hospitals. The infestation with mice was treated by the department and in order to deal with the cockroaches the department took advantage of an offer by one of the larger insecticide firms to carry out experimental treatment. This, together with the follow up treatment, successfully cleared the infestation. Details of the rodent infestations found during the year are given below: Properties other than sewers Type of Property Non-agricultural Agricultural 1. Number of properties in district 91,095 102 2. (a) Total number of properties (including adjacent premises) inspected following notification 2,076 6 (b) Number infested by (i) Rats 1,302 3 (ii) Mice 471 3 3. (a) Total number of properties inspected for rats and mice for reasons other than notification 1,804 53 (b) Number infested by (i) Rats 13 12 (ii) Mice 12 4 Sewers Treatment of main sewers was concentrated on five areas in Ruislip and Uxbridge, where 194 inspection chambers were test baited and 34 found to be infested. In addition, 16 chambers of a branch sewer on a housing estate were found to be infested and subsequently treated. The use of single dose poison fluoracetamide was adopted later in the year. This allows a considerable saving in manpower as each treatment requires only a single lifting of the manhole covers. Squirrels and Foxes Squirrels continue to be the subject of complaint, and during the year 59 such complaints were received from members of the public. The majority of these related to squirrels in lofts or chimney stacks and in several cases damage was caused to the building fabric due to the gnawing of timbers, electric cables, water pipes, plastic rainwater guttering, etc. There were also instances 97 where squirrels drowned in the cold water storage tanks. Shoots were organised in the Council's woods and open spaces together with certain private land and 1,411 squirrels were killed. Such shoots invariably produce a number of protests from members of the public who see the squirrel only as an attractive part of the scenery being unaware of the destructive side of its nature. 22 Complaints were received concerning the presence of foxes. Thirty-three foxes were shot, 14 fox earths gassed and 9 fox cubs removed from under buildings where it was dangerous to gas. Stray cats Wild cats breeding on open spaces and communal premises were the subject of four complaints. The presence of these cats gave rise to a public health nuisance, the complainants being at a loss to deal with the problem and any amateur attempts at their destruction might well have caused unnecessary suffering. The approval of the R.S.P.C.A. was sought and eventually obtained for trapping and destroying stray cats. Two of the society's traps were purchased and any cats caught are disposed of in the manner approved by them. Insect Pests Complaints of insect pests doubled during the year, being 1,480 as compared with 735 for 1970. Details of these complaints are as follows: Wasps 1,336 Flies 42 Cockroaches 1 Ants 10 Maggots 16 Lice 1 Fleas 72 Beetles 2 1,480 The biggest increases were in respect of wasps and fleas (complaints for 1970, respectively, 655 and 23). Wasps nests are destroyed without charge on domestic premises provided they are accessible and this increase placed a considerable strain on the resources of the department as it was necessary to maintain the more important rodent control duties. The majority of complaints of fleas related to animal fleas and in these cases action was confined to advising the householder on the preventive measures to be taken. The alleged presence of lice was found upon investigation to be an infestation of the red mite of poultry Dermanysous gallinae. This species often gives rise to skin irritation in humans, especially when they disperse after their host birds have left the nest. In this particular case an old bird cage was taken to the house and shortly after the aged occupant complained of skin irritation. The bird cage was removed and clothing and bedding disinfested. This effectively dealt with the infestation. PORT SANITARY ADMINISTRATION—LONDON (HEATHROW) AIRPORT Imported Food Since the opening of the cargo terminal at the south west corner of the Airport, which is in the Urban District of Staines, this work has decreased to negligible proportions. Details of the food inspected are given below: Article lbs Article lbs Canned Puddings 360 Fresh Vegetables 9,988 Canned Poultry Products 2,761 Frozen Vegetables 500 Canned Fruit Jelly 1,125 Dried Turtle Meat 9,038 Canned Meat Products 640 Five samples were submitted to the Public Analyst and found to be satisfactory. 98 Food Hygiene There are numerous food preparing premises within the airport complex, including high-class restaurants, aircraft catering establishments, snack bars, grill and griddle restaurant and industrial and non-industrial canteens. Each of these establishments compete for roughly the same type of labour and from time to time their difficulties in recruitment are reflected in deteriorating standards of hygiene. In addition, maintenance of all the premises is difficult because of the extended working hours of the establishments—many of them work the full 24 hours daily throughout the year. Regular inspection of all the food handling premises is carried out and it must be stated that full co-operation in improving the standard of hygiene is received from all the operators who are anxious to meet the standards. Unfortunately, the responsibility for cleaning is divided in many of the establishments between the occupier and the British Airports Authority, and all structural matters are the responsibility of that Authority. As with all large undertakings when expenditure is planned it is difficult to effect the completion of emergency works notwithstanding their urgent nature from the food hygiene point of view. Nevertheless, by consistent pressure it has been possible to secure improvements in a relatively short time, but it is important that works in food premises to comply with the Food Hygiene Regulation should receive much more urgent attention. Water Supply Two companies supply the whole of the airport with mains water. Regular samples are taken from aircraft and submitted for bacteriological examination. 366 samples were taken during the year with the following results: Satisfactory Unsatisfactory From fixed tanks 161 12 From portable flasks: (1) filled in Borough area 74 30 (2) filled outside Borough area 14 22 (3) foreign filled 17 23 From bowsers 10 1 From mains 2 Fixed tanks are fitted to modern aircraft and portable flasks are used for supplying drinking water to the older types as well as supplying iced water to many foreign airlines. Although sterilization is practised between each filling the water in them is frequently unsatisfactory particularly in the peak holiday season. Vermin Control It has been possible during the year because of the improved staff situation (infestation control staff) to carry out more detailed surveys throughout the airport, both land and buildings, and these have revealed levels of infestation which were previously unsuspected. Although both the British Airports Authority and the occupiers of the various establishments employ contractors for rodent and vermin control large infestations of rats and cockroaches have been found. In addition the presence of crickets was found in one of the tunnels. The rodent infestation was found on land and is now under treatment. The cockroach situation was extremely bad and it was necessary to insist on control measures throughout the airport in order to deal with the situation. There is no doubt that this is the major vermin problem on the airport and to achieve control it is necessary to maintain continuous treatment. 99 OTHER SERVICES DEPARTMENTAL LABORATORY During the year, the facilities of the laboratory were extended to include chromatograph determinations to identify colouring matter in food and flammability tests on fabrics. Tests in connection with food have been detailed elsewhere and the following is a summary of the remainder of the examinations carried out: Type of Examination Total number of tests Agar sausage incubation and assessment (check on surface cleanliness of food premises and equipment) 217 Atmospheric pollution: (a) sulphur dioxide determinations 2,458 (b) measurement of smoke concentrations 2,458 Celluloid in toys 3 Chromatography 40 Flammability tests on fabrics 4 Foreign matter in food identification 35 Insect identification 70 Kerosene determinations 4 Mould identification 21 Water examinations: Permanganate value test 75 Nitrite test 20 Nitrate test 14 Chloride test 20 Dissolved solids 2 Suspended solids 2 RIVER POLLUTION Owing to the shortage of staff it has been necessary to restrict the work in this field in the main to the investigation of complaints although it has been possible to continue the checks being carried out to control oil pollution from the Uxbridge Industrial Estate. The improvement reported confirms it has been maintained. A total of 335 inspections were made in connection with pollution of rivers, ponds and water courses, but regular checking of all the sewer outfalls into the waterways in the Borough was impossible. It was, however, essential to locate and rectify specific causes of pollution details of some of these are: (a) While a member of staff was addressing a meeting of the Natural History Society a reference was made to difficulties which were being experienced through oil pollution affecting the stream flowing through the sanctuary at Harefield. This was traced to an oil depot. This pollution was found to be due to insufficient maintenance of the oil interceptors. The oil interceptor traps are now regularly maintained and cleansed and it is hoped the nuisance will not recur. (b) Following oil pollution into the canal feeder in the South Ruislip area a survey was made of an industrial estate in that vicinity, and it was necessary to request 8 firms to improve their oil storage and handling techniques and work is in progress. (c) A discharge of soapy water into a ditch was traced to a factory at Ruislip. A scheme has been submitted by the occupiers showing a proposed revised drainage layout which when completed will eliminate this problem and the existing cesspool. (d) From a garage at Northwood oil was found to be polluting allotments. A notice requiring cleansing of the petrol interceptor and the provision of bund walling to the oil storage area was served on the occupier of the garage. The work requested was carried out but not to an acceptable standard, and it has been necessary to ask for the work to be improved. 100 Oil pollution in a surface water sewer (e) Inspection followed by laboratory tests on the effluent in a surface water sewer discharging into the Grand Union Canal in the Hayes area showed it to be polluted with oil and to have a high biological oxygen demand. The oil pollution was much reduced after a petrol interceptor at a factory had been improved. The high biological oxygen demand was caused by washing water from another factory discharging into the surface water sewers. This has been discontinued and now discharges into the foul sewer. Maple Cross Sewage Disposal Works Samples of effluent from the Maple Cross Sewage Works have all been satisfactory. Results of the examination of these samples are set out below. Effluent Samples Sample No. 1 2 3 4 5 Date taken 14.1.71 10.3.71 10.5.71 20.7.71 2.11.71 Location of Sample 100 yds down stream 100 yds down stream Appearance Yellowishy clear Brownish fairly clear Yellowish solid matter Yellowish Hazy yellow Odour Earthy Earthy Earthy Earthy Earthy Reaction pH 7.7 7.7 7.6 7.9 7.7 PARTS PER MILLION Total dissolved solids 721 664 648.8 8000.0 549.6 Suspended solids 5 3.6 4.05 4.4 5.8 Chlorion 114 115 86.0 58.0 68.8 Ammoniacal Nitrogen 0.5 0.07 0.1 0.1 0.1 Albuminoid Nitrogen 1.6 0.45 0.5 0.25 0.35 Nitrate Nitrogen 13 9.80 11.0 4.20 6.6 Nitrite Nitrogen Absent Absent Absent Absent Absent Permanganate value 7.9 7.60 7.4 7.0 4.0 Total Alkalinity 175 205 152.5 240.0 240.0 B.O.D. 6 2.40 3.6 2.2 3.0 Remarks: Not exceptionally high. Satisfactory Not exceptionally high. Satisfactory Not exceptionally high Satisfactory Not exceptionally high. Satisfactory Not exceptionally high. Satisfactory 101 SECTION V Other Services "The healthy know not of their health but only the sick."—Carlyle 1831 Other Services HOUSING ALLOCATION—MEDICAL FACTORS The number of new applications for rehousing referred to the department for consideration because of the presence of medical factors was at 415 the highest total since the formation of the Borough and 62 more than last year. Applications for transfer numbered 161 making a total of 576 referrals during 1971. The following table gives a summary of the cases referred over the last five years: Year New Applications Transfers Total Special recommendation or points No recommendation Total Support No support Total 1967 84 215 299 63 113 176 475 1968 115 242 357 86 90 176 533 1969 150 226 376 101 160 261 637 1970 162 191 353 85 102 187 540 1971 178 237 415 57 104 161 576 In the Annual Report for 1970 (page 115) attention was drawn to the fact that of the applications for rehousing in which the medical factors were supplied by general practitioners less than 12% were considered deserving of support compared with 90% of those in which the primary source of referral was hospital staff. General practitioners certificates issued "on demand" appeared to have outlived any usefulness they might have had particularly as the general practitioners themselves are always prepared personally to draw attention to genuine cases of hardship where housing factors play an important part. During 1971 the Housing Committee agreed that a doctor's certificate would no longer need to be submitted in support of applications where priority on medical grounds was being sought, although the contents of any such certificates submitted would continue to be considered. Applicants themselves are now invited to give full details concerning any medical condition which they feel is being aggravated by existing housing factors and also in giving the names of the general practitioner or hospital consultant, they are free to give written consent for the medical attendant to be approached for additional information if this is considered necessary. Although the medical form was not introduced until mid-year a total of 124 applicants made use of it during 1971 (96 when applying for rehousing and 28 with transfer applications). In many cases, few details of a truly medical nature were supplied and there may be a tendency for some applicants to use the form even when the medical factors are of questionable significance. The continued use of the form will be viewed with interest. Housing Needs of the Elderly Of the 415 applications for rehousing referred by the Director of Housing during 1971, 156 were from people of pensionable age and medical factors deserving of support were considered to be present in 99 of these cases. A special recommendation to the Housing (Selection) Sub-Committee is made in cases where it is clear that serious and permanent medical conditions are being aggravated by the 105 existing housing circumstances in cases which would not otherwise qualify for rehousing. Of the 45 special recommendations made in 1971, 36 of them were from applicants in the pensionable age group and a review of the "specials" made over the past five years is of interest. 1967 1968 1969 18 25 23 1970 1971 15 45 From these figures it is seen that the number of special recommendations made over the previous four years varied from 15 to 25 but during 1971, the number rose to 45. The same medical officer has been responsible for making the assessments over the five year period so it is unlikely that a variation in standard of assessment has played any significant part in this increase. It is recognised that the percentage of elderly people in the community continues to increase and the number of elderly persons who are meeting with difficulty in their accommodation due to the infirmities and illnesses which come with advancing years is increasing and it is clear that the specialist housing needs of the elderly will require continuing attention. Mass radiography was originally introduced as part of the tuberculosis control programme with a view to detecting cases of tuberculosis through factory and office surveys and radiography of the general public. In 1954, a total of 8,720 cases of active respiratory tuberculosis were detected throughout the country by this service but from this peak, there has been a steady fall in the number of new cases discovered. The examinations which yield the highest proportion of new cases of active disease are those performed at the request of family doctors and a review by the Department of Health and Social Security of the effectiveness of the Mass Miniature Radiography Service suggested that the general need for mass radiography of the chest no longer exists. The Secretary of State's Standing Medical Advisory Committee recommended that the number of mass miniature radiography units should be reduced and during 1970, regional hospital boards throughout the country considered, in consultation with local health authorities, how the need for chest X-ray services in their regions could best be met, with a view to integrating mass miniature radiography units with hospital radiological departments. The North West Metropolitan Regional Hospital Board considered the future of the mass radiography service in the region in the light of the recommendation of the Department of Health and Social Security and were of the opinion that with the low incidence of new cases found through general factory and office surveys in this region and through radiography of the general public, the need for mass radiography which the service was established to meet no longer existed. Following consultation with local health authorities, executive councils and local medical committees, the North West Metropolitan Regional Hospital Board formulated a policy which provided amongst other things, that— (a) references by general practitioners should be concentrated as opportunity arises on the static mass X-ray units, chest clinics and hospital X-ray departments; (b) routine surveys should be withdrawn in areas where the yield is consistently low; (c) special epidemiological situations should be investigated by mobile units; (d) a mobile service should be continued in the susceptible communities such as prisons, schools, etc. (e) as far as practicable, the units should continue to serve local authorities for the examination of teachers, health visitors and other staff involved with young children. The North West Regional Hospital Board have given an assurance that the services of the mobile units will not be withdrawn until the Board are satisfied that hospital X-ray departments can deal with the increased work load. During 1971, chest X-ray facilities continued to be provided at six points reasonably accessible to residents of the Borough as listed on page 107. MASS RADIOGRAPHY 106 Static X-ray Centres Central Middlesex Hospital Monday to Friday 9.30 a.m.-4.30 p.m. Acton Lane, Park Royal Saturday 9.30 a.m.-11.30 a.m. (nearest LTB Station—Park Royal) West Middlesex Hospital, Monday to Friday 9.00 a.m.-5.00 p.m. Isleworth, Middlesex (closed 12.30-1.30 p.m.) Mobile Units Northcote Clinic, Northcote Avenue, Southall Weekly—on Tuesdays 10.30 a.m.-noon Car Park, Grant Road, Wealdstone 2nd and 4th Thursday of each month 10.00 a.m.-noon Council Offices Car Park, Rickmansworth Weekly—-on Mondays 2.45 p.m.-3.15 p.m. During 1971 also, the Mass X-ray Unit visited the Uxbridge area and examined 5,502 members of the public compared with 5,363 examinations on the occasion of the previous visit to the same area in 1967. Thirty-seven persons were referred for further investigation but in only eight cases were abnormalities requiring treatment discovered, two of these being cases of active pulmonary tuberculosis. In the 1967 survey, four cases of pulmonary tuberculosis were discovered. LONG STAY IMMIGRANTS Since 1965 it has been the practice for port medical inspectors to forward to Medical Officers of Health destination addresses of all long stay immigrants referred to them. Such immigrants on arrival at the port of entry are issued with a pink card which is printed in four European languages as well as Punjabi, Hindi, Urdu and Bengali, drawing their attention to facilities provided under the National Health Service and urging them to register with a doctor. The Medical Officer of Health arranges for visits to be made to the destination addresses with which he has been supplied so that the immigrant can be pursuaded to act on the advice given on the pink card. The table below gives the number of advice notices received during the year from ports and airports relating to arrival of immigrants in this area. It frequently happens, because of language difficulties at the port of entry or for other reasons that the destination address is not known, or the immigrant has not been there, or has alreadv left for an unknown destination and not all visits to destination addresses are successful. The table also includes the number of successful visits at which contact was made with the immigrants during the year. Country issuing passport Notifications Received Successful visits completed Commonwealth Countries Caribbean 18 17 India 53 44 Pakistan 22 16 Other Asian 7 5 African 39 30 Other 34 24 Non-Commonwealth Countries European 37 30 Other 46 32 Total 256 198 107 NATIONAL ASSISTANCE ACT, 1948—SECTION 47 This provision authorises the Medical Officer of Health to effect the compulsory removal to a suitable place of any person who by reason of age, illness or infirmity is living in insanitary conditions or is unable to care for himself, and is not receiving such care from others. It was not necessary to take such action during 1971. The old lady compulsorily removed in 1970 was subsequently transferred from hospital to one of the Council's homes where she remained happily until her death from a stroke early in 1971. It is usually possible to avoid compulsory removal by the use of the domiciliary health team of home nurses, home help, social workers and doctors. Good relationships between the department's staff and the local consultant geriatrician also avoid the need for compulsion when hospital admission becomes inevitable. A considerable amount of time and energy is, however, expended in supporting certain old people, and during the year a special observation register was started. This was in no way similar to the list of persons over 65 years living within the Borough, which is being compiled as a result of the social services survey, but constitutes a much smaller collection of people likely to need urgent removal to hospital or other residential accommodation under compulsion. The situation is a familiar one to all who work in this field; the elderly person (or couple) lives alone with fierce independence. Physical powers have declined and dust and dirt have settled on the accumulation of old boxes, newspapers, etc., in the one room in the house which is favoured. Domestic pets have added their contribution and their offspring. The home help, when allowed to do so, battles in vain against the rising tide of dirt. The home nurse tends her patients with increasing difficulty, her ingenuity stretched to the utmost. Meals on wheels are delivered as frequently as possible and keep the recipient strong enough to resist all enticements of "Holidays", warmth, cleanliness or company. The purpose of the new register is to bring forward the names of such people at intervals so that they are not forgotten, and so that they are visited by someone when all supportive services have been rejected. In this way it is hoped to identify the moment of crisis when really effective action can be offered and accepted voluntarily without recourse to legal channels. During 1971 a total of 14 people were placed on this register, and it is anticipated that as more experience in its use is gained this number will increase. MASSAGE AND SPECIAL TREATMENT Licences, which are renewable annually, are issued in respect of premises used for the reception or treatment of persons requiring massage or special treatment, in accordance with the Middlesex County Council Act, 1944. All such premises were inspected by a Principal Medical Officer and found to be of a satisfactory standard. The number of premises licensed and the type of treatment offered is shown in the following table: Treatment Carried Out Number of Premises Chiropody 13 Chiropody, physiotherapy 1 Physiotherapy 1 Physiotherapy, manipulative therapy 1 Beauty massage, electric treatment, radiant heat, steam or other baths, manicure, pedicure, electrolysis for face and limbs 3 108 NURSING HOMES There are no private nursing homes in the Borough. One hospital subject to registration under the Public Health Act, 1936 is visited by officers of the department from time to time. NURSING AGENCIES There is one nursing agency in the Borough, and this continues to be conducted in a satisfactory manner. OCCUPATIONAL HEALTH SERVICES Due chiefly to a sharp increase in the number of students medically examined prior to admission to teachers training college, the total number of medical assessments issued during 1971 was at 2,255 the greatest for any year since the inception of the Borough. Of the four hundred 14TT forms completed (examination required by the Department of Education and Science) three hundred and four were for students and ninety-six for newly trained teachers taking up their first appointment. 1967 1 968 1969 1970 1971 Total Number of Assessments 2,022 2,072 1,773 2,233 2,257 MEDICAL EXAMINATIONS Routine (i) Teachers (First appointment) 129 111 66 78 96 (ii) Students (On selection forTeachers Training College) 240 219 177 188 304 (iii) Requests from other Authorities 14 7 11 10 9 Other Staff Examined 409 398 323 240 259 Total number of Medical Examinations 792 735 577 516 668 Number Assessed without Examinations 1,230 1,337 1,196 1,717 1,589 % Total Assessed by Medical Examination 39% 35% 32.5% 23% 29% % Assessed by Examination when Routine Medical not required 25% 23% 21% 12% 14% Two important changes relating to medical assessments were introduced during 1971. One relating to the admission of manual workers to the Council's sick pay scheme and the other to chest X-ray examination requirements. It has been the practice since 1965 for wage earners who were being considered for employment and who suffered from medical conditions which although present prior to taking up employment were likely to recur, to be offered conditional admission to the Council's sick pay scheme provided they were otherwise fit to undertake the full duties of the post. In October 1971, the Council's Establishment Committee instructed that admission to the sick pay scheme should 109 no longer have conditions attached to it in the case of any employee. Although it may prove necessary in the future to call for medical examination candidates for employment whose medical questionnaires have disclosed the presence of conditions which might later cause recurring absences on sick leave and which before could have been "covered" by conditional sick pay admissions, it is hoped that a re-styling of the medical questionnaire may make sufficient details available to obviate the need for a medical examination in many cases and keep the percentage of assessments by medical examination down to the 14% of last year. During 1971, the Council agreed that a chest X-ray examination should be made a condition of appointment for all prospective employees whose work involves close and continuous contact with children and that such employees should be required to have regular chest X-ray examinations subsequently at three yearly intervals. Although the incidence of tuberculosis has declined over recent years and tuberculous infection in children is becoming increasingly uncommon, a report issued by the Joint Tuberculosis Committee of the British Thoracic and Tuberculosis Association, pointed out that epidemics of tuberculosis amongst groups of children still occur and against a background of declining incidence, such outbreaks appear even more tragic and every effort should be made to prevent them. On page 19 ot this report, reference is made to the investigation carried out in one of this Authority's junior schools, when four schoolchildren were discovered to have been infected with tuberculosis and one of the teachers was found to have active disease. The Department of Education and Science Circular 3/69 recommended the need for three yearly chest X-ray examinations for all teaching staff and the report of the Joint Tuberculosis Committee already referred to, recommended that all adults whose employment involved close contact with groups of infants and children should be X-rayed before taking up employment and a further chest X-ray examination carried out at intervals of three years. After consultation with the groups of employees affected, through their appropriate Joint Committees, the recommendation was accepted. PUBLIC MORTUARY During the year the public mortuary was closed for 6 weeks whilst the work of extending the premises and increasing the accommodation was carried out. The opportunity was taken to carry out other necessary works of maintenance and repair. There is now a total of 21 refrigerator units of which 3 are deep freeze. The number of bodies received and post mortem examinations carried out during 1971 at the Council's mortuary in Kingston Lane, Hillingdon were: From Home Address: Residents of Hillingdon 206 Residents of other districts 25 231 From Hospitals in the Area: Residents of Hillingdon 371 Residents of other districts 275 646 From London Airport: Residents of other districts 17 894 110 PREVENTION OF BREAK-UP OF FAMILIES With the retirement of the Children's Officer the previous arrangements for formal meetings attended by a variety of social agencies from different departments within the Council and from other statutory bodies were discontinued. This responsibility was transferred by agreement to the Director of Social Services, but no formal meetings were held during the year following the transfer. BREAKSPEAR CREMATORIUM The Borough Council continues with the Harrow Borough Council to be a constituent member of the Breakspear Crematorium Joint Committee. The crematorium is situated in Breakspear Road, Ruislip. On 1st January, 1971, the Director of Health Services took up additional duties as medical referee to the Joint Committee. The Deputy Medical Officer of Health and a Principal Medical Officer were appointed during the year to assist with such duties. Year Total Cremations Year Total Cremations 1965 3,439 1969 3,802 1966 3,399 1970 3,929 1967 3,412 1971 3,870 1968 3,677 The number of cremations, 3,870 showed a slight reduction compared with the previous year, the first since the crematorium was opened at the end of 1957. It is one of the objectives of the Council to encourage cremation in appropriate cases. Arrangements were made with Her Majesty's Coroner (Dr. J. D. K. Burton) for post mortem (autopsy) examinations to be undertaken in cases referred by the medical referee. During 1971, three cases were referred for an autopsy in this way. The proportion of cremations authorised as a result of a Coroner's certificate in 1971 was 30.5% compared with 26.5% in 1966 and 27.3% in 1965. The increasing proportion of cremations which have been referred for a coroner's examination has been noted for some years, and carries implications for the role of the medical referee. A small survey of 212 consecutive cremation certificates received during two weeks in December showed that 35.4% were authorised under the Coroners certificate E. Nevertheless, of the remaining certificates 28.5% presented problems requiring further elucidation by the medical referee before the cremation could proceed. Report of the Committee on Death Certification and Coroners A Committee appointed in March 1965 under the Chairmanship of Judge N. J. L. Brodrick, Q.C., issued its report on this subject in November 1971. Sweeping changes in the present death certification process were proposed which would introduce some much needed improvements and result in greater precision concerning the cause of death. As far as cremation was concerned, the Committee saw no need for the present special arrangements for cremation certificates and recommended that they should be abolished together with the office of Medical Referee. Most of the criticism of present practice centred upon the value of the confirmatory medical certificate which, it was concluded did not provide much additional information and upon the role of the medical referee whose task was considered to be an impossible one. Although the statistical evidence presented in the Committee's report was impressive, it must be questioned whether it provided all the information relevant to such major changes in established procedure. Thus, although it was noted that the Cremation Regulations do not require any particular answer to the question on the confirmatory medical certificate, the Committee's own enquiries showed that medical referees, who have an absolute right to refuse cremation, in practice always require the second doctor to see the body of the deceased and to discuss the case with his colleague who gave the first certificate. Similarly the nature of the Committee's enquiry into the practice of medical referees did not provide information concerning any additional requirements which might 111 be imposed. At Breakspear Crematorium it is usual to discuss particular matters with the doctors giving the certificates as well as with other doctors who may be able to provide contributory information. The Report showed that the proportion of cases in which a post-mortem examination was required before the cremation was permitted was only 0.2%. In part this low figure is surely the result of the curious legal anomaly which gives the medical referee power to require a postmortem examination but no power to authorise the payment of the necessary fee. The Committee made it clear that a greater proportion of post-mortem examinations was desirable. This objective could better be achieved by providing the medical referee with these necessary additional powers than by excluding him completely. In view of the extent of the Committee's recommendations it seems unlikely that immediate legislation will be possible. The Report therefore recommended an early decision to abolish the confirmatory medical certificate. It is to be hoped if such a change is introduced it will be accompanied by some strengthening of the first medical certificate and of the medical referee's powers concerning post-mortem examinations. 112 Appendix Tables CLINICS FOR THE EXPECTANT MOTHER Premises Ante-Natal Clinic Mothercraft and Relaxation Elers Road Clinic, Elers Road, Hayes Every Tuesday p.m. Every Tuesday a.m. Grange Park Clinic, Lansbury Drive, Hayes Every Tuesday p.m. Every Wednesday p.m. Harefield Clinic, Park Lane, Harefield Every Wednesday a.m. Haydon Hall Clinic, High Road, Eastcote Every Wednesday p.m. Every Tuesday a.m. Ickenham Clinic, Long Lane, Ickenham Every Monday p.m. Every Thursday p.m. Laurel Lodge Clinic, Harlington Road, Hillingdon Every Tuesday p.m. Every Wednesday p.m. Manor Farm Clinic, Manor Farm, Ruislip Every Tuesday p.m. Every Tuesday a.m. Minet Clinic, Coldharbour Lane, Hayes Every Thursday p.m. Every Thursday p.m. Northwood Hills Clinic, Ryefield Court, Ryefield Crescent Every Wednesday p.m. Every Thursday a.m. Oak Farm Clinic, Long Lane, Hillingdon Every Tuesday p.m. Every Wednesday a.m. Queen's Hall Clinic, Station Road, Hayes 2nd, 4th and 5th Wednesdays p.m. Ruislip Manor Clinic, Dawlish Drive, Ruislip 2nd, 4th and 5th Tuesdays p.m. Every Wednesday a.m. Sidmouth Drive Clinic, Sidmouth Drive, Ruislip Every Thursday p.m. Every Tuesday a.m. Uxbridge Clinic, Council Offices, High Street, Uxbridge Every Monday p.m. Every Monday p.m. West Mead Clinic, West Mead, South Ruislip Every Monday p.m. Every Wednesday p.m. Yiewsley Clinic, Baptist Church Hall Every Wednesday p.m. Every Wednesday a.m. 115 CAUSES OF DEATH Cause of Death Sex Total all Ages Under 4 weeks 4 weeks and under 1 year AGE IN YEARS 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 & over B4 Enteritis and Other Diarrhoeal Diseases M 1 1 F 5 1 1 1 2 B5 Tuberculosis of Respiratory System M 1 1 F B6(2) Other Tuberculosis M 1 1 F B18 Other Infective and Parasitic Diseases M F 1 1 B19(1) Malignant Neoplasm, Buccal Cavity, etc. M 5 2 1 2 F 1 1 B19(2) Malignant Neoplasm, Oesophagus M 5 1 1 3 F 1 1 B19(3) Malignant Neoplasm, Stomach M 29 3 4 14 8 F 21 1 4 6 10 B19(4) Malignant Neoplasm, Intestine M 28 2 3 4 10 9 F 42 1 13 7 21 B19(5) Malignant Neoplasm, Larynx M 2 1 1 F 2 1 1 B19(6) Malignant Neoplasm, Lung, Bronchus M 102 2 5 45 29 21 F 26 1 2 9 9 5 B19(7) Malignant Neoplasm, Breast M F 60 7 14 17 12 10 B19(8) Malignant Neoplasm, Uterus F 13 2 4 4 2 1 B19(9) Malignant Neoplasm, Prostate M 26 3 8 15 B19(10) Leukaemia M 10 1 1 1 2 4 1 F 11 1 1 1 2 1 2 3 B19(11) Other Malignant Neoplasms M 84 1 6 3 7 22 30 15 F 69 1 2 1 3 13 15 18 16 B20 Benign and Unspecified Neoplasms M 2 1 1 F 3 1 1 1 B21 Diabetes Mellitus M 4 2 1 1 F 11 1 2 3 5 B22 Avitaminoses, etc. M F 2 2 B46(1) Other Endocrine, etc., Diseases M 1 1 F 1 1 B23 Anaemias M 5 2 1 1 1 F 5 1 4 B46(3) Mental Disorders M 1 1 F B24 Meningitis M 2 1 1 F B46(4) Multiple Sclerosis M 1 1 F 4 2 1 1 B46(5) Other Diseases of Nervous System M 10 1 1 1 4 3 F 8 1 1 5 1 B26 Chronic Rheumatic Heart Disease M 10 1 1 2 2 4 F 18 1 3 5 8 1 B27 Hypertensive Disease M 14 1 3 3 2 5 F 34 7 6 21 B28 Ischaemic Heart Disease M 363 1 8 45 95 121 93 F 256 1 6 23 66 160 B29 Other Forms of Heart Disease M 41 1 1 1 6 13 19 F 57 1 3 7 46 116 Cause of Death Sex Total all Ages Under 4 weeks 4 weeks and under 1 year AGE IN YEARS 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 & over B30 Cerebrovascular Disease M 97 5 3 12 26 51 F 170 4 9 40 117 B46(6) Other Diseases of Circulatory System M 42 1 5 6 14 16 F 46 2 1 5 8 30 B31 Influenza M 1 1 F 1 1 B32 Pneumonia M 56 2 3 1 1 7 12 30 F 96 3 2 1 1 1 5 11 72 B33(1) Bronchitis and Emphysema M 80 1 2 11 33 33 F 38 2 4 11 21 B33(2) Asthma M 1 1 F 3 1 1 1 B46(7) Other Diseases of Respiratory System M 8 3 1 2 2 F 6 1 1 1 3 B34 Peptic Ulcer M 8 1 1 1 2 3 F 8 2 6 B36 Intestinal Obstruction and Hernia M 3 1 1 1 F 6 1 5 B37 Cirrhosis of Liver M 2 2 F 2 1 1 B46(8) Other Diseases of Digestive System M 8 1 2 4 1 F 14 1 1 1 11 B38 Nephritis and Nephrosis M 2 1 1 F B39 Hyperplasia of Prostate M 3 1 2 B46(9) Other Diseases, Genitourinary System M 7 1 3 3 F 4 1 1 2 B46(11) Diseases of Musculoskeletal System M 3 1 1 1 F 7 1 2 4 B42 Congenital Anomalies M 12 7 2 1 1 1 F 10 6 1 1 1 1 B43 Birth Injury, Difficult Labour, etc. M 13 13 F 6 6 B44 Other Causes of Perinatal Mortality M 1 1 F 4 4 B45 Symptoms and Ill-defined Conditions M 4 1 1 2 F 8 1 7 BE47 Motor Vehicle Accidents M 23 6 2 1 2 7 4 1 F 5 1 1 1 1 1 BE48 All Other Accidents M 13 1 4 2 4 2 F 11 1 2 1 1 6 BE49 Suicide and Self-inflicted Injuries M 11 2 2 1 1 4 1 F 7 1 1 1 2 2 BE50 All Other External Causes M 2 1 1 F 2 1 1 Total All Causes M 1,148 25 12 4 4 18 17 26 89 254 354 345 F 1,105 20 5 4 6 7 5 22 60 139 237 600 117 ATTENDANCES AT CHILD HEALTH CLINICS 1971 Cavendish Pavilion Thurs. a.m. & p.m. Elers Road Mon. p.m., Thurs. p.m. Grange Park Mon. p.m., Thurs. p.m. Harefield Mon. p.m., Thurs. p.m. Harmondsworth Thurs. p.m. Haydon Hall, Eastcote Mon. p.m.. Wed. a.m. Hayes End Thurs. a.m. & p.m. Ickenham Wed. p.m., Fri. a.m. Laurel Lodge Mon. p.m., Thurs. p.m. Manor Farm Thurs. a.m. & p.m. Infants Born 1971 61 152 209 104 58 104 89 123 211 63 All other Attendances under 1 year 1,217 2,228 2,802 1,658 796 1,934 1,282 2,137 2,894 1,100 Children 1-5 years 1,431 1,714 1,189 1,633 853 1,625 1,015 1,145 2,033 1,224 Total Attendances 2,709 4,094 4,200 3,395 1,707 3,663 2,386 3,405 5,138 2,387 Consultations with Doctors 322 782 975 689 312 556 327 728 983 397 Number of Sessions 101 97 100 99 52 100 104 102 101 103 Average Attendance per Session 1971 26.8 42.2 42.0 34.3 32.8 36.6 22.9 33.4 50.8 23.2 Average Attendance per Session 1970 25.8 33.3 36.4 29.8 33.4 29.0 20.5 35.4 38.1 29.5 Maurice Child, Carfax Road Tues. p.m. Minet Mon. p.m., Thurs. a.m. Northolt Grange, Ealing Premises Mon. p.m., Wed. p.m. Northwood Hills Mon. p.m., Tues. p.m. Oak Farm Wed. p.m., Fri. p.m. Queens Hall, Hayes Wed. a.m. Ruislip Manor Wed. p.m., Fri. p.m. Sidmouth Drive Mon. p.m. Uxbridge Wed p.m., Fri. p.m. Westmead Tues. p.m., Thurs. p.m. Yiewsley Mon. p.m., Fri. p.m. Infants Born 1971 85 231 109 145 189 104 172 70 188 171 279 All other Attendances under 1 year 994 1,166 1,489 2,045 2,366 683 2,322 1,039 2,291 1,933 2,693 Children 1-5 years 716 1,080 1,315 2,695 1,458 665 1,092 730 691 1,267 1,551 Total Attendances 1,795 2,477 2,913 4,885 4,013 1,452 3,586 1,839 3,170 3,371 4,523 Consultations with Doctors 418 691 616 948 1,068 370 860 390 731 1,108 966 Number of Sessions 52 100 100 98 123 52 102 48 102 102 98 Average Attendance per Session 1971 34.5 24.8 29.1 49.8 32.6 27.9 35.2 38.3 31.1 33.0 46.2 Average Attendance per Session 1970 29.6 25.3 33.7 52.6 35.5 27.6 32.2 35.9 28.3 33.4 50.4 118 ATTENDANCES AT MOBILE HEALTH CENTRES 1971 Barra Hall Circus 1st & 3rd Tues. a.m. Charville Estate 2nd, 4th & 5th Mon. a.m. Cowley 1st, 2nd. 4th B 5th Fri. p.m. Cranford Cross Estate 1st & 3rd Wed. a.m. Glebe Estate 2nd & 4th Wed. p.m. Harlington Mon. a.m. Northwood, The Grange 2nd B 4th Thurs. p.m. Sipson 1st B 3rd Fri. a.m. Wise Lane Estate 2nd B 4th Wed. a.m. Yeading Tues. p.m. Infants Born 1971 23 20 71 11 27 55 23 23 21 69 All other Attendances under 1 year 204 151 563 276 240 1,111 229 167 270 907 Children 1-5 years 244 98 293 254 362 435 151 267 163 651 Total Attendances 471 269 927 541 629 1,601 403 457 454 1,627 Consultations with Doctors 132 77 251 119 196 312 130 149 118 605 Number of Sessions 23 24 37 23 25 47 23 23 24 74 Average Attendance per Session 1971 20.5 11.2 25.1 23.5 25.2 34.1 17.5 19.9 18.9 22.0 Average Attendance per Session 1970 22.3 10.2 20.8 26.7 28.2 33.9 19.0 21.8 18.0 20.0 119 CHILDREN ON OBSERVATION REGISTER Category Year of Birth 1967 1968 1969 1970 1971 Pre-Natal Rubella or virus infection 3 11 6 Blood incompatibility 1 13 5 Ante Partum Haemorrhage 1 1 14 9 Toxaemia 1 1 2 26 22 X-ray 1 Thyrotoxicosis 2 1 Diabetes 1 2 3 1 Other complications of Pregnancy 3 10 6 Psychiatric illness 1 2 2 Peri-Natal Prolonged or difficult labour 5 3 15 145 174 Post Maturity 6 4 Birth Weight under 5 lbs 1 1 2 19 29 Gestation under 36 weeks 1 6 16 19 Foetal distress 1 1 14 21 Birth Asphyxia 1 2 3 20 30 Prolonged poor sucking 1 3 13 4 Post Natal Jaundice 2 1 4 43 31 Convulsions 1 2 7 4 Respiratory Distress 1 1 3 10 13 Cyanotic attacks Congenital Abnormality 68 53 47 75 49 Genetic Family History deaf or blind 2 1 2 7 9 Other 2 5 5 13 General Socio Economic 4 3 3 4 3 Other 7 8 4 6 2 Total 94 80 113 472 457 Grand Total: 1,216 120 IMMUNISATION The following table shows the numbers of children immunised during the year at Council Clinics or by private medical practitioners: Primary Immunisation—Disease Year of Birth Total 1971 Total 1970 1971 1970 1969 1968 1964-67 Others under 16 Diphtheria 151 1,945 855 72 140 46 3,209 3,634 German Measles *1,553 *1,553 221 Measles 10 770 723 307 341 51 2,202 3,217 Poliomyelitis 93 1,842 782 103 187 59 3,066 3,707 Tetanus 152 1,945 855 79 140 66 3,237 3,687 Whooping Cough 147 1,866 797 46 44 8 2,908 3,299 * This figure represents 68 3% of eligible school population. Re-inforcing Doses—Vaccine Year of Birth Total 1971 Total 1970 1971 1970 1969 1968 1964-67 Others under 16 Diphtheria 3 15 18 29 Tetanus only 4 4 30 239 277 345 Combined Dip./Tet. 25 75 42 2,412 3,211 5,765 4,286 Triple— Dip./Tet./W.cough 41 130 67 437 200 865 796 Poliomyelitis 179 239 81 2,606 2,174 5,279 4,296 121 SMALLPOX VACCINATION During the year the following vaccinations of children were undertaken: Age Vaccination Re-vaccination Generalised Vaccinia 1971 1971 1970 1971 1970 Under 3 months 6 12 3-6 months 18 40 1 6-9 months 52 46 1 9-12 months 117 44 1 1 year 621 787 9 2-4 years 601 705 110 164 5-15 years 114 389 All 741 Totals 1,529 2,023 594 905 Nil The above-mentioned figures include 119 children vaccinated and 326 children re-vaccinated at London Airport. In 1971, 5,968 adult persons were vaccinated at London Airport. Not all these vaccinations were performed on arriving passengers, as in certain circumstances it was necessary to vaccinate outgoing passengers. DEATHS FROM CANCER Male Female Total 1970 1971 1970 1971 1970 1971 Malignant neoplasm, buccal cavity, etc. 3 5 6 1 9 6 Malignant neoplasm, oesophagus 2 5 4 1 6 6 Malignant neoplasm, stomach 33 29 11 21 44 50 Malignant neoplasm, intestine 27 28 36 42 63 70 Malignant neoplasm, larynx 2 2 1 2 3 4 Malignant neoplasm, lung, bronchus 142 102 28 26 170 128 Malignant neoplasm, breast 56 60 56 60 Malignant neoplasm, uterus 14 13 14 13 Malignant neoplasm, prostate 10 26 10 26 Leukaemia 4 10 7 11 11 21 Other malignant neoplasms 66 84 61 69 127 153 Totals 289 291 224 246 513 537 Rates per 1,000 of population Hillingdon All causes 2.27 Lung and Bronchus 0.54 122 PRIORITY DENTAL SERVICE STATISTICS Attendances and Treatment Children under 5 Expectant and Nursing Mothers First visit 765 81 Subsequent visits 916 170 Total visits 1,681 251 Number of additional courses of treatment commenced 133 17 Treatment provided: Number of fillings 1,176 191 Teeth filled 1,171 164 Teeth extracted 213 28 General anaesthetics 90 1 Emergency visits by patients 91 16 Patients X-rayed 8 18 Patients treated by scaling, etc. 450 76 Teeth otherwise conserved 142 Teeth root filled 5 Inlays Crowns 3 Number of courses of treatment completed during the year 804 65 Inspections Number of patients given first inspections 1,292 75 Number of patients who required treatment 813 69 Number of patients who were offered treatment 800 65 Prosthetics Patients supplied with full upper or full lower (first time) — Patients provided with other dentures 5 Number of dentures supplied 6 Sessions Number of dental officers sessions devoted to Maternity and child welfare patients (for treatment) 125 Total number of Dental Officer sessions 3,394 123 Staff HEALTH VISITING SERVICE Establishment—excluding managers 55 Principal Nursing Officer 1 Senior Nursing Officers 3 Health Visitors—full time 17 Health Visitors—part time (full-time equivalent 8:1) 15 Tuberculosis visitor 1 Clinic nurses—full time 2 Clinic nurses—part time (full time equivalent 8:5) 18 Health Assistants 4 Statistics Cases Visited Number of Cases 1 Total number of cases in lines 5, 6, 8, 10, 14 15,986 2 Children born in 1971 3,825 3 Children born in 1970 3,255 4 Children born in 1967-69 7,324 5 Total number of children in lines 2-4 14,404 6 Persons aged 65 or over 427 7 Number included in line 6 who were visited at request of G.P. or hospital 67 8 Mentally disordered persons 164 9 Number included in line 8 who were visited at request of G.P. or hospital 14 10 Persons, excluding Maternity cases, discharged from hospitals (other than mental hospitals) 44 11 Number included in line 10 who were visited at request of G.P. or hospital 14 12 Number of tuberculosis households visited 24 13 Number of households visited on account of other infectious diseases 330 14 Other cases 895 15 Number of tuberculosis households visited by tuberculosis visitor 467 16 Families with a subnormal child under 5 52 17 Families with a subnormal child over 5 150 124 DEATHS UNDER ONE YEAR ARRANGED IN DAYS WEEKS AND MONTHS Causes of Death 1st Day 2nd Day 3rd Day 4th Day 5th Day 6th Day 7th Day 8th-14th Day 15th—21 st Day 22nd-28th Day Total under 1 Month 7 Month 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months Total Congenital Malformations 1 2 1 2 1 3 1 2 13 2 2 1 18 Prematurity 9 1 3 3 16 16 Birth Injury 2 2 4 4 Resp. Distress Syndrome 3 1 1 5 5 Haemorrhagic Disease of Newborn 1 1 1 Pneumonia (All forms) 1 1 2 4 2 2 1 9 Bronchitis 1 1 1 3 Meningitis 1 1 1 Cot Death 1 1 1 1 1 4 Trauma 1 1 Total 16 6 6 2 2 1 7 1 4 45 5 6 2 1 2 1 62 125 SECTION VI Report of the Principal School Medical Officer for the year 1971 "Our most important are our earliest years."—William Cowper 1 731-1800 Annual Report of the Principal School Medical Officer for the year 1971 Dr. J. Stuart Horner, M.B. Ch.B., M.F.C.M., D.P.H., D.I.H. The Chairman and Members of the Education Committee. Ladies and Gentlemen, I have pleasure in reviewing the progress of the School Health Service in Hillingdon during 1971, the first full calendar year for which I have been responsible. There remain many doubts and uncertainties concerning the future role of the school health service, and none of these were resolved during the year. It was most encouraging that the Committee was able to accept my advice to the London Boroughs Association that the staff of the school health service should transfer to the new Area Health Authority, but that the Local Education Authority should retain a significant role determining the objectives and organisation of the services provided. The year was marked by dramatic improvements in recruitment of skilled professional staff to undertake the routine duties which form the essential foundations of the service. During the year five medical officers were recruited on a full-time basis together with some improvement in the recruitment of part-time school medical officers. This happy outcome may in part be related to the extension of the Borough's very progressive training policies to medical and dental staff. As a result of these improvements the normal programme of routine medical inspections was resumed and significant extensions towards a more comprehensive school dental service were introduced. It will be seen from the following pages that the number of medical inspections undertaken exceeded by 51% the figure for 1970. There are many today who would question the necessity for these routine medical examinations, although it is significant that such critics are rarely found amongst parents and teachers who recognise the value to be gained by the close involvement of skilled medical staff in the many problems which the satisfactory teaching of all children of school age presents to the Education service. Nevertheless, the quality of the examination and the significance of its clinical results are kept constantly under review. During 1971 a small working party of school medical officers exclusively engaged in clinical duties in the department was set up with wide powers to review and make recommendations upon present methods of examining school children in this area. It may well be found that a more comprehensive and time consuming examination is necessary upon school entry whilst a drastically modified form of examination would be sufficient for the examination in secondary schools with its emphasis upon the occupational health needs of the adolescent about to enter employment. During the year each school medical officer in regular practice within the Borough was issued with a special test of speech discrimination developed in a neighbouring local authority in order to obtain a more accurate assessment of the child's speech at school entry. Delays in acquiring verbal fluency are known to be associated with reading delay, and a survey in the Isle of Wight has shown that the latter carries a particularly poor prognosis. It is most important that such children are identified as soon as possible, and that scarce speech therapy resources are concentrated upon the acquisition of language in the 4-7 age group. Treatment Facilities The improvement in medical staffing has also allowed increased attention to be given to the continuing statutory responsibility to ensure that satisfactory treatment facilities are available for all school children. Dr. Karim took over responsibility for the orthopaedic clinic. The dramatic reduction in serious orthopaedic problems in school children in recent decades has allowed increased medical attention to be given to common but apparently insignificant orthopaedic abnormalities. In the majority of cases it is not known whether the treatment of such defects is either necessary or desirable. Nevertheless the problem presented by the enormous demand for chiropody amongst the elderly suggests a continuing need for skilled medical officers to look for possible contributory factors in childhood. In October an experimental enuresis clinic was commenced under the clinical direction of Dr. Jennings. In recent years there has been a dramatic 129 improvement in the treatment of this relatively common but annoying condition by the use of an electric alarm which wakens the child as soon as the bed wetting commences. Although the rationale of the treatment seems self-evident, its precise mode of operation is known to be complex. Experience suggests that considerable support for families is necessary if success rates are to approach the desired 100%. In spite of a substantial increase in the number of alarm machines owned by the department, the enormous demand for treatment of the condition revealed by the new clinic resulted in substantial waiting lists. Mr. Peter Busfield was appointed by the Committee as its first consultant adviser. His advice with the orthopaedic problems arising in special schools within the Borough provides a valuable addition to the services which the Committee is able to provide. Facilities for psychiatric investigation and treatment amongst children in the area continue to fall below known demands. The assistance provided by Dr. Urquhart and the staff of the Child Guidance Clinic is considerable, and continues to enable the service to meet most emergency demands. Negotiations with the North West Regional Hospital Board had reached the stage of agreed practical proposals by the end of the year. Recruitment of speech therapists, particularly on a full time basis presented problems throughout the year but again substantial improvements were in prospect by its close. The very exciting facilities for speech therapy and for the teaching of students which are being included in the new health centres will be very attractive to speech therapists interested in advanced treatment work amongst children. Health Education A study day on drug abuse proved most successful, although the attendance of teachers for whom the day was primarily designed was a little disappointing. A subsequent series of seminars held in schools provided detailed information for a wider range of teaching staff. The assistance of the Metropolitan Police at these seminars was particularly helpful. The appointment of a principal health education officer on the staff of the health department raised anxieties that the teachers' primary responsibility for the education of the pupil was being encroached. The health education unit exists to provide specialist support for teachers as they seek to introduce health topics to their pupils and to provide a necessary advisory service concerning the presentation of particular subjects and the choice of appropriate teaching aids. By the end of the year a number of pilot projects in a variety of schools had been established. Special Education On 1 st April, 1971, children of school age formerly excluded from the education system were integrated into it by the transfer of administrative responsibility from the health department to the education department of Moorcroft special school. The transfer did nothing to increase the number of places available, and increased provision for severely mentally handicapped school children is an urgent priority in the development of special educational facilities in the Borough. St. Michael's school for physically handicapped children terminated its responsibilities for residential care at the end of 1971, as discussions continue for its adaptation to meet the more specific special educational requirements of the Borough. Hillingdon is certainly large enough to support a viable unit for the satisfactory education of children who by reason of physical handicap or other seriously disabling medical conditions are not able to make the progress in ordinary schools of which they are known to be capable. Nutrition The maxim that the School Health Service is today more concerned with the over-weight than with the under-weight child no doubt contributed to the initial scarcity of informed professional opinion concerning the desirability of providing school milk for children in junior schools. It should be remembered, however, that the over-weight school child is mal-nourished not wellnourished; the child is receiving an excess of certain types of food, not of all types of food. Since milk is one of the most well-balanced natural foods any reduction in its intake by growing children would certainly not assist the problem of the over-weight child, and could seriously threaten the 130 nutritional status of the below average weight child. Fortunately, the Education (Milk) Act, 1971 provided considerably greater discretion to school medical officers to ensure that children in a precarious nutritional state receive free school milk than seems generally to have been realised. Strenuous efforts were made by the staff of the health department to identify such children as quickly as possible although it was not considered practicable to institute a specific survey. By the end of 1971 a total of 1,300 special recommendations under the terms of the Act had been made, representing approximately 10% of the relevant age group. The year saw the retirement from regular clinical practice of a number of long serving members of staff. Particular mention must be made of Dr. G. Malmberg, who came to the area in 1937, and who had for many years taken a close and very personal interest in the children and schools of the Northwood area. It is a pleasure to place on record my grateful thanks to the Committee for their constant support and encouragement. I am most grateful for the help so readily received from two Chief Education Officers and from Mr. D. A. Gohl during the year, together with the staff of the education department and the head teachers of the schools. The Town Clerk and his staff have provided much helpful advice and support. Finally, my particular thanks are due to Dr. J. W. E. Bridger who is responsible for the day to day administration of the service. Yours faithfully, J. Stuart Horner, February 1972 Principal School Medical Officer 131 School Health Service Dr. J. W. E. Bridger (Principal Medical Officer) Part I MEDICAL INSPECTION IN SCHOOLS Historical Background The School Medical Service came into being through the passing of the Education (Administrative Provisions) Act of 1907. In the years following the advent of the principle of education for all children (Elementary Education Act of 1870), teachers, school boards and others became increasingly aware that large numbers of children in the schools were unable to take advantage of the education offered because of chonic illness, malnutrition, poor clothing and a very unsatisfactory environment. Some attempts were made by individual Boards of Education to help remedy these evils by appointing medical officers and nurses to their staff to advise upon the health and treatment of pupils. This medical cover was sketchy and only some 85 authorities had appointed medical officers by 1905; fewer still had nurses. The reports published by three Royal Commissions just after the turn of the century were instrumental in drawing the Government's attention to the medical plight of school children and adolescents. The Report of the Royal Commission on Physical Training in Scotland 1903 remarked upon the poor condition of children attending Board Schools giving convincing examples of glaring physical defects and suggested medical inspection and feeding of school children. The Inter-departmental Committee on Physical Deterioration 1904 enquired into the physical condition of young men offering themselves as Army recruits, and the rejection of many of them due to physical causes. Among this Committee's recommendations were that a systematised medical inspection of children at school should be the duty of every school authority and that provision should be made by local authorities for feeding necessitous children; recommendations which reinforced findings of the Scottish Royal Commission. The third report was that of the Interdepartmental Committee on Medical Inspection and Feeding of Children Attending Public Elementary Schools 1905. A great deal of evidence was taken which showed, without any doubt, that very many children were in poor physical condition, were poorly nourished, poorly clothed and verminous. The Committee also reported that medical inspection by every local education authority was a necessity and that school meals provisions should be improved. A result of these various reports was the passing of two Acts of Parliament: (1) The Education (Provision of Meals) Act, 1906, and (2) Education (Administrative Provisions) Act, 1907. The first allowed local education authorities to provide meals for children attending elementary schools if the children were unable to take advantage of the education through insufficient feeding. The second Act laid a duty upon local education authorities to provide medical inspection for all children in elementary schools and to make arrangements for treatment of their physical condition. The School Medical Service was firmly established. In the years following, school treatment clinics were gradually set up throughout the country. Treatment at first was simple, being applied to those conditions which were easily remedied, for instance, the treatment of various skin conditions and the eradication of vermin. Later, when arrangements were made with local hospitals and doctors in private practice, more sophisticated treatments were applied. Specialist clinics for the treatment of ophthalmic and orthopaedic conditions were soon followed by clinics for other specialties, i.e. ear, throat and nose, speech therapy, child guidance, and audiometry. Dental treatment clinics were also established soon after the school medical service began and were extended to most parts of the country in the following years. Undoubtedly the health of school children has improved since those early days. In addition to the searching out of frank disease and defects in the physical and mental health of children, 132 in other fields of medical care there has been tremendous progress, especially in the discovery and refinement of specific drug treatment for many childhood disorders. Parallel with this advance, was the impact made by the preventive services on the killer diseases of whooping cough and diphtheria: 874 children per 1,000,000 under the age of 15 years were killed by whooping cough in the five-year period 1901-1905; in the same period of time diphtheria accounted for 653 children per 1,000,000 under 15 years of age, and measles accounted for 955! In the four years, 1936-1939 these figures were still high—whooping cough 163 per 1,000,000; diphtheria 287 per 1,000,000 and measles 149 per 1,000,000. Today, diphtheria is a rarity; measles and whooping cough are no longer killers—but they can maim. During the Second World War, preparations were made by great social reforms for the emergence of a welfare state. Part of this planning was directed towards education and resulted in the Education Act of 1944 which became law on 1st April, 1945. The School Medical Service became the School Health Service implying a change of medical thought from the curative or treatment aspects of medical care to the prevention of defects and diseases by careful surveillance of the school child from his entry into school to his leaving date. The emphasis was to maintain good health by early inspection and early detection of variations from the normal, advice on food and clothing, and active participation in measures designed to secure for the child a good environment and early treatment where necessary. The screening of thousands of children every year for general health purposes, specific tests of hearing and visual acuity, mean a great deal of steady hard work where the main aim and satisfaction is the establishment and maintenance of a healthy school population. In conjunction with this is the continuing reinforcing of immunisation against diphtheria and tetanus. This is now extended to protect the child against poliomyelitis and measles, and the children in the secondary schools are offered BCG vaccination against tuberculosis. During 1971 teenage girls have been offered rubella vaccination, to protect future mothers from the possible effects of German measles virus on their babies during the first three months of pregnancy. The effect upon the unprotected child can be disastrous, causing eye damage, loss of hearing, mental deficiency, and heart disease. In addition to the inspection of school children, the school health service is concerned with the ascertainment of handicapped children. This is dealt with more fully in Part III of this report. The development of the school health service has been briefly sketched from its inception in 1908 to its present role in 1971. What will be the position in 1974 when a newly-structured National Health Service comes into being? Has the school health service a useful function to perform in 1974 ? There is no doubt that the Education Authority and teachers will look to a doctor for advice concerning medical and psychological problems of children within the school situation. Doctors so consulted will need to have had specialist training and experience not only in paediatrics and social medicine but also to have some first-hand experience of the work of education methods generally and special education methods in particular. These skills are already in the possession of the medical officers of the school health service in post at the present time and this wealth of expertise should not be lightly cast aside. There is a strong case to be made for the retention of a school health service. In general, three main methods of forming such a service present themselves: (a) General practitioners and paediatricians could be asked to provide a service to the local authority in respect of examination of children and advice to the authority concerning their medical needs in the education situation. It is unlikely, however, that the extra work involved in maintaining a service by medical practitioners already overburdened with the task of caring for acute and chronic sick will be reasonable or indeed a possibility. (b) Local Education Authorities could set up a separate school health service. This would mean competing for medical, nursing and administrative skills with the new National Health Service. Such a service would be comparatively small and isolated and would be unlikely to support a career structure sufficiently attractive to skilled personnel. 133 (c) Maintain the service as it is now constituted and transfer it to the new National Health Service with arrangements being made for Local Education Authorities to negotiate with the Area Health Boards for the secondment or allocation of medical, nursing and administrative staff to provide facilities for school children in its area. Unless new legislation specifically makes other arrangements, the Local Education Authorities will still have statutory obligations under the 1944 Education Act which must be discharged and will require skilled medical advice and expertise. The third alternative would seem to be the most appropriate one. Medical Inspection in Schools Under Section 48 of the Education Act, 1944, the Borough has a duty to provide medical inspection of school children attending maintained schools in its area. Medical officers in the school health service of the Authority carry out these inspections periodically in the schools, other special inspections being conducted in the Authority's clinics. All parents are given the opportunity of being present at every medical inspection of their children. Periodic medical inspections are carried out as follows: (a) Children entering school under 5 years of age are to be inspected as soon as possible after entry into school and to be inspected again after reaching the age of 5 years providing an interval of at least one year has elapsed between routine inspections. (b) Children entering school at 5 years of age and over to be inspected during their first year at school. (c) An intermediate medical examination is made in the last year of the primary school or in the first year of secondary school education. (d) An inspection is made within the child's last year at secondary school, that is to say the school year in which the child reaches its fifteenth birthday. (e) Where pupils continue at school beyond 15 years of age, another inspection is made at approximately 17 years of age. In addition to these periodic inspections, the pupil may be inspected at any time at the request of the parent, headteacher, or school nurse. The total number of routine medical inspections of children during 1971 was 13,459; in addition, a further 6,670 children were examined at special inspections and re-inspections at school or school health clinics. In the Annual Report of the Principal School Medical Officer for the year 1970, it was remarked that fewer routine medical inspections were completed in that year than in the previous year (1969) due to shortages of medical staff. By the end of 1970 and the beginning of 1971 this position had been largely re-couped. At a time when there is a national shortage of medical practitioners, it is significant that the Borough has been able to attract a number of young and enthusiastic doctors to its staff. As a result, early in 1971, the Principal School Medical Officer was able to report to the Education Committee that inspections of all school children could now be made in accordance with the decisions formulated in 1965, and an assault was also made on the backlog of inspections not able to be done in 1970. This work is continuing. It is encouraging to note the number of parents who attend these inspections. Of the 13,459 children inspected at routine medical inspections, 9,915 parents were present, 73-6% of those invited. At special medical inspections, 4,460 parents came with their children out of a total of 6,670 children being so inspected; this represented 67%.of parents invited. This is a high standard of parental involvement; they do not give up valuable time for a worthless exercise. Many parents wish to seek advice or reassurance from the examining doctor; some are present to support the child on an occasion of some anxiety, or to take the opportunity of discussing points of medical or educational interest with the teacher. The event, no matter what the ultimate reason for using it, is an important one for parents and their interest must be maintained and enhanced. This valuable opportunity for a parent, teacher and a doctor meeting is somewhat fleeting, occurring only three times in the child's school career in most cases, but many schools are denied it because 134 of the inability to hold inspections on their premises. The routine medical inspections for some 19 schools are at present held in clinics; some of these are fortunate in having clinic premises in the grounds of the school; Grange Park, Lady Bankes, Oak Farm, Minet, and although this presents few problems in arranging for children to attend the clinic, the teacher is not involved with the parent or doctor as closely as might be hoped. In other schools, the clinic is situated at some distance away, providing little chance of busy teacher and doctor ever meeting. It is essential that medical inspections be carried out in the school where a quiet, warm, well-lit room can be supplied for the use of the doctor, and a place where parents can be accommodated with their children in some degree of comfort whilst conferring with the nurse in attendance and awaiting their turn for inspection. The 13,459 routine medical inspections produced a total of 3,809 defects, i.e. 28%. 1,363 of these defects required treatment and 2,446 needed further observation. This is a somewhat higher proportion than last year's figures when 1,945 defects were discovered in 8,922 routine medical inspections—17.3% of the total. A summary of the defects found at routine medical inspections in 1971 has been recorded on Table C, page 164. Personal Hygiene A Local Education Authority has the power to ensure that the person or clothing of any pupil in attendance at one of its maintained schools is not infested with vermin or is not in a foul condition. The Authority may, for this purpose, authorise a medical officer to cause examination of the person or clothing of pupils in attendance at any or all of its maintained schools, whenever in his or her opinion such examinations are necessary in the interests of cleanliness. The examination will be made by a person authorised by the Authority, and if the person or clothing of a pupil is found to be infested with vermin or in a foul condition, an officer of the Authority may serve on the parent of the pupil a notice requiring him to cause the person or clothing of the person to be cleansed within the time stated on the notice. This notice should give at least 24 hours in which the parent can attend to the child, otherwise the cleansing will be carried out by the Authority. After the cleansing has been carried out, if the person or clothing of the pupil is again, owing to neglect, found to be infested with vermin or in a foul condition at any time while he is attending a school maintained by the Local Authority, the parent will be liable upon summary conviction to a fine. If a medical officer suspects that the person or clothing of a pupil is verminous or in a foul condition and action for the examination or cleansing cannot be taken immediately, he or she may, if it is considered necessary, either in the interest of the pupils or of other pupils, direct that the pupil be excluded from attendance at school until such action is taken. The London Borough of Hillingdon in implementing its powers under Section 54 has adopted the following procedure: Primary Schools A full inspection for cleanliness of persons and clothing be conducted each Autumn term in every school and that revisits to schools be made until an inspection of all the children on roll at each school has been completed. If after completing inspection— (a) Not one case of infestation is found, then no further routine inspection for cleanliness will be carried out until the following Autumn term; (b) One or more cases of infestation are found, then a full inspection for cleanliness be conducted during the following Spring term. If there should be a further case or cases of infestation found during the Spring term, then another full inspection will be conducted during the Summer term. If no cases of infestation are found during the Spring term, the next routine inspection will take place in the following Autumn term. Secondary Schools The first, second and third year children to be inspected on exactly the same principles as outlined for the primary schools. The cleanliness and inspection of the fourth year children will be carried out at the same time as a routine medical inspection, which takes place during the school year in which a pupil attains the age of 15 years. 135 Pupils who stay on at school beyond the compulsory school age, will have their next cleanliness inspection at the routine medical examination which takes place at approximately 17 years of age. If a case of infestation is reported from these two latter groups of senior pupils, the method of inspection adopted to combat further infestation is left to the discretion of the Principal School Medical Officer. At any other time complaints of infestation of individual pupils cause immediate inspection under this Section in the interests of the health and well-being of all school children. Cleanliness Inspections There has been a further increase in the number of children found to have head lice infestation. 184 children were found so infected for the first time during the year out of a total number of 61,030 inspections; this compares with 112 in 1970 and 68 in 1969. This reflects locally a general rise of infestation on a national scale and greatly concerns the health department. In view of recent reports which have suggested that the head louse is acquiring some resistance to the drugs commonly used in treatment, other preparations are being tried. The careful inspection of children in all schools must obviously be continued and re-examination of class mates and contacts vigorously pursued. 1970 1971 Number of cleanliness inspections 52,856 61,030 Found infected for the first time 112 184 Skin Defects The decline in skin defects noted last year was not maintained in 1971. 1.7% of all defects were those of the skin in 1970, in 1971 there were 2.5% of defects due to skin conditions. The incidence was greater this year among the junior school children at the intermediate examinations followed by infant school children. The reason for the increased number of skin defects among juniors is probably due to infections of the skin, e.g. plantar warts (verrucae). Plantar warts are discovered among all groups of the school child population but more so among those in the junior schools and the early years of the senior schools. The reason for this special predilection for these ages is not known but may be connected with the communal use of dressing rooms and wash rooms after games. The numbers of verrucae being reported by headteachers was much larger than the figures for routine medical inspection showed and highlighted a cause of discomfort for many children that could no longer be tolerated. The number of children affected was too large for individual chiropodists to deal with and some other approach was sought. Various methods of treatment were considered and it was decided to adopt one which required the application of a small ring of plaster containing a keratolitic agent to the wart for a period of one week (7 days). After a variable length of time the wart is shed with the surrounding dead skin. The experience gained so far is limited but shows some promising results and the statistics of treatment and cure rate should be available during the next few months. Scabies During 1971, 25 visits were made to 21 different schools where investigations were thought to be necessary; 21 cases of scabies infestation were diagnosed. All parts of the Borough were involved as was the pattern of infestation last year. There has, however, been a reduction in the number of cases diagnosed from 32 in 1970 to 21 in 1971. Four doctors have received special training for the diagnosis of scabies and these doctors lead teams where investigation of school contacts has been required. It is expected that the expertise developed from this approach will hasten the clearing up of this disease in the Borough and the smaller figure of scabies cases this year points towards some success in this direction. Further details are recorded on page 172. 136 Vision Defects This group of defects still remains the largest found at routine medical inspections—30.7% of all defects; last year the figure was 39.4%. Of the 1,111 children presenting with vision defects, 504 were in the 5/6 year old group. 75 needed treatment and 429 were referred for observation and retesting. At the intermediate examination (11/12 year old group) 141 were sent for treatment and 254 were noted for further observation. Among the leavers, 69 needed treatment and 143 were to be seen again before the leaving date. It is clear from these figures that careful, frequent examinations are required to identify children whose vision may deteriorate; ideally the inspections should be conducted every two years. As will be noted in the figures given for routine vision testing below, vision tests are made at 5, 7, 11 and 15 years of age. A slightly smaller proportion of infant children presented with squints in 1971 than in 1970. Other conditions of the eye, blepharitis, conjunctivitis, etc., remain at a low level. Routine Vision Testing The routine vision testing scheme is intended to augment vision testing given to pupils when examined at routine medical inspections. For several years now, the scheme has covered children at seven years of age. Other children are included from junior departments where there is evidence from previous vision tests, that the child's vision needs to be observed. At the end of 1970, the Local Education Authority had agreed that with the medical staff at well below establishment level, it would not be possible to carry out the routine medical inspection of the primary leaving group (i.e. children of eleven years of age approximately). In these circumstances, it was decided at the beginning of 1971, that the whole of this primary school leaving group should be included in the routine vision testing scheme. Consequently, the number of children tested during 1971, was more than double the figures obtained for 1970. The results were: Number of children tested 8,058 Number referred for opinion of school medical officer 326 Of these: 94 were referred to the Authority's Ophthalmic Clinics. 56 were referred for treatment via general practitioners, at the request of parents. 110 were referred for re-examination at School Health Clinics. 42 were considered to have normal vision. 24 were already having ophthalmic treatment. Of the 94 children referred to the Authority's Ophthalmic Clinics: 61 were prescribed glasses. 28 were noted for re-examination. 5 were discharged. Five of the 94 were also referred to the Authority's Orthoptic Clinic. Defects of Ears This is the second largest group of defects found at routine medical inspections accounting for 13-8% of the total (12.8% in 1970). Of this number, reduction in hearing acuity produces the largest proportion of disability. The 5/6 year old group produced a total of 225 children with some hearing loss in one or both ears at the time of testing and 177 of these were referred for treatment. 125 out of 150 in the intermediate group needed treatment, a figure only slightly smaller than the infants and indicates the effects of infectious diseases, such as cold and childish ailments have upon the ability to hear. Only 56 leavers were referred for treatment; this, however, is still a large 137 number, especially when compared with 1970 (21) and demands a close scrutiny of the hearing of senior school children. Some of these children so referred will have had hearing losses as a result of previous illnesses during their early childhood, but some loss may be due to the noisy environment which many senior school children seem to enjoy. Sustained loud noise as produced in discotheques, etc., has been shown to give rise to gradual loss of hearing ability and a warning should be given that young people run risks with this precious faculty under such conditions. One of the penalties of advancing age is the gradual loss of hearing particularly in the higher frequencies which impedes the enjoyment of music and quiet verbal communication; this process can be expedited if the noise pollution increases beyond reasonable limits. It is gratifying to note the very small number of children with middle ear disease, 22 out of 13,459. The impact of modern drugs on this one-time scourge of children has been immense. Defects of Nose and Throat 202 children were noted to have some condition of the nose and throat which needed attention. Entrants to school provided the largest number, this age group inevitably having to deal with the infections of the large school population after leaving the shelter of the family and the neighbourhood environment. Running noses (rhinorrhoea) and sore throats with inflammation of tonsillar beds and enlargement of lymph nodes are common but settle down after varying lengths of time with no further trouble. Occasionally, a child is left with a chronic tonsillar enlargement and infection which will require surgery, but the mass removal of "tonsils" of the school child population has now gone. Only 36 of the 131 children seen at these inspections required any form of treatment. The figures are even less for the junior (20) and senior (5) pupils. Defects of Speech The reports of speech therapists have been included elsewhere in this report (page 150). It is interesting to note the comparatively large numbers of infant school children who display some difficulty in speech production. 45 of this group needed attention and referral to a speech therapist and a further 152 were asked to return for re-examination after a period in a communicating environment. Children with defective speech are confronted with considerable difficulties in a normal infant class. They are frequently unwilling to talk because of the unfortunate effect their speech has on other children; they become shy and unresponsive, frustrated in their attempts to communicate. Their education often suffers and time lost in prolonged speech therapy can add to the deprivation. Also there may well be a correlation between defective speech and later reading ability. All this really means that children with speech defects should be identified earlier than the school entrance age and the appropriate treatment begun. Defects of Heart and Circulation The figure obtained for this defect remains at a low level, 2.1% (2.7% in 1970). For the most part, the children were in infant classes and presented with heart murmurs many of no great significance but all needing careful examination. 5 of the 47 were referred for further investigation or treatment, the remaining 42 for observation and re-assessment. In all three groups examined, 9 children needed referral for consultant opinion and 70 were noted for further observation. Defects of Lungs The proportion of defects of the lungs to the total number of defects is similar to last year (2.7% in 1971; 2.5% in 1970). The number of entrants presenting with lung conditions is similar to that of the intermediate examinees, 41 entrants and 49 intermediate. The commonest diseases are bronchitis, and asthma. Many of these children are seen with wheezy chests which may be due to underlying bronchitis with spasm and which may develop into frank asthma or may not. It seems that many children who display these conditions in early childhood are free of them by the time they reach school leaving age and this clearly appears to accord with the figures for routine inspection. The number of school leavers with lung defects is only 12; 2 of whom needed treatment and the remaining 10 having treatment already and requiring supervision only if they remained at school. A few children will still be left with their asthma or bronchitis when they begin their working life. 138 Developmental Defects These are usually a fairly consistent proportion of the total number and are tabulated as Herniae (usually umbilical or inguinal) and other developmental defects such as absence of one or both testes in the scrotum, cleft palates, extra digits, etc. 20 children were noticed to have herniae, 13 infants and 7 juniors. No school leaver was found to have a hernia. Of the remainder of children with developmental defects, 59 entrants and 53 intermediates were so noted and 12 leavers. 29 of these required treatment. Orthopaedic Defects 12-4% of all defects are gathered under this heading and after eye and ear conditions, produce the highest figure afflicting school children. From the earliest days of the school medical service, this group of defects has attracted the attention of teachers and doctors, mainly because of their obvious nature, i.e. poor stance, posture, awkward or crippling gait, deformed limbs, etc. Orthopaedic clinics were, therefore, among the first to be set up to improve these conditions and have remained in the forefront of treatment centres with specialist attendants. The Borough has had an orthopaedic clinic on its premises since it took over responsibility for the School Health Service from the Middlesex County Council. An account of this clinic is presented in Part II of this report. The headings of defects under this general orthopaedic grouping are: (a) Posture (b) Feet (c) Other 51 children showed abnormal posture at inspections, 29 of these among the intermediate examinees. The large number of 11/12 year olds displaying this defect is somewhat surprising but could be associated with the period of rapid growth, or of slack attitudes adopted at desks. 7 of the 29 children were sent for further investigation and treatment compared with one of the 13 entrants. Defects of the feet affected the largest number of children in this group. Again the 11/12 year olds were the greatest sufferers accounting for 184 children, 55 of whom were referred for treatment. During this period of rapid growth of the feet, shoes need to be changed frequently to allow for this. Tight socks and shoes are responsible for many crippled feet and wise choice of footwear pays dividends in the future. Feet well cared for will cause little trouble in the middle and later periods of life, but when neglected in childhood will reward their owners with much pain and misery. So the emphasis is directed towards healthy, well-shod feet in childhood and where early defects noted, treatment must be applied quickly and energetically. Defects of the Nervous System Epilepsy was recorded in 29 children examined at routine medical inspections in 1971, all except three of whom were receiving adequate treatment. The three children were referred for a review of therapy to ensure a satisfactory school attendance. Most of these children progress normally through ordinary schools and do not present difficulties in teaching or in behaviour. Headteachers and school medical officers should be given full details by parents of any fits or fainting attacks which occur in their children or of any treatment they may be receiving, thus promoting healthier attitudes to this disease amongst all who may be faced with an otherwise unexpected attack. Psychological Defects These are considered under two headings—Development and Stability. Development involves the progress of a child's intellectual capacity in reasoning and space abilities, memory, etc. Generally speaking, the tests of intelligence made during the first five years on the occasions when they need to be done, must be regarded as indications of possible future progress and not necessarily for decisions of future need to be made; but observation made during the next two years or so will be of great value and added to previous records of ability and progress, will show the need of the child for special schooling or otherwise. Thus, whilst the figures indicate that 25 entrants were identified as showing some degree of psychological under-development, only five needed 139 to be referred for investigation or educational treatment; in the next group of 43, twenty-four were so referred. Some of the children noted above may require treatment at the Child Guidance Centre as well as special educational treatment. In addition, a further 172 children were considered to exhibit some degree of psychological instability. It is interesting to note that 118 of them were entrants to school; 11 sufficiently so to be referred to the child psychiatrist for investigation and treatment. 107 of the children displayed behaviour or emotional problems which might be expected to be managed or solved in the normal school situation but nevertheless needed to be kept under observation. Among the children at intermediate examination, 48 were showing psychological problems and 11 of these were referred for further investigation. There appears to be an increasing incidence of psychological problems affecting school children (2.9% in 1968; 5.8% in 1969; 4.9% in 1970; 6.3% in 1971) and this is also reflected in the numbers being referred to child guidance clinics in the Borough and elsewhere. The occasional need for a child presenting with severe acute mental disorder to be admitted to a children's psychiatric unit or hospital may become very necessary and very urgent both for its security and for its treatment. The position was referred to in last year's Annual Report and it is regretted that the provision of hospital beds for such children locally is no better than it was a year ago. School Health Service and Employment The employment of school children is strictly defined by law and local education authorities may apply restrictions by means of bye-laws. A child who is 13 years old and not yet of school leaving age may be employed, in certain occupations, up to a maximum of 20 hours per week. A certificate must be obtained showing that a medical assessment of the child has taken place and that the medical officer is satisfied that the work the child has to perform will not interfere with its health or education. The medical officer must consider whether the work is liable to induce undue or excessive fatigue; is liable to induce some postural disability—excessive weight carrying, working in a cramped attitude, etc.; is liable to take up too much of the child's leisure time. If the child is on the Handicapped Pupils' Register stricter conditions must be applied to be certain that the handicap is not exacerbated. All assessments are made at school health clinics. Upon the issuing of the medical certificate, the child is given an Employment Card which must be produced for inspection when required to do so by an authorised officer of the Authority or a Police Officer. The Authority has a Careers Office which is set up to assist school leavers in obtaining employment. At every leaver's examination a form is issued for the information of the Careers Officer indicating conditions of employment which are not considered suitable for the child. For most children no prohibition is necessary, but for a few, certain defects are present which may limit a child's choice of occupation, e.g. colour vision defect where accurate discrimination of colours is essential; poor eyesight in an occupation involving strain to the eyes; dusty or damp atmosphere for children with chronic diseases of the chest, etc. The disease is not specified but the certificate indicates to the Careers Officer that certain occupations are unsuitable. There is a special liaison between the School Health Service and the Careers Office where Handicapped Children are concerned. A Specialist Careers Officer, Mr. P. Holmes, has been appointed by the Authority and the name of every school leaver on the Handicapped Pupils' Register is reported to him. With parents' written permission more information concerning the type of handicap is disclosed and the sort of occupation most suitable is discussed enabling the Careers Officer to help place the majority of handicapped children in a congenial work setting. THE EDUCATION (MILK) ACT, 1971 AND CIRCULAR 12/71 ISSUED BY THE DEPARTMENT OF EDUCATION AND SCIENCE This Act received the Royal Assent on 5th August, 1971, and its provisions were brought into effect by the provision of Milk and Meals (amendment No. 2) Regulations, 1971, which were made on 17th August, 1971. Under these Regulations, Local Education Authorities were placed under a duty from 1st September, 1971 to provide free school milk only for the following classes of pupils at maintained schools: (a) Pupils in Special Schools. 140 (b) Pupils in other maintained schools up to the end of the Summer Term next after they attain the age of seven. (This means that children whose 7th birthday falls in the summer holiday, should receive free school milk for the whole of the following year. This provision should cover some 8%-10% of children on average in the first year group of Junior Schools. It virtually ensures that some supply of free school milk is distributed in all Junior Departments, except possibly where the school roll is of small proportion.) (c) Other pupils in Primary Schools (and Junior pupils in all-age and middle schools*) where a school medical officer certifies that the pupil's health requires that he should be provided with milk at school. * Not applicable to schools in Hillingdon. The Secretary of State did not consider it appropriate to issue advice or guidance to Authorities about the criteria to be adopted by school medical officers in identifying children between 7 and 12 who need milk on grounds of health. This is regarded as a matter for the professional judgement of school medical officers who have had long experience of identifying children in need of special consideration for any one of a number of purposes. The provisions of the Act clearly envisage that a certificate is given in respect of a child recommended for free school milk on health grounds and that such a certificate is signed only by a medical officer of the Local Authority. A certificate can be given from documentary evidence without carrying out a further medical inspection of the pupil concerned. It is essential that all children in need of free school milk on health grounds are identified and the co-operation of teachers, education, welfare and other officers, together with other responsible persons in contact with pupils thought to be in need, is sought. Parents may approach school medical officers directly or through the schools that their child may be in need of milk on health grounds. Certificates issued by school medical officers generally will cover the whole school year or the remainder of the school year. A school medical officer cannot certify that a pupil's health requires that he/she be provided with more than one-third pint of free milk a day at school. Section 1(2) of the Education (Milk) Act, 1971 and 4(3) of the Regulations as amended, confer on Local Education Authorities a new power to sell milk to pupils at schools maintained by them and this includes senior pupils. The expense of providing milk under this power must be defrayed by pupils or their parents and there is no provision for Authorities to reduce the charge on hardship or other grounds. Authorities can decide the charge to be made which apparently must cover the cost of supplying the milk. This power for Local Authorities to sell milk is a general one and pupils who have been recommended to receive free school milk on health grounds (as above) may buy extra milk if it is offered for sale. The power allows Local Authorities to offer milk for sale at any time during the school day. The Authorities' power to sell milk is confined to day pupils at maintained schools. 141 Part II SPECIALIST SERVICES AUDIOMETRY The routine audiometry service was continued as in previous years with the Audiometer Operator working on a part-time basis of three days per week. Investigations were continued in junior and infant departments of primary schools. Of the 427 found to have hearing loss: 102 were found to have a hearing loss in the right ear 123 were found to have a hearing loss in the left ear 202 were found to have a hearing loss in both ears The 427 children were referred for examination by the school doctors with the following results: 34 were found to have normal hearing on clinical testing 219 were noted for re-examination 3 were referred to hospital 60 were referred to family doctors 10 were referred to Audiology Units 48 were already attending hospital 11 were already attending Audiology Units 4 had left the area 38 were still under observation CHILD GUIDANCE CLINICS I am grateful to Dr. R. P. M. Urquhart, Medical Director for the following report: The year has been one of consolidation. Clinical work proceeded, complemented by discussion and the presentation of papers by clinic staff at our weekly conferences. A particularly successful meeting with staff of neighbouring clinics was held at Meadow School through the kindness of Mr. Everett, Headmaster. Papers were read by Dr. Urquhart, Mrs. Zadik and Miss Reynolds, and a lively discussion followed on the subject of school phobia. A welcome trend has been a greater readiness of both parents to be involved in the processes of assessment and further treatment. This must reflect an increased recognition among the general public of the nature of children's emotional difficulties and that they are often a family problem. A limited but larger number than before of families have been seen altogether for treatment where this has been appropriate for the family's needs. Consultation for people working in related professional fields has been provided as in the past by the psychiatrist and psychiatric social workers, and has proved mutually rewarding as well as beneficial to the children concerned. The difficulties of working in the present premises have increased with the increased staff working here, although the establishment is not completely filled, and would need, as previously indicated, the addition of a further part-time consultant or senior registrar for whom currently there is no available accommodation. The increased pressure on secretarial help mentioned in the report for 1970 has not diminished, and the needs of the clinics are simply not being met, as shown, for example, by the impossibility The numbers of children tested this year are very similar to those of last year, but the number found to have a hearing loss is less: 427 in 1971, 467 in 1970. Number of children tested 6,795 Number found to have normal hearing 6,368 Number found to have a hearing loss 427 142 of preparing adequate statistics, but this is, in terms of work done, only a small point. Miss Sheppard and Mrs. Varley have borne the considerable strain of the necessary demands on their services, but these demands have, out of consideration for them, had to be limited, secretarial work being undertaken by professional staff with an inappropriate expenditure of time. The psychiatric social workers, with the addition of Mrs. R. Brand, social worker to the schools for maladjusted children, have worked together in professional discussions and in collaboration over families of children at the schools, refining the kind of help which they can appropriately give according to the problems which different families present. The year at Hayes was a particularly successful one in terms of seeing and helping children and their families, and much credit for this must go to Mrs. Bonard with her particular knowledge of the neighbourhood and its problems. It has also been possible for more constructive work to be done there through Miss Sobat visiting as psychotherapist to see children there, and she is fortunately able to continue to do so. The team at Uxbridge have had the benefit of working together for a settled period, and the mutual understanding through joint discussion of problems between psychiatrist, psychiatric social worker, psychotherapist and psychologist has worked to the advantage of staff and patients alike. We are able to congratulate Mrs. Zadik and Miss Hamilton on successful completion of their training, so that now they are fully recognised and qualified psychotherapists, and the Education Department's investment in their training has been clearly warranted. At Uxbridge, Miss M. Sobat, psychotherapist, having advanced to an appropriate point in her training, began seeing children individually at the Clinic in September. Miss Kerbekian was appointed to a psychotherapist vacancy in July and is at a preliminary stage of the psychotherapy training course at the Tavistock Clinic. She is currently employed, as Miss Sobat was, at the Unit for Autistic Children, but is able to attend some meetings at the Uxbridge Clinic. We hope that she, too, will be able to complete the training successfully in time. While the future of child psychiatric services continues to await government decision, it is anticipated that the particular combination of training and skill which clinics have been able to offer until now will still be needed by the community. The continuing demand for placement of students in such clinics, and for consultation by people working in allied fields, shows the need for such an independent clinic. We continue to be fortunate in the good liaison we have with members of the local authority departments with whom we have most contact—Health, Education, Social Services and the Probation Service—and look forward to this being maintained and improved. Child Guidance Centres Number of cases referred in 1971 Boys 127 (85) Girls 65 (55) 192 (140) Number of cases brought forward from 1970 50 (62) Total 242 (202) Number of cases dealt with by psychiatrist 225 (121) Number on Waiting List at 31.12.71 34 (43) Number of cases uneventuated, left Hayes and Uxbridge or improved before appointment given 41 (46) Number of cases dealt with by other means — (2) Number of cases seen regularly for treatment by psychiatrist 1 (3) Number of cases seen for follow up by psychiatrist 147 (150) Number of cases seen regularly for treatment by psychotherapist 21 (30) Number of cases recommended for residential placement 7 (12) Number of cases recommended for day maladjusted schools and units 9 (25) 143 Sources of referrals Principal School Medical Officer 26 (37) Heads of schools via Educational Psychologist 48 (69) Chief Education Officer 7 (21) General Practitioners and Hospitals 26 (23) Probation Officer 1 (3) Social Sevices Department 4 (—) Parents 46 (38) Other 8 (11) 166 (202) SCHOOL DEIMTAL SERVICE Mrs. B. Fox, B.D.S.—Principal School Dental Officer Equipment of Dental Surgeries The major achievement in the school dental service has been the re-equipping of eight dental clinics with equipment suitable for modern low-seated dentistry. This has taken one year to complete due to delays in delivery. The premises of the pre-war clinics present problems when adapting to new equipment and there remain difficulties. However, new techniques, particularly in general anaesthesia, have now been adopted, resulting in a far better and safer service for our patients. Handicapped Children In April, 1971 the school dental service accepted responsibility for the dental examination and treatment of mentally handicapped children and carried out the first inspection at Moorcroft School. Many children were given treatment as a result of the examination and a number referred to Leavesden Hospital, Abbots Langley or to University College Hospital for fillings under a general anaesthetic. There is a great shortage of centres able to undertake this work. I would like to record appreciation, particularly, of Leavesden Hospital Dental department, who have accepted the majority of children for treatment. The major problem of handicapped children is not dental caries but gum conditions. This may be the result of drugs taken by the child, poor natural cleansing by the musculature of the mouth and, frequently, inability to use a toothbrush effectively. Great emphasis has been placed on oral hygiene instruction by all members of the dental team in contact with the children. Miss M. H. Hutchinson was appointed as a dental auxiliary in September 1971 and has pioneered this work. She has visited Moorcroft School twice weekly to see the children in small groups to encourage them to clean their teeth to the best of their ability and to give them a simple dental health message. This regular contact has produced response from the children and the headteacher, Mr. Nicholas has kindly allowed us to install some basic dental equipment at the school. It is hoped that as the children become more familiar with the equipment they will be less anxious about entering a dental surgery. Miss Hutchinson will also undertake routine polishing of the teeth for children at school. Dental Health Education A programme of dental health education in junior schools was initiated in the latter half of the year. It is hoped to expand this during the next year when a second senior dental officer is appointed in April 1972, with special responsibilities in this field. The form of dental health education is slowly changing and more emphasis is being placed on project work done by the children. This is more time consuming for dental staff and requires active co-operation from the teachers. It is thought to be more effective in the long term but 144 evaluation of the results is difficult. It has necessitated in-service training for all the dental staff involved; dentists, dental auxiliary and dental surgery assistants, so that our aims are clearly defined and our approach has a degree of uniformity. Park Place School Basic surgery equipment has been installed at Park Place Residential School, Henley-onThames, which is the responsibility of the Borough of Hillingdon. This has enabled on the spot dental treatment to be given to the boys, many of whom suffer from asthma and other medical conditions. As a consequence of spending long periods in residential schools, many boys did not have regular dental treatment. Their oral hygiene was often very poor and home support was not always given. Initially, great attention was paid to oral hygiene instruction and a significant improvement has been noted recently. The boys were at first very apprehensive of dental treatment, but as more preventive-orientated treatment has been introduced they have shown less anxiety. A small project on dental health was completed with the youngest boys. They made plaster models of their own teeth and completed fillings in the models. The informal atmosphere gave them the opportunity to talk over their own anxieties with the dentist and assistants away from the intimidating atmosphere of the dental surgery. It is hoped that a more favourable attitude towards dentistry will be created, so that they are not afraid to continue regular treatment when they leave school. School Inspections The number of children inspected has risen and emphasis has been placed on examining children in primary schools. Children on the handicapped pupils register have received particular attention. The facilities available for examination of children in school are not ideal and recall examinations in the surgery at six monthly intervals are offered whenever possible. This enables all modern diagnostic aids to be used. Children living in Yiewsley and West Drayton have found difficulty travelling for dental treatment to Uxbridge and Laurel Lodge Clinics. This has resulted in a high proportion of appointments not kept and the opening of the Yiewsley Health Centre is eagerly awaited. Dental Staff The shortage of wholetime dental officers continued throughout the year. A scheme of accelerated increments in salary for satisfactory performance of duties was introduced. It is hoped that this will attract younger dentists to whole-time posts and retain them for longer periods. At present, younger dentists find it is financially more favourable to work on a sessional basis. The Chief Dental Officer, Mrs. B. Fox, was appointed as honorary clinical assistant in the Children's Department, University College Dental Hospital. Patterns of Treatment The emphasis of dental treatment has moved steadily away from the relief of pain to the prevention of dental disease. Many children receive routine application of fluoride to the teeth and it is hoped to introduce the new methods of sealing the fissures of the teeth before they decay. At present, the high cost of the materials used prevents their widespread adoption. However, in certain handicapped children this type of treatment may become increasingly important. Advanced conservative treatment, particularly for fractured front teeth, is now provided in the Borough, by the Senior Dental Officer, Mr. J. G. Windmill, and other staff. Many children who were previously referred for treatment to London teaching hospitals are now able to obtain this locally. Review of Dental Services The dental services in the Borough were reviewed by a dental officer from the Departments of Education and Science, and Health and Social Security in January 1971. The visiting officer reported on the development of the service and the pattern of treatment being carried out by the 145 authority's dental staff, the condition of the premises and plans for their improvement. An official letter on behalf of the two Secretaries of State was received in June. The recommendations were in accordance with the improvements being carried out in the dental service. School dental statistics are recorded on page 1 66. ENURESIS CLINIC Dr. V. Jennings—School Medical Officer A new clinic for enuretic children was begun on 12.10.71 at Ickenham Clinic. It is held weekly on Tuesday afternoons and is staffed by a school medical officer, a clinic nurse and a clinic clerk. Patients are referred from other school medical officers, family doctors and from local paediatricians. Each new patient is allowed about | hour during which a full medical and social history is taken and full physical examination and urine testing undertaken. Where relevant, reports may be obtained from headteachers, health visitors and social workers. The method of treatment is then decided upon. In all cases simple advice and management is given to the parent and the matter is explained to the child in such a way as to relieve anxiety and guilt feelings and to give an optimistic outlook. This alone has been shown in most other clinics to produce good results. Most children are asked to keep a chart, marking the dry nights only with a drawing. In addition, suitable children are given an alarm. This applies only to children over seven as full co-operation is necessary. The bell is demonstrated in detail to parent and child by the clinic nurse who may also visit the family during the week to ensure instructions are properly carried out. The nurse is also able to follow up defaulters and sort out various practical problems which may occur. Types of Alarm New alarms were purchased at the start of the Clinic which have proved to be very effective due to their booster alarm for the deep sleeping children and to the fact that the mesh mats that go with them are far more durable than the foil ones. The old type of alarm is still being used but it was found necessary to purchase another 20 new ones in December owing to the heavy demand. Up to 31st December there were 74 patients on the waiting list some of whom have been waiting since June, and it is probable that further clinics will be necessary in different parts of the Borough if the demand increases. Results 33 new cases were seen in the 11 weeks up to 31 st December. The total number of attendances was 86 and it is expected to see one or two new cases and seven to eight review cases each session. Patients over seven are reviewed monthly until dry and then less frequently. 12 patients had been supplied previously with an alarm without success. One patient was under seven years of age. 17 patients were issued with alarms. Three of these were dry by the 31st December. Several more were on the way to becoming dry and four who were just keeping charts alone were showing marked improvement. It is not yet possible to assess the success of the Clinic but the initial results are encouraging. ENURESIS ALARMS 41 Enuresis Alarms were in use (issued in 1970) on the 1 st January, 1971. During the course of the year, they were all returned with the exception of 2. These two children are now being treated at the Enuresis Clinic, Ickenham. In 26 cases there had been a successful result, whilst in 10 cases, the result was unsuccessful. The results of 3 cases were not disclosed by the parents and are being investigated. 146 Health Education in Schools—A joint endeavour by teacher and health educator During 1971, 87 new issues were made and of these, 48 were returned in the year. In 33 cases there had been a successful result whilst in 9 cases, the result was unsuccessful. The results of 6 cases were not disclosed by the parents and are being further investigated. 39 alarms were still in use on the 31st December, 1971, in addition to the 2 issued in 1970 (total 41). Altogether 78 specific results were known in 1971 of which 59 were successful (75%) and 19 unsuccessful. On 31 st December, 1971, there were 74 children on the waiting list to be seen at the Enuresis Clinic. HEALTH EDUCATION IN SCHOOLS Mrs. P. Mahy, S.R.N., C.M.B. (Part I), H.V.Cert., Community Care Cert., F.E. Teachers Cert., M.I.H.E., M.R.S.H.—Principal Health Education Officer "A wise physician instructs the healthy."—Emperor Huang-Ti of China 2,700 B.C. History of Health Education The law of Moses, laid down in the Old Testament, enshrines a traditional code, much of which is directly concerned with maintaining practices conducive to personal and community health. The Ancient Greek was an educated man, combining moral, intellectual and physical excellence as an ideal. Christ's teaching was of both physical and spiritual needs. Chaucer's physician was greatly concerned with diet. John Ardenne (1376) a physician, was mindful of the need for hygiene. Ruskin and Dickens, to name but a few lay-men, were also concerned with both mental and physical well-being. In spite of this long history and the famous persons mentioned, Health Education is a comparatively young discipline. There is no doubt that health education is making a wider impact. The subject is now seen to be desirable within schools, colleges and teacher training establishments. Since most patterns of human behaviour are developed during the years of formal education, this provides an ideal situation to impart information in order to promote a healthy way of life which it is hoped will be maintained. The policy of "building health into education" is established by liaison between Education Officer and Advisors, teaching staff and the health department, Health Education in schools being structured as appropriate to local needs, age and development. Health Education is essentially "team work" providing both active participation and an advisory service to Headteachers as required. The Health Visitors maintained their high standard of health education in schools throughout the year. Support was offered to Mother's Clubs where such exist. It is hoped to extend the services to schools, indeed many approaches from Headteachers are currently being received. A study day for teachers was organised on 30th January, 1971, the subject being "Drug Abuse and the School Child". This was arranged by Dr. J. S. Horner, Director of Health Services and held at Douay Martyrs R.C. School, Ickenham. Speakers included Professor F. Camps, Dr. Chappie, an expert in this field, Inspector Piatt (Metropolitan Police); Dr. Horner, himself a well known speaker, summarised the conference. Parent Teacher Associations are requesting more specialised talks. This involvement of the parent is highly desirable and one which will be encouraged more as the unit expands. Colleges of further education are also calling upon the Health Education Service; currently a programme for Brunei University is being processed. Projects, visits and general information have been made available to many students of varying age groups. This field of work is becoming greater and demands much time and energy from 147 many members of the Health Department Staff. Visits are arranged by the Principal Health Education Officer and information supplied. In conjunction with the Borough Librarian, a list of suitable books held in libraries throughout the Borough covering most aspects of health, but more especially the subject of sex education, is being reviewed by the Principal Health Education Officer. This will enable those parents wishing to do so, to provide sex education for their own children. By providing this book list for parents, it is hoped that both parents and children will benefit. In schools, the out-dated concept of "sex education" has gone. The subject is included in Biology Classes, Religious Instruction and progresses to personal relationships, then on to special subjects. The Health Education Unit provides a service by offering specialist personnel to assist the teachers in presenting the more specialist subjects such as Child Development Drug Abuse et al. It is hoped that more Headteachers will use the service being offered and that a comprehensive pattern of health education will exist in infant, junior and secondary schools throughout the Borough. The overall aim is to introduce not only specific health topics into the school curriculum but to increase the number of schools providing a Community Health Syllabus. Health Education in Schools 1971 Number of Talks Given Total Audience Reached Schools Medical Officers 16 900 Secondary Pupils & Teachers Parent/Teachers Associations Dental Officers and Dental Auxiliary 21 811 St. Michael's, Moorcroft, Meadow, Park Place, Glebe School, Newman Ave., Eastcote Ruislip Gardens Special Class Principal Health Education Officer October-December 1971 20 400 Grammar Secondary Health Visitors 67 1,440 Secondary Schools Primary Schools Public Health Inspectors 1 20 St. Helens INTELLIGENCE ASSESSMENT Children who may need special education because of lack of progress in their normal school are referred to the school health service for an assessment. This includes not only a physical examination but also a test of intelligence and, if educational sub-normality is suspected, a formal recommendation is made. Tests of intelligence may also be necessary whilst investigating certain medical conditions and can be applied to pre-school as well as to school children. Special training is necessary before intelligence tests can be administered by medical officers, and during 1971 three doctors attended the necessary courses. One was approved and two were completing their probationary period at the end of the year. A fourth doctor was given specialised training in the assessment of the intelligence of pre-school children. There were 106 intelligence assessments completed by the medical staff of the school health service, and 73 by medical staff of the child health service during the year. A total of 309 medical examinations and re-examinations of educationally sub-normal pupils were completed during 1971. 148 ORTHOPAEDIC CLINIC Dr. A. Karim—School Medical Officer This clinic was re-organised in April, 1971 on a monthly basis. Since that time 135 school and pre-school children have been seen with a variety of foot problems. The commonest of these were knock knees, flat feet, and weak ankles. A scheme has been put into being to study the effects of various ways of treating these conditions. Group 1 were advised to wear inneraze shoes. Group 2 were fitted with a valgus insole to the shoe. Group 3 were given foot exercises by a Physiotherapist. The children will be reviewed at six-monthly intervals; it is too early yet to show any conclusive results. Children presenting with more serious conditions are referred to the Orthopaedic Surgeon at Hillingdon Hospital for further investigation and treatment. ORTHOPTIC CLINIC Mrs. G. Lister— Orthoptist Orthoptic therapy is used in the diagnosis and treatment of disturbances of binocular vision, that is, the ability to use both eyes together in the normal way. In a school clinic the most common causes of anomalies of binocular vision are squints and errors of refraction. If it is suspected that a child has a defect in vision, or in the movements of the eyes, by either his family, or at a routine school vision test, or in younger children by the health visitor or school nurse, he will be referred to an Ophthalmologist for a comprehensive eye test. After an examination of his eyes and the correction with glasses of any error of refraction, the patient is sent to the orthoptist for further treatment. This may include: (1) the occlusion of the better eye for children who are losing the use of one eye due to squint or unequal refractive error. (2) weekly exercises at the clinic to restore binocular function and to teach the patient to control his squint. (3) in cases where the squint is too large for voluntary control, the patient may be referred to a hospital for surgery on one or more of the muscles controlling eye movements. No child is too young for an eye test and early diagnosis and treatment can do much to prevent the further development of a squint and the loss of visual acuity which almost always accompanies it—a condition which will not respond to treatment in an older child, and will result in complete loss of vision in the squinting eye. The prognosis for most cases of squint and muscle imbalance is good with full binocular vision being restored. In those cases where this is not possible, a cosmetically satisfactory result can be achieved. PHYSIOTHERAPY SERVICE Mrs. J. M. Gilboy—Senior Physiotherapist Basically three categories of patient have been referred for treatment at Uxbridge Clinic, namely medical chest patients, those with slack or defective posture and those with foot defects. The majority of patients who suffer from asthma, bronchitis, etc., are referred from the Consultant Physicians at the Chest Department at Hillingdon Hospital and some are referred 149 directly by school medical officers from routine medical inspections. The children are taught to practice their exercises daily at home. Mothers sometimes observe the treatment and where necessary are taught the postural drainage position as well as the children, so that mother can help to manage the child's chest at acute times. Only a few patients have been referred for treatment concerning slack or defective posture, although some postural exercises were included for chest patients. The largest group of patients currently on treatment is that with Pes Planus either with or without associated Genu Valgum. These patients were referred for remedial feet exercises usually by the medical officer at the monthly orthopaedic clinic. A few babies and infants with over-riding toes have attended for corrective strapping, and one case of unilateral talipes-equinovarus for corrective strapping also attended during 1971. Last year saw the introduction of pre-school physically handicapped children being referred for treatment at Uxbridge Clinic. Each child requires its own particular programme of activities broadly incorporating techniques of developmental physiotherapy combined with teaching the mother how to improve her handling of the child at home. At the Special Care Unit at Moorcroft School, the children need a wide range of treatment and the teaching staff welcome advice on suitable chairs, walking aids, and help with feeding and toiletting. During the spring term contact was made with Martindale School, Hounslow, and with the Spastic Society's Social Worker and the Physiotherapy Department at Hillingdon Hospital to discuss treatments of certain patients. During November, Mr. Busfield, F.R.C.S., held an orthopaedic clinic at Moorcroft School which was of great benefit to the patients and parents. A visit was made with some of these young patients to Dr. Sperryn's Physical Medicine Out-patients' Department at Hillingdon Hospital to obtain wheelchairs for the school use. Type of Patient Number of new patients referred in 1971 (A) Medical chests 17 (B) Postural, defective posture 2 (C) Feet defects 30 Approximate number of treatments concerning physiotherapy at Uxbridge Clinic = 455, two sessions a week. Approximate number of treatments at Moorcroft School during 1971 = 728. SPEECH THERAPY SERVICE This has been a difficult year for the speech therapy service. Five part-time speech therapists have endeavoured to give a service which in total was the equivalent of 1.2 full-time speech therapists. An endeavour was made to give as wide a service as possible to the Borough although this meant inevitably that a number of children were unable to secure treatment. Speech therapy was offered to the severest disabilities in most cases. During 1971 one weekly speech therapy clinic has been carried out at Harefield. Fifteen children have received treatment during the year, nine of these have been discharged leaving six having regular weekly treatment. There are five children at present on the waiting list. Apart from one child with cleft palate speech, all the children seen at this clinic have been or are simple or multiple dyslalics with varying degrees of language retardation. Contact with the children's teachers by school visits is felt to be valuable, but care is taken to keep in touch with parents, both personally and by letter. Sometimes a simple speech error can be helped by the child "seeing" the fault in the written word especially when the visual memory is good and the child finds auditory discrimination difficult. 150 At Uxbridge Clinic a large backlog of cases had accumulated by September 1971. Apart from the usual number of children seen in the clinics, there were a number of children from special schools who needed urgent treatment because no speech therapy had been available in the area for some months. Work began with groups of patients with similar difficulties seeing four or five children during each session. By the end of December, 339 had been given appointments, the average number of children being seen in one month being 120. Most of the patients had articulatory defects (165) several of them having associated language difficulties. There were six patients with predominantly language difficulties not including two from E.S.N, schools. One patient was dysarthric, and two had speech difficulties associated with a cleft palate. There were four stammers. The number of children receiving treatment at Northwood Clinic is 10 and the number under observation nine; five are on the waiting list. The patients are referred by the medical officer at a medical inspection, sometimes by the health visitor, occasionally by the family doctor. The type of speech defects seen is mainly that of the dyslalic, varying from a mild degree, i.e. omitting "s" sounds or substituting "t" for "k", etc., to a severe dyslalia where all sounds are defective or omitted. It is essential for children who display this latter defect to begin treatment at the earliest age, certainly before the child begins school, in order to help him to acquire normal speech before he begins to read. Conditions at clinics are not always very satisfactory for speech therapy, i.e. the ceiling of the room may be very high or the acoustics poor and often there is constant noise of traffic outside the windows. It is essential that a quiet room be set aside for this type of treatment since it requires a great concentration on behalf of a child and a clear appreciation of the sounds to be reproduced. This cannot be done in an atmosphere of noise. The number receiving treatment at Ickenham Clinic is six and five are under observation; three are on the waiting list. In the first six months of 1971 there was no speech therapist at Minet Clinic, Hayes. From the end of June until the end of December, 210 attendances were made. Until the end of December 1971 much time was still taken up in interviewing patients on the observation list, and by completing initial interviews of the backlog of patients referred during the earlier part of the year. Inevitably many children have to wait for some months before receiving treatment, and many of the less severe cases were put on the review list after parents had been given the necessary advice on handling their children's particular problems. With the commencement of more sessions each week the situation has been greatly improved and by the end of December, 25 children were receiving regular therapy and there were only two children on the waiting list. Patients treated for defective articulation are seen individually. The stammerers and pre-school children with delayed speech and language development have group therapy. During 1971, two school visits were made— one to Minet Infant School and one to Minet Junior School. The help and co-operation given by the heads and the teachers was much appreciated, especially in the case of teachers who have helped children with exercises. In November, two student health visitors came as observers to a speech therapy session. The interest of health visitors is most welcome. Their early advice to mothers on encouraging and stimulating language could in some cases avoid the necessity of children needing treatment at a later date, and their unique advantage of meeting mothers and young children in their homes gives them the opportunity to refer speech defective children to the doctor at an earlier stage than might otherwise occur. 151 Part III HANDICAPPED PUPILS From very early times, enlightened members of the community have accepted a responsibility for certain handicapped children, the degree often determined by emotional reasons, especially in the case of private benefactors, rather than by a rational approach to all handicaps. In Great Britain, a school for blind children was established in Liverpool in 1790, although a school for deaf children was already in operation in Edinburgh in 1760. The passing of the Elementary Education Act of 1870 meant that large numbers of children were now gathered into the schools. Within a few years teachers and social workers were drawing attention to a number of pupils whose medical condition made the task of educating them extremely difficult, if not impossible. The first measure to secure special education was the Elementary Education Act of 1893 (Blind and Deaf Children) Act, which placed a responsibility on local education authorities for providing education for blind and deaf pupils up to the age of 16 years. The Elementary Education Act of 1899 (Defective and Epileptic Children) Act gave the local authorities the power to provide education for physically and mentally defective, and epileptic children. Other special schools for cripples and delicate children were established as the need for them was recognised, often by private individuals, but also by Boards of Education. At the establishment of the School Medical Service through the Education (Administrative Provisions) Act of 1907, some 16,000 children were already placed in special schools because of some handicapping defect. The medical staff of this service thus already had a large number of children to assess and advise upon, although most Authorities had made arrangements with local doctors or recruited a small staff to give guidance to their hard-pressed teaching staff. Medical treatment was incorporated into the special schools and arrangements made with medical practitioners and hospitals to give advice and special treatment in many cases. The Service developed in the years up to 1944, Authorities taking on the task of providing for the needs of handicapped children where obvious deficiencies existed. With the inspection of children also undertaken by the School Medical Service, it was soon apparent that many of these handicaps could be prevented by action taken early in the child's life. Medical Officers in the Infant Welfare Clinics and School Clinics began to build up an impressive medical expertise in the early detection of defects and thus a "new" faculty of preventive medicine emerged and the rudiments of developmental paediatrics laid down. When the Education Act of 1944 was passed the number of categories of handicapped pupils rose from five (blind, deaf, epileptic, mentally defective and physically defective) to eleven (blind, partially sighted, deaf, partially deaf, educationally sub-normal, epileptic, maladjusted, physically handicapped, speech defect, diabetic and delicate). Later the Handicapped Pupil and the School Health Service Regulations of 1953 included diabetic in the category of delicate pupil. Section 34 of the Education Act of 1944 imposes a duty on all Local Education Authorities to ascertain what children in their area may require special education and to provide it where it is needed. In the London Borough of Hillingdon there is a total of 1,217 children on the Handicapped Pupils Register, an increase of 122 over 1970. Part of the increase in the total number is due to the transfer of children attending Moorcroft School from the Health Department to the Education Department as from 1st April, 1971. This welcome event has increased the number of children in the educationally sub-normal category since they require special education suitable to their abilities and aptitudes. There were 442 children in Day Special Schools (364 in 1970, which did not include children from Moorcroft School) and 25 in day special classes, compared with 22 in 1970. There has been an increase of 16 children in residential special schools, 112 pupils in 1971 against 96 in the previous year. The increase was mainly in placements of educationally sub-normal children, 36 in 1971, 12 in 1970. The total for 1971 also includes some previously designated severely subnormal children now attending special residential schools. Five children received home tuition. 553 Handicapped children were attending normal schools with some variation of their curriculum which permitted them to receive medical or paramedical treatment such as 152 therapy at clinics or hospitals. 19 children were attending normal schools but have been recommended for special schools and were awaiting a vacancy. 7 were in normal schools in a trial capacity with careful educational and medical surveillance. 12 pre-school children were recommended for special school placement (5 awaiting placement at Moorcroft School) and 7 for a school for the physically handicapped. 15 pre-school children have been admitted to day nurseries in an effort to improve their medical and social development. Experienced nursing staff in these nurseries as well as materially helping in this special care, frequently supply very valuable information to the Medical Staff and the staff of the school psychological service. The future educational needs of these children are carefully assessed by a co-operative effort of many disciplines, medical and psychological together with the teaching staffs of the special schools so that an appropriate placement of the young child can be facilitated. Handicapped Pupils Register for 1971 Category No. of Children Placed in No. of Other Children Ascertained (See Separate Table) Total New Cases Referred to Local Education Authority during 1971 Day Special Schools Day Special Classes Residential Special Schools Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls A—Blind 2 3 1 5 1 1 B—Partially Sighted 5 2 1 1 3 2 9 5 2 C—Deaf 6 3 2 2 8 5 1 D—Partially Hearing 3 2 5 11 9 13 17 26 2 3 E—Educationally Sub-normal 175 127 26 10 13 10 214 147 83 64 F—Epileptic 1 20 8 21 8 5 2 G—Maladjusted 38 6 6 23 3 5 2 72 11 11 2 H—Physically Handicapped 22 19 1 1 4 53 38 77 61 17 13 1—Speech Defect 1 172 74 173 74 22 9 J—Delicate 1 3 1 15 6 122 92 139 101 22 22 Multiple Defects 16 12 7 6 2 23 20 5 3 Totals 268 174 14 11 79 33 397 241 758 459 169 120 Handicapped Children under 5 years of age Category Year of Birth 1967 1968 1969 1970 1971 Total Defective vision 3 3 2 2 10 Defective hearing 5 2 3 2 12 Mental defect 10 13 8 5 36 Down's syndrome 6 2 1 5 2 16 Autism 1 1 Cerebral palsy 3 3 1 7 Epilepsy 1 1 2 Heart disease 6 6 1 6 4 23 Spina bifida 3 5 1 4 2 15 Fibrocystic disease 1 1 1 3 Other physical handicap 11 10 9 5 4 39 Totals 48 43 30 27 16 164 153 (A) Blind Children In residential schools 4 Pre-school children ascertained in 1971 Nil One boy was ascertained as blind in 1970. Two Residential Schools are used for the education of the four blind children in the Borough. Linden Lodge School, S.W.19 is administered by the Inner London Education Authority and has admitted three children, two boys and a girl. The remaining boy is accommodated at the Royal London Society for the Blind School, Sevenoaks (Dorton House). These schools give a general education up to C.S.E. and G.C.E. standard. The number of blind children remains very small. The major causes of blindness in children in past years has been infections of various kinds together with the usual hereditary and congenital conditions; but today hereditary congenital and developmental factors predominate. The incidence of blindness in children is also falling. In 1925 it was 37 per hundred thousand, in 1950, 21 -1 per hundred thousand and in 1968, 18 1 per hundred thousand. (B) Partially Sighted In residential special schools 2 In day special schools 7 In normal schools 3 Two girls were ascertained as Partially Sighted in 1971. The seven children in day special schools are educated at John Aird School for Partially Sighted Pupils at Hammersmith, one of the I.L.E.A. Special Schools. Three children are able to be educated at normal schools and where this leads to no further deterioration in sight it is to be encouraged. This, however, is not for every child and the placement depends as much upon the cause as upon the degree of sight loss. Cataracts appear to be the main cause of partial sightedness followed closely by myopia. (C) Deaf In residential special schools 4 In day special schools 9 One boy was ascertained as deaf in 1971. Heston Hearing Unit at Vicarage Farm Road, Hounslow, is the referral point for most deaf children in this Borough. The children are examined at this Unit and if necessary are admitted to the day school for the Deaf attached to the Unit. The 4 children who attend Residential Schools go to Woodford School for Deaf Children, E.18, the Royal School tor Deaf Children, Margate, or Mary Hare Grammar School for the Deaf, Newbury. (D) Partially Hearing In day special schools 5 In day special classes 16 In day nurseries 2 Attending normal schools 18 5 children were ascertained as Partially Hearing in 1971—2 boys and 3 girls. Most of these children are examined at Heston Hearing Clinic after a preliminary investigation in the School Clinic or Child Health Centre. The recommendation regarding education is made by the Otologist in consultation with the Principal School Medical Officer, the parents, the schools and Educational Psychologists. Many are able to be taught in normal schools with certain precautions being observed concerning their hearing, e.g. use of hearing aids, position in class, etc., and with the helpful interest and co-operation of the teachers this type of education is undoubtedly the most advantageous for the child since he is in a "hearing" environment; he is surrounded by meaningful sounds most of his working day. A peripatetic teacher of the deaf visits the schools regularly to discuss progress with the teachers and also keeps contact with the homes. Special classes or schools are necessary for a 154 number of children whose hearing acuity is much greater and when special methods of teaching are required. Two children entered day nurseries because of deafness. Here a child is surrounded by many small children with normal hearing, whose method of communication is simple speech expressed in oft repeated loud tones; he soon learns to adapt to the variety of sounds of normal life and naturally acquires speech, his auditory experience being widened by daily contact with other young children. (E) Educationally Sub-Normal Pupils In residential special schools 36 In day special schools 302 Recommended for special schools 14 In normal schools 1 Pre-school children recommended for special schools 5 Pre-school children placed in day nurseries 4 Of the 147 new cases of educationally subnormal children reported during 1971, most were transfers into the education system from Hillingdon Junior Training Centre. This large group of children is made up of those whose achievements in academic work is much below the average for their age. This may be due to lack of ability, or lack of opportunity, or some other factor, and which indicates that they require some specialised form of education either entirely or partially in place of the normal education given in normal schools. In April 1971, the children formerly deemed as unsuitable for education at school were transferred into the education service. Previously the responsibility for the care and training of these children devolved upon the Health Department of the Borough. From the inception of the Borough in 1965 until 1st April, 1971, both the Junior Training Centre and the Adult Training Centre were under the supervision of the Mental Health Service. Hillingdon Junior Training Centre was rebuilt in 1969/70 and opened in April 1970. It continued the tradition of enlightened teaching and the supervision for which the Middlesex County Council was well-known and following the passing of the Education (Handicapped Children) Act, 1970, became Moorcroft Special School on 1st April, 1971. These pupils are now considered to be children in need of special educational treatment as educationally sub-normal pupils. There are, therefore, three day schools in Hillingdon for the education of this category of handicapped pupil, namely Meadow School, Hedgewood School and Moorcroft School. 36 pupils attend residential schools, the majority being received into Swaylands School (boys), and Wavendon House, Bucks, (girls). Meadow School, Royal Lane, Hillingdon Mr. Everett, Headteacher, has kindly sent the following report: "Our roll is 157. This number includes 13 children from the former Ruislip Gardens Diagnostic Unit who are staying with us temporarily. This year has been a very full one. The out-of-school activities include camp, both in this country and abroad. The senior pupils spent a week on the Borough's narrow boat "Pisces", in the charge of two members of staff who have acquired qualifications as master and mate. We have had a successful games year and a new fixture has been against Longford School, Gloucester. Together with a number of other schools, we have been experimenting with the use of a new reading teaching machine called the "Talking Page". We have also been fortunate in working with Brunei University. Among other things we have been given the use of their television studios. Recently, all the school leavers were given a mock interview by a personnel officer of a local factory. The interviews were telerecorded and after the playback, there was much fruitful discussion. I am pleased to report that at a time of considerable unemployment, our school leavers have been successful in finding jobs. At the end of the Summer Term, 17 pupils left school. Of these, 14 were found employment by the Youth Employment Officer, or found it for themselves. One went to the Industrial Training Unit at Perivale and two went to the Adult Training Centre." 155 Hedgewood Day Special School for E.S.N. Pupils I am grateful to Mr. 0. G. Best for the following report: "Hedgewood School is a school for educationally sub-normal children which opened with 40 pupils in September 1968. We now have 117 pupils on roll. We feel it is very important to give the children an opportunity of living away from home for a few days, and this year we have run a more varied programme. Two teachers took a mixed party of 15 of our pupils Youth Hostelling in Surrey for a week. Eight of our boys went on a four-day camping holiday to Park Place School. We also took two parties of children to stay at a residential school in Evesham, Worcestershire, one party for four days and the other party for five days. In all 46 of our pupils had the opportunity this year of living away from home for a little while. We feel these experiences give the children a lot of self-confidence. At Hedgewood we realise it is important to involve the parents as much as possible in the school. In the winter months our Parent-Teacher Association organised a monthly club when activities such as dressmaking, model aeroplane construction, creche, chess and draughts, badminton, table tennis, etc., were run mainly by the parents. The attendance of parents, children, staff and neighbours reached about 90 on most occasions. As it was so successful we organised the club fortnightly during the autumn of 1971. Within the school we have also started the Duke of Edinburgh Award Scheme. All the activities I have mentioned in my report involve my staff working with our children out of school hours. I am very grateful for all the help they give to the school." Moorcroft School for E.S.N. Pupils Dr. B. P. Westworth, Principal Medical Officer, retained special responsibilities for the care and supervision of the children at Moorcroft School and she comments as follows: "At the beginning of 1971 the waiting list for admission to Hillingdon Junior Training Centre was halved. This was made possible by the hiring from the Hillingdon South Society a room in their social centre which is conveniently situated in the Moorcroft grounds. A large proportion of the new admissions attended on only two or three days each week but it was felt that this small relief to parents would be most acceptable. During the year it was possible to increase attendance to five days each week. In April the centre changed its name to Moorcroft School and at long last the children attending were brought together with all other children within the amended Education Act. This also meant that "helpers" were recognised as teachers and given encouragement, for those who had not already obtained teaching qualifications, to do so. Weekly visits have been made to the school by the Principal Medical Officer in order to carry out routine medical inspections, and to meet and discuss problems with parents personally concerned about their child's welfare. The exchange of ideas between staff and parents has also been actively encouraged so that tuition does not cease when the child goes home. The appointment of a school nurse has done much to help develop a smooth liaison between school and home life. Team work has been the aim and regular communication between the physiotherapists and their colleagues in hospitals has been maintained." I am grateful to Mr. W. D. Nicholas, the head teacher, for the following report on the work of the school: "Our aim has been, through careful observation, to consider a suitable programme of the activities which the teachers wish to introduce to the children, and for them to obtain the maximum benefit from them. Particular consideration has been given to the importance of play in all its forms and this will probably be the major approach to their education in the future. Through this kind of stimulation, and the stimulation of out-of-school experiences, we hope to encourage the children to use spontaneous and intelligible language. 156 Alongside this approach teachers will spend a proportion of their time each day on planned, systematic individual teaching. We hope to encourage parents to feel that there is always a welcome for them at the school, and it is intended to involve them in the life of the school as much as possible. School events which have taken place in 1971, and parents were invited to attend on each occasion, were: Sports, Harvest Festival Service, Bonfire Celebration, Children's Christmas Plays and Carol Service, Coffee Evening. The children were entertained for Christmas by Terry Burgess (Magician); a party of entertainers from Greenway School; a party of entertainers from Chantry School; a party of our children went to Meadow School to see the Staff Pantomime. We are encouraging contacts with other schools and we have regular visits by pupils from these schools. Pupils from the Greenway School come on Friday afternoons to play games like Ludo, etc., or to help in the play of younger children. As part of our Christmas entertainment for the children we were able to show films as we managed to have black-out curtains fitted in the Main Hall. Various visits to places of interest were made by groups of our children: 45 to Littlehampton (the cost of transport was paid for by the South Hillingdon Society for the Mentally Handicapped), a visit to Harefield School Farm, a visit by the Special Care Unit and Nursery to the Recreation Centre at Sunbury-on-Thames, a party for a week to Park Place School, Henley (arranged by the Social Services Department), Meadow School Sports, Nature Trail at Norwood Hall, Meadow School Christmas Party, Wood End Park Infants' Christmas Play, visit to Park Place, Henley to see animals and to hear the Band, many visits to local shops, Post Office, Supermarket, walks to Recreation Ground at Hayes End, to Uxbridge Road to shops to use crossings, etc., walks of general interest, such as for collecting Autumn leaves, acorns, etc., visits in small groups to Meadow School." (F) Epileptic In day special class 1 Attending normal school 26 Pre-school child placed in day nursery 1 Pre-school children recommended for normal schooling 1 Seven children were ascertained in 1971. Modern drug treatment has changed the life of the epileptic in the community in recent years. The control which these drugs have over the varying degrees of disability displayed by epileptics has enabled most to live a perfectly normal life in the community. Similarly, children who suffer from this complaint pursue a normal course in education, the only concessions to the condition being restrictions based upon above-ground activities and swimming in large groups. The placement of each child is carefully considered and as for every handicapped child, he is re-assessed each year in order to examine his progress in education and the propriety of his placement. (G) Maladjusted In residential schools 26 In day special schools 44 In day special classes 6 Attending normal school 1 Attending normal school but recommended for special school 6 13 children were ascertained during 1971. Children who present unusual patterns of behaviour are referred to the Child Guidance Clinic where their problems are examined with great care by the professional staff of Psychiatric Social Workers, Educational Psychologists and the Child Psychiatrist. After each discipline has made its contribution to the sum of knowledge, which includes information based upon advice from the family doctor, school doctor, social workers, etc., a case conference then decides upon a course of treatment designed to help the child's psychological needs, and the part the family and school 157 must play in this treatment is defined. Sometimes the educational need is met by special arrangements being made in the normal school but frequently the child is recommended for special education in a day school for the maladjusted or indeed in a residential school. The type of school recommended is decided by the Child Psychiatrist who leads the child guidance team and an ascertainment is made with the agreement of the parents. There are two day schools for the education of the maladjusted pupil in this Borough: Townsend House School, a junior establishment for children up to the age of about 11 years and Chantry School for the senior pupils. Townsend House Day Special School for Maladjusted Children I am grateful to Mrs. J. M. Clarke, Headmistress, for her report on this school. "This is a small school for infant and junior maladjusted children which opened in January 1969. There are at present 18 pupils on roll, from five to eleven years of age. The children at Townsend House have all failed in the normal school situation and have been prevented from learning by their emotional difficulties. They fall, roughly, into two categories: the aggressive "acting out" children and those that are timid and severely withdrawn. The staff, then, are faced with the task of helping the children to adjust, and at the same time, providing a climate in which they may not only succeed in the basic skills, but also be stimulated by a sense of achievement, which they have not experienced hitherto. A close contact is maintained with parents, both directly and through the services of the Child Guidance Service." Chantry School for Maladjusted Pupils I am indebted to Mr. R. Cambell for the following report: "Our roll at the end of the year was 34, 30 boys and 4 girls. We always have a preponderance of boys—probably because their symptoms are more overt. Our turnover during the year was 22, 10 going out and 12 coming in. Two returned to normal schooling, full-time, one part-time, and the rest to work. The newly appointed Careers Officer has been most helpful in placing the leavers. We have had a very active year. The children co-operating in a positive manner, we had fewer incidents and very little damage to property or person. We paid many visits to factories, museums and art galleries. We followed nature trails in Black Park and Langley, and canoed, camped, rock climbed and went Youth Hostelling. We entered a "float" in Hayes Carnival; displayed Art and Craft at various exhibitions; went to the Theatre; watched the Lord Mayor's Show; chugged along the canal on the Pisces narrow boat. The children made up a concert party and went round to several schools giving a "show" which helped the Christmas festivities along and raised much laughter. In short, we tried in many ways to build up trust, self-confidence and self-discipline in children who were beginning to lose a zest for life. Academic work has not been neglected. One boy achieved three "0" Levels, two others joining a bank staff, and one girl starting a Nursery Nurses Course. We hold a Club night once a fortnight for old pupils. Many come and keep us in touch with all their problems, and so help us in planning our programme and revising our aims for the next generation!" (H) Physically Handicapped In residential schools 5 In day special schools 41 In day special classes 1 Attending normal school 77 Attending normal school on trial 2 Attending normal school but recommended for special school 4 Pre-school children recommended for normal school 1 Pre-school children recommended for special school 6 Receiving home tuition 1 158 30 children were ascertained in this category during 1971. The most seriously physically handicapped children are in the special schools, either day or residential. Five children are at present in residential schools and 41 in day schools. The latter attend either Martindale School for the Physically Handicapped in the London Borough of Hounslow or St. Michael's School for Physically Handicapped Children at Eastcote. Cerebral palsy still presents the largest number of children in this category. The problems posed by children suffering from this condition are many and require the concerted efforts of many disciplines. Education by specialist teachers in small groups is essential for often mental retardation is accompanied by defects in the body and the Educational Psychologist has much to contribute in this field. At St. Michael's School, in close co-operation with the teaching programme, physiotherapy and speech therapy are given. Physiotherapy is reinforced by archery to develop the muscles of the upper limbs, and fine finger work is assisted by teaching pupils to play musical instruments such as recorders, triangles and drums, etc. Indeed the school "orchestra" is a thriving and musically competent qroup which has qiven much pleasure to parents, friends and visitors. The school, however, accepts children with a variety of physical handicaps. The 25 children on the roll are as follows: Cerebral palsy 10 Spina bifida 5 Congenital heart disease 3 Muscular dystrophy 3 Hemiplegia 2 Congenital dislocation of hip 1 Post road traffic accident 1 Martindale School for Physically Handicapped Children, Hounslow, has accepted 15 children from Hillingdon: Cerebral palsy 9 Congenital heart disease 2 Haemophilia 1 Rheumatoid arthritis 1 Post paralytic poliomyelitis 1 Motor retardation 1 St. Michael's School, Joel Street, Eastcote I am grateful to Mr. Thornton, Headteacher, for the following report: "During 1971, St. Michael's has changed from a residential school to a day school. This was done in two stages—after half-term of the Autumn term the Boarding Unit was closed at weekends and at the end of the term the Boarding Unit was closed completely. There is now a much wider range of craft and practical subjects available, including horticulture, home economics, pottery, enamelling and modelling of various types. Events during the year have included a concert given to the parents on prize day which featured the orchestral use by the children of various instruments including the piano, organ, glockenspiel, xylophone, guitar, tenor and descant recorders and tuned drums. The success of the school Sports Day was helped by the participation and interest of many of the parents. St. Michael's also had some success at the Area Physically Handicapped Schools Sports held at Martindale School, Hounslow, doing particularly well at archery, the wheelchair dash and wheelchair slalom. Another event of the Summer term was a school picnic which took place in a local park, and was enjoyed by all. With the help of the Ruislip Round Table our Summer Fete was particularly successful and a nett profit was shown of over £800. This money was passed to the friends of St. Michael's Club Room Fund which now stands at almost £2,800. This means that with parental help the school will be able to erect a Club Room as soon as a definite decision has been made with regard to re-building or extension. Another co-operative venture between the parents and staff was a firework party, held in carefully controlled conditions, with regard to safety, and added to by the provision of traditional "bonfire night" food. The last main social occasion of the calendar year was the Christmas play. 'A Shepherd's Tale' by Steuart Allin was chosen, and with the help of the staff, the children provided the considerable amount of orchestral music needed, as well as the drama content. Both performances 159 were well attended and the play seemed to be well received by the invited audiences, as were the programmes also produced by the school. St. Michael's School is maintaining close links with the surrounding community, largely through the agencies of local organisations such as Beta, Sigma, Phi, Round Tables, Rotary Club, Residents' Associations, etc. The school also maintains contact with ordinary schools and to this end pupils from Newnham School were entertained to a special performance of the Christmas play." (1) Speech Defect In residential school 1 In normal school and receiving speech therapy 231 Pre-school children receiving speech therapy 15 31 children were ascertained in 1971. The inclusion of all children who require speech therapy on the list of handicapped schoolchildren is neither logical nor sensible. Although such children must have their education modified by the need to attend a clinic for treatment, they are not significantly different from children attending regularly for other forms of medical care. The handicap will certainly have an impact upon educational performance in those conditions where language development is delayed since the child with poor verbal vocabulary usually develops reading retardation and the prognosis of this latter condition would appear to be gloomy. Nevertheless, the special educational treatment of the child with poor verbal vocabulary is not qualitatively different from that of the normal child. In order to clarify the objectives in categorising these children, it was agreed during the year to revise the criteria for regarding a child as handicapped. It will be seen from the figures above that only 0-4% of the children currently ascertained as speech handicapped actually required any significant modification in the educational programme in schools. In future the criteria for regarding a child as handicapped will be a permanent and substantial handicap which is having or likely to have a significant effect on the child's education in school. Permanent is defined as a condition continuing for longer than twelve calendar months. The application of these criteria is likely to result in future years in a significant reduction in the number of children categorised as handicapped pupils particularly in this category. (J) Delicate In residential schools 21 In day special schools 4 In day special classes 1 In normal schools but with some variation of education 196 Pre-school children placed in day nurseries 6 Pre-school children recommended for normal school 3 In normal school recommended for special school 3 In a normal school for a trial period 3 Receiving home tuition 3 This category is the second largest of all the categories and contains children with handicaps not dealt with under any of the others. It contains many who suffer from such diverse conditions as asthma, diabetes, bronchiectesis, bronchitis, rheumatic fever, haemophilia, etc. Most of the pupils (196) attend normal schools with a variation of education and are able to maintain progress with the minimum of absence. There are 27 children who are in residential schools for the delicate. Many of these suffer from chest complaints and the education in a residential school is geared to allowing as much outdoor activity as possible having due regard to the most important aspect of education. Park Place School, Henley-on-Thames This is a residential school for delicate boys at Henley-on-Thames and is maintained by the London Borough of Hillingdon. I am grateful to Mr. Owen, the Headmaster, for the following report: 160 "The school can cater for 64 delicate boys aged 10-16 years, but the present roll covering a wide number of conditions numbers 49. The school has a rural science department, library, gymnasium, woodwork room, pottery room and an indoor swimming pool. Classes are small permitting a greater degree of individual attention. Remedial teaching and a programme of study learning to C.S.E. is provided. The main aim of the school is to provide the boys with an environment in which they can learn to cope with their disabilities, both medical and emotional, and improve their academic standard. There is a full range of evening and weekend activities including photography, archery, rifle club, enamelling, woodwork, natural history, football, cricket, swimming instruction, amateur radio, chess, model making, cookery, billiards and snooker, pioneering club and Scouts. Special instructors come to the school for music and judo instruction. The teaching staff take an active part in school life outside the classroom and are responsible for general supervision of the social and domestic life assisted by four house-fathers and matron. Medical coverage is provided by a qualified trained staff at all times, including night supervision. Visits are made regularly, using the school bus to sporting fixtures, concerts, careers visits to factories, etc. Special visits of three day duration were made to the International Eisteddfod in North Wales and a successful fortnight camp for the Scouts was held at La Bailloterie in Guernsey. Another camp is arranged for 1972 (Summer Camp) possibly on the Isle of Wight." All these children are suffering from more than one handicap, but the primary handicap is taken as that which is the most disabling one from the educational point of view. Great care is taken to ensure that the correct educational setting is found initially and yearly assessments are made as with all handicapped pupils to ensure that any variation of education to the child's advantage that is possible is put in hand. Chronically Sick and Disabled Persons Act, 1970 This Act came into being in August 1970, and placed a duty upon Local Education Authorities to provide special educational treatment for children who suffer from three further conditions, namely, deaf/blind, autism and early childhood psychosis, and acute dyslexia. Deaf/Blind Children In 1970 there were four children who were considered to be deaf/blind, two of whom also suffered from mental subnormality. In 1971 there were three children remaining who were so assessed. The education of these children is very specialised and it has been found to be practicable to use the provisions set up in the London Borough of Hounslow for its deaf/blind children in the Deaf Unit at Heston for one child. Another has been admitted to the Parkway Unit at Condover Hall and the third child attends Moorcroft School. Autism and Early Childhood Psychosis The autistic child presents a syndrome of learning, behaviour, and certain developmental disorders but the outstanding characteristic is a difficulty in understanding and reproducing speech. It is clear that this precludes the introduction of such a child into a normal school and specialist attention is required as an individual in a small group. A unit for autistic children is situated in Long Lane, Hillingdon (Oak Farm School) where six children are grouped for this specialised education. It can be given in a variety of ways and each method has its own advocate; but whatever method is pursued, the first essential is to establish a rapport with the child, to make some communication possible; this is the fundamental problem of treatment and of teaching. The paucity or absence of language is a severely retarding Multiple Handicaps In residential schools 13 In day special schools 28 Pre-school children recommended for special school 1 Attending normal school 1 8 children were ascertained in 1971. 161 phenomenon as is noticeable, for example, in teaching the profoundly deaf; but in addition the autistic child has an added difficulty, the non-comprehension of language. In an endeavour to overcome these disabilities other experts need to be recruited to the task and include educational psychologists, psychotherapists and speech therapists. These resources are scarce and the unit has had its problems intensified by difficulty in recruiting specialist staff. Not least among these, is the speech therapist who must also be experienced in dealing with autistic children. The unit is fortunate in being placed in a normal school area which allows a certain amount of integration of its members with other normal school children. This must help the autistic child to be able to respond to and become part of the play activities of their more fortunate fellows eventually and perhaps to be absorbed into a normal teaching environment at some future date. Acute Dyslexia The problem of the child who is backward in reading is a universal one; the remedies applied depend upon the particular difficulty each child presents and usually are a matter for teacher and educational psychologist to consult together to provide. It has been stated that some 14% of school children exhibit some difficulty in reading and in this age of technological skills which depend upon rapid and accurate communication, the lack of reading ability, which includes comprehension of the written word, can be a crippling handicap. The majority of this group acquire a certain competency when given the encouragement of expert remedial teaching. This is done in normal schools and in the five special remedial classes set up in the Borough. It is agreed, however, by many nowadays that a small proportion of this group have very great difficulty in reading despite average or high average intelligence; and despite having no emotional disturbance nor brain damage nor having an inhibiting environment. This small group of children appears to present peculiar difficulties which affect the ability to read. They may be slow in their acquisition and understanding of speech and this language defect will reflect in their ability to learn to read; this may also be accompanied by poor memory for words. Some may have difficulty in the visual memory of letters or words, and may persist in reversing letters (p and q, b and d) and words; indeed the letters in a word may be haphazardly written down. The term dyslexia has no universally accepted definition and no agreement has been reached on the use of it. Sometimes "specific reading disability" or word blindness has been used to describe a child handicapped by severe reading disability but whatever title is assumed for the condition the remedy must lie in the provision of special small groups where the expert help of psychologists, specialist teachers and other professional workers can be brought together in the elucidation and treatment of this puzzling phenomenon. 162 Part IV STATISTICAL RETURNS Number of pupils on registers of maintained primary and secondary schools (including nursery and special schools) towards the end of 1971 was 39,304. TABLE A—PERIODIC MEDICAL INSPECTIONS Age Groups Inspected (By year of Birth) Number of Pupils Inspected Physical condition of pupils Inspected Pupils found to require treatment (excluding dental diseases and infestation with vermin) Satisfactory Unsatisfactory For defective vision (including squint) For any other conditions in Table C Total individual pupils (1) (2) (3) (4) (5) (6) (7) 1967 and later 249 249 2 16 16 1966 1,595 1,595 25 167 176 1965 2,165 2,164 1 41 244 262 1964 347 346 1 6 50 53 1963 142 142 4 26 26 1962 184 184 3 30 27 1961 729 729 14 88 95 1960 1,746 1,746 34 112 134 1959 1,969 1,967 2 57 132 182 1958 736 733 3 25 43 65 1957 1,280 1,280 24 63 82 1956 and earlier 2,317 2,314 3 50 107 149 Totals 13,459 13,449 10 285 1,078 1,267 Column 3 total as a percentage of Column 2 total: 99.9% Column 7 total as a percentage of Column 2 total: 9.4% TABLE B—OTHER MEDICAL INSPECTIONS Note: A special inspection is one that is carried out at the special request of a parent, doctor, nurse, teacher or other person. A re-inspection is an inspection arising out of one of the periodic medical inspections or out of a special inspection. Number of special inspections 3,240 Number of re-inspections 3,430 Total 6,670 163 TABLE C— DEFECTS FOUND BY MEDICAL INSPECTION Defect Code No. Defect or Disease Periodic Inspections Special Inspections Entrants Leavers Others Total (T) (O) (T) (O) (T) (O) (T) (O) (T) (O) (1) (2) (5) (4) (5) (6) (7) (8) (9) (10) F. Re. F. Re. 4 Skin 11 15 12 8 41 11 64 34 56 6 14 28 5 Eyes: (a) Vision 75 429 69 143 141 254 285 826 117 143 91 323 (b) Squint 6 15 4 8 10 23 4 3 4 (c) Other 2 3 1 2 10 10 13 15 1 8 5 6 Ears: (a) Hearing 177 48 56 6 125 25 358 79 170 360 60 266 (b) Otitis media 8 7 1 3 3 11 11 3 3 (c) Other 16 7 6 1 24 13 46 21 10 32 8 26 7 Nose and throat 36 95 5 13 20 33 61 141 25 22 28 49 8 Speech 45 152 3 3 28 20 76 175 26 48 13 45 9 Lymphatic glands 3 10 1 4 3 15 4 2 2 10 Heart 5 42 1 8 3 20 9 70 1 5 6 46 11 Lungs 13 28 2 10 9 40 24 78 10 4 19 55 12 Developmental: (a) Hernia 6 7 2 5 8 12 2 1 4 (b) Other 12 47 3 9 14 39 29 95 2 3 14 54 13 Orthopaedic: (a) Posture 1 12 9 7 22 8 43 2 13 (b) Feet 18 87 15 32 55 129 88 248 49 17 75 141 (c) Other 5 29 8 11 9 27 22 67 5 6 9 43 14 Nervous system: (a) Epilepsy 9 3 3 14 3 26 4 19 (b) Other 5 32 1 4 6 9 12 45 5 9 6 25 15 Psychological: (a) Development 5 20 1 1 24 19 30 40 3 4 4 11 (b) Stability 11 107 6 11 37 22 150 17 27 34 86 16 Abdomen 2 8 3 4 4 14 9 26 34 86 2 1 17 Other 66 55 23 42 83 109 172 206 11 11 14 (T) Requiring treatment, 1,363 (O) Requiring observation, 2,446 164 TABLE D—PUPILS TREATED AT SCHOOL CLINICS Eye Diseases, Defective Vision and Squint Number of cases known to have been dealt with External and other, excluding errors of refraction and squint 71 Errors of refraction (including squint) 1,552 Total 1,623 Number of pupils for whom spectacles were prescribed 710 Diseases and Defects of Ear, Nose and Throat Number of cases known to have been dealt with Received operative treatment: (a) for diseases of the ear — (b) for adenoids and chronic tonsilitis — (c) for other nose and throat conditions — Received other forms of treatment 18 Total 18 Total number of pupils still on the register of schools at 31st December, 1971, known to have been vided with hearing aids: (a) during the calendar year 1971 1 (b) in previous years 65 Orthopaedic and Postural Defects Number known to have been treated (a) Pupils treated at clinics or out-patients departments 56 (b) Pupils treated at school for postural defects — Total 56 Diseases of the Skin Number of pupils known to have been treated Ringworm—(a) Scalp — (b) Body — Scabies — Impetigo — Other skin diseases 7 Total 7 Child Guidance Treatment Number known to have been treated Pupils treated at Child Guidance clinics 148 165 Speech Therapy Number known to have been treated Pupils treated by speech therapists 318 Other Treatment Given Number known to have been treated (a) Pupils with minor ailments — (b) Pupils who received convalescent treatment under School Health Service arrangements 10 (c) Pupils who received B.C.G. vaccination 2,170 (d) Other than (a), (b) and (c) above — TABLE E—SCHOOL DENTAL SERVICE STATISTICS Attendances and Treatment Ages 5-9 Ages 10-14 Ages 15 and over Total First visit 3,740 2,599 612 6,951 Subsequent visits 5,445 4,591 967 11,003 Total visits 9,185 7,190 1,579 17,954 Additional courses of treatment commenced 540 128 21 689 Fillings in permanent teeth 2,616 4,468 1,308 8,392 Fillings in deciduous teeth 5,088 679 5,767 Permanent teeth filled 2,351 4,052 1,191 7,594 Deciduous teeth filled 5,854 621 6,475 General anaesthetics 698 304 11 1,013 Emergencies 474 233 33 740 Prosthetics Pupils supplied with full upper or full lower (first time) 1 1 Pupils supplied with other dentures 2 2 4 Number of dentures supplied 1 2 2 5 Number of pupils X-rayed 858 Orthodontics Prophylaxis 3,281 Cases remaining from previous year 176 Teeth otherwise conserved 498 New cases commenced during year 167 Number of teeth root filled 67 Cases completed during year 148 Inlays 2 Number of removable appliances fitted 315 Crowns 18 Number of fixed appliances fitted 10 Courses of treatment completed 5,852 Pupils referred to Hospital Consultant 6 Anaesthetics Inspections Total number administered 1,013 First inspection at school, no. of pupils 19,351 First inspection at clinic, no. of pupils 3,893 Sessions Number found to require treatment 9,939 Number of sessions devoted to treat- Number offered treatment 9,416 ment 3,064 Pupils re-inspected at school clinic 1,861 Number of sessions devoted to Number found to require treatment 1,499 inspection 205 166 TABLE F—ORTHOPTIC CLINIC During the year 20 patients were discharged, cured or cosmetically satisfactory and 4 were referred to other areas. Monthly Attendance Record New Patients Attending for Exercises Attending for test and/or Observation Total January 7 6 64 77 February 5 7 47 59 March 7 8 49 64 April 7 3 61 71 May 7 6 40 53 June 4 11 41 56 July 3 11 52 66 August September 7 59 66 October 4 10 35 49 November 11 8 37 56 December 5 1 28 34 Totals 67 71 523 661 Total new patients, 1971 67 Referred from school clinics 56 Referred from Medical Eye Centres 11 Type of Case Convergent strabismus Anisometropia amblyopia 7 Including: (i) With amblyopia 17 (ii) Requiring surgery 8 Heterophoria/corweraence weakness: 1 (iii) Others 15 40 Apparent strabismus 4 Divergent strabismus Including: (i) Latent 4 (ii) Manifest 1 Children with family history of refrac- — tive error or squint examined and 5 found N.A.D. 10 167 168 TABLE G—SCHOOL CLINICS Premises School Health Sessions Dental Clinics Speech Therapy Ophthalmic Clinics Immunisation and Vaccination Cavendish Pavilion, Field End Road, Eastcote 1st Thursday a.m. in the month Elers Road Clinic, Elers Road, Hayes Every Thursday a.m. Every day except Tuesday Every Wednesday a.m. & p.m. 1st Friday a.m. in the month Grange Park Clinic, Lansbury Drive, Hayes Every Tuesday a.m. Every Tuesday, Wed. & Thursday Every Friday a.m. & p.m. Every Wednesday p.m. 2nd & 4th Thursday a.m. in the month Harefield Clinic, Park Lane, Harefield Every Thursday a.m. Every Monday & Wednesday Every Tuesday a.m. 4th Friday p.m. in the month Harmondsworth (Old School), Moor Lane, Harmondsworth 3rd Thursday p.m. in the month Haydon Hall Clinic, Joel Street, Eastcote 1st Thursday a.m. in the month Hayes End Clinic, Methodist Church Hall, Uxbridge Road, Hayes 1st Thursday a.m. in the month Ickenham Clinic, Long Lane, Ickenham 1 st & 3rd Tuesday a.m. in the month Monday, Tuesday, Thurs. & Friday Orthodontic Clinic Tues., Wed., Thurs., & Friday a.m. Every Tuesday a.m. 4th Friday a.m. in the month Laurel Lodge Clinic, Harlington Road 1 st & 3rd Wednesday a.m. in the month Monday to Friday Every Tuesday & Friday p.m. 2nd & 4th Wed. a.m. in the month Manor Farm Clinic, Ruislip 2nd & 4th Tuesday a.m. in the month 3rd Tuesday a.m. in the month Maurice Child Memorial Hall, Carfax Road, Hayes Last Tuesday p.m. in the month 169 Premises School Health Sessions Dental Clinics Speech Therapy Ophthalmic Clinics Immunisation and Vaccination Minet Clinic, Coldharbour Lane, Hayes Every Friday a.m. Every Monday, Thursday & Friday Every Monday & Tuesday a.m. & p.m. Every Wednesday a.m. 2nd Monday a.m. in the month Northolt Grange, Edwards Road, Northolt (London Bor. of Ealing) 1st Wednesday p.m. in the month Northwood Clinic, Ryefield Court, Ryefield Cresc., Northwood Hills 1 st & 3rd Tuesday a.m. in the month Every Tuesday & Friday Every Monday & Friday a.m. 2nd Wednesday a.m. in the month Oak Farm Clinic, Long Lane, Hillingdon 2nd, 4th & 5th Thurs. a.m. in the month Every Monday, Tues., Wed., Thurs. & Fri. Every Tuesday a.m. 2nd Friday a.m. in the month Queen's Hall Station Road, Hayes 3rd Wednesday p.m. in the month Ruislip Manor Clinic, Dawlish Drive, Ruislip 2nd & 4th Friday a.m. in the month Every Monday, Tues., Wed. & Thurs. Every Thursday a.m. & p.m. Every Tuesday a.m. 1st Friday a.m. in the month Sidmouth Drive, Ruislip 4th Wednesday a.m. in the month Uxbridge Clinic, Council Offices, High Street, Uxbridge Every Friday a.m. Monday to Friday Orthodontic Clinic By appointment Every Monday a.m. & Thurs. a.m. & p.m. Every Tuesday a.m. (except 1st) & p.m. (Orthoptic Clinic Every Tues., Wed. & Friday a.m.) 1st Wednesday a.m. West Mead Clinic, West Mead, South Ruislip 1 st & 3rd Fri. a.m. in the month Monday to Friday Every Monday a.m. & p.m. 1 st Tuesday a.m. in the month 2nd Tuesday a.m. in the month Yiewsley Clinic, Baptist Church Hall, Yiewsley Every Tuesday a.m. in the month Monday, Thurs. & Friday at Laurel Lodge Clinic Every Thurs. a.m. Alternate Fridays a.m. Specialist Clinics are held at Uxbridge Clinic as follows: Orthopaedic—1st Friday p.m. in month. Physiotherapy—Every Monday and Thursday p.m. 170 TABLE H—HANDICAPPED CHILDREN NOT ATTENDING SPECIAL SCHOOLS OR CLASSES Category Pre-schoo/ but placed in Day Nurseries Pre-school but recommended for Attending ordinary School Receiving Home Tuition If compulsory school age not attending School but recommended for Special School Total Special School Ordinary School and satisfactorily Placed but recommended for Special School for a Trial Period Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys / A-Bind B—Partially Sighted 2 1 1 1 3 2 C—Deaf D—Partially Hearing 2 7 11 2 9 13 E—Educationally Sub-normal 2 2 2 3 1 3 1 6 3 13 10 F—Epileptic 1 1 19 6 1 20 8 G—Maladjusted 1 3 2 1 5 2 H—Physically H'cap 6 1 41 36 3 1 1 1 1 53 38 Speech Defects 2 7 6 165 66 172 74 J—Delicate Multiple Defects 2 4 1 1 1 115 81 1 1 2 2 1 1 3 122 92 2 Totals 7 8 8 4 9 8 350 203 10 9 4 3 2 3 7 3 397 241 ORTHOPAEDIC Sessions First Attendance Total Attendance Physiotherapy - Uxbridge 119 56 434 Specialist - Uxbridge 10 98 135 SPEECH THERAPY Elers Road 11 19 61 Grange Park 12 32 93 Harefield 35 13 188 Ickenham 39 22 165 Laurel Lodge 10 27 54 Minet 44 58 209 Northwood 72 30 224 Ruislip Manor 94 43 530 Uxbridge 34 44 171 West Mead 84 30 388 HEALTH VISITORS/CLINIC NURSES/HEALTH ASSISTANTS Visits and Sessions for School Health Service (1) Number of children visited (exclusive of infestation) 3,076 (2) Number of homes visited 1,874 (3) School Health Sessions 58 (4) Follow up sessions (5) Enuresis sessions (6) Hygiene inspections 480 (7) Pre-medicals 601 (8) Routine medicals (9) Health Education 134 (10) Health Survey visits re pertussis 126 171 SCABIES 1971 Schools where Investigations made Date No. of Cases Northwood S.M. 21 January 1 St. Anselm's 6 January 0 Hillingdon J.M. 13 & 19 January 1 Harefield S.M. 27 January 0 Lady Bankes J.M. 18 January 0 Douay Martyrs 25 January 2 Sacred Heart 19 February & 24 May 1 Bourne S.M. 11 February 1 Rabbs Farm 8 February & 22 March 1 Harefield Infants 25 March 0 Cherry Lane Infants 29 April 0 Ruislip Gardens Nursery 26 May 0 Barnhill S.M. 24 June 2 Glebe 28 June 2 Meadow 23 June 1 Barnhill J.M. 21 June 1 Whitehall Infants 1 October 2 Hedgewood 25 November & 8 December 2 St. Stephen's 3 November 1 Charville Infants 17 November 1 Whitehall J.M. 3 December 2 21 Schools 25 Visits (Sessions) 21 cases 1971: 21 Schools 25 Visits 21 Cases All Areas 1970: 18 Schools 22 Visits 32 Cases All Areas 1969: 17 Schools 17 Visits 33 Cases One Part of Borough Comment: Development of professional expertise in diagnosis seems to have paid dividends this year. 172 Index Agricultural (Safety, Health and Welfare Provisions) Act, 1956 94 Aliens, Medical Inspection of 27 Animals - Diseases of Act, 1950 81 Slaughter of Acts, 1933-1958 81 Ante and Post-Natal Clinics 33, 115 Atmospheric Pollution, measurement of 65 Attachment and Liaison Schemes 40 Audiometry 142 Autism 161 Bacteriological examination of food . . 79 B.C.G. Vaccination 46 Bonfires, Industrial . . 67 Cancer, Deaths from 122 Caravan Sites 89 Cervical Cytology 38 Chantry School 158 Chief Public Health Inspector, Report of 63-101 Child Guidance Clinics 142 Child Health Centres 34, 118 Chimneys 66 Chiropody 38 Cholera Surveillance 16 Chronically Sick and Disabled Persons Act 55 Cleanliness Inspections 136 Clearance areas and Individual Unfit Dwellings 82 Common Lodging House 88 Community Nursing Service 40-42 Congenital Errors of Metabolism 33 Congenital Malformations 33 Consumer Protection Act, 1961 95 Cream 70 Crematorium—Breakspear 111 Deaf/Blind Children 161 Deaths — All Causes 15 — Cause of, Statistics 116 Defects found at School Medical Inspection 164 Dental Service — Priority 43,123 — School 144 Diseases of Animals Act, 1950 81 Diphtheria Immunisation 121 Drug Abuse 48 Dust and Grit 67 Dysentery 16 Dyslexia—Acute 162 Education (Milk) Act, 1971 140 Effluent Samples 101 Employment of Young Persons Act, 1958- 1964 94 Enteric Fever 17 Enuresis Alarms 146 Enuresis Clinic 146 Environmental Health 59-101 Factories—Inspections 92 — Defects 93 Families — Prevention of Break-up 111 Family Planning 36 Fertilizers and Feeding Stuffs Act, 1926 81 Food and Drugs Act, 1955 74 Food — Complaints 76 — Hygiene . . 99 — Imported Regulations, 1968 80 — Inspection at London (Heathrow) Airport . . 98 — Poisoning . . 17 — Premises, Inspection of 78 — Sampling . . 75 — Unfit, Surrendered 73 Gypsies and other Itinerants 89 Handicapped Pupils 152-170 Handicapped Children under 5 years 153 Health Committee . . 8 Health Control Unit, Heathrow Airport 22-28 Health Education 44 Health Education in Schools 147 Health Visiting Service 124 Health Visiting Statistics — School Health Service 171 Hedgewood Day Special School 156 Holidays — Recuperative 48 Home Dialysis 43 Housing — Allocation on Medical Grounds 105 — Certificates of Disrepair 88 — Clearance Areas 82 — Improvement Areas 83 — Improvement Grants 86 — Multiple Occupation 88 — Qualification Certificates 83 — Slum Clearance 82 Hygiene—Personal 135 — of Food Premises 77 Ice Cream 71 Immigrants—Long Stay 107 — Commonwealth — Medical Inspection of 26 Immunisation 46 Imported Food Regulations, 1968 80 Infant Mortality 125 Infectious Disease 15 Infective Jaundice 18 Insect Pests 98 Intelligence Assessment 148 Introduction 3-7 Laboratory — Departmental 100 Legal Proceedings 79 Lifts and Hoists 92 Liquid Egg (Pasteurising) Regulations 80 Malaria 18 Massage and Special Treatment 108 Mass Radiography 106 Meadow School 155 Measles 16 Meat 71 175 Medical Examination of Staff— Statistics 109 Medical Inspection—In School 132 — Other 1 63 Mental Health Services 47 Midwifery Service 41 Midwives Act, 1902-1951 33 Milk and Milk Products 69 Mobile Child Health Centre — Attendances at 119 Moorcroft School 156 Mortuary 110 Mothercraft and Relaxation 33 Multiple Handicaps 161 Multiple Occupation 88 National Assistance Act, 1948 — Section 47 108 Night Nursing Service 41 Noise 94 Noise Insulation Grants — London Airport 95 Nursing Agencies and Nursing Homes 109 Nursing Service 41 Observation Register 120 Occupational Health Services 109 Odours—- Industrial and Others 67 Offices, Shops and Railway Premises Act, 1963 90 Operational Research Study 29 Orthodontics 166 Orthopaedic Clinic 149 Orthoptic Clinic 149, 167 Other Services 100 Outdoor Catering 81 Outworkers 93 Park Place School 160 Pest Control 96 Personal Health Service 33-49 Physiotherapy Clinic 149 Poliomyelitis Vaccination — Statistics 121 Port Health London (Heathrow) Airport 22 Port Sanitary Administration, London Airport 98 Post-Natal Clinics 33 Poultry Inspection 73 Prevention of Damage by Pests Act, 1949 96 Principal School Medical Officer— Report of 129-172 Priority Dental Service 43, 123 Pulmonary Tuberculosis 18 Pupils Treated at School Clinics 165 Rabies Vaccination 47 Rats and Mice 96 Recuperative Holidays 48 River Pollution 100 Salmonella Investigations 17 Sampling of Food and Drugs 75 Scabies 136, 172 School Clinics and Sessions 168 School Dental Service 144, 166 School Health Service — Future of 132 School Health Service and Employment 140 Schools — Primary 135 — Secondary 135 Sewage Disposal 60 Shops Act, 1950 94 Slum Clearance 82 Smallpox Vaccination — Statistics 122 Smoke Control Areas 64 Smoke Nuisances 67 Speech, Defects of 160 Speech Therapy Service 150 Social Services 53-56 Squirrels and Foxes 97 St. Michael's School 159 Staff of the Department 9 Statistics 13-15 Swimming Pools 68 Tetanus 18 Toys (Safety) Regulations, 1967 96 Town send House Day Special School 158 Treatment of School Children — Statistics 165 Tuberculosis 18 Venereal Diseases 20 Vermin Control 99 Vision Testing — Routine 137 Water — Aircraft Drinking 99 — Private Supplies 60 — Public Supplies 59 Welfare Foods 35 Well Women's Clinics 37 Whooping Cough 21 Working Environment 89 X-ray Unit, Heathrow Airport 27 Printed by R. G. Baker & Co. Ltd., Farnham Common, Bucks., SL2 3PJ.