HIL 8 THE HEALTH OF HILLINGDON 1972 ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and PRINCIPAL SCHOOL MEDICAL OFFICER 1972 DR. J. STUART HORNER, M.B., Ch.B.,M.F.C.M D.P.H., D.I.H. Health Department, Belmont House, 38 Market Square, Uxbridge, Middlesex. Contents page Introduction 3-6 Health Committee 8 Staff 9 SECTION I Statistics Infectious Diseases Health Control Unit London (Heathrow) Airport 13-28 SECTION II Personal Health Services 31-51 SECTION III Environmental Health 55-102 SECTION IV Other Services 105-111 APPENDIX TABLES 115-127 SECTION V Report of the Principal School Medical Officer 131-172 Index 181-184 The Worshipful the Mayor, Aldermen and Councillors of the London Borough of Hilling don. Mr. Mayor, Ladies and Gentlemen, I have the honour to present my third Annual Report which covers the work of the health department for the year 1972. Progress towards previously agreed standards of performance continued and the higher levels of output achieved by the service in the previous year were, in general, maintained. The year under review has been one of continuing improvement as the additional numbers of staff required to bring the community services to an appropriate level have been recruited and assimilated into the general work of the department. The strengthening of the administrative support necessary to enable field workers effectively to discharge their responsibilities was particularly welcome. The year was marked by an emphasis upon the reorganisation of the National Health Service. The need to integrate the three separate branches into a unified whole has been recognised for many years, and the first suggestions concerning a possible reorganisation were introduced in May 1968. Since that time a succession of documents has steadily modified the original concept as the final proposals presented in the White Paper in August 1972 and the National Health Service Reorganisation Bill published in November made clear. Preparation for this major reform involved considerable time and effort by individual members of the department usually at the most senior levels. Certain officers in the department were asked to participate in a local field trial of management hypotheses which have been developed for the new service. A Committee, established by the Secretary of State and advised by Messrs. McKinsey and by the Brunei Institute of Organisation and Social Studies, had formulated certain proposals concerning the management arrangements which might be appropriate at each level in the new organisation. Senior staff from all branches of the health services in Hillingdon were invited to study these proposals in depth, and to suggest how they might be applied on a theoretical basis in the Borough. It was pleasing to note that the final document "Management Arrangements in a Reorganised National Health Service" published later in the year included many of the amendments which had been suggested during the course of the field trial in Hillingdon. The arrangement of area health authority boundaries in London caused problems throughout the year since not all Boroughs could be considered self-sufficient as far as health services provided within their boundaries were concerned. Thus the general principle of co-terminous boundaries between health services (administered by the new area health authorities) and social services (administered by the new local authorities) could not be applied universally in London. Many combinations of Boroughs were suggested and a number of reports were produced justifying the views of particular groups. One such report showed that over 81 % of Hillingdon residents receive their in-patient hospital care within the Borough boundaries, and the announcement by the Secretary of State in November that Hillingdon would form an area health authority on its own was, therefore, particularly welcome. Vital Statistics The total number of births showed a 2% reduction compared with the previous year and was the lowest yet recorded since the inception of the Borough. The number of deaths confirmed the trends identified in previous years. There continues to be a steady increase in the number of deaths from lung cancer (166), whilst cardiovascular manifestations continue to account for the largest number of deaths. It is upon these diseases processes that preventive action must be concentrated although it should be remembered that these diseases characteristically occur in older people. The proportion of births delivered at home decreased slightly to 19% but it is clear that an excessive number of mothers for whom it is now recommended that a hospital confinement should invariably take place are, in fact, accepted for home delivery. Some 28% of such mothers in Hillingdon are subsequently rushed into hospital either late in pregnancy or early in labour and this fact suggests that better selection of cases for home confinement is urgently necessary. During the year arrangements were completed to ensure that all "high risk" mothers were encouraged to accept hospital delivery. 3 Infectious Disease The number of cases of smallpox reported to the World Health Organisation (64,989) represents a further 23 2% increase on the figure for the preceding year. It is unfortunate that the total world incidence of smallpox should have increased so dramatically in the last two years since the decision by the Department of Health and Social Security that the routine vaccination of young children against smallpox should be abandoned in this country. Nevertheless, although there was an increase in the number of importations into non-endemic areas the number of countries in which the disease was endemic was again reduced. There were no cases of smallpox identified at the health control unit at London (Heathrow) Airport and there were a smaller number of suspected cases for which the opinion of a smallpox consultant was required. Venereal conditions were this year the most common form of infectious disease in the Borough, and since the only known method of prevention seems now to be unacceptable to a significant proportion of young people, preventive measures are difficult to suggest. The number of cases of food poisoning showed an increase and represents an area where health education programmes might be further improved. Nevertheless approaches to the food retail industry in the Autumn with a view to providing courses in clean food handling produced a disappointing response at least from the small trader. By contrast the number of cases of measles (200) was the lowest since the Borough was created. Co-ordination and Co-operation The extension of the clinic at Harefield to include accommodation for local general practitioners was brought into operation and quickly demonstrated the tremendous advantages of health centre arrangements. Building work on the first purpose built health centre was almost completed and that on another commenced. A meeting arranged with the family doctors in Hayes was well attended and led to general agreement with an existing group practice that a comprehensive health centre should be developed on land adjoining the present surgery site. The improvement in staffing of the community nursing service allowed the introduction of several attachment schemes during the year, and by its close a total of 25 nurses were fully attached to general practitioners. It was quickly evident that the anticipated benefits were indeed forthcoming but the new arrangements were not without their own difficulties. The appointment of Dr. W. H. G. Batham as Principal Medical Officer (Social Services) during the year in succession to Dr. B. D. Westworth permitted even closer co-ordination of the mental health services as the psychiatric unit at Hillingdon Hospital developed. Dr. Batham was created an honorary clinical assistant permitting him to participate fully as a member of the hospital team. Following changes in the arrangements for medical supervision at Hayes Park Hostel, Dr. Batham was able to assume a much greater role in the rehabilitation of the psychiatrically disordered. Although the health control unit is an important part of the department's work its geographical separation makes full integration with the health services in the area difficult. Nevertheless during the increase in work which occurred as the result of the arrival of large numbers of refugees from Uganda, clinical medical officers engaged in the child health services provided the necessary additional medical support out of normal working hours. In addition arrangements were completed by kind permission of the consultant radiologist to allow the superintendent radiographer at the health control unit to visit the department at Hillingdon Hospital to undertake a wider variety of clinical work. These developments emphasised the fact that present administrative divisions need not create barriers to total health care. Environmental Health Services A small survey was undertaken amongst a defined population around London Airport and compared with a similar enquiry amongst a group of residents in the north of the Borough. Although there was evidence that the population around the airport were subjectively affected by noise, and that they considered their health to be affected by it, there was absolutely no objective evidence of any adverse health factors affecting this group rather than the other. 4 The Health Committee agreed to sponsor a three-year research project at Brunei University concerned with the investigation of a number of environmental factors in Hillingdon including the possible identification of fuel hydrocarbons in the air, the state of filled land, and the analysis of the chemical composition of local water-ways. It is hoped that this comprehensive study will provide much basic information about the effect of environment on health. There were no further developments during the year concerning the fluoridation of water supplies, but the application of fluoride gels to the teeth of individual children was continued and a pilot scheme for fluoride mouth rinses in schools was commenced. Personal Health Services The expansion of family planning services was continued throughout the year. On 1st April an entirely free advisory service was introduced and in addition to the provision of free supplies on medical and social grounds certain additional groups were also provided with free supplies. Improved publicity was reflected in an increased demand for services and greater clinic attendance. New clinics were opened at Elers Road and at the adapted Harefield health centre whilst existing clinics at Mount Vernon hospital and at Laurel Lodge were expanded. Later in the year the Family Planning Association was able to open two further evening clinics at Grange Park and at Oak Farm. Although the average number of mothers attending per session was reduced at most child health centres the number of children examined by a medical officer increased by 7.2% which represents an additional five children every working day. Since many of these children attend by appointment it seems likely that the reduction in numbers attending per session reflects the trend for mothers to visit the centres in order to receive specialist advice rather than attending on a routine repetitive basis. Proposals for the development of the home nursing service foreshadowed in the previous year were implemented by the recruitment of a much increased number of state enrolled nurses, and nursing auxiliaries. The concept of a nursing team led by a state registered nurse who deploys other grades of staff according to their professional skills was further developed and resulted in a much improved level of service. A work study of the health visiting service fully confirmed the local need for the national staffing levels proposed by the Department of Health and Social Security, and suggested that, in addition, some of the work could be undertaken by less qualified staff. A separate establishment of clinic nurses was therefore agreed during the year together with the support of nursing auxiliaries and clerical assistants. A phased programme was commenced which will allow most of the staffing levels suggested by the work study report to be implemented by the beginning of 1974. The development of health education continued and a health education officer took up her duties during September. This is an area where spectacular results cannot be expected in a short period of time, but the steady increase in demand for the service noted during the year is most encouraging. Social Services The final separation of the joint administrative support section between the health and social services departments was accomplished in anticipation of the reorganisation of the National Health Service. The new arrangements allowed a better standard of service to be given to the health department with a greater emphasis on manpower planning. A number of studies were undertaken to predict likely staff patterns in the future. Community Medicine The reorganised National Health Service will also incorporate the newly defined discipline of community medicine. The wide ranging activities covered by this specialty include the assessment of health needs, and the evaluation of health services. In order to assist in this important development a statistician was appointed and took up his duties in September. At present his activities are concerned with the identification of appropriate data and the analysis of existing statistical patterns. A comprehensive analysis of the infant mortality trends in Hillingdon is reported on page 15. 5 The reasons for the observed differences are unclear but it must now be a major task to determine whether service deficiencies could be a significant factor or whether there is perhaps some undetected environmental factor. Similarly an analysis of the number of deaths from carcinoma of the pancreas shows an upward trend which is greater than would be expected from changes in the age structure of the population or the proportionate increase in all causes of death. Such investigations require much detailed study before relevant conclusions can be made. Another aspect of the work of the community physician is the application of computers to the organisation of health services, and the report on page 46 describes the introduction of computer data processing to the immunisation programmes currently operated by the department. It is my pleasure to thank the Town Clerk and chief officers for their continued support and help throughout the year. I am particularly glad to express my gratitude to the staff of the health department for their unfailing assistance despite the steadily increasing pressure of work at this time. Finally my thanks are due to all members of the Council without whose encouragement we could not hope to succeed. I am, Yours faithfully, J. Stuart Horner Director of Health Services March 1973 6 HEALTH COMMITTEE (as at 31st December, 1972) Ex-officio: The Mayor (Councillor R. J. Came, J.P.) The Leader of the Council (Alderman J. C. Bartlett) The Leader of the Opposition (Alderman W. D. Charles, J.P.) Chairman: Councillor J. E. E. Walters Vice-Chairman: Councillor R. H. Collman Aldermen: K. A. Gigg Mrs. C. 0. Parsonage, M.A. Councillors: Mrs. B. D. Bell, N.D.D. Dr. C. H. Nemeth, M.A. J. Rowe Mrs. E. G. Boff L.R.C.P., M.R.C.S., F. E. Walsh, F.A.P.H.I. N. H. Butler, M.R.C.G.P. F.Inst.L.Ex. A. J. Potts Advisory: Mr. E. S. Saywell (representing Harefield & Northwood Group Hospital Management Committee) Councillor G. P. Buttrum (representing Hillingdon Group Hospital Management Committee) Mrs. G. A. Armfield Dr. M. E. Binks (representing Hillingdon Association of Voluntary Social Service) Mrs. E. Kelly Mrs. W. Hobday (representing Hillingdon Federation of Residents and Tenants Associations) Dr. P. Knight (representing Middlesex Local Medical Committee) Mr. L. P. Emerson (representing Pharmaceutical Society of Great Britain) 8 STAFF Senior Staff and Approved Establishments: Director of Health Services and Principal School Medical Officer: Dr. J. Stuart Horner, M.B., Ch.B., 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., M.F.C.M., D.P.H., D.C.H. Principal Medical Officers: Dr. V. M. D. N. Shaw, M.B., Ch.B., M.F.C.M., D.R.C.O.G., D.P.H. Dr. J. W. E. Bridger, L.R.C.P., M.R.C.S. Dr. W. G. Batham, M.R.C.S., L.R.C.P., M.F.C.M., 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., M.F.C.M., D.I.H., D.P.H., D.T.M. & H. (Medical Officers in Department - 9) (Airport Medical Officers — 10) Chief Dental Officer: Chief Nursing Officer: Mrs. B. Fox, B.D.S. Miss J. Byatt, S.R.N., S.C.M., M.T.D., Q.N., (Dental Officers - 13) H.V.Cert. (Dental Auxiliary - 1) (Dental Surgery Assistants - 18) Liaison and Administrative Officer W. H. Knapton Chief Public Health Inspector: (Administrative and clerical staff - 78) A. Makin, M.R.S.H., F.A.P.H.I. (Public Health Inspectors - 20) Statistician (Technical Assistants -10) M. J. Southgate, B.Sc., M.Sc., F.S.S. Principal Health Education Officer: Mrs. P. Mahy, S.R.N., C.M.B.(Pt. 1), H.V.Cert., Community Care Cert., F.E. Teacher's Cert. (Health Education Officer and Health Education Technician - 2) 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 - 59) Principal Nursing Officer: Miss A. L. Drossou, S.R.N., S.C.M., Q.N. (Home Nurses - 54-5) (Auxiliaries - 10) (Midwives - 19) Senior Nursing Officers: Miss G. M. Austin, S.R.N., S.C.M., H.V.Cert. Miss S. A. Murray, S.R.N., S.C.M. Miss J. Fielding, S.R.N., S.C.M., H.V.Cert., Q.N. Mrs. D. N. Philcox, S.R.N., C.M.B.(Pt. 1), Mrs. P. Fisher, S.R.N., N.D.N.Cert. H.V.Cert. Mrs. M. Gow, S.R.N., S.C.M., Q.N. Mrs. A. M. Read, S.R.N., S.C.M., H.V.Cert. Mr. D. B. McBain, S.R.N., B.T.A., Q.N. 9 SECTION I Statistics Infectious Diseases Health Control Unit London (Heathrow) Airport "Research, though toilsome is easy; imaginative vision, though delightful, is difficult."—A. C. Bradley 1851 -1935 General Statistics Area—square miles 42.5 Population—Registrar General's Census for mid-year 1972 236,390 Number of dwellings 77,484 Rateable Value as at 1 st April, 1972 £18,838,052 Product of Penny Rate—1972/73 (Estimated) £189,670 13 Vital Statistics Live Births: Male Female Total Legitimate 1,658 1,493 3,151 Illegitimate 91 80 171 1,749 1,573 3,322 Birth Rate per 1,000 population: Hillingdon —Crude 14 1 —Corrected 13.8 England and Wales Area comparability Factor: 0.98 14.8 Illegitimate Live Births: Male Female Total Percentage of total live births: ... 5 91 80 171 Still Births: Male Female Total Legitimate 16 18 34 Illegitimate 2 2 4 18 20 38 Rate per thousand live and still births: Hillingdon 11 England and Wales 12 Total Live and Still Births: Male Female Total Legitimate 1,674 1,511 3,185 Illegitimate 93 82 175 1,767 1,593 3,360 These births occurred as under: Live Births Still Births At home 628 1 In hospitals, nursing homes or other maternity establishments 2,694 37 3,322 38 Infant Deaths (under 1 year of age): Male Female Total Legitimate 25 20 45 Illegitimate 1 - 1 26 20 46 Legitimate—rate per 1,000 legitimate live births 14 Illegitimate—rate per 1,000 illegitimate live births 6 Infant Death Rate per 1,000 total live births: Hillingdon 14 England and Wales 17 Neo-natal Deaths (under 4 weeks of age): Male Female Total Legitimate 15 13 28 Illegitimate 1 - 1 16 13 29 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 12 10 22 Illegitimate 1 - 1 13 10 23 Rate per 1,000 total live births: Hillingdon 7 England and Wales 10 Perinatal Deaths (Still Births and deaths under 1 week combined): Male Female Total Legitimate 28 28 56 Illegitimate 3 2 5 31 30 61 Rate per 1,000 live and still births: Hillingdon 18 England and Wales 22 Maternal Deaths: Total 1 Rate per 1,000 live and still births: 0.30 Deaths from All Causes: Male Female Total 1,110 1,068 2,178 Death Rate per 1,000 population: Hillingdon —Crude 9.2 —Corrected 10.4 England and Wales Area comparability Factor: 1.13 12.1 14 Trends in Infant Mortality Reference has been made in each of the three preceding Annual Reports to the unusual pattern of infant mortality in Hillingdon which is very different from that which would be expected in an Outer London Borough with relatively few areas of unsatisfactory environmental conditions and with health services whose quality is above average. When Mr. M. J. Southgate took up his duties as statistician he was asked to investigate the statistical validity of the conclusions reached, and the following comments are based on his report. The infant mortality rate has always been considered to be an extremely important indication of the general health of a population. Since the inception of the London Borough of Hillingdon in 1965 it has been observed that this rate has been on the increase, only two years (1970 and 1972) showing a decrease on the previous year's figure. It was realised that any conclusions reached would carry greater weight if Hillingdon was not considered in isolation and the corresponding figures for the whole of England and Wales together with those for the Greater London Council area as well as several other London boroughs were also obtained. In Research Report 9 of the Intelligence Unit of the Greater London Council comparisons were made between boroughs based on six parameters in the 1966 census as follows: Housing conditions Population and household structure Housing Tenure Birth place characteristics Socio economic characteristics Characteristics of the young transient population The intention was to group a particular borough with those most closely similar to it based on these parameters. By this analysis Hillingdon is thought most closely to resemble the London Boroughs of Bexley and of Havering. There was also some evidence from overseas that the presence of a major airport could be related to adverse trends, and the statistics for the London Borough of Hounslow were therefore also included. The analysis showed that the average figures for infant mortality, neo-natal mortality and perinatal mortality for the six years under review were indeed lower in Hillingdon than in any of the other populations studied. The average figure for the still-birth rate in Hillingdon was the third lowest, but in all rates reviewed the average figure was less than in Greater London, in England and Wales and in Hounslow. This highly satisfactory result becomes less encouraging when it is appreciated that the variation around the average figure is considerably greater in Hillingdon than in most of the other areas studied, and that Hillingdon's good performance largely results from advantages obtained before 1969. The averages for the years 1969 to 1971 are all higher than those for all seven years, and substantially higher than those for the initial four years. The analysis shows that the national trend in infant mortality is towards a reduction in the infant mortality rate. In Greater London there is as yet no definable trend, and this is also the case in the London Borough of Hounslow. In Hillingdon, however, there is a significant upward trend in infant mortality. As has been pointed out this upward trend is particularly noticeable when the earlier results are compared with more recent ones, whereas in Havering an exactly reverse pattern appears with an initial increase in rate being followed by a very significant decrease. The London Borough of Bexley does show a similar pattern to Hillingdon except that the increase is far less marked and in fact not statistically significant when all seven years are examined together. It is concluded that the upward trend in infant mortality in Hillingdon is a statistically significant one and is not accounted for by the proximity of a major airport, although the hypothesis that stillbirths rise in the vicinity of a major airport is not excluded by this data, since the average rate in Hillingdon is not as favourable as that for other rates, whilst the figure for Hounslow is greater than the average for still-births in the Greater London area generally. Detailed analysis within Hillingdon An analysis of the particular rates shows that increases in the infant mortality have been accompanied by increases in the neo-natal and early neo-natal mortality rate. This suggests that any adverse factors which may be operating do so principally in the first month of life. 15 An analysis of individual wards within the Borough in respect of both 1970 and 1971 shows that there is no consistent pattern throughout the Borough which could not equally have occurred by chance. There are, however, three wards which show significantly higher rates than others. Research Report 13 of the Intelligence Unit of the Greater London Council suggested methods of grouping wards which allows those in Hillingdon to be divided into three groups. The mean values together with the degree of variance of infant deaths within these groups can be calculated as follows: Group 1 Group 2 Group 3 Eastcote Manor Belmore Haydon South Ruislip Colham-Cowley Hillingdon West Uxbridge Frogmore Ickenham Harefield Northwood Hayes Ruislip Hillingdon East South Yeading Yiewsley Mean 3.1667 4.0000 8.0000 Var. 2.8056 0.6667 17.5556 Although the differences between groups 1 and 2 are not statistically significant those in group 3 are indeed significantly less satisfactory than those in the other two groups. It is therefore clear upon this analysis that it is the wards in group 3 upon which action must be concentrated to arrest the current trend in infant mortality in the Borough. In allocating resources of health visitors, child health centre medical officers, midwives and beds for hospital deliveries the needs of this group of wards must be particularly considered. Carcinoma of the Pancreas This is a relatively rare form of malignant disease affecting one of the endocrine glands and usually resulting in jaundice (yellowness). It usually runs a rapidly fatal course for which no curative treatment is yet known. After an impression had been formed that the disease was becoming more common, more thorough studies of the number of deaths in Hillingdon, in the Greater London area and for England and Wales were undertaken. The initial analysis is as follows: There has been a statistically significant increase in the number of these deaths over the past two years in Hillingdon as compared with the average number for the five year period 1966-1970. That this is not a local phenomenon is evidenced by a study of the national monthly returns (kindly made available by the Registrar General) for the years 1966-1970, which indicate that there has been a statistically significant increase during this period. Such an increase could of course occur as a result of an increase in the total number of deaths and the changing age patterns of the population. Initial investigations confirm however that the numbers dying per million living show no particular trend whilst the number dying from cancer of the pancreas per million living is steadily and significantly rising. It is considered unlikely that this increase is due merely to an increase in the number of persons dying. Further investigations of this interesting observation are continuing. Detailed statistics are shown on page 116. An examination of such time trends is of particular interest in the field of preventive medicine. Where disease processes are changing over time it is likely that there may be some environmental factor which is influencing the trend. Although the identification of such an environmental factor is often a very long and tedious process it does raise the long term possibility of prevention as the investigation of the epidemiology of lung cancer so clearly showed. 16 Infectious Diseases Dr. C. Lydon—Deputy Medical Officer of Health The following table shows the incidence of infectious diseases during 1972. 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 1972 1971 1972 1971 Scarlet Fever 7 13 19 4 1 1 45 91 Diphtheria Whooping Cough 1 6 7 5 2 2 23 135 Measles 11 53 70 56 6 3 1 200 1208 Acute Meningitis 1 1 2 4 5 Poliomyelitis (Paralytic) (Non-Paralytic) Acute Encephalitis Infective 1 1 2 9 Post Infective 1 1 1 3 2 Smallpox Tetanus 1 Typhoid 1 1 Paratyphoid 2 Dysentery 6 3 8 2 8 8 35 38 Food Poisoning 1 4 3 1 8 18 35 25 Malaria 3 Tuberculosis Respiratory 1 5 39 45 53 1 Other 2 2 19 1 Infective Jaundice 8 10 7 8 19 52 53 DIPHTHERIA Although the table indicates that for the 23rd consecutive year no case of diphtheria has occurred in the area, one adult was found to be harbouring C. Diphtheria. He was an ambulance driver who was involved in transporting a patient from London (Heathrow) Airport to an Infectious Disease Hospital. This patient, a British citizen who became ill while travelling abroad, was found to have diphtheria infection and as a result of follow-up investigations carried out amongst contacts, the ambulance driver's nasal swabs demonstrated the presence of diphtheria organisms. It is more than likely that this was an incidental finding and was not directly related to the contact with the patient. Following one week's course of antibiotic treatment further swabbing demonstrated that the diphtheria carrier state had been corrected. In a separate incident a 12 year old child had also to be investigated following contact with a patient attending the Out-Patients' Department at a hospital in a neighbouring borough who was later found to be a carrier of C. Diphtheria. Nose and throat swabs demonstrated that this girl was free from infection. DYSENTERY Shigella sonnei was isolated from 13 of the 35 cases of dysentery notified during the year. In one other case Shigella boydii was isolated and no organism was discovered from stool examination in the other 21 cases. 17 ENTERIC FEVER The one case of typhoid which occurred within the Borough during the year was in a lady who returned to this country following a four week holiday in Ceylon. She became ill on her return flight and on admission to hospital was found to have a pneumonia. Salmonella typhi were isolated from the stool but blood examinations had not produced any significant findings. The possibility that the illness was due to a pneumonic condition in a person who was a symptomless excreter of salmonella typhi could not be excluded. All family and other contacts were investigated but no other person was found to be infected. FOOD POISONING During the year there were 35 sporadic cases of food poisoning. No general or family outbreak was notified. In 24 of the 35 notified cases salmonellae (the organism causing food poisoning) were isolated. The types of salmonellae organisms identified were as follows: salmonella typhimurium 11 salmonella dublin 1 salmonella agona 3 salmonella ibadan 1 salmonella enteritidis 3 salmonella montevideo 1 salmonella bovis morbisicans 1 salmonella taunton 1 salmonella derby 1 salmonella st paul 1 During the year an employee at a large hotel contracted food poisoning whilst on holiday abroad. His symptoms cleared up in a matter of days and although he remained in good health repeated stool examinations showed the continued presence of the salmonella organism. It was necessary to exclude this person from his employment as a food handler for a period of four months until his carrier state was finally resolved. A similar instance arose in respect of an employee at a food factory, and in this case the period of exclusion was twenty-eight days. The total amount paid to these two persons in compensation for financial loss as required by Section 41 of the Public Health Act 1961 was £882. Bacillus cereus Investigations carried out into two individual food poisoning outbreaks showed that the possible cause of the food poisoning was Bacillus cereus which was isolated from two specimens of vomit from patients who had become ill. This organism was also isolated from specimens of boiled rice eaten as part of the meals consumed in the two Chinese restaurants involved. As a result of the investigation advice on improved methods of rice preparation were given to the proprietors of the restaurants concerned and this advice was translated into Chinese and distributed to all the Chinese restaurants in the Borough. (Further details concerning these investigations will be found on page 76). INFECTIVE JAUNDICE Out of the 52 cases of infective jaundice notified during the year, details concerning four of the cases were notified to the Blood Transfusion Centre so that the names of family contacts who might have become infected with the virus could be removed from the list of blood donors. MEASLES The number of cases of measles notified during 1972 was the lowest on record, and this no doubt reflects the increasing effectiveness of the vaccination programme. It should, however, be remembered that measles is likely to be a particularly difficult disease to control in this way and continued viaorous action is necessary. 18 Year 1966 1 967 1968 1969 1970 1971 1972 Measles Notifications 832 3,481 471 1,204 1,256 1,208 200 TUBERCULOSIS Comment was made in the report for 1971 (page 18) that the notifications of tuberculosis for the Hillingdon area had increased which against a background of decreasing national incidence had given cause for concern. The decrease in notifications from 72 in 1971 to 47 last year is therefore particularly welcome. 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 1968-72 Year Under 25 years Over 25 years Total 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 1972 P 6 39 45 NP 2 2 P = Pulmonary. NP = Non-pulmonary. This decrease in notifications is also reflected in the number of tuberculin skin tests and the BCG vaccinations carried out as part of the contact tracing procedure as illustrated by the table on page 20. During the year an active case of pulmonary tuberculosis was discovered amongst the staff of one of the Council's offices employing 130 people. Arrangements were made for a unit of the mass radiography service to visit this office and all of this worker's colleagues were X-rayed. No secondary cases were discovered. 19 TUBERCULIN TESTS AND BCG VACCINATIONS FOR YEAR ENDING 31st DECEMBER 1972 Contacts: 1972 1971 i. Skin tested 83 722 ii. Found positive 1 84 iii. Found negative 82 233 iv. Vaccinated 78 233 v. Babies vaccinated at birth 6 - School children and students excluding those known to have received BCG Vaccination already i. Skin tested 3,006 2,259 ii. Found positive 181 89 iii. Found negative. 2,825 2,170 iv. Vaccinated . 2,825 2,170 VENEREAL DISEASE 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 1,192 5 2 103 717 365 Central Middlesex 44 6 17 21 Middlesex 89 7 47 35 St. Bartholomew's 2 2 St. Thomas' 2 2 Seamen's Westminster 10 2 7 1 Whitechapel Clinic 2 1 1 Totals: 1972 1,341 5 2 118 791 425 1971 1,371 2 9 124 1,236 1970 1,011 3 3 108 897 1969 992 2 4 109 807 The above table suggests that the total number of persons suffering from venereal conditions may have stabilised. 20 This increase reflects the increasing pressures which the venereal disease services throughout the country have been facing during recent years although as pointed out by the Chief Medical Officer of the Department of Health & Social Security in his annual report for 1971 nearly half the case load for the whole of England is dealt with in the Greater London Area. It will be noticed that the increase in the total figure given above is accounted for chiefly by conditions other than syphilis and gonorrhoea, the incidence of these diseases remaining relatively small. WHOOPING COUGH The 23 cases of whooping cough notified during 1972 shows a big drop on the 135 cases reported last year. This Department continues to co-operate with the Public Health Laboratory Service in carrying out the survey into the efficacy of the whooping cough vaccines at present in use. During the year 35 per-nasal swabs were taken from contacts of notified cases of whooping cough and in four of these cases Bordetella pertussis (the organism which causes whooping cough) was isolated. CHOLERA SURVEILLANCE A total of 203 persons arriving in Hillingdon from areas in which cholera was at that time present were placed under surveillance during the year 1971. The fact that only 6 people had to be similarly surveyed during 1972 is a reflection of the decreased incidence of cholera throughout the world during the year. Infectious diseases cases admitted to St. John's Hospital direct from Heathrow Airport (not notified on weekly return). Food Poisoning 14 Malaria 2 Infective Hepatitis 12 (1 Falciparum) Measles 4 Pulmonary Tuberculosis 2 Typhoid Fever 4 Salmonellosis 1 Bacillery Dysentery 3 Bronchopneumonia/Erythema Gastro Enteritis 3 Multiforme 1 Health Control Unit, London (Heathrow) Airport Dr. P. R. Cooper—Principal Medical Officer (Port Health) Probably the year under review will be remembered by the Health Control Unit more on account of the expulsion from Uganda of some 30,000 residents who held British passports than for any other event. The whole operation was expected to be completed in two months and it was thought that if all the immigrants had to be medically screened on arrival, the staff both medical and clerical, would be subjected to considerable pressure. As events turned out, charter flights brought the Asians to Stansted and Gatwick Airports, leaving Heathrow to accept for the most part, only the scheduled services. Nevertheless, some 15,000 Asians arrived at Heathrow during the operation and quite a few of these were brought into Terminals 1 and 2 on special flights laid on by such airlines as Air France, Luxair, Lufthansa and Alitalia. The arrivals in Terminal 3 came on East African Airlines and B.O.A.C. September and October are normally the busiest months for the Unit as so many overseas students arrive for the start of the academic year. This fact was known to the Department of Health 21 and Social Security as well as to the Borough of Hillingdon and special contingency plans were drawn up so that additional medical staff could be made available from among the Borough's departmental medical officers to come to the Airport, especially during the night and early hours of the morning, to supplement the Health Control Unit staff. Many of the Asians arriving at Heathrow had nowhere to go and special transit camps were established to receive such persons. These camps had medical screening facilities on the spot and it was therefore agreed that all Asians who were destined for these camps would be examined at their destinations, leaving only those who were going to private addresses to be examined at Heathrow. This was a great relief and in the event the whole operation was very successful. In fact, the Unit had seen far busier and more hectic times when in 1968 and 1969 medical examination of dependant wives and children was first introduced. During 1972, a start was made upon the in-service training programme for clerk/receptionists and three courses were held at various times, further details being included elsewhere in this Report. The new Immigration Act 1971 should have become operative during the year under review. This Act replaces the Aliens Order of 1953 and the Commonwealth Immigrants Act of 1962 and the same medical provisions will now apply to both former categories of immigrant. The old Forms Port 12 and Port 23 will be replaced by a single report form. The Immigration Act 1971 will come into force on 1 st January 1973 and will at the same time provide for Britain's entry into the European Economic Community. The Department of Health and Social Security issued a cholera advice notice during the year. This was to be distributed to all passengers arriving from countries where the condition was being reported. It obviated the requirement of presenting a valid international cholera certificate at the port of arrival and as a result, it also did away with the practice of surveillance of those passengers who had come from cholera-infected areas without valid international certificates. The difficulties of obtaining adequate accommodation from the British Airports Authority for the Unit to carry out its function at the Airport have always been recognised and in the past year protracted negotiations took place between the Borough and the Authority on this subject. It is gratifying to record that by the end of the year the Health Control Unit had regained the control of two rest rooms in Terminal 3 and arrangements were in hand to acquire similar accommodation in Terminals 1 and 2. It is worrying, on the other hand, to note the difficulties experienced in communication with the Authority. One result of this is frustration due to long delays in attention to sometimes comparatively minor problems. The most tragic event during the year was without doubt the accident near Staines to the BEA Trident on 18th June with the loss of 118 lives. This accident upset the wonderful record that Heathrow had in regard to the very few fatalities that had occurred over the years, taking into account the ever increasing number of aircraft movements in and out of the Airport. It is unhappily reported that "airline passengers are now faced with disturbing evidence that it is becoming progressively more dangerous to fly on scheduled services because of 'human factors' which cannot be fully controlled. For the first time since 1950, the safety record of airlines in Western countries has deteriorated for two years running". STAFF Medical Officers Dr. N. D. Walker resigned from the staff early in the year on his return to New Zealand. In his place, Dr. C. J. V. Helliwell was appointed and took up duty on 4th April. Dr. Helliwell had previously been engaged on "locum" duty and was no stranger to the Unit. On 31st December there was one vacancy on the establishment. Receptionists At the end of 1971, authority had been received from the Department of Health and Social Security for an additional twelve receptionists, bringing the establishment up from 65 to 77. 22 ing the recommendations contained in the Birmingham Report, a further ten receptionists were authorised as from 1st April 1972, bringing thetotal to 87 which included the Senior Clerk/Receptionist and six Shift Leaders. On 31 st December there were 13 vacancies. During the year 45 receptionists were newly recruited; of these two had their services terminated, as they proved unsatisfactory. Thirty receptionists resigned and in addition one, appointed in 1971, had her services terminated. Each receptionist, on submitting her resignation, was requested to complete a questionnaire indicating the reasons which prompted her decision. The value of these forms was questionable since they were usually completed by the receptionist in the staff rest room surrounded by her colleagues who were offering advice on what to include. The impression gained during the year was that in almost all cases of resignation there was a genuine reason for the move, not in any way connected with conditions of service or conditions obtaining at the Airport. The Birmingham Report's recommendation regarding early and late shifts, in addition to day and night shifts, was brought into operation in March. After meeting with some initial resistance the arrangements soon began to work smoothly and satisfactorily, and these ensured that the peak traffic periods were covered at all times. Plans were drawn up towards the end of the year to introduce a shorter working week with effect from 1 st January 1973. Associated with this, it was proposed to increase the shift allowance, but both measures in the event were deferred under the Counter-Inflation Act of 1972. Another measure introduced in order to make conditions more attractive was the decision to improve the uniforms and to issue both winter and summer uniforms. This was discussed with the staff over a long period of time and finally agreement was reached. Training Courses As part of the Training Programme for Clerk/Receptionists, it was decided to hold courses of three or four days' duration which could be attended by newly appointed staff. Two such courses were held for clerk/receptionists in February and in December, while in June a short course was attended by the shift/leaders. These courses were organised by the Principal Health Education Officer and there was general agreement that they were useful and valuable. The courses included lectures, practical demonstrations, sometimes with slides, and general discussions in which questions were asked of a panel comprising senior staff. The subjects covered vaccination, its history and general outline, the World Health Organization, forms and procedures used routinely by clerk/receptionists in their day-to-day duties tracing their follow-up to destination, infectious disease and other medical conditions encountered by health control staff, drug addiction and psychiatric disturbances, first aid and general nursing procedures, the care of the unconscious and practical instruction in mouth to mouth resuscitation. As these courses were so well received it is hoped to continue them in 1973. ACCOMMODATION Towards the end of the year, negotiations were opened between the Borough and the British Airports Authority with a view to taking over the two rest rooms in Terminal 3, formerly in the possession of the Authority. Such rooms had always been included in the basic design of a port health unit and during the process of time, it seems that succeeding authorities had lost sight of their original function. Now it is proposed to negotiate with the Authority for similar accommodation also to be made available to the Health Control Unit in Terminals 1 and 2. The whole of the Unit's accommodation in Terminal 3 was redecorated towards the end of the year. Terminal 1 No alterations took place during the year. Space was provided temporarily for medical examinations to be carried out on behalf of the British Airports Authority. This was due to alterations taking place in the Authority's own accommodation in Terminal 2. 23 Terminal 2 Improvements to the ventilation in the Immigration Hall were undertaken during 1972. This caused a temporary upheaval associated with the installation of new ducting above the ceilings of the waiting room and isolation room. During this time alternative accommodation was provided by the British Airports Authority. It is hoped that the Unit's accommodation will benefit from the improvements to the ventilation of the Immigration Hall. Terminal 3 (Arrivals Building) Piers 5 and 6 The conversion of many of the airside finger lounges, from conventional-type aircraft facility to "Jumbo" jet facility was started in May. The work is not likely to be completed before April 1973. During this time, health controlled flights, presenting on these fingers, are being checked, by general agreement, on the galleries of the two piers. Negotiations between the Borough, the British Airports Authority and the Airlines regarding the use of desks on these piers was shelved until structural work of conversion had taken place. In the meantime, the year passed without too many complaints being received relating to heating and lighting. North Coach Station The British Airports Authority in an effort to counter criticism on heating problems in the North Coach Station laid down a carpet on the concrete floor. This action followed the erection of antidraught screens between the check desks and the outside doors and was very welcome. Nevertheless as each winter progresses it is apparent that an adequate temperature cannot be maintained in this area, and it is usually several days before the authorities can be persuaded to take action and during this period the staff have to work under most difficult conditions. Pier 7 The ten "Jumbo" stands on Pier 7 were kept fully utilised throughout the year. Desks and stools were provided by the British Airports Authority in each of the gate-rooms, the former being screwed down as an anti-airline security measure. The two rooms, forming the immunisation unit, adjacent to gate-room 16, were handed over during the year, but the number presenting vaccination queries arriving on this pier were so few that it was possible to continue the existing practice whereby the airline representative escorted them to the medical officer in the arrivals building. COMMUNICABLE DISEASES Smallpox The United Kingdom again remained smallpox-free in 1972. Only on one occasion was it necessary to call upon a smallpox consultant. The passenger, a school boy aged ten years, arrived from Colombo via Delhi where he had stayed two nights. The child, who was picked up on account of a rash during the processing of the flight through health control, had two scars following primary vaccination at the age of one year and had evidence of having been revaccinated on the day before arrival at Heathrow. Clinically the child had a chickenpox rash with an equivocal distribution. The gel-diffusion test was negative for variola and positive for varicella. In March, there was an outbreak of smallpox in Yugoslavia. On 29th March the whole country was declared infected and remained so until 9th May. During this time, all flights arriving at Heathrow from Yugoslavian airports were subject to health control. From Yugoslavia one case was imported into Hanover, but there were no secondary cases. During this outbreak, the United States and Canadian authorities temporarily re-imposed their requirement for the presentation of valid international certificates of vaccination from passengers from Europe. The number of passengers placed under surveillance for smallpox during the year was 4,354. During the latter part of the year, health departments in Britain were invited to co-operate in a 24 survey undertaken by the Borough in order to check how many persons placed under surveillance were in fact contacted. To assist in this a reply-paid envelope and detachable sheet were enclosed with the surveillance notification. In analysing the results of the last quarter of the year, it was found that of 1,285 persons placed under surveillance, replies were received in respect of 548 persons and of these 471 had been contacted. Of the 77 not contacted, 46 were found not to be at the address given, 19 had already left the address and in 2 cases the address was non-existent. In only one case was the address inaccurately given. Cholera The year passed without an outbreak of cholera in either Portugal or Spain, as happened in 1971, although there were outbreaks in Tunisia, Algeria and Morocco, from where there is considerable migration of labour to the south european countries. The Department of Health and Social Security introduced an advice notice to be issued to travellers arriving from countries where there was a risk of contracting cholera, rather on similar lines to the yellow warning card for use in partial agreement countries. As a result of the issue of this leaflet, it was no longer necessary to inspect cholera vaccination certificates and the clearance of flights through the health control check-point was effected much more quickly. The number of passengers placed under surveillance was 555. Other Infectious Diseases Eighty-eight persons were admitted usually to St. John's Hospital, Uxbridge, or, if it was full up, then to Coppett's Wood Hospital. The conditions for which admission was requested included: Enteritis or gastro-enteritis 32 Varicella 2 Suspected tuberculosis 14 Bacillary dysentery 2 Infective hepatitis 8 Typhoid fever 1 Broncho-pneumonia 7 Rubella 1 Malaria 3 Herpes zoster 1 Measles 3 Other conditions included secondarily infected eczema, cellulitis, upper respiratory tract infection, peritonsillar abscess, sickle-cell anaemia and salmonella infection. MEDICAL EXAMINATION OF COMMONWEALTH IMMIGRANTS The total number of Commonwealth Immigrants referred to the Medical Inspectors over the last five years was: 1972 44,629 1971 39,961 1970 44,611 1969 44,575 1968 46,828 The number of forms port 23 completed in 1972 was 61 (62 in 1971, 69 in 1970). The categories of those immigrants seen in 1972 was: (a) Voucher-holders or entitled dependants 21,183 (b) Non-entitled dependants 23,328 (c) Those appearing to be mentally or physically abnormal 28 (d) Those appearing not to be in good health 32 (e) Those mentioning health as a reason for their visit 58 The number of refusals following medical recommendation was 20. Mental instability 18 Pulmonary tuberculosis 1 Diabetes mellitus 1 25 The number of immigrants admitted conditionally upon reporting to the destination health department within a specified time was 243, and in 219 cases the reason was that the immigrant's chest was suspect and required follow-up. The number of notifications advising health departments of the arrival in their areas of new immigrants and their families totalled 32,484. It was not known in what proportion of cases contact was established between the health departments and the immigrants and at the beginning of October a system of follow-up was introduced. To the usual advice notice was attached a second page on which health departments were asked to indicate whether contact had been made or if it had not been, the reason, if known. A prepaid envelope was enclosed. An analysis of the findings covering the three month period October 1st-December 31st 1972 reveals that of 10,050 notifications issued, replies were received in respect of 3,087 (30.7%) and of these, in 71 % of cases contact was made. The two main reasons for failure to contact were that the immigrant was not at the address given or had already left the address. MEDICAL INSPECTION OF ALIENS The total number of aliens referred to the Medical Inspectors during the last five years was: 1972 8,643 1971 9,432 1970 8,488 1969 6,203 1968 5,351 The number of forms port 12 issued in 1972 was 115 (103 in 1971, 81 in 1970). The categories of aliens seen in 1972 was: (a) Those appearing to be mentally or physically abnormal 104 (b) Those appearing not to be in good health 39 (c) Those appearing to be bodily dirty 9 (d) Those mentioning health as a reason for their visit 119 (e) Those intending to make their home in this country or to remain for more than six months 8,372 There were 87 refusals on medical recommendation (73 in 1971, 68 in 1970). The reasons for recommending refusal were: Mental instability 70 Bodily dirty 1 Pulmonary tuberculosis 3 Liver failure and diabetes 1 Venereal disease 2 Heart disease 1 Drug addiction 2 Emphysema and hernia 1 Infective condition 2 Cirrhosis and fractured femur 1 Hepatitis 1 Intra-cerebral pressure 1 Alcoholism 1 X-RAY UNIT Efforts continue with a view to obtaining a second X-ray plant for service in Terminals 1 and 2. With no facility in this area, it was necessary during the year to transport 555 immigrants over to Terminal 3 for X-ray; these were persons clinically suspect whom the medical officer considered it desirable to X-ray. Number of immigrants X-rayed: 1972 8,893 1971 9,383 1970 7,128 1969 4,229 1968 9,585 26 Of the 8,893 persons X-rayed during the year, 940 were aliens and 7,953 were Commonwealth immigrants: these figures compare with 807 and 8,576 in 1971. There was as usual a build up in the figures from 713 in January to a peak of 1,204 in September, 1,062 in October and then falling off to 582 in December. The peak figures in September and October coincided both with the start of the academic year and the influx of Ugandan Asians into Britain. The radiographer was able to train 12 clerk receptionists to a degree of competence adequate to operate the plant during her absence. Pulmonary Tuberculosis Twenty-seven persons were found to have active pulmonary tuberculosis on arrival during the year. This figure compares with 33 in 1971 and 40 in 1970. The country of origin was as follows: Pakistan 6 Hongkong 5 India 5 Uganda 3 Kenya 2 Ceylon 1 Gambia 1 Nepal 1 Philippines 1 Portugal 1 Tanzania 1 Three aliens were refused landing on account of the condition, one each from Nepal and Portugal and a Chinese from Hongkong. One commonwealth immigrant from Gambia was refused landing. Fifty immigrants were landed on condition that they contacted their destination health departments within a specified number of days. These immigrants came from: Pakistan 13 Kenya 11 India 9 Uganda 9 Hongkong 5 Tanzania 2 Ceylon 1 The follow-up of these 50 persons revealed that 13 had active tuberculosis, 5 were negative and as regards the remaining 32, the results are still awaited. The analysis of the thirteen active cases was: Pakistan 4 India 4 Ceylon 1 Hongkong ... 1 Kenya 1 Tanzania ... 1 Uganda 1 OTHER ACTIVITIES Visitors During the year distinguished medical visitors were received from Egypt, Japan and Sweden together with a senior public health inspector from the Seychelles. Three groups of student nurses from Charing Cross Hospital, and three groups of local student public health inspectors visited Heathrow at various times to learn something of the procedures followed at an international airport. In April, a party of second year nursing students from the Devon Technical College and College of Further Education and in October a group of student nurses from St. Bernard's Hospital came to the Airport for the same purpose. Conferences Early in June, the Principal Medical Officer visited Strasbourg and attended the 7th Session of the meeting of the Group of Experts set up by the Public Health Committee of the Council of Europe (Partial Agreement) to discuss questions arising from the implementation of the administrative arrangements for the health control of sea, air and land traffic. Several amendments to the text of the administrative arrangements were recommended. The situation brought about by the outbreak of smallpox in Yugoslavia was examined and the application of Spain to join the partial agreement countries was provisionally recommended. 27 Later in June the Annual Conference of the Association of Sea and Air Port Health Authorities took place. To mark the centenary of the establishment of their Port Health Authority, the City of London played host to the Association on this occasion. The Conference was attended by the former Chairman of the Health Committee, the Director of Health Services and the Principal Medical Officer. STATISTICS No. of Passengers seen by Health Control 790,724 No. of Aircraft issued with Disinsectization Certificates 423 No. of Aliens inspected under Aliens Order 8,643 No. of Forms Port 12 issued 115 No. of Aliens refused entry 87 No. of Commonwealth Immigrants examined 44,629 No. of Forms Port 23 issued 61 No. of Commonwealth Immigrants refused entry 20 No. of Immigrants X-rayed 8,893 No. of Long-Stay Immigrants Notifications sent to Medical Officers of Health ... 32,484 No. of Conditional Landing Forms sent to Medical Officers of Health ... 243 No. of Surveillance Notifications sent to Medical Officers of Health 4,909 No. of Smallpox Vaccinations carried out 8,664 No. of Cholera Vaccinations carried out 1,919 No. of Yellow Fever Vaccinations carried out 292 No. of Unvaccinated Passengers Isolated 105 1968 1969 1970 1971 1972 Total aircraft movements: 247,417 293,745 270,169 273,490 279,227* Total passenger flow: 13,355,906 14,314,882 15,606,719 16,174,756 18,621,886 * Provisional figure. IMMUNISATIONS Vaccinations against Smallpox Vaccinations against Cholera 1972 8,664 1972 1,919 1971 6,413 1971 2,008 1970 8,998 1970 1,515 1969 10,254 1969 611 1968 10,293 1968 327 Number of Passengers Isolated Vaccinations against Yellow Fe ver 1972 105 1972 292 1971 92 1971 225 1970 137 1970 131 1969 88 1969 103 1968 46 1968 73 28 SECTION II Personal Health Service "Surely the members of a household must have health just as they must have life. And as from one point of view the master of the house and the ruler of the State have to consider about health, from another point of view not they but the physician."—Aristotle 384-322 B.C. Personal Health Services ANTE AND POST-NATAL CLINICS Although each of the three branches of the National Health Service currently have a statutory responsibility for ante-natal and post-natal care, there is an increasing trend for such care to be provided by the family doctor except in respect of patients who require specialist obstetric supervision. The figures given below indicate that a larger number of sessions (1010) were held at which the attendance of patients (862) was somewhat lower than the previous year. This apparent contradiction is explained partially by the overall reduction in number of domiciliary deliveries and partially by the increasing general practitioner supervision of care described above. The number of domiciliary deliveries in the area is still greater than the average in London especially amongst mothers who may be considered at greater risk of obstetric complications. The trend towards general practitioner supervision has resulted in fewer patients being seen in any one session since, whilst these are of shorter duration, the family doctor is unlikely to have as many patients attending a clinic in his practice as would attend a specialist ante-natal clinic organised by a hospital department or by a local health authority. 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 847 15 33 977 1,010 The number attending the Relaxation and Mothercraft classes was 1,010 representing a decrease of 0-7% compared with 1971. Since the birth rate declined to a greater extent the proportion of mothers attending these classes showed a marginal increase. Classes were held at 14 clinics and the total number of attendances during the year was 5,923, an increase of 1 2% compared with previous year. Training for health visitors and others concerned with ante-natal care and mothercraft teaching continued during the year so that all those undertaking such classes were aware of modern developments in technique. 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 83. 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 64 children with congenital conditions were notified in 1972. 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 31 brain damage, and mental subnormality. A blood test (Guthrie test) has been developed and is carried out on the sixth day of life by the midwife. The blood samples are collected on a special filter paper which is posted to the regional centre for processing. A number of other rare diseases including histidinaemia and homocystinuria are excluded by the laboratory investigations now undertaken. 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 1971, and the progress which has been made since that time to change the emphasis of the centres to that of developmental screening has continued. The standard of service for each child is set out under the management by objectives procedure and involves seven examinations during the first five years of life. These examinations should take place on or before the sixth week, at six months, at twelve months, at eighteen months and at 2 years of age. Thereafter examinations are arranged at approximately yearly intervals until the child commences at school. Arrangements to modify the child health centre programme were implemented during the year allowing a greater proportion of medical resources to be allocated to this important work. Most sessions were transferred to the afternoons where experience has shown that parents find it easier to attend. In consequence the proportion of child health centres at which a medical officer was present increased by one quarter to 94.4%. The attendance at individual child health centres was, however, variable, and some centres were unable to complete a full programme as set out above in respect of every child because of limitations of medical man-power. Arrangements were completed by the end of the year to transfer medical officers from less well attended sessions to those where the need was greater but the difficulties of inadequate accommodation in some clinics sometimes militate against the provision of all the medical sessions which are required. In consequence special emphasis has been given to the child who is considered "At risk" particularly in respect of the first four routine examinations. At the time of the birth notification the department is advised of factors affecting the pregnancy and the birth which may increase marginally the risk of handicap in the child. Every effort is made to ensure that all of these children are examined at appropriate intervals so that by the age of two years any handicaps will have been identified. All children are discharged from the "At Risk" register at this stage but those who have been found to have some handicap are followed up at appropriate intervals in order that special educational facilities may be provided. The condition of non-accidental injury syndrome (the so-called "Battered Baby") has shown a need to extend this "At Risk" concept. A special section of the Observation Register has been created which allows special emphasis to be given to the potentially battered child. Observation and support are usually all that is necessary but because of the risk that staff changes may lead to loss of contact, health visitors are asked to visit such families at their discretion, and according to the prevailing situation but to report briefly to the central register at monthly intervals. If a report is not received it is requested so that the child is not overlooked. In this way early deterioration in the family atmosphere can be detected and preventive action taken to avoid serious damage to the child. Research has shown that, whilst any child is potentially at risk, the syndrome is far more likely in certain groups, and it is upon them that preventive action must be focused. The assistance of the social services department or officers of the National Society for the Prevention of Cruelty to Children is particularly appreciated in this important work. During 1972 a total of 24 children were placed on this special register of whom 12 were referred to the social services department and 6 were taken over by N.S.P.C.C. officers. Four names were removed from the register. In some cases it is necessary for all the various agencies to meet together to discuss a common policy concerning a particular 32 child and such case conferences attended for example by the probation service, the hospital medical social worker, the consultant paediatricians, or psychiatrist, the family doctor, were held on four occasions. Since the developmental screening of all children is a relatively new concept a considerable amount of in-service training has been required to equip the professional staff with the necessary skills. This has been particularly important with the improvement in the medical and nursing staffing situation and a comprehensive training programme for both doctors and nurses has been prepared. Two medical officers undertook training for assessment of mentally retarded children, one the course for assessment of babies and young children and one a six week course in developmental paediatrics. Induction training sessions were arranged for all new doctors joining the service during their first month. Nevertheless a great need for practical demonstrations rather than theoretical training was expressed, and in order to satisfy this a special training day was held on Saturday 4th March 1972. Eminent specialists in this field including Dr. Dorothy Egan, Dr. Peter Robson and Dr. Pamela Zinkin attended. Not only were talks given but practical application on normal and handicapped children added to the benefits of the day. It was fortunate to have Mr. Romano, a consultant ophthalmologist at Hillingdon Hospital speaking on the examination of young children for eye conditions. It is pleasing to report that observation in the child health centres subsequent to the course has confirmed that the new training is being applied in practice. In addition a number of courses were held during the year for nursing staff and also for medical officers in connection with the screening of hearing and vision in young children. The object of these training courses is to provide a universal standard of testing throughout the Borough, and then, by means of regular review, to ensure that the necessary standards are maintained. In October 1972 one of the full-time medical officers commenced a course at the Institute of Child Health in London for an academic year in connection with the advanced assessment of handicapped children. Handicapped Children in Day Nurseries As an advisory service to the Social Services Department, medical officers continue to visit the day nurseries periodically in order to examine the children and to assess the progress of handicapped children who are placed there. A principal medical officer is also available for consultation and advice and visits the nurseries to carry out more detailed assessments on the handicapped children. During the year 19 routine visits were made by medical officers. Since the education department assumed responsibility for the education and training of all handicapped children including mentally handicapped the costs of all handicapped children in the nurseries are borne by the education department. The table below gives some detail of these children. Category (handicap) Number Deaf or partially hearing 4 Delicate 2 Mentally Handicapped 3 Speech defect 3 Epileptic 1 Physically handicapped 1 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 these three separate parts of the service which will continue in the reorganised structure after 1974. The assistance of hospital specialist staff in training medical officers in these techniques of developmental paediatrics has already been mentioned, and the provision of information about children diagnosed or treated in hospital is gradually becoming easier to obtain. These are significant advances and are complemented by the increasing readiness of family doctors to seek the specialist help which the department can provide in respect of children with particular handicapping problems. 33 Welfare Foods The welfare foods provided through the local health authorities include National Dried Milk, multi-vitamin drops and tablets. Unfortunately the latter, which had been introduced following the withdrawal of orange juice and cod liver oil were not well accepted. 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 these welfare foods is unlikely to assist these objectives and there is a continuing need closely to review existing policies in the light of local circumstances. The distribution of welfare foods has been a particular field of health department activity where voluntary efforts have been much in evidence. The department owes a great debt of gratitude to these voluntary helpers, who not only provide a particular service to the community within the child health centre but also introduce by their very personalities a particular friendliness which does much to encourage the regular attendance of mothers on which so much depends. FAMILY PLANNING Family planning advice has been available in clinics throughout the Borough for many years. Apart from those held at Hillingdon and Mount Vernon Hospitals they have been sited in local authority premises where facilities were offered rent-free to the Family Planning Association. Women who required the service on health grounds received this free of charge, the total cost being borne by the Health Committee. However, since 1st April 1972, advice has been offered free to all Borough residents, and only those not needing it on health grounds have had to pay for their supplies. In 1971 the Council opened a directly-operated clinic as a pilot scheme. This proved so popular that the session was doubled in April 1972 and two further clinics were started, one at Elers Road in Hayes in July and one in Harefield in October. Total attendances were 1,403. The clinic held at Mount Vernon Hospital by the International Planned Parenthood Federation became too busy for a single team to operate, so in April, a doctor, nurse and clerk employed by the Borough were introduced to share the load. The Federation was changing its policy and expressed a wish to withdraw from this clinic. Discussions were held with the Hospital authorities and with effect from 1 st October 1972 the Borough assumed responsibility for these two sessions as well. The Family Planning Association also wished to expand their services, and in December they opened clinics at Oak Farm and Grange Park. Details of the number of women seen in the clinics are given below. Owing to a change in the Family Planning Association's method of recording it is no longer possible to differentiate between those receiving a free service on medical and on social grounds. Information collected in the Council's well women's clinics shows that male sterilization is an increasingly popular method of contraception with couples who have completed their families. This is an operation which is available as part of the National Health Service when there are medical reasons for it. Close co-operation and discussion between local authority doctor, general practitioner and surgeon have resulted in this facility being given to a few families in the Borough during the year. Family Planning Attendances 1972 Service given Number seen by FPA IPPF Brook Advisory Number seen by local authority Total Consultation only 3,244 346 3,590 Consultation and supplies 143 128 271 Domiciliary 12 1 13 Number seen in 1971 for consultation and supplies and domiciliary - 173. 34 The Health visitor and Midwife work together to ensure a healthy mother and child Abortions The number of abortions conducted at hospitals in Hillingdon was as follows 1971 1972 Provisional 730 806 Actual 743 - Family Planning Service (general enquiries—not appointments) Uxbridge 38290 Elers Road Clinic, Wednesday 1.30 p.m.-3.30 p.m. Elers Road, Hayes Harefield Clinic, Friday 1.30 p.m.-3.30 p.m. Harefield Health Centre, (not 3rd Park Lane, Harefield Friday in month) Laurel Lodge Clinic, Tuesday 9.30 a.m.-11.30 a.m. Harlington Road, Hillingdon (by appointment only) Mount Vernon Hospital, Thursday 2.00 p.m.-5.00 p.m. Northwood (by appointment only) Family Planning Association Clinics Grange Park Clinic, Tuesday 7.00 p.m.-8.00 p.m. Lansbury Drive, Hayes Hillingdon Hospital by appointment only—Uxbridge 38282 Ickenham Clinic, Monday 7.00 p.m.-8.00 p.m. Long Lane, Ickenham Minet Clinic, Wednesday 1.45 p.m.-3.15 p.m. Coldharbour Lane, Hayes 5.30 p.m.-7.00 p.m. Northwood Clinic, Tuesday 7.00 p.m.-8.00 p.m. Ryefield Court, (by appointment only) Northwood Hills Oak Farm Clinic, Thursday 7.00 p.m.-8.00 p.m. Long Lane, Hillingdon Uxbridge Clinic, Thursday 1.45 p.m.-3.15 p.m. Council Offices, 5.30 p.m.-7.00 p.m. High Street, Uxbridge West Mead Clinic, Friday 1.45 p.m.-2.45 p.m. West Mead, Ruislip 6.30 p.m.-8.00 p.m. WELL WOMEN'S CLINICS The number of women attending these clinics has remained much as in previous years with a considerable increase at the Elers Road and Laurel Lodge Clinics. Many of these, however, are women who have had previous cytology and have returned for repeat screening after an interval of some years. Details of the attendances and the abnormalities found are given in the table on page 36. The proportion of women considered to be at greater than average risk has also been shown and can be seen to vary widely from one clinic to another. 35 We are concerned that many of the women who fall into a risk category do not present themselves for screening and in order to give the service greater publicity, arrangements were made for the mobile unit of the Women's National Cancer Control Campaign to attend the Borough Show during the summer. No screening was undertaken but photos taken in local sessions were displayed and there was a considerable quantity of literature available including request cards for appointments. The amount of interest shown however was extremely disappointing. Only four cases of malignancy were identified during 1972 and all were referred for further investigation and treatment. In addition 163 women were referred to their family doctors for further advice about conditions of varying severity. Elers Road Laurel Lodge Minet North wood Ruislip Yiewsley Industry No. of women seen 308 873 335 297 329 141 36 "At risk" 47% 31% 37% 19% 21% 50% 19% Healthy 160 376 215 196 277 84 26 Abnormalities found: Pelvic: Malignancy 2 1 1 Cervical 44 323 24 16 21 18 2 Infection 43 151 23 17 13 18 2 Fibroids 16 34 18 16 2 9 2 Ovarian 5 12 7 1 1 Prolapse 1 7 4 3 Other 19 15 17 27 6 14 Breasts 10 41 10 3 2 7 2 Hypertension 7 18 3 10 4 1 2 Urine 8 14 Referred to G.P. 23 87 17 16 5 14 1 Previous cytology 187 587 130 147 115 50 22 CHIROPODY The difficulties forecast in the report for 1971 unfortunately became realities and the demand for chiropody services has far outstripped the ability to satisfy it. By the end of the year the average waiting time for a first appointment was over 12 weeks and that between appointments 16-18 weeks. The situation was not improved by the death of two chiropodists who had given good sessional service to the department for many years. The staffing position was reviewed and a structure for full-time area and sector chiropodists was agreed, but it was not until the end of the year that it was possible to make the first appointment of area chiropodist. In addition to clinical and supervisory duties, it is envisaged that this officer will be responsible for some health education in schools and clubs for the elderly. He will also participate in the training of community nurses and welfare home attendants. This should improve the standard of foot care in the Borough and help to prevent some of the crippling disabilities which come with increasing age. 36 Chiropody facilities are available at the following clinics: Minet, Coldharbour Lane, Hayes Laurel Lodge, Harlington Road, Hillingdon Northwood, Ryefield Crescent, Joel Street, Northwood Hills Uxbridge, High Street, Uxbridge Westmead, Westmead, 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 3,206. This shows an increase over the figure for 1971 (3,140). Number of Persons Treated By local Authorities By voluntary organisations Total Persons aged 65 and over 2,379 743 3,122 Expectant mothers 2 2 Physically handicapped or otherwise disabled persons under age 65 67 67 Others 15 15 Total 2,463 743 3,206 Number of Treatments In clinics 4,533 4,533 In patients' homes 3,574 1,066 4,640 In old people's homes 1,172 117 1,289 In chiropodists' surgeries 1,874 1,874 Total 9,279 3,057 12,336 37 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 1972 has been a year of considerable growth and development in the nursing services. The nursing management structure, introduced late in the previous year, has enabled new projects to be introduced satisfactorily, and the health visiting, district nursing and midwifery staff have responded well to working in teams led by the senior nursing officers. Domiciliary Nursing Service The work study carried out during November 1971 showed a clear need for additional nursing staff, mainly in the state enrolled nurse and nursing auxiliary grades. A new and increased establishment of nurses was agreed by the Council, and is gradually being implemented according to a phased programme. This programme will be completed in November 1973, by which time there will have been a 50% increase in staff. A small recruitment drive was held in August and on the whole recruitment to the service has been very good. There is even, at times, a waiting list for state registered nurses who wish to work in the community. Because of the employment of nursing auxiliaries it has been possible to free the qualified nurses from some of the routine duties, thus giving them more time for skilled nursing tasks. The state registered nurse, however, always retains responsibility for her patients even though she may delegate some of their care to other members of the team. In conjunction with Hillingdon Hospital, equipment from the central sterile supply department has been used in a pilot scheme involving one third of the Borough. This scheme has been so successful that it is hoped to extend it to cover the whole Borough during 1973. The contents of the nurse's bag have changed greatly with the advent of pre-sterilised packs, and it has therefore been necessary to re-design these bags completely. Some of the new type cases are in use and eventually all nursing sisters will be issued with them. During the year a survey was undertaken to consider the need for a laundry service for seriously ill patients nursed at home. Plans are in hand for such a service to be established in 1973. A community nursing service van, which came into service during the year, has proved invaluable, both for the carrying of large items of equipment and for the use of nursing staff when their own cars are out of service for any reason. Because of problems which arose early in the year, due to lack of storage space for nursing equipment, arrangements were made for the establishment of a store at Harefield Hospital. Although this is not as centrally placed in the Borough as would be desirable, it has been reasonably satisfactory. Night Nursing Service This service, new in 1971, has grown rapidly and provides round-the-clock nursing care for patients seriously ill who would otherwise have to be admitted to hospital. A total of 184 patients received night nursing care, and the number of visits paid by the night staff per month varied from 155 in May to 571 in November. The total number of visits made during the year was 4,179. On 177 occasions patients were cared for throughout the night by the auxiliary nursing staff with supervision from the night sisters. Other patients were visited as necessary during the night and treatment given as prescribed by the family doctor. It became obvious during the year that an additional night sister was needed between 8 p.m. and midnight as this is a very busy time when patients are settled down for the night. The establishment of nurses for this service has therefore 38 The Community Health team plans the day's work been increased to 3.5 S.R.N.s and 4.5 auxiliaries. The service has aroused much interest and several visits have been made to the Borough by nursing officers anxious to start night nursing services in their own authorities. The Health Visiting Service The staff situation in this service is improving and at the end of the year was considerably better than at the end of 1971. Nine students sponsored by the Borough qualified in September, and in addition there was increased recruitment of qualified health visitors to the service. A work study undertaken during the year demonstrated the need for more clinic nurses, clinic clerks and nursing auxiliaries in this service. A programme of phased implementation of these proposals will start in 1973. Health visitors' uniform was also changed during the year. They are now able to wear any style of suit (including trouser suits) providing the colour is of royal or darker blue, and may wear any colour blouse. The ability to wear a trouser suit has been much appreciated, particularly by the younger members of staff. At two clinics pilot schemes have been established whereby mothers bringing their toddlers to the clinic can attend a "mothers' club" where health education topics are discussed and a planned programme of discussion subjects is prepared. A considerable part of the health visitor's work is health education, both formal and informal, and full details of this will be found in the Health Education Section of this report. Attachment and Liaison Schemes With the gradual increase in overall staffing of the Community Nursing Service it has been possible to start new attachment and liaison schemes. At the end of the year four practices of general practitioners had full attachment of nurse, midwife and health visitor, and twenty-two practices had part attachment, i.e. attachment of one member of the nursing team only. In one attachment scheme it has been possible to arrange for the nursing staff to visit patients of the practice who live outside the geographical boundary of the Borough. This has already proved very successful and it is hoped that further such arrangements may be possible in other parts of the Borough. Where attachment is not yet possible liaison schemes are being established between groups of general practitioners and community nursing staff. In these schemes the nurse continues to work in a geographical area but establishes and maintains a close contact with the general practitioners. Domiciliary Midwifery Service The expected trend in domiciliary midwifery continues, reflecting the trend in the rest of the country. The number of mothers who were discharged home early after hospital confinement rose to 711 as against 313 in 1971, of these 126 were discharged before the fifth post-natal day. In order to deal effectively with this increased load on the service four part-time midwives were appointed whose main task is to care for the "early discharge" mothers. A total of 629 mothers were delivered by the domiciliary midwives, of whom 136 had their babies in the unit at the Duchess of Kent Maternity Wing. This is an increase of unit deliveries from 98 in 1971. Packs for midwifery deliveries have been available as a pilot scheme from the central supply department at Hillingdon Hospital for about one third of all cases, and this, it is hoped, will extend to fully cover the service in 1973. Recruitment of suitably qualified midwives is difficult and the service has consistently been below the desirable staffing levels. Concern is felt about the high numbers of mothers in the "At Risk" categories who continue to book for home confinement, and every effort is made to encourage them to go into hospital for delivery. 39 Training Scheme Throughout the year students of various types spend time training in the community. Below are listed the numbers of students who came to the Borough during 1972: Student nurses—observation visits125 Student nurses from psychiatric unit, two weeks course 6 Student nurses from mental subnormality unit, four weeks course 4 Pupil midwives, three months course 26 Obstetric nurse students—observation visits 27 Midwife Teacher's Diploma students, one week 2 Programmes have also been arranged for nursing officers from other Boroughs and for hospital nursing officers and tutors—a total of fifteen in all. We also arranged a week's course for two Swedish nurses and one Greek nurse who were on scholarship study tours. The total number of students and visitors during 1972 was therefore 208. This figure does not include health visitor students and student nurses taking integrated courses. In addition 47 talks and discussions were given by nursing officers to student nurses as part of their training programme. This participation in training throws a considerable burden on the shoulders of the community staff. Although it is recognised that such training is very necessary, it is sometimes difficult to reconcile training and service needs, and the prospect of increased training responsibilities in the community is worrying. Community care training for student nurses will commence in 1973, and further community training is envisaged in the working party on nursing ("Briggs Report") published late in 1972. In-service training for members of the community nursing staff includes monthly lecture sessions, and special courses in vision and hearing testing and ante-natal psychoprophylaxis instruction. Use is also made of "outside" courses and all the senior nursing officers attended management courses during the year at various centres. Because training and liaison schemes have grown so rapidly and need considerable organisation, a new senior nursing officer was appointed during the year to deal specifically with these fields of work. She is also in charge of the night nursing service. We are most grateful to all those officers in other departments who have so willingly assisted with student training. DENTAL SERVICE (MATERNITY AND CHILD HEALTH) Mrs. B. Fox, B.D.S.—Chief Dental Officer The number of pre-school children examined has continued to rise this year. This is due to the continued efforts made by all dental officers actively to seek out the younger brothers and sisters of attending school children. Posters advising mothers that the first dental examination should be at three years old have been placed in clinic waiting rooms. These have resulted in an increased number of requests for appointments, indicating that many mothers either needed reminding to make an appointment or were unaware of the desirability of early examination. The statistics (see page 124) show an increase in the proportion of pre-school children receiving treatment compared to previous years. This reflects an increase in the amount of preventive dentistry which the service is undertaking and does not necessarily indicate a worsening of the dental health of pre-school children. Treatment may be simply polishing the teeth with a fluoride enriched polishing paste but may also include application of fluoride gels to the teeth, or even diagnostic radiographs. We rarely find children, even very young children, without a toothbrush but they cannot usually use them effectively. Many mothers are anxious to learn how they should teach a child to brush their 40 teeth. In many clinics the child is often shown by the surgery assistant who has received special training for this task. Tiny children are unable to use the complicated techniques often taught to adults and mothers often feel that the job is not being well done when the child uses the "scrubbing" movements which come most easily. In fact, many experts now recommend that this is the best way of cleansing the teeth. It has been disturbing to see an increasing number of Asian pre-school children with rampant caries—this may mean extraction of as many as eight teeth or more before the child is four years old. These are children born in this country but a common factor is heavily sweetened milk given in a bottle at night to children well into their second year. Where possible, health visitors have followed up the children and given the family further instruction in the home. Language and cultural differences may mean our help is not as effective as it might be. Many parents cannot understand why their children's teeth decay. They, themselves, often have excellent teeth as they have frequently had fluoridated water, particularly those from Kenya and some parts of India. Handicapped children present many management problems in the dental surgery so a dental officer has established a routine six monthly visit to the Wren Playgroup for Handicapped Children in South Ruislip. She has visited when the mothers were present at a coffee morning and has found them appreciative of advice on dental health. The children's teeth were also examined so that any dental disease could be found and treated in the early stages. We are now aware that gum diseases, ranging from a mild inflammation to chronic inflammation destructive of bone supporting the teeth, can be found in young children. It may be particularly severe in some handicapped children. Visits by dental officers to day nurseries have continued but lack of staff has meant that these were not as frequent as would be advisable. A number of children have been found to need dental treatment and they have been brought to the dental surgery by members of the day nursery staff. This is of considerable help to single parents. Talks on dental health are being given by dental staff to all expectant mothers attending antenatal classes. Difficulty was experienced in the first half of the year as some ante-natal classes were held at clinics where the dentist was only present for a few sessions a week. Adjustments have now been made so that all mothers now receive dental health education. The aim is to inform them about their own teeth and the problems they may encounter with their children. The majority of mothers receive their dental care from general dental practitioners under the National Health Service. Efforts have been made with newsletters to inform the dental practitioners of the message we give to mothers so that we combine our efforts to give the most effective service. The survey of dental health of five year old children in the Borough carried out in 1971-72 illustrates that there are still many pre-school children with untreated dental decay. Parents may be unaware of the problems caused by extraction of baby teeth and may also be unaware that treatment is available at the school dental clinic. Fortunately many children also attend the family dentist and this is encouraged as the dental clinics would never be able to provide all the examination and treatment facilities required. The emphasis must be on a joint effort by local authority and family practitioner services. Mentally Handicapped The dental department is being approached with increasing frequency by parents of mentally handicapped young people requesting help with dental problems. A dental survey of adults in Uxbridge and Hillingdon Training Centres was carried out in April 1972 to assess the need for dental treatment. It was estimated that 87 per cent of the adults aged sixteen years and over required dental treatment. Their needs covered the whole range of dental services; fillings, dentures, gum treatment, surgery and oral hygiene instruction. As only 45 per cent of mentally handicapped adults attend training centres in the Borough, and the majority of the remaining 55 per cent are at home and unemployed, the need of this group of people for dental treatment is probably great. A service is being provided to advise parents where they may obtain treatment and arrangements have been made with local hospital dental departments to see selected patients. However, it seems evident that present services are not fully meeting the needs of these families. Expansion of existing services, particularly hospital and local authority hospitals, depends on recruiting specialist staff experienced in treating the mentally handicapped. 41 Dental Health Education Fluoridation Exhibition—Hillingdon Show An exhibition on Fluoridation was arranged for the Hillingdon Show in June. Local statistics were produced that demonstrated approximately 60% of 5 year old children in the Borough had dental decay. If the water supply was fluoridated this could be reduced to about 24%. One of the features of the exhibit was an opportunity for members of the public to try and distinguish by taste between local Uxbridge water (containing 0.1-0.3 parts per million Fluoride) and Yiewsley Well water (containing 1.2 p.p.m. Fluoride). There was also a display of topical flucrides and fluoride toothpastes. Part of the exhibition was converted into a mobile unit which has been on display at a number of the clinics. 42 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 "A man convinced against his will, is of the same opinion still" —William Shakespeare During 1972 the health visitors and midwives maintained their high standard of teaching in mothercraft classes. A standardised syllabus has been introduced, this is really a "framework" enabling the individual health educator to bring her own expertise to the class; however, it does ensure that the teaching of mothercraft is consistent throughout the Borough. During November and December a course of psychoprophylaxis classes for new health visitors joining the staff was arranged by Miss Byatt, Chief Nursing Officer, and the Principal Health Education Officer. Dr. E. W. Jones arranged a course of first aid lectures for employees of the Borough; the Health Education Unit participated in this course. The "Welcome to Citizenship" evening involved the unit in a fair amount of preparation. The final presentation showed the work of all sections of the Health Department—midwifery, home nursing, health visiting, dental service, health education and the public health inspectorate. The Hillingdon Show caused many manhours of the health education staff to be directed towards producing an impressive exhibition, the topic being fluoridation of water. The Women's National Cancer Control Campaign kindly made available their mobile clinic in order to encourage the general public to make use of the service provided for cervical cytology and for cancer control. It was disappointing that in spite of the thousands of visitors to the Show so few were sufficiently interested in the prevention of disease to visit the exhibition. It was hoped that regular health education "workshops" and "teach-ins" could be arranged throughout the year. Unfortunately owing to illness and pressure of work, only four were arranged for health visitors; it is hoped that in 1973 a greater number can be organised. During the year, three courses of in-service training were arranged by the Principal Health Education Officer. These were successful due to the co-operation of the medical staff and Miss Wills, the radiographer at the Health Control Unit. Dr. E. W. Jones, Mr. Crane (Safety Officer) and staff of the public health inspectorate were also involved and completed the "team". Two of the courses were for new clerk/receptionists at health control, the third provided in-service training for the shift leaders. All courses appeared to be of value and were enjoyed by the participants. A true evaluation can only be made over a period of time; it is hoped that an assessment can be made during 1973. The students at Brunei University requested a lecture on Venereal Disease followed by a film and discussion. Dr. E. W. Jones and the Principal Health Education Officer were involved and the discussion lasted until very late in the evening. As in previous years, visitors from many parts of the world have come to the unit to discuss health education. All have shown great interest, especially in the visual aids section, for it is in this area that the unit has made rapid growth. Mr. C. E. Read, the health education technician, has produced numerous excellent community health slides. The display work is of a most high standard; this has been achieved in spite of very limited working space and inadequate storage facilities. Many of these visual aids were used by the Principal Health Education Officer to illustrate the work of the Health Department to newly appointed members of the staff during the three induction courses in which the unit has been involved. As in 1971, a pre-retirement course was arranged by the Uxbridge Technical College. The team involved in the health session was Mrs. Gilboy, physiotherapist, Dr. E. W. Jones and the Principal Health Education Officer. The group appeared to enjoy the session and Mrs. Gilboy involved the class in appropriate exercises. To date, contact has only been made with one factory; it is hoped to extend health education to industry as soon as possible. A visit to the Nestles Ladies Club to give a talk on diet and nutrition 43 was much appreciated. However, we still have a long way to go in this field. In conclusion, whilst all that one hoped to achieve has not been fully realised, the unit is now well established and working to capacity. Firm contact has been made and health education talks given at two hospitals but with the reorganisation of the National Health Service drawing near it is hoped to extend the programme without delay. STUDY DAY/TRAINING COURSES Talks Given By Length of Course Audiences Total No. of Persons Medical Officers Public Health Inspectors Safety Officers Radiographer Health Education Staff 3 days Airport Clerk/Receptionists 16 Medical Officer Physiotherapist Health Education Staff 1 day Pre-retirement 15 Medical Officers Health Education Staff 1 day Teachers 30 Medical Officers Health Education Staff 2 days Health Visitors 28 Chief Nursing Officer Health Education Staff 2 days Health Visitors 20 HEALTH EDUCATION DURING 1972 Talks Given By No. of Talks Audience Total Persons Reached Medical Officers 24 Professional Groups 169 22 Local Government employees 105 6 Voluntary Organisations 275 Nursing Staff 521 Mothercraft Classes 849 12 Fathers' Evenings 339 16 Professional Groups 181 9 Voluntary Organisations 318 Dental Officers 30 Mothercraft Classes 360 5 Voluntary Organisations 172 Public Health Inspectors 4 Professional Groups 24 5. Voluntary Organisations 72 Health Education Officers 18 Professional Groups 173 3 Voluntary Organisations 85 3 Local Government employees 75 1 Industrial Group 24 44 IMMUNISATION The previously agreed programme of immunisation continued without amendment during 1972. The number of primary immunisation doses given was less than that in the previous year except in the case of poliomyelitis vaccination, and may reflect the gradual decline in the birth rate. On the 1 st July 1972 the immunisation records were transferred to computer processing in respect of children born on and after 1 st January 1971, and a detailed description of the new procedure is set out below. Experience in other local authorities suggests that this transfer can lead to an increased level of protection against the common disease processes and the figures for future years are awaited with interest. The number of reinforcing doses of vaccine given shows a sharp reduction compared with the previous year and the reasons for this situation are unclear. Significant fluctuations in the number of doses given from year to year do occur but the trend in 1972 has been particularly disappointing. With the virtual eradication of these disease processes by the immunisation programmes now in operation a generation of mothers has grown up for which these diseases hold no real fear. Nevertheless the effective control of these diseases in the future depends on a maintenance of the present immunisation programme. As the children born in 1971 reach school age the appointment system generated by the computer will ensure that individual notification of the need for immunisation is given. In the intervening three years a vigorous health education programme will be necessary to ensure that mothers recognise this continuing need. BCG Vaccination—Production of acquired resistance to tuberculosis The following table gives details of BCG vaccinations carried out during 1972 and the preceding 3 years for children in the 2nd year of secondary school life. Year Children Eligible Children Tested Children Vaccinated Children not vaccinated (Heaf positive) Percentage of eligible children tuberculin tested 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 1972 3,475 3,006 2,825 181 86.5 It will be noted that the number of children in the second year of secondary school life who were eligible for BCG vaccination was higher (3,475) during 1972 than for any of the previous years. A total of 3,006 children volunteered for tuberculin testing and this high acceptance rate (86.5%) no doubt accounts at least in part for the increase in the number of children who were found to be tuberculin positive (181). At 6% of those tuberculin tested the number of children found to be tuberculin positive during 1972 was higher than one would have expected from the rates for the 3 years from 1969 which were 4.6%, 4.5% and 3.9% respectively. All children found to be tuberculin positive are referred to a chest physician for chest X-ray examination and, where considered necessary, follow-up observation. In many cases children found to be tuberculin positive have a history of BCG vaccination earlier in childhood, but although the total number of children found to be tuberculin positive remains comparatively small, the trend in the rate of "conversion" needs clearly to be kept under observation. Rabies Vaccination A Committee of Enquiry (the Waterhouse Committee) set up in 1970 has made recommendations concerning the precautions which should be taken in Great Britain against the introduction of rabies. Although prophylactic inoculation against rabies has been offered to the staff of two kennels in the Hillingdon area for many years, a consideration of the recommendations of the Committee suggested that such prophylaxis might also be offered to certain personnel involved in cargo (including animals) handling duties at London (Heathrow) Airport. From enquiries made it was clear that the number of personnel involved would exceed 3,000 and as a primary course of inoculations would involve three injections over an eight month period and a serological test for rabies anti-bodies would be required after each annual booster dose, this clearly would be quite an 45 undertaking. The present vaccine is prepared as a suspension of embryonic duck tissue and although this has been found to be less likely to produce adverse reactions than the vaccine previously in use the possibility of such reactions could not be excluded if a satisfactory vaccination state was to be retained for so many people during the remainder of their working lives. After personal examination of the methods of handling employed at the Airport by the Director of Health Services it was concluded that the risk to which any individual would be exposed would be minimal, particularly as he was provided with protective clothing and the regulations of the International Air Transport Association in connection with the handling of animals were already very strict. Rabies prophylaxis continued to be offered to the staff of the two kennels already mentioned and blood tests were carried out at regular intervals following booster doses in order to assess the rabies anti-body levels attained. Influenza Vaccination 1971-72 During the winter period of 1971-72 members of the Council's staff approached the department with a view to receiving vaccination against influenza. Vaccine (A2/Hong Kong) was offered to certain selected groups of staff including those involved in duties in residential establishments whose continued services would be greatly relied upon in the event of an outbreak of influenza. A total of 154 such persons were vaccinated against influenza. Although the epidemic of influenza expected during the winter of 1971—72 did not materialise, a total of 7 of the members of staff who were vaccinated did develop the disease compared with 33 out of the 416 other members of staff engaged in similar type duties who were not vaccinated. This gave an attack rate of 8 per 1,000 amongst those who remained unvaccinated against an attack rate of 4.5 per 1,000 amongst those vaccinated. Immunisation statistics are recorded on page 121. THE INTRODUCTION OF COMPUTER PROCESSING OF VACCINATION RECORDS E. W. Jones, M.B., B.S., M.F.C.M., D.I.H., D.P.H., D.T.M. & H. The computerisation of inoculation records has become a widely accepted part of community health services in the United Kingdom. By providing a detailed record of all the children in a particular area, the computer service is in a position to ensure a regular and reliable appointment system for the recommended immunisations. In 1970, the first proposals were made in Hillingdon towards the introduction of a computer system, that would assist the Health Department in carrying out a wide range of medical activities. It was felt in the initial planning stages, that an observation and handicapped child register, hearing and vision test results, and dental inspection notification, should be included as additional information to the basic immunisation computer file. Preliminary Investigation A working party comprising members of the Health Department, the London Boroughs Management Services Unit, and Dr. Knight of the Local Medical Committee, met in April 1971 to formulate a procedure policy. It was recognised that its main purpose was to outline a method of assessing the value to the department, and degree of support among general practitioners, for the computer service. As a result of this meeting, it was decided to adopt three separate lines of investigation. Firstly a feasibility study was undertaken by Mr. Mills of the computer division LBMSU, and a cost benefit analysis made on the transfer of immunisation procedures to the Leo III computer. Secondly an examination of the Hillingdon inoculation rates was carried out by Dr. E. Jones and Mr. Benson. These percentage rates are quoted annually in the Department of Health and Social 46 Security returns, and involve many variable factors. These had complicated the working party's assessment of their true value, in comparison with other local authority rates. Thirdly a statistical survey involving a 20% stratified sample of the Borough's family doctors revealed a considerable degree of support among the general practitioners, and a likely 60% acceptance rate for the computer service. It was concluded from these investigations that the main areas of benefit lay in the provision of a detailed computerised filing system, and the close co-partnership with the Hillingdon family doctors, which would result from their involvement in the scheme. It was decided to recommend the adoption of the computer system, and arrangements were made for the service to commence on 3rd July 1972. The details of each child, who was born on or after 1st January 1971, were entered on the computer file. The working arrangements of the computer section are best illustrated by two "flow charts" which demonstrate the daily inflow, processing and delivery of information within the department, and which are recorded on the two following pages. Computer Statistics Number of Hillingdon Children on the Computer File 6,505 Number of Treatment Centre Clinics 32 Number of family doctors in the service 70 Number of Vision tests recorded 211 Number of Hearing tests recorded 282 Number of children on the Observation Register 1,065 Average weekly number of inoculations 500 The adoption of a computer system has provided a considerable degree of challenge to the Health Department. In the initial months of the service, there were many alterations in working procedures, and the staff were required to adjust to the change from a manual recording system of information to the sophistication of a computer. It is pleasant to record that this difficult period of transition has been carried out smoothly and efficiently. Mr. Benson, Mr. Feasey and the staff in the immunisation and vaccination section have operated the new service with considerable skill, and have received full co-operation from all clinic staff. With the expanding range of techniques in health monitoring and screening, it is confidently anticipated that the computer will play an increasing role in a modern Health Service. By the adoption of the computer system, the Health Department has taken an initial step in preparation for these future developments. 47 RECEPTION OF INFORMATION 48 DISTRIBUTION OF INFORMATION 49 MENTAL HEALTH SERVICES Dr. W. H. G. Batham—Principal Medical Officer—Mental Health Approval of Medical Practitioners Two applications were approved under the Mental Health Act 1959 in respect of medical practitioners having special experience of the diagnosis of mental illness. Dr. Batham, Principal Medical Officer, joined the staff in May. He is approved under the Mental Health Act 1959 as having special experience in the diagnosis of mental illness. Psychiatric Services The work in this field has continued to develop in close association with the social services department and the hospital service with exchange of knowledge and discussions on both topics and individual problems as they arise, including the prevention of mental ill health. Weekly support is given to the staff and residents of Hayes Park Hostel and advice on mental health problems is always available. A psychiatrist visits the hostel every four weeks to advise on the psychiatric treatment of the residents in association with the Warden, Deputy Warden and the Principal Medical Officer. A general practitioner attends the Hostel twice weekly and, in addition to this, any emergency treatment which may be required. Close association with the Psychiatric Unit at Hillingdon Hospital (In-patients and Day Hospital) was secured during the year by the attendance of the principal medical officer on one session each week with Dr. Wiseberg and Dr. Freeman the Consultant Psychiatrists at the Unit. This has given rise to a first-class opportunity for exchange of ideas to provide the best service for the patients within the catchment area. Weekly contact is also made with the senior social worker, psychiatric nurses, clinical psychologist, registrar and senior house officers in psychiatry. Advice is now given to students at Uxbridge Technical College by the Principal Medical Officer (Mental Health) on psychiatric problems, personality disorders, or general difficulties of a psychological nature through the student adviser. Mental Subnormality Health visitors pay regular home visits every six months to help and counsel the parents of children under the age of sixteen years, and as a result of their reports the best available help is obtained from the departments including the social services department. The communication channels, co-ordination and liaison in this sector have progressed satisfactorily during the year. Dr. Finn, the consultant psychiatrist at Leavesden Hospital undertakes consultations and domiciliary visits in the Borough as requested. This system works very well and provides a good service. Future Developments The continued emphasis on community care for the mentally handicapped and also for the mentally ill requires close co-operation and liaison with both the social services department and the hospital services, and this has developed throughout the year. Planning for the present and long term is vital for the service and medical administrators, community physicians and specialists in community medicine should find a major role in the planning, monitoring and liaising with the medical consultants, hospital service, social services department and voluntary organisations in order to ensure the best service possible for the mentally handicapped and the mentally ill. The date set for the unification of the N.H.S. 1 st April 1974 should lead to a new challenge in community medicine including preventive medicine. Moorcroft School for E.S.N. Pupils Twice weekly visits during term time are made to the school by the Principal Medical Officer to carry out routine medical inspections and I.Q. assessments. This affords opportunity to discuss with parents the child's welfare and placement. The school nurse is very valuable in the special care unit liaising between school, home and medical officer. 50 Monthly visits are paid in term time by Dr. Jones, assistant principal medical officer, to talk and discuss with the staff topics associated with the mentally handicapped. Drug Abuse The Drugs Advisory Panel composed of professional workers from various Council departments and other medical and social agencies in the area met on two occasions during the year to consider the extent of drug abuse in the Hillingdon area. It was concluded that whilst Hillingdon was not exempt from the general problem of drug abuse in the London area there was no particular local problem requiring vigorous action. A small focus of heroin abuse was identified during the year and appropriate preventive action was taken. The Director of Health Services spoke at a conference at the Hospital Centre concerned with the problems of drug abuse throughout Greater London. The role of the Drugs Advisory Panel in Hillingdon was described and some assessment of its effectiveness given. It was concluded that the panel had made a significant contribution towards a responsible approach to this problem in which the dangers of over-reaction are very well known. The local press were particularly helpful and featured an article based on an interview with the Director of Health Services. This was accompanied by an invitation to those with drug problems in the area to approach the newspaper on a confidential basis. The negligible response to this approach appeared to confirm the view of the Drugs Advisory Panel that the present facilities in Hillingdon were responding satisfactorily to the identified need. HOME DIALYSIS During 1972 a request was received from a London Hospital for the necessary arrangements to be made for the installation of equipment so that a resident of the Borough could be provided with facilities for intermittent haemo-dialysis to be carried out in his own home. The home circumstances did not permit a room to be adapted for dialysis so a Portakabin Unit had to be provided. This is the fourth unit to be provided for dialysis patients in the Borough and makes a total of 8 Hillingdon residents who are now making use of artificial kidney machines within their own home environment. RECUPERATIVE HOLIDAYS The number of persons placed on recuperative holidays during the past five years is given in the following table. Adults School Children Arranged Taken 1968 65 53 15 1969 44 26 2 Arranged Taken 1970 48 29 12 10 1971 43 29 9 8 1972 19 11 15 7 It will be seen that the number of persons who availed of the recuperative holiday scheme during 1972 was much smaller than in previous years. There is no clear explanation for this decrease in numbers although it is likely that some elderly persons who in previous years would have applied to the Health Department for placement on recuperative holiday are now availing of the services provided by the social services department and the old persons associations. Of the 11 adults who were placed on holiday, 9 were assessed to pay the £2.00 per week minimum accommodation charge while 2 persons paid the maximum charge of £8.40 per week. A total of 16 patients (8 adults and 8 children) who had applied for recuperative holidays did not for various reasons proceed with the arrangements. 51 SECTION III Environmental Health "As we enter the global phase of social evolution, it becomes obvious that each one of us has two countries—his own and the planet earth." —Rene Dubos (UN Conference on Environment 1972) 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 Three water companies supply the Borough:— Rickmansworth and Uxbridge Valley Water Company, Colne Valley Water Company and the South West Suburban Water Company. The results of chemical analysis of water from these three companies 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 (Znl) Not detected Not detected Not detected Copper (Cu) 0.15 Not detected Not detected The fluoride content of the respective water supplies is as follows: South West Suburban Water Company 0.262 parts per million Colne Valley Water Company 0.075 parts per million Rickmansworth & Uxbridge Valley Water Company 0.25-1.4 parts per million The naturally high fluoride content of one of the wells supplying the Borough accounts for the variation in the case of the Rickmansworth and Uxbridge Valley Supply. 55 A survey was carried out on behalf of the Chief Dental Officer to determine the fluoride levels at the draw off points in houses at varying distances from the source of this supply. PRIVATE WATER SUPPLIES One house is still dependent upon a well for supplying water and a number of factories use wells for manufacturing and process work. Periodical checks are made on water drawn from storage tanks or supplied through dispensers etc. 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 41 Nil 41 From mains supply via storage tanks, etc. 9 1 10 Private supply 9 Nil 9 Drinking water dispensers 2 1 3 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. A contract involving work to the value of £399,000 for foul and surface water sewerage in the Ickenham/Hillingdon area was started in April 1972 and is expected to be completed in July 1973. Further works estimated to cost £684,000 have been designed and are programmed to start in 1974. 56 The resewerage of Harefield which includes the replacement of the Dews Farm Pumping Station was started in August 1972 and is expected to be completed in May 1974. The total estimates cost of these works is £386,000. Surface water relief works are in progress at Nine Elms Farm Estate, Cowley at a cost of £78,000. A contract was started in January 1973 for resewerage works in the Northwood/Ruislip area costing £961,000. The works are planned to be finished by June 1975. Authority for the resewerage of the Harlington area at an estimated cost of £1,073,000 has been received from the Department of the Environment. It is aimed to start in July 1973. Proposals have been approved by the Council for: Surface water sewers in the Bath Road/Colnbrook By-Pass area at an estimated cost of £250,000. These works will start in July 1973. The Springfield Road area in Hayes will be provided with a new surface water sewer in 1973/74 at an estimated cost of £45,000. The total estimated cost of the work the Council has authorised to date is approximately £5,000,000, this being the work entailed in 6 of the 10 resewerage areas of the Borough. 57 ANNUAL REPORT OF THE CHIEF PUBLIC HEALTH INSPECTOR Mr. A. Makin, M.R.S.H., F.A.P.H.I. The implementation of the career development scheme has resulted in a full establishment of public health inspectors for the first time since the formation of the Borough in 1965. The scheme has resulted in a positive approach to the work and it has been a most pleasant and rewarding experience. During the year considerable work on pollution has been initiated viz: (1) The establishment of a working party to be known as The Town Clerk and Chief Executive's Working Party on Pollution with the Chief Public Health Inspector in his capacity as Pollution Officer of the Council holding regular meetings, in accordance with a planned programme, of a small working group composed of members of the planning department and the principal assistant solicitor and such members of other departments as are appropriate for the purpose of identifying and investigating sources of pollution and proposing to the Town Clerk and Chief Executive for the consideration of the Committee steps to be taken within the Borough for the solution of the continuous problem of the many activities which involve pollution of the atmosphere, the ground etc., in accordance with the following terms of reference: (a) The Chief Public Health Inspector will be designated "Pollution Prevention Officer" of the Council. 59 (b) The Chief Public Health Inspector shall thus be responsible for ensuring that effective measures are taken to combat pollution in whatever form it may manifest itself in the Borough whether ground, water, air, fire, smell, aural, visual, health etc., and shall take steps to ensure that the necessary research is undertaken not only to identify instances of pollution occurring in the Borough and the causes thereof but also to establish the means of dealing with the pollution and its causes together with further examination of additional powers or the means whereby more effective action can be taken to eliminate existing pollution and prevent further pollution occurring in any form. This action committee met three times during 1972 and is in the process of preparing a report on the present pollution problems in the Borough. (2) The support of a research programme on the environmental quality in Hillingdon to be carried out by Brunei University. This is to be directed by Professor Bond, Dr. Lacey, Mr. Thorburn and Mr. Jones of the University and the work of research will be undertaken by five graduates working for higher degrees, two of whom are already employed as public health inspectors by the Borough Council. The research will be in four parts: A. AIR POLLUTION—A survey of the major atmospheric pollutants in the Borough with special reference to "kerosene" odours associated with London Airport. B. WATER—A survey of the waters in the Borough and in the Colne Valley Park. C. LAND—A historical survey of the gravel and sand workings in the Borough and the reclamation of the areas by filling with refuse. The fate of refuse in the tips from biological, chemical and physical activity. D. ECONOMIC ASPECTS—An investigation into the economic aspects of pollution in the Borough. AIR The Clean Air Acts 1956 to 1968 authorise local authorities to undertake publicity and research concerning atmospheric pollution. This legislation also enables pollution of the atmosphere from a number of specific sources to be controlled i.e. (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 also have general powers under other public health legislation to control emission of dust and offensive effluvia from industrial processes. Some information as to the endeavours made to improve the atmosphere in this Borough are set out under the various headings. Research into Atmospheric Pollution In addition to the monitoring of atmospheric pollution carried out by staff of the health department, in September arrangements were made between the authority and Brunei University for a research programme into atmospheric pollution with particular reference to kerosene pollution from aircraft. The research programme is expected to extend over 3 years. SMOKE CONTROL PROGRAMME The smoke control programme made good progress in 1972. Five smoke control orders were originally made to become operative in 1972 but it was necessary to postpone the date of operation 60 of two of these until 1973. These postponements were necessary to permit the re-organised maintenance division of the Housing Department to adjust to the accelerated programme. It is not anticipated that this will be a permanent difficulty and a further five areas were surveyed in 1972 and orders have been made so that a total of 7 orders will become operative in 1973. Measurements of Smoke and Sulphur Dioxide in the Atmosphere The routine monitoring of the daily smoke sulphur dioxide in micro-grammes per cubic metre in the atmosphere was carried out at the 7 stations already established in the Borough. A table showing the monthly averages for both smoke and sulphur dioxide is set out on page 62. The stations are designed to operate continuously for seven days without attention and in the event of a breakdown monthly averages are not calculated as the results obtained from the lesser number of days would be inaccurate. For this reason some monthly results are not shown. Towards the end of the year the station at West Drayton was discontinued to permit some checks to be made at another location. The equipment was adjusted so that it required daily attention but gave recordings at 3 hourly intervals throughout the 24 hours in preference to giving a single daily return. It was gratifying to note that although there was an inversion, and fog occurred for several continuous days during the December period there was little or no evidence of smog in the Borough, the highest smoke concentration was in Northwood. INDUSTRIAL CHIMNEYS The Clean Air Act requires that the intention to install any industrial furnace, or any domestic furnace with a rating of 55,000 or more Btu/hour shall be notified to the local authority. During 1972 notifications of the intention to install 27 furnaces were received. One of these related to a solid fuel domestic furnace, 10 related to gas furnaces, 14 related to furnaces burning light fuel oil which has a lower sulphur content than solid fuel, one to a furnace burning heavy fuel oil which has a sulphur content greater than solid fuel and one to an incinerator. Thirteen inspections were made in connection with boiler installations and chimneys and no contraventions were recorded. In addition to the formal notifications received, one large industrial boiler house in the Borough converted its boilers from burning heavy fuel oil to permit the burning of dual fuels, natural gas and heavy fuel oil. The natural gas is used as the main fuel but oil has been retained for emergency use. This conversion should cause a considerable improvement in the atmosphere in the immediate vicinity of the boiler house by reducing the sulphur dioxide content in the atmosphere. Where a new furnace has a rating of a million and a quarter or more Btu/hour in addition to notifying the intention to install a furnace, approval has to be obtained to the chimney height. This control is to ensure that the ground level concentration of sulphur dioxide is kept within reasonable limits. Six applications for approval were received, in each case prior consultations had taken place and it was not necessary to refuse any of the applications. A proposal to include in a Greater London Council (General Powers) Bill a restriction to the use of light fuel oil only i.e. that which has a sulphur content of less than solid fuel was supported but only providing the condition was adoptive and not compulsory. The present sulphur dioxide level in this Borough would not justify imposing additional expense on those individuals using heavy oil. INDUSTRIAL BONFIRES Under the provisions of Section 1 of the Clean Air Act 1968 it is an offence for dark smoke to be emitted from industrial bonfires. One such offence relating to the emission of dark smoke from burning of waste on an industrial refuse tip was observed and legal proceedings have been authorised. The case has not yet been heard. Thirteen complaints of nuisance from industrial bonfires were investigated in 1972. SMOKE NUISANCES 147 complaints of smoke nuisance were received during 1972 and 408 visits were made in an attempt to abate and prevent recurrences of such nuisances. No legal action was recommended 61 62 Monthly Averages for Smoke and Sulphur Dioxide in Microgrammes per Cubic Metre for 1972 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 Drayton Hall, Station Rd., West Drayton Smoke SO2 Smoke SO2 Smoke SO2 Smoke SO2 Smoke SO2 Smoke SO2 Smoke SO2 January 57 81 44 140 55 142 45 148 55 81 45 131 82 179 February 51 101 45 166 50 160 48 149 58 96 45 148 March 45 121 47 184 80 232 53 133 50 189 80 252 April 11 77 18 96 10 70 11 54 12 74 24 87 May 11 56 21 78 10 56 14 39 13 61 29 78 June 9 24 9 44 19 60 9 41 20 43 July 9 30 11 50 17 62 10 44 11 34 10 54 31 66 August 16 40 17 61 24 52 18 43 22 40 September 35 63 34 69 44 85 33 89 39 55 47 83 October 28 66 24 88 35 105 24 90 33 70 26 95 November 36 57 31 96 43 102 33 88 37 55 29 91 December 55 105 46 144 38 146 47 108 42 161 arising from these visits. A number of locations exist in the Borough where people can take and deposit any type of refuse. It is regrettable that while many people are urging that central and local government increase their efforts to provide a better environment, some people still find it necessary to burn garden refuse. DUST AND GRIT It was not necessary to serve any formal request to measure the emissions of dust and grit from a plant in the Borough. 19 complaints of nuisance from dust were investigated, no legal action was recommended against any of the persons causing the complaint. INDUSTRIAL AND OTHER ODOURS There were 214 inspections in connection with fumes from industrial boilers and processes and 700 inspections in connection with offensive odours from other sources compared with 245 and 892 respectively in 1971. The perchloroethylene emissions from twelve coin operated dry cleaning establishments were checked and found to be satisfactory. In addition the plant at 8 dry cleaning premises where the equipment is operated by the staff was also checked and at one of these the emission was considered to be excessive and the equipment was renewed. The emission of obnoxious fumes from a newly established factory engaged in anodising was found to be unsatisfactory and created a nuisance. This process is under the control of the alkali inspectorate and modifications to the plant fume scrubbing tower have been carried out. Extensive modifications were again carried out to the fume extraction system at a factory in Harefield handling pitch fibre pipes. This again is a process under the control of the alkali inspectorate and while there has been considerable improvement over the past years it is still not possible to say that this problem is satisfactorily solved. Unfortunately there have been a number of fires in refuse tips where tipping is no longer taking place. These caused nuisance to the local residents both from smoke and smell. It is virtually impossible to extinguish a fire which has a good hold on the material in the tip other than by isolating the section which is on fire from the rest of the tip before attempting to put out the fire. This is a costly operation and, whenever the interior of a refuse tip which is not completely inert is opened up, there is always a danger of further fires. WATER SWIMMING POOLS There are 23 swimming pools in the Borough of all sizes from small hotel pools to public baths. They are divided as follows: Covered Pools Open Pools Public 2 3 Private schools 3 Local authority schools 3 4 Clubs 1 2 Hospitals 2 Hotels 1 2 Many of the pools are unheated and during the past year, due to the poor summer weather, these received very little use. One local authority school was out of use during the whole season whilst a cover was erected by its parent teacher association and another developed faults which prevented its use. Regular tests are carried out on pool waters to ensure the efficiency of the water purification 63 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. Details of the samples taken and the results obtained are set out in the following table. Satisfactory Unsatisfactory Total Bacteriological examination 6 20 26 Chlorine determination 48 7 55 Bromine determination 2 — 2 The 20 unsatisfactory bacteriological results were all taken from Ruislip Lido. 4 of the 6 satisfactory were also from the Lido. These unsatisfactory samples do not represent any danger to health as they included investigations into the problem of adequately treating the area of the lake used for bathing purposes. The water in the bathing area is subject, not only to natural turbulance but also to the disturbance created by boating activities. This results in treated water being constantly diluted by the main body of water in the lake. There has been close liaison with the Director of Parks and Recreation and the pipe work distributing the chlorine is at present being renewed and extended to ensure an improvement in the efficiency of the water treatment. FOOD One of the most important duties placed upon a Local Authority is the protection of food supplies. It is also one of the most difficult. Legislation provides the statutory controls and the sanction for failure to comply with the laid down standards and the enforcement of the multitudinous requirements so necessary to maintain the safety and quality of the food supply throughout the Borough rests with the public health inspector. The enforcement of these regulations brings the inspector into daily contact with those involved in the many trades and interests which make up the food industry. From the foreman to the factory manager, from the agricultural worker to the continental driver of a container lorry, he learns of all the practical difficulties involved in complying with the standards fixed by law. He deals with architects during the design stage, engineers and builders during the construction stage and management when the premises are operational. He is consulted about constructional problems, operational difficulties, staff shortages and, in an increasing number of cases, is finally presented with a language barrier as the number of foreign workers in the food trade increases. A report such as this can only briefly outline the problems encountered and the action taken to deal with them. MILK AND MILK PRODUCTS The safety and quality of milk is the subject of a system of statutory control and licensing covering all stages of production, processing and distribution. There remains a loop hole in these safeguards in that milk, which has not been subjected to heat treatment process may still be sold, as provision is made for this to take place under the designation "Untreated". While the amount of this class of milk sold in the area is relatively small it does constitute a possible risk to health. Tuberculosis has been eradicated from the diary herds in the United Kingdom and progress has been made in the eradication of Brucellosis. With two exceptions all of the milk from the 15 dairy farms in the Borough is sent for processing. In both the exceptions quoted, milk is bottled on the farm and without heat treatment supplied to the customer. In one case there is a direct sale while in the other, sale is via a major dairy company to members of the Jewish faith. The Brucella ring test is an indicator test for the possible presence of Brucella abortus, positive identification being by way of guinea pig inoculation. The presence of Brucella abortus was not confirmed in any of the samples taken. The T.T.C. test indicates the presence of antibiotics in the 64 Food Hygiene—Meat Inspection milk which may arise through failure to reject the milk of an animal which has been given an antibiotic preparation, usually for the treatment of mastitis. The positive result obtained resulted from such a failure and a warning was issued to the farmer responsible. The T.T.C. tests were carried out by the Public Health Laboratory Service. The following table gives details of the number of samples of raw milk taken and the result obtained. Brucella ring test Guinea pig inoculation TTC Test Negative Positive Total Negative Positive Total Negative Positive Total 111 8 119 3 0 3 36 1 37 Processing Plants There are two dairies within the Borough where milk is pasteurized and bottled. Regular inspections are made to ensure the efficiency of the processing operations and washed bottles and churn rinses are periodically taken for laboratory examination as a check on the efficiency of the cleaning methods. The following table shows the results of the washed bottles and churn rinses submitted for laboratory examination: Bottles Churns Satisfactory Unsatisfactory Satisfactory Unsatisfactory 40 10 14 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 140 Registered Dairies 2 Licences to use special designations: (a) pasteurised 123 (b) sterilised 74 (c) ultra heat treatment 101 (d) untreated 18 (e) Dealers licence (pasteurised) 2 In addition to the traditional milk round, milk is increasingly being distributed through grocer shops and supermarkets where the storage conditions and efficiency of stock rotation have to be carefully watched. The results of all milk samples taken for the statutory tests are set out in the following table: Pasteurised—Phosphatase test Untreated-—Methylene Blue test Satisfactory Unsatisfactory Satisfactory Unsatisfactory 13 — 8 — 65 One of the disturbing features in connection with the distribution of milk is the dirty milk bottle. Invariably the dirty bottle is the result of misuse of the bottle by the public—the bulk of the dirty bottles contain cement as the result of lying about on building sites, but there are many other sources of contamination e.g. the use of bottles for paint, for the discharge of fireworks and as substitute flower vases. When these bottles are returned to the dairies they are subjected to a standard cleaning process which is most efficient in dealing with the average returned bottle but is incapable of coping with bottles used as described. These bottles should be removed in the inspection process but there is a high proportion of failure in the inspection systems which will only be resolved by reducing the speed of the inspection cover or by the provision of more efficient electronic scanners which will automatically reject the unsatisfactory bottle. Cream The Public Health Laboratory Service applies the methylene blue test to cream and any failure indicates the need for closer examination of the handling and storage of the product. The failures reported were invariably due to excessively long storage or storage at incorrect temperatures. The results of cream samples submitted for methylene blue test are as follows: Satisfactory Unsatisfactory Total Major dairy companies 49 18 67 Farm produced 3 1 4 Catering sales 2 2 4 Total 54 21 75 A failure rate of 28% is most unsatisfactory but it is a slight improvement on last year's failure rate of 36-3%. Inspectors are now able to give more attention to the storage of this type of food and the position should greatly improve in the future. Ice Cream The methylene blue test as applied to ice cream affords a provisional assessment of bacterial cleanliness of the product. Most of the failures were due to faults in the storage and handling of the product. The principle fault being failure to properly sterilise the utensils used in the final dispensing of the ice cream. Details of the samples taken are set out in the following tables: Results of all samples taken: Vehicles Premises Grade 1 2 3 4 1 2 3 4 Soft ice cream 1 4 1 3 26 4 5 — Hard ice cream 10 — — — 25 4 4 — Total number of ice cream samples taken 91. 66 Results of ice cream samples: Grade No. Taken Percentage 1 66 71 (73) 2 12 13 (12) 3 12 11 (7.5) 4 3 5 (7.5) Percentages in brackets 1971. MEAT There is one privately owned slaughterhouse in the Borough where cattle, sheep and pigs are slaughtered. All the carcasses are inspected in accordance with the Meat Inspection Regulations 1963 to 1966. 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 265 2 7 357 3,961 All diseases except Tuberculosis and Cysticerci Whole carcasses condemned Carcasses of which some part or organ was condemned 66 1 2 2 14 11 942 Tuberculosis only Whole carcasses condemned Carcasses of which some part or organ was condemned 6 Cysticerci Carcasses of which some part was condemned 5 Carcasses submitted to refrigeration Generalised and totally condemned 5 67 Condemnation (All Causes) Quantities Pound Weight Cattle Calves Sheep Pigs Carcass Offal Carcass Offal Carcass Offal Carcass Offal Abscess 16 184 3 3 646 33 Arthritis 18 35 Ascariasis 65 4½ 5661 Bruising 18½ Cysticerci 65 Emaciation 12 30 Fascioliasis 223 Haemorrhagic 14 Hepatitis 15 Parasitic 7 5 9½ 107 Pericarditis 10 142 1 5oz Peritonitis 2 Pneumonia/ Pleurisy 97 2 9734 Pyaemia 224 2 Septicaemia 45 Telangiectasis 98 5 Tuberculosis 62 Other conditions 195 20 54 573 132½ Total 99 896 20 5 60 29½ 15884 1958 11 oz Total of all meat condemned—2 tons 1 cwt 64 lbs 11 oz POULTRY INSPECTION There is occasional slaughter of poultry on a number of farms within the Borough. The main involvement of the inspectorate in poultry inspection is at a processing establishment which deals chiefly with birds that have been slaughtered and plucked outside the Borough where the birds are eviscerated and either packed and frozen or sold fresh. A small amount of ritual slaughter also takes place at these premises. In accordance with the Ministry of Agriculture, Fisheries and Food birds which show evidence of disease on evisceration are rejected and retained for examination by the meat inspector. Details of the poultry processed are given in the following table: Chickens Hens Ducks Geese Capons Turkeys Total 60,450 3,267 107 6 294 8,263 72,387 INSPECTION OF OTHER FOOD As a matter of policy all food premises are inspected not less than twice a year and food manufacturing premises and premises on which open foods are handled, not less than 4 times a year. During the course of these inspections in addition to food hygiene matters, attention is paid to the type and condition of the food on the premises. Note is taken on manufacturing premises of the presence of preservatives and colouring matters. Unfit food found on food premises may be seized and taken before a Justice of the Peace for consideration and subsequently if unfitness is confirmed legal proceedings may be taken for the possession of that food although it is more usual for traders to ask inspectors to call on them to deal with food they themselves consider to be unfit. Details of the unfit food surrendered are set out in the following table. 68 Unfit Food Surrendered Class of Food Weight (lbs) Fresh Meat 5,882 Fresh fish 99 Fresh fruit 165 Fresh vegetables 4,943 Frozen meat 5,300 Frozen fish 4,448 Frozen vegetables 7,991 Frozen fruit 154 Canned meat 2,038 Canned fish 167 Canned fruit 4,802 Canned vegetables 3,584 Canned soup 541 Canned dairy produce (milk, cream and evaporated) 619 Canned meals 73 Poultry 1,367 Cereals 271 Flour confectionery 967 Sugar confectionery 904 Fruit juice 1,678 Cheese 57 Other foods 2,716 Total 48,766 lbs Totals 1968 53,264 lbs 1969 39,494 lbs 1970 57,941 lbs 1971 30,869 lbs Food Complaints The number of food complaints has again risen which has been the regular pattern except for 970. The comparative figures are: 1967 1968 1969 1970 1971 1972 114 155 181 175 192 202 The investigation of food complaints is a time consuming operation involving the careful collection of all the evidence in order that proper action may be taken. A proportion of the complaints are found to be "false alarms" the food itself being quite sound, while in other cases the delay in bringing the matter to the attention of the department makes it impossible to determine who is responsible. From time to time instances occur where the complainant is unwilling to give evidence in a court of law and in such cases the matter has to be dealt with informally. Twelve prosecutions were taken as a result of food complaints and details are set out in the table on page 71. A further 12 prosecutions are due for hearing in 1973. Legal proceedings were instituted against the company which supplied catering packs of sponge pudding mixture to the Borough's schools. Bags of mixture delivered to eight schools 69 were found to be infested with Ephestia Cautella (Tropical Warehouse Moth) and unfit for human consumption. Proceedings were taken under section 9 of the Food and Drugs Act 1955. The defendant company accepted liability for the sale but pleaded a warranty against the manufacturers under section 115 of the same Act. However, as the product was manufactured in Scotland, the case against the defendant was dismissed under section 114 and the matter was referred by the magistrates to the Procurator Fiscal in Scotland. To date no further action has been reported. This is the second case against this particular company which has been referred to the Scottish authorities under section 114 of the Food and Drugs Act 1955. The previous case concerned mice droppings in similar bags of sponge mixture and on that occasion no further action was taken after the case had been referred to Scotland. It is regrettable that as the law exists at present serious offences can be committed without the imposition of any penalty. The complaints are classified in the following table: Food Foreign Matter Mould Other Type of Foreign Body Bacon 1 3 Maggotts Beer 1 Beverages 1 Moth Biscuits 1 1 Bread 26 14 10 Dirt, Oil, Cockroach, Fruit stone, fly, brawn, dough, husks, wood, grease, gauze, carbonised dough, sacking, string, cigarette end, rubber, knife blade Butter 1 String Cereals 1 Weevil Cheese 1 3 4 Tin foil Chocolate spread 1 Cornish pasty 1 1 Bovine Cheek Confectionery 6 3 7 Hair, fruit stalk, maggott, plastic insect Cream 5 Eggs 2 2 Fish 2 2 Parasites Fruit canned 2 2 Crystals, fly Fruit/dessert 2 2 Instant Whip 2 Margarine 1 Bead Meat/Meat products 4 8 5 Screw, hair, spider, skin Milk 7 9 Bones, glass, rusty filings, dirt Preserves 1 Sausages 5 2 3 Bristle, nail, bone, beetle, metal tag Sausage roll 1 Finger dressing Vegetables 4 3 4 Worm, beetle, slug, vegetable debris Yoghourt 1 2 Other Foods 8 3 21 Insects, carbonised matter, crystals, bone, dirt, grit, hair Total 72 43 87 Total: 202 Food Complaints 70 Details of twelve prosecutions taken as a result of food complaints: Offence Statute Trade of Defendant Fine Costs Total Selling a mouldy cream Sect. 8 Food & Drugs Wholesale Dessert Act 1955 Dairyman £40 £5 £45 Selling yoghurt containing mould do. Grocer £25 — £25 Selling mouldy Cream Grocer £20 £5 £25 Dessert do. Insect in a Raspberry Pie Section 2 Confectioner £50 — £50 Insect in Honey do. Food Manufact. £10 £10 £20 Insulation tape in a sausage do. Food Manufact. £10 £10 £20 Insect in a bun do. Baker £25 £8 £33 Metal in loaf do. Bakers £100 £15 £115 Finger dressing in a sausage roll do. Food Manufact. £40 £5 £45 Foreign matter in milk do. Wholesale Dairyman £50 £10 £60 Selling mouldy yoghurt do. Wholesale Dairyman £5 £5 £10 Selling prawns described as lobster do. Caterer £20 £5 £25 It is felt that the increase in complaints which have been reported does not necessarily indicate a deterioration in the standards of food production and handling, rather, it reflects an increased consumer awareness in such matters. A contributory factor to the increase is the impersonal service of the large food market as it is so much more difficult to complain than it was to a family grocer. In these circumstances the complainant finds it easier to deal with the local authority. While these complaints are welcomed and are a valuable part of food control, it is to be hoped that the interests of the consumer will soon embrace the insanitary habits and practices which exist in many food shops. FOOD AND DRUGS ACT 1955 Samples examined in the Departmental laboratory Food Satisfactory Unsatisfactory Total Buttered rolls 5 5 Canned fruit 4 4 Cream 11 11 Cream confectionery 6 6 Food colours 8 8 Jam 1 1 Jelly 7 7 Milk 62 3 65 Mincemeat 10 10 Sausage rolls 4 4 Spirits 16 16 Vinegar 1 1 Totals 135 3 138 71 Details of food examined in accordance with the Food and Drugs Act 1955 are set out in the following table: Examined by the 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 Beefburgers 2 Instant Whip 1 1 Beer 2 Lobster 5 3 Beverages 2 Mayonnaise 3 Biscuits 10 2 Meat and meat products 31 Bread 1 3 Cake & Pudding mix 1 1 Milk and milk products 5 Canned fish 6 Minerals 1 Canned fruit 10 1 Pasta 1 Canned meat 4 Pate 8 Canned vegetables 15 Pickles 1 Cereals 3 Pizza 1 Cheese 19 2 Pork in batter 1 1 Coffee 3 Poultry 2 Confectionery 2 21 3 Powdered fruit Cooking oil 1 dessert 1 1 1 1 Croquettes 2 Preserves 4 Curry 4 Puree 1 Dairy produce 1 Salad cream 1 Dried milk 1 Sauce and sauce mixes 15 Drugs 17 Essences 1 Sausages 17 19 Fats 1 Sausage rolls 1 Fish and salad 1 Soup 1 7 1 Food (baby) 1 1 Spices and savoury spreads 5 Frankfurters 4 11 3 1 Fruit juices 13 Vegetable juice 1 Hamburgers 2 2 Vinegar 1 Ice Poles 1 1 Indian foods 21 4 Instant potato 4 Total: 39 289 9 17 72 A further 37 samples of milk were examined by the public health laboratory for the presence of antibiotics, all but one of which were found to be satisfactory. A total of 503 food and drug samples were examined of which 29 or 5-8 per cent were classed as unsatisfactory. Details of the action taken regarding the unsatisfactory samples are set out in the following table: Product No. Contravention Action taken Sweet and sour pork 1 Excessive amount of gristle in the meat Advice given to manufacturer Sugar confectionery 4 Incorrectly labelled (2) Containing foreign matter (1) Label amended Warning letter sent Cheese spread 1 Containing foreign matter Prosecution awaiting hearing Indian foods 3 Incorrectly labelled Label altered in respect of the two samples Third sample investigation still proceeding Flour confectionery 2 Incorrectly labelled Product fermenting Alterations made to label Stocks withdrawn Bread 1 Containing foreign matter Warning letter sent Canned sausages 4 Deficient in meat (3) 2 prosecutions taken. Fines of £25 and £10 imposed in each case. 1 warning letter sent Incorrectly described While label was considered inaccurate there was insufficient evidence to justify legal proceedings Lobster 3 Incorrectly described 3 prosecutions taken 1 case dismissed, second case a fine of £5, costs £5 Third case £20 and £18 costs on each of the two defendants Dessert mix 2 Incorrectly labelled Labels amended Soup mix 1 Incorrectly labelled Label amended Imported figs 1 Incorrectly labelled Advice given re: labelling Baby food 1 Incorrectly labelled Investigations continuing Cheese 1 Incorrectly labelled Investigations continuing Milk 3 Low fat content Farm sample, advice given regarding bulk mixing of supply. Legal Proceedings The average period between the matter being reported for legal proceedings and the court hearing is six months during which time, in the case of food hygiene contraventions, the premises may continue to sell food under dirty conditions. In certain cases where the charges are defended and adjournments of the hearing obtained, this interval may be considerably longer. In view of this and the fact that it is obviously in the interest of both the proprietor and his customer that money is better spent in affecting improvements rather than in paying fines, every effort is made to obtain the necessary remedial action without resort to prosecution. There are however cases where it is not possible to effect improvement except by formal action and in order to speed the process of dealing with these unsatisfactory cases the Council agreed to recommend the inclusion in the Greater London Council (General Powers) Bill 1973 of a clause enabling application to be made for the closure of premises where contraventions of the Food Hygiene Regulations were likely to endanger health. This clause would apply until the court had the opportunity of hearing the summonses concerning the contravention. 73 Seven prosecutions were taken for hygiene offences, five being in respect of contraventions of the Food Hygiene (General) Regulations and two for contraventions of the Food Hygiene (Market Stalls and Delivery Vehicles) Regulations. Prosecutions concerning food hygiene contraventions found at two restaurants and a bakers shop are due for hearing in 1973. Details of the prosecutions taken are summarised below: Statute Nature of Business/ Occupation of Defendant Fine Et Costs Remarks Food Hygiene (General) Regulations 1970 Butchers £50 Food hygiene offences Grocer £80 do. Take away food shop £75 do. Restaurant proprietor £20 Hygiene offences Restaurant proprietor £15 do. Food Hygiene (Market Stalls Delivery Vehicles) Regulations 1966 Food Hawker £5 do. Fruit puddings contaminated by mouse droppings found in a dry goods store room of a restaurant where other mouse droppings were present resulted in a prosecution being taken against the proprietor. The charges, which were brought under the Food and Drugs Act 1955 and the Food Hygiene (General) Regulations 1970 were dismissed but no costs were awarded against the Council. An appeal is pending. Unfit food found in another restaurant resulted in the proprietor being fined £60 with £10 costs. FOOD HYGIENE The standards of cleanliness in relation to the handling and preparation of food for human consumption vary considerably and at most premises difficulties are experienced in consistently maintaining the high standards which are so essential. Cleaning is a task which is not very popular, cleaning operations are frequently not planned to a schedule and when they are insufficient supervision is given with the consequence that even the conscientious worker is encouraged to skimp his task. Dirt accummulations due to neglected cleaning are the most frequent contraventions found. To offset this difficulty very close attention is given to all proposals for new food premises, alterations etc., which are received by the Director of Planning and made available to this department. Such proposals are assessed for compliance with the various regulations and particular attention is given to avoiding any possible contraventions of the Food Hygiene Regulations. In addition to examination of the plans for compliance with the Regulations, recommendations are made concerning adequate working space required, working surfaces, types of finishes and the siting of equipment so as to allow for easy cleaning with the minimum of labour. Premises are also visited during the construction stages and further advice on hygiene and associated public health requirements are given. This procedure has been found particularly valuable in the case of the numerous large hotels and other food businesses at present under construction in the Borough. 74 The various classes of food premises and businesses within the Borough are shown in the following table: [ Type of Business Total number BAKEHOUSES 20 BAKERS SHOPS 58 BUTCHERS SHOPS 130 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 CONFECTIONERS 100 DAIRIES 2 FISHMONGERS AND POULTERERS 45 FOOD FACTORIES 1. Bakery and confectionery 3 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 100 GROCERS SHOPS 238 HAWKERS OF FOOD 100 POULTRY PROCESSORS 1 POULTRY SLAUGHTERHOUSES—CASUAL 11 VENDING MACHINE SITES (NOT ON FOOD PREMISES) 60 TOTAL 1,573 75 Bacteriological Examination Type of Food Satisfactory Suspicious Unsatisfactory Total Aircraft meals 10 - 2 12 Cooked chicken 14 1 6 21 Cooked Ham 10 1 3 14 Cooked fish 1 1 Cooked meat (excluding ham) 25 1 2 28 Curry powder 1 1 Food mix 1 1 Seven soup 1 1 Total 63 3 13 79 17 samples of raw meat from the slaughter houses operating within the Borough were submitted for bacteriological examination, counts ranging from 400 organisms per gramme at 35°C to 3.5 million were obtained. All the specimens were free from salmonella organisms. A further 31 samples of raw meat and chicken were submitted from wholesalers and manufacturers premises the counts ranging from 100 to 13 million organisms per gramme at 35°C. Salmonella organisms were isolated from 3 samples. They were typed as S. derby, S. typhimurium U71 and an unnamed strain. SPECIAL LABORATORY INVESTIGATIONS Bacillus cereus During July and August complaints were received from members of the public who had become ill after eating food prepared at a Chinese take-away restaurant. The clinical symptoms included vomiting and nausea and were mostly of short duration, twenty-four to forty-eight hours. The incubation period was very short, forty-five minutes in one instance. On tracing the food consumed it was found that everyone affected had eaten fried rice as part of their meal. There was close collaboration between the Central Public Health Laboratory at Colindale and the health department and numerous samples of food were examined including boiled and fried rice, beaten egg, sweet and sour vegetables beef curry, flour, breadcrumbs and seasoning. Bacillus cereus, an aerobic sporing bacillus, was isolated from the remains of the meal consumed and from boiled and fried rice obtained at the restaurant. Bacillus cereus is common in soil, on vegetation and in many raw or processed foods. Methods of preparation of the rice were investigated in great detail and it was found that it was the custom to boil the rice at 8.30 a.m. approximately. This was then piled in large colanders and left to cool at ambient temperatures. A crust formed over the surface which prevented the interior of the pile of rice from cooling. At no time was cooled rice refrigerated. Before the premises opened to deal with customers' orders, quantities of the cool, boiled rice were mixed with beaten shell eggs and fried. This was then kept warm on a tray near the stove and reheated quickly in small quantities as required. A bowl of beaten egg left uncovered in the kitchen was replenished as the initial quantity was used, and any remaining at the end of the day was refrigerated for use next day. Further rice was boiled during the afternoon to meet the evening requirements but this was usually sold as "boiled rice". Any which was left was reclaimed to use as fried rice the following day. It is believed that this method of rice preparation is a traditional practice in Chinese restaurants. A further similar outbreak occurred shortly afterwards. In this case a different restaurant was concerned but the methods of preparation of the rice were almost identical. Following these outbreaks improved methods of rice preparation were discussed with Dr. Betty Hobbs of the Central Public Health Laboratory and were then translated into Chinese. The recommended methods were put into operation at the restaurant where the original outbreak occurred and frequent check samples of the rice are continuing. If the new methods are practical and successful, efforts will be made to enforce their use in all restaurants where rice is boiled and fried. 76 Sausages In conjunction with the food hygiene laboratory, at the Central Public Health Laboratory, Colindale, samples of sausages were submitted for examination for the presence of salmonella organisms. Samples were taken from two national sausage manufacturers and two local producers. Details of the results obtained are set out in the following table: Producer Number Examined Number Found Positive Salmonella National Producer A 50 National Producer B 52 6 types: salmonella anatum (2) salmonella derby (1) salmonella panama (2) unnamed salmonella (1) Local Producer A 30 — Local Producer B 30 - Clostridium welchii Small outbreaks of food poisoning occurred after two people had eaten bread rolls filled with roast beef. Samples of the meat eaten by the patients were not obtainable but samples of beef cooked in the same way were taken the following day. These produced scanty aerobic sporing bacilli and moderate streptococci. Samples taken five days later produced Clostridium welchii (untypeable). The origin and preparation of the food was investigated and the following details were obtained: The premises consisted of a delicatessen shop which also supplied filled rolls and sandwiches and had a small restaurant service. The beef in 10 lb. rolled joints was supplied by a local butcher. The meat was roasted in an oven at regulo 1 (290°F/143.3°C) for three hours to produce rare beef which it was stated was preferred by the customers. The meat was then displayed under transparent covering in the shop at ambient temperature. It is understood that the remaining meat was placed in a refrigerator after the busy lunch period was over. It was assumed that the probable origin of the infection was long, slow cooking at an inadequate temperature and subsequent display for several hours at ambient temperature. IMPORTED FOOD REGULATIONS 1968 There was a further increase during the year in the number of containerised food imports delivered to firms in the Borough which had either not been examined at the port of entry or which required further examination. Details of these imports together with the country of origin are given in the table on page 78. The following details of conditions found and action subsequently taken are considered worthy of note: (a) Tinned Spanish mandarin oranges Notification was received that a containerised import of 950 cases of tinned mandarin oranges had arrived from Spain and been released "unexamined" by the port health unit concerned. The consignment was destined for wholesale within the Borough. 500 cases duly arrived in the Borough, the remainder were sent to another branch of the same wholesaler outside the Borough. Of the 500 77 Products No. of Containers Tons Cwts. Stones Lbs. Origin Apricots 5 35 16 0 1 Spain Bacon 35 298 9 4 0 Denmark Beef 1 0 14 4 0 Armagh Brisket beef 5 7 13 2 5 Dublin Cheese 1 13 0 0 0 Switzerland Chocolate 3 29 8 6 1 West Germany Coffee 6 26 5 2 11 Brazil Confectionery 7 75 15 5 0 Ireland Crisps 1 0 10 0 0 Ireland Fruit salad 6 39 19 2 0 Spain Grapefruit juice 6 53 14 6 12 Israel Mandarin oranges 4 29 14 4 3 Spain Nutriment 6 4 10 0 0 Canada Orange juice 5 45 14 3 2 Israel Peaches 2 20 2 6 0 California Pineapples 3 45 8 0 0 Malaya Popcorn 1 1 17 0 0 Ireland Potatoes 1 2 18 0 0 Foreign Sausages 6 47 10 7 0 Ireland Swiss Pate 1 8 6 4 8 Switzerland Truffles 1 13 12 4 5 Switzerland Tomatoes 11 108 17 4 1 Spain/Italy Total 117 907 19 2 7 Totals for 1971 32 612 12 8 3 cases, 2 were condemned for leakage, blowing etc. and during a joint examination of the contents of the sound tins together with the buyer of the organisation concerned it was found that approximately 20 out of 40 tins examined had charring of the vertical seam of the can with detached lacquer contaminating the contents. Examination of further tins revealed about 50% showing discolouration of the lacquer with about 10% having charring and detached lacquer. The wholesaler decided to reject the total import which was collected and re-exported. The chief public health inspector for the area receiving the remainder of the import were notified of the sequence of events. Information was eventually received that the wholesaler's representative had inspected the production process at the Spanish factory concerned and found further faulty cans in use as a result of which the remaining consignment of 1,000 cases were cancelled. Subsequently contracts for 1973 season were placed with a Spanish firm using tin plate cans. Samples of an identical product in tin plate cans from a different source were taken and stored under adverse conditions. These were opened in the department's laboratory at the expiry of 8 months and found to be in perfect condition. (b) Imported chilled beef and chilled boneless strip loin During the period February to April 1972 two consignments of Argentine strip loin, totalling 45 lbs. in weight, were inspected at the request of a wholesaler within the Borough and condemned for early putrefactive changes. Bacteriological investigation of samples of strip loin and chilled beef were carried out and plate counts of 3-5 million and 5-5 million respectively were obtained. Details of the producing establishments were obtained and the information and findings were passed to the Ministry of Agriculture, Fisheries and Food to arrange for resident veterinarians in the Argentine to make checks of the establishments involved. Repeat samples taken in October 1972 gave results of 130,000 and 75,000 respectively these latter counts being considered satisfactory for raw meat. The results themselves in isolation are not conclusive and further monitoring will continue. 78 (c) Containerised Danish Bacon 3 containers of Danish bacon each containing 360 sides are imported weekly by a wholesale organisation in the Borough. These are subject to a percentage inspection by the health authorities at the port of entry. In March 1972 it was noted that a number of carcasses had a slight coating of pin cushion appearance in the body cavities, on the cut surfaces of the flesh and on the external surfaces of the sides. The sides were treated by cleansing with disposable wiping cloths and the nature of the condition was reported to the importers London representative who in turn sought advice of the Danish Meat Research Institute of Roskilde, Denmark. The condition was identified as bacterial slime formation and a suitable technique for treating affected carcasses was devised. This consists of rubbing the carcasses with a dry salt after cleaning with disposable towelling. The condition occurred at the time of the industrial dispute in the mining industry and consequent electricity failures. Subsequent monitoring has shown no further instance of this condition. (d) Imported bales of Polish de-fatted back bacon This bacon, which consists of de-skinned and boned out short backs was packed in bales of 8 cuts, average weight 60 to 70 lbs. It was muslin wrapped with a matchboard protective packing and sewn hessian outer cover. It was shipped as orginary cargo and not containerised and took up to 3 weeks to arrive. With the onset of warmer weather it was noted that some consignments were moist and sticky requiring wiping and trimming before release. Subsequently bacteriological samples were arranged resulting in surface plate counts of 10-5 million and 13 million respectively. Salmonella and coliform organisms were not found. The results were reported to the wholesalers who subsequently cancelled the contract for this bacon and substituted a similar line from Holland with a delivery time of under 1 week from the producer and protected by sealed plioform bag packs and cardboard cartons. Initial shipments were inspected and found to be satisfactory and follow up bacteriological samples gave counts of 150,000 without coliform or salmonella being present. This was considered to be very satisfactory. DISEASES OF ANIMALS ACT 1950 The local authority's duties under this Act and various orders made thereunder are enforced by the public health inspectors assisted by a part-time veterinary officer. The orders are concerned with the prevention and control of animal diseases and in addition to dealing with specific diseases and animals they cover such matters as animal transportation, disinfection of premises and vehicles. As a result of an outbreak of swine vesicular disease, the Swine Vesicular Disease Order 1972 was made by the Minister of Agriculture, Fisheries and Food making the disease notifiable. This outbreak focused attention on the dangers of feeding swill which had not been properly processed and on the need to ensure that processed swill does not become recontaminated by any raw swill and that animals, birds or vermin are prevented from having contact with the raw swill. The Diseases of Animals (Waste Foods) Order 1957 prohibits the feeding of unboiled waste foods to certain animals or poultry. With a few minor exceptions plant used for the boiling of swill has to be the subject of a licence issued by the local authority. All swill boiling plants within the Borough were inspected immediately following the outbreak of this disease. Operators were reminded of their obligations and given details of any works or repair or improvement necessary to their installation. There are 29 licensed boiling plants in the Borough. THE SLAUGHTER OF ANIMALS ACT 1958 During the year 3 licences to slaughter were issued. FERTILISERS & FEEDING STUFFS ACT 1926 FERTILISERS & FEEDING STUFFS REGULATIONS 9 samples of fertilisers and 4 samples of animal feeding stuffs were taken during the year and submitted to the Council's agricultural analyst for examination. One sample of bonemeal was found to have an excess of nitrogen and phosphoric acid and a sample of poultry ration to contain an excess in the fibre content. In the case of the bonemeal the excess of nitrogen and phosphoric acid 79 was to the benefit of the purchaser the contravention arising through the attachment of an incorrect label to the product. As a result of the report a revised system of labelling was introduced. The poultry ration was an isolated result a repeat sample being found satisfactory. The probable cause for the original failure was believed to be a temporary disruption in the normal source of ingredients. HOUSING As in previous years there has been no less effort directed to the department's objectives in this vital sector of housing. The objectives are clear: to eliminate slums and to aim for the repair and improvement of those houses which require attention in order to prevent these falling into slum category. It is to give an extended life to dwelling houses where it is economically viable to do because of the extreme housing shortage in the Greater London Area. There is little doubt that where an old house lacks modern amenities and is in disrepair, it is nearly always possible to extend its life and justify the economies of rehabilitation, providing it is structurally sound. Small cottage type properties which in 1965 might have fallen within the unfit provision of the Housing Act are now selling at prices around £8,500. With an expenditure of £2,500 offset by an improvement grant of £1,000 a substantially modern house can result with a further life of 30 years. The following information reflects in detail the year's progress in housing. SLUM CLEARANCE The original slum clearance programme has now been completed and it has not been necessary to declare any clearance area during the year. 40 demolition orders and 1 closing order were made. The 40 demolition orders were all concerned with one property, namely Brook House, West Drayton. The action taken during 1972 relating to slum clearance has been concerned with the rehousing of families and the demolition of vacated properties in clearance areas dealt with some time ago owing to the fact that a period of 2 years often takes place between declaration of an area and its total clearance. In some cases where compulsory purchase is involved the time is longer. The action taken during the year is reported 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) 40 4. Closing Orders made (rooms) (Section 18) 1 5. Closing Orders determined (Section 27) 4 6. Closing Orders revoked and Demolition Orders stituted (Section 28) — 7. Houses demolished following Demolition Orders 3 8. Houses demolished following Closing Orders — 9. Number of persons displaced: (a) individuals 7 (b) families 2 Clearance Areas and Individual Unfit Dwellings Since the 1st April, 1965 the Council have made 89 Demolition Orders, 34 Closing Orders and declared 43 Clearance Areas. (1) Clearance Areas represented during the year: (a) Number of areas — (b) Houses unfit for human habitation — (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 — (ii) families — 80 (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 14 (ii) families 7 REPAIR AND IMPROVEMENT The continuing process of house repair and improvement is achieved by the use of various statutory powers and the methods are as follows: (a) Landlords applying for qualification certificates are requested to bring the property concerned up to a standard of good repair and schedules requiring repair works are sent out where necessary. There must be satisfactory compliance with these schedules before qualification certificates are issued. (b) Improvement grants are given subject to the house concerned being brought up to a similar standard of good repair. (c) By use of the repair sections of the Housing Acts 1957/1969. (d) By use of the nuisance provisions of the Public Health Acts 1936/61. Since the procedure started in 1969 enabling landlords to obtain qualification certificates, 2,880 applications have been received and 1,764 qualification certificates have now been issued. It is becoming increasingly evident, especially since the Housing Finance Act 1972 came into operation which gives automatic decontrol of houses on future dates fixed in the Act in accordance with rateable value, that owners will not now fulfil the requirements of the good repair provisions to obtain qualification certificates. There are approximately 1,000 applications outstanding some of which date back to early 1970. Consideration is now being given to refusing these outstanding certificates and to serving notices on landlords to require defects to be remedied which are enforceable by Public Health or Housing Act notices. It must be remembered that the "good repair" standard required to obtain a qualification certificate is not an enforceable standard for other purposes, and therefore only those defects which constitute nuisances or fall within disrepair provisions of the Housing Act can be included on statutory repair notices. Although the qualification certificate procedure enables the landlord to obtain a fair rent it has nevertheless been the means whereby the department has succeeded in getting many more houses repaired than it would otherwise have done. Applications for Qualification Certificates received during 1972: Number of applications for Qualification Certificates received 227 Number of houses inspected 227 Number of applications for Qualification Certificates cancelled 65 Number of Qualification Certificates refused 80 Number of Qualification Certificates granted 507 Number of combined applications received (Improvement Grant and Qualification Certificate) 23 Number of houses inspected 23 Number of Certificates of Provisional Approval issued 38 Number of combined applications granted 32 Number of combined applications refused — Improvement Areas Progress continues to be made in respect of the 4 areas declared by the Council under the Housing Act 1964. This enabled the Council after declaring an improvement area to require landlords 81 of tenanted dwellings to provide missing standard amenities where the tenants were willing to have the improvements and to pay an increased rent. Twelve statutory notices have been satisfactorily complied with resulting in 12 more improved houses in these areas. The position at the end of 1972 is shown in the following table: 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 76 24 — 4 4 houses demolished 2 159 38 45 25 20 20 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. 4 houses are owned by the Borough Council and are being comprehensively improved by the housing dept. No default action is being taken as there are redevelopment proposals. 3 189 70 104 7 7 London Borough of Hillingdon owned 4 158 49 60 20 24 5 purchase notices Number of: 1. Preliminary Notices served — 2. Undertakings accepted — 3. Immediate Improvement Notices served — 4. Suspended Notices served — 5. Final Notices served — 6. Dwellings improved (a) full standard 12 (b) reduced standard — 7. Dwellings improved by Local Authority in default: (a) full standard — (b) reduced standard — General Improvement Areas Two possible general improvement areas were described and commented on in the last year's report (page 85). One area is in Uxbridge and the other in Yiewsley. The one in Uxbridge had been declared an improvement area under the 1964 Housing Act and much work has already been done in this area by use of the compulsory powers. These compulsory powers cannot be used under the Housing Act 1969 relating to general improvement areas. The housing programme action 82 group, formerly the redevelopment working party is still considering whether these areas can be declared general improvement areas but as a result of action by this department the position in both areas is as follows: Cowley North Area This area forms part of improvement Area No. 3 declared in January 1968. The improvement area included both sides of Cowley Mill Road, the north side of the Greenway, west side of Whitehall Road, Derby Road, Waterloo Road, Chiltern View Road, Bridge Road, Tachbrook Road, Mill Road, Glebe Avenue, Westcott Way and the east side of Waterloo Road. There are 189 private houses in this area, 122 owner/occupied and 67 tenanted dwellings. As a result of formal action against landlords only 21 tenanted dwellings are lacking in standard amenities and as a result of voluntary action only 56 owner/occupied dwellings are lacking out of the original 122. The proposed general improvement area being considered by the housing programme action group contracted the boundaries of the improvement area by excluding roads on the east side of Cowley High Road and the south side of Cowley Mill Road. This area contained 130 private houses lacking in standard amenities but the position in August 1972 is that 36 owner/occupied dwellings are lacking and only 13 tenanted dwellings are lacking. The owners of these remaining dwellings have been approached and advised of the improvement grant scheme and there is no doubt there will be a further reduction in outstanding numbers. West Drayton Area (Bentinck Road/Padcroft Road) When this area was considered by the former redevelopment working party there were 40 private houses lacking in standard amenities out of a total of 134 dwellings. The 40 houses comprised 21 owner/occupiers and 19 tenants. 10 owner/occupiers were willing to improve and 4 tenants only were unwilling to have the standard amenities provided. Today there are only 24 houses lacking as follows: 10 owner/occupiers (6 willing 4 not willing) 8 tenants (4 willing 4 not willing) 6 occupancy not known but 2 are vacant. The four willing tenants have been advised on improvements and will shortly make representations to the Council to use its powers to secure the provision of the standard amenities. It does appear that all the tenanted dwellings will be provided at least with the standard amenities when the tenants are willing, and unless the Director of Planning and the housing programme action group find there is a necessity on planning grounds to declare these areas general improvement areas existing Housing Act powers can deal with the individual properties. Dwellings Outside Improvement Areas—Section 19 Housing Act 1964 The opportunity of a tenant of a dwelling house to make a representation to the Council with a view to the exercise by the Council of its power under the above Act to require a landlord to provide missing standard amenities is still retained, and public health inspectors use every opportunity to advise tenants of this procedure. Experience of the use of this Act by tenants continues to be disappointing. Old people do not wish to have the inconvenience of building alterations, and there is some reluctance to pay higher rents. Dwellings outside Improvement Areas (Section 19 Applications) 1. Number of representations made by tenants 8 2. Number of Preliminary Notices served (full standard) — 3. Number of Immediate Improvement Notices served (full standard) — 4. Number of dwellings improved: (a) full standard 6 (b) reduced standard — 83 The position with the 8 representations is as follows: Applications for grants by owners Nil Houses found to be unfit and dealt with by Closing Orders — Representations cancelled 1 Immediate Notices served on owners — Negotiations with owners in progress 7 Improvement Grants Many more applications for improvement (discretionary) grants were made than for standard grants and more owner/occupiers applied than landlords of tenanted properties. The improvement (discretionary) grant enables a grant to be made not only for improvements but also for repairs which are necessary to make the improvements fully effective and to give the property the requisite life of 30 years. Owners of property who received repair notices were not unwilling to carry out the repairs and improvements which were necessary because of the attraction of financial aid for this purpose and the scheme was a very useful instrument in the long term objective of preserving older houses. Towards the end of the year however the Council reviewed its policy on improvement grants with the possibility that this type of grant may be restricted to owner/occupiers. Unimproved tenanted dwellings will not altogether be excluded from the benefits of this grant, but a special committee may wish to investigate the rent aspect of tenanted dwellings before agreeing to make this higher grant. The standard grant may be made to a qualified applicant for the provision of standard amenities, but this grant excludes any element for repairs. More financial aid has been made this year than in any other previous year since 1968, and some interesting figures have been extracted showing that of the 94 houses improved and the 17 new dwelling units formed from the conversion of larger houses the following defects were remedied. W.C. pans and traps repaired/renewed 8 W.C. ventilation improved 2 Manhole covers renewed 2 Gullies repaired/renewed 12 Roofs repaired/renewed 106 Chimney stacks repaired/renewed 58 Brickwork pointing, rendering etc. repaired/renewed 92 Gutters R.W.P.'s waste pipes repaired/renewed 79 Yard paving repaired/renewed/provided 23 Paintwork renewed 23 Dampness remedied 203 Walls and ceilings repaired/renewed (rooms) 172 Floors repaired/renewed 79 Doors, windows, repaired/renewed 533 Stairs repaired/renewed 17 Flues repaired/improved 1 Fireplaces repaired/renewed 17 Sinks renewed/provided 11 Ventilation provided/improved 8 Other defects 18 Lighting improved 3 84 Details of Improvement Grant Applications received and given in 1972 are as follows: Standard Grants Owner/ Occupier Tenanted 1. Number of applications received 7 10 2. Number of applications approved 6 7 3. Number of applications refused — — 4. Number of dwellings improved 8 14 5. Works carried out in default — — 6. Number of applications cancelled or changed to Improvement Grants 1 1 The total number of applications for Standard Grant in 1971 was 33. Amount paid in grants £1,136 00 Average grant per house £47-33 Amenities Provided (a) fixed bath 5 (b) shower — (c) wash hand basin 17 (d) hot water supply (to any fittings) 20 (e) water closet: (i) within dwelling 8 (ii) accessible from dwelling — (f) food store — (q) sink — Improvement Grants (Discretionary) Owner/Occupier Tenanted Number of applications received 90 65 Number of applications approved 55 44 Number of applications refused 3 4 Number of dwellings improved 31 41 Number cancelled 9 6 The total number of applications in 1971 was 158. Amount paid in grants £42,225 Average grant per house £586 Improvement Grants—Publicity Apart from the usual media of advertising improvement grants namely the public notice boards and general office correspondence, 1972 saw the launching of the Greater London Improvement Grant Campaign which took place from 17th April to 13th May. Considerable effort was put into this campaign and it is sad to report that the results did not merit this effort. The Borough Architect's department and housing department assisted by making available two show houses in Waterloo Road, Uxbridge, and the Mayor and Mayoress performed the opening ceremony to commence the campaign in Hillingdon. The show houses were open 6 days each week and manned in the main by public health inspectors who have given advice on the improvement grant scheme—staff of the Borough Architect's department assisted in meal time relief. In addition to demonstrating the improvement grant scheme, 85 the show houses were used to exhibit the types of fireplaces which would be eligible for grant in the current smoke control area programme. In addition to the show houses, mobile exhibitions were arranged as follows: Date Location National Coal Board 11 th-17th May Adjoining show houses Fibreglass Ltd. 4th-6th May Adjoining show houses Department of Environment 11 th-13th May Hayes Working Men's Club, Hayes Solid Smokeless Fuels Federation 24th-29th April Adjoining show houses North Thames Gas Board 8th-10th May Adjoining show houses and car park, Pinner Road, Northwood Static display units were also arranged explaining improvement grants at the North Thames Gas Board showroom, 165 High Street, Uxbridge, the South Ruislip Library, Victoria Road, South Ruislip, and The Odeon Cinema, High Street, Uxbridge. The public relations officer arranged wide distribution of improvement grant literature and 1,800 occupants of older houses were told about the scheme and invited to attend the show houses. There were 531 visitors to the houses and 131 written enquiries were made about the improvement grant scheme. In addition 218 telephone enquiries for information on improvements were also received during the period of the campaign. Unfortunately there were only four extra firm applications for improvement grants afterwards. A principal officer of the Department of the Environment visited the show houses on 4th May and thought the scheme was excellent. Exhibitors in the show houses were: The National Coal Board Fibreglass Ltd. (Insulation) Rentokil Ltd. (Damp-proofing, woodworm treatment etc.) Southern Electricity Board Peter Cox Ltd. (Damp-proofing) North Thames Gas Board It was only possible to present this exhibition through the co-operation of the various departments of the Council and the various exhibitors, whose help is gratefully acknowledged. Repair (Housing and Public Health Acts) The table on page 87 in the form shown is presented for statistical returns to the Department of Environment and as the heading states relates to unfit houses of which there are few in Hillingdon. Action to secure the repair of dwellings has been effected by the improvement grant scheme, by the conditional requirement to carry out necessary repairs to obtain qualification certificates, by the nuisances sections of the Public Health Act, and by the substantial repair provisions of the Housing Act 1969. By these powers 381 houses were satisfactorily repaired. MULTIPLE OCCUPATION Again it is necessary to report that multiple occupation is on the increase but the Council's policy wherever multiple occupation has been discovered has been pursued. There were 67 cases discovered as against 36 in 1971 and more legal proceedings taken for contraventions. Every effort is made to explain to immigrant arrivals and the Council's direction order procedure and pamphlets are available in Urdu, Bengali and Hindi. The issue of direction orders does not necessitate eviction and consequential hardship that would result, but controls multiple occupation and gradually reduces it to acceptable standards. A contravention only takes place when an extra person (or persons) comes to reside in a dwelling after a direction has been served and in excess of the limit allowed in the direction. During the year a talk was given to the Community Relations Association and the Council's policy explained in detail. The newly appointed community relations officer will be very useful to the department's officers in cases of translation or other difficulties involving immigrants. 86 During the year 67 new cases of multiple occupation were discovered. 67 notices of "Intentions to serve directions" and 67 directions were served. Satisfactory means of escape in case of fire were required in 16 cases. Thirty-two 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 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. 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 4 Other Houses in which Defects were Remedied After formal notice under Public Health Acts 9 After formal action under Section 9(1 A), Housing Act, 1957: (a) by owner 10 (b) by local authority — After informal action by local authority 381 87 CONTROL OF CARAVAN SITES Caravan Sites and Control of Development Act, 1960 The following table shows the number of licensed sites in the Borough. Four new licences were issued during the year, and the site conditions as in the case of existing licences were based on the model standards of the Department of Environment. Licensed Sites in the Borough Temporary Licenses Permanent Licenses 22 14 Gypsies and Other Itinerants The only permanent trouble spot during the year was the site on the Colnbrook By-Pass formerly used as an experimental road by the Road Research Laboratory. It is regrettable that the disgraceful condition of this site had to be mentioned in the last Annual Report and similar conditions still exist today. The land is in Crown ownership and representations to the Department of the Environment have so far failed to bring about its discontinuance. UXBRIDGE CENTRAL REDEVELOPMENT AREA Prior to the commencement of the redevelopment of Uxbridge the area of phase 1 and 2 of block 1 contained many public health problems, i.e. small businesses operating in semi-derelict property, a common lodging house of extreme age and poor construction and many areas of behind the scene desolation and rubbish accumulation with their resultant health hazards. The clearance of such areas allows a new broom approach to be made by various departments of the local authority. In this situation the opportunity presents itself to set standards in all matters of public health and general environment at one time without the hindrances of adapting requirements to suit a committed situation. Regrettably the aims of various departments of the local authority in such a situation sometimes conflict with a resultant necessity to compromise to some degree. In addition the interests of an architectural designer concerned with a large development of this kind are naturally guided by an overall aspect or conception to which the subsequent detail designer is committed by the early stages of the development. It is at this stage that most of the public health inspector's work is involved e.g. in the detailed fitting of shops, restaurants, refuse disposal facilities, matters of safety etc. During 1970, 1971 and 1972 with the advancement of these stages of the work in phase 1, considerable effort had to be expended in consultations with proposed occupiers, architects and members of other departments of the Council, on examination and comment on plans and proposals. This has enabled, in many cases, standards to be incorporated from the outset which comply fully with, or are an improvement on, current legislation. In addition many problems which have arisen during the planning and construction stages of phase 1 have provided valuable experience and enabled the department to suggest alternative methods of overcoming similar problems in phase 2. At the time of reporting many premises in phase 1 are in occupation and some are nearing completion and/or occupied in phase 2. These reflect some measure of success in the objects striven for during the period under review. Progress in phase 2 of block 1 is now well in hand and will continue to demand the constant involvement of the public health staff with the aim of securing the best possible standards in an area which should become one of the show pieces of the Borough for many years to come. The movement of the open market to the new site has now taken place with its own particular problems relating to the Food Hygiene (Market Stalls and Delivery Vehicles) Regulations and a high standard is being set for the food traders so affected. The effect of the move has been amongst 88 other things to select those traders who are prepared to go to some lengths to meet the standards demanded whilst others not so disposed have chosen to discontinue trading in the open. To date standards incorporated in the new market square are far better than has ever been attained at either of the previous sites at Chequers Yard or Vine Street. Much work still remains to be done in this respect and strict surveillance of practices will continue. Concurrent with the above a programme of wild pigeon control has been undertaken. Experiments were carried out resulting in a trap being developed by this department which proved successful in the humane capture of large numbers of birds. The system necessary involves daily attendance at the trap for baiting and clearing the traps which avoids any suggestion of cruelty. During the past three years the following numbers were caught: 1970—300; 1971—981; 1972—695. At the present time a reduction of the numbers of birds in the Uxbridge Station and Market House area is evident, even though extensive demolition of derelict buildings has tended to produce a general movement to these roosting places. Arrangements have been made with the secretary of the Uxbridge and District Pigeon Association to take away birds which carry registration rings and the Association has been most helpful. Although the pigeon nuisance has been considerably reduced, trapping is continuing and no doubt will have to continue for some time if eradication is to be achieved. WORKING ENVIRONMENT During 1972 the working party under the chairmanship of Lord Robens published its report. The recommendations in the report if introduced as legislation would resolve some of the anomalies that now exist whereby persons employed in some specific occupations do not have any statutory safeguards as regards their working conditions. When inspections are made of places of employment under the relevant specific legislation, attention is also given to the following matters and if necessary action taken. (a) Nuisances—(e.g. dampness). (b) Drainage—(e.g. storm and fire water drainage with particular reference to cross connections and to any pollution from chemicals). (c) Refuse storage and disposal. (d) Rodent infestation. (e) Food Hygiene—including canteens and vending machines. OFFICES, SHOPS AND RAILWAY PREMISES ACT, 1963 There are 3,174 registered premises in the Borough employing 34,306 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 935 545 20,752 Retail shops ... 1,854 1,544 8,365 Wholesale shops, warehouses 108 85 2,086 Catering establishments open to the public, canteens 265 265 2,985 Fuel storage depots ... 12 10 118 Totals 3,174 2,449 34,306 89 4,905 visits were made to this class of premises during 1972 and 523 Notices requiring various works as shown in the table below were served. Except where referred to in the paragraph on legal proceedings the defects were remedied by informal action. Defect Number of Premises Cleanliness 183 Overcrowding 3 Temperature 105 Ventilation 53 Lighting 76 Sanitary convenience 180 Washing facilities 150 Supply of drinking water 1 Accommodation for outdoor clothing 10 Seats or sitting facilities 2 Facilities for meals 1 Disrepair 164 Fencing exposed parts of machinery 30 First Aid Equipment 142 Other matters 461 It was necessary to take legal action in respect of failure to notify the employment of persons, failure to display an abstract, inadequate ventilation, absence of thermometer and fines totalling £20 with £2 costs were imposed. Action in respect of a dirty W.C. compartment was discussed. 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. ACCIDENTS A total of 67 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 accidents occured and the causes of the accidents. Falls still continue to be the most prevalent cause of accidents. The only fatal accident in the Borough since notification has been necessary was caused by a fall from a ladder and another from a similar cause took place this year. During the year senior members of H.M. factory inspectorate lectured at an in service training session on the guarding of dangerous machinery, organised for the professional and technical staff of the department. The guarding necessary for several relatively new pieces of equipment such as waste disposal units and refuse containers was fully discussed. Many people fail to appreciate that there is a serious danger if any machine can be made to operate with the guard removed. The following action taken as part of accident investigation illustrates the wide variety of causes of accidents. Over a period of time several accidents have occurred while loading or unloading lorries at a local wholesale metal warehouse. The company were requested to make enquiries into alternative methods available for tightening down the load. A new system was introduced to permit the tension to be applied while standing on the ground avoiding falls and also providing a safer load. Investigation into a bank employee's fall from a chair revealed that a comfortable well padded chair had been provided the seat of which could be raised or lowered vertically and also be adjusted 90 backwards and forwards horizontally. At the extreme top and forward position there was a tendency for the chair to tilt. The chances of this happening were remote and it was not considered necessary to request withdrawal of the chairs. All employers were made aware of the possible danger and the design will be reconsidered when renewal is necessary. Advice on protective clothing to be worn, the length of time to be engaged in work, the rest facilities to be provided and necessity for medical examination for all persons so employed was given to a company employing persons to work in a low temperature warehouse and it is hoped that this will assist in preventing accidents. Table 1 Type of premises No. Reported Action Recommended Fatal Non -Fatal Prosecution Formal Warning Informal Advice Offices 17 17 Retail Shops 23 2 21 Wholesale Warehouses 12 12 Catering Establishments 15 15 Totals 67 2 65 Table 2 Cause Offices Retail Shops Wholesale Warehouses Catering Establishments Total all NonFatal Fatal NonFatal Fatal NonFatal Fatal NonFatal Fatal NonFatal Machinery 1 1 1 3 Transport 2 5 7 Falls 6 5 3 5 19 Stepping or striking against object or person 1 2 2 5 Handling goods 4 6 2 1 13 Struck by falling object 2 1 3 6 Hand tools Not otherwise classified 3 6 1 1 1 2 7 7 Total 17 23 12 15 67 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 the engineer must submit a copy of his report to the local authority. The occupier of the premises must retain copies of all reports whether or not repairs are indicated, for inspection for two years. 75 premises are known to contain lifts or hoists and 23 reports from engineers referring to defects were received, all repairs were carried out without the necessity of statutory action. 91 FACTORIES ACT 1961 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 982 power factories and 24 non-power factories in the Borough and during 1972 1,046 visits were made to the factories and 25 notices requiring works to be done were served. Tables giving details of the inspections and defects are set out opposite. 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 outworkers. Notifications of 172 persons employed as outworkers by factories outside the Borough were received. Inspections were made of 90 homes at which this work is carried out and no contraventions of the Act or other matters needing attention were recorded. Details of the number of persons employed as out-workers and the category of work they undertake is set out below: Type of work No. of out-workers Alterations or finishing wearing apparel 28 Making Christmas crackers 141 Making lampshades 3 Total 172 SHOPS ACT 1950—1965 EMPLOYMENT OF YOUNG PERSONS ACT 1938—1964 This legislation controls the hours of employment of young persons including restriction on night work, regulates the general closing hours, early closing and Sunday opening and provides for rests and meal breaks for employees. The Shops (Airports) Act 1962 exempts the shops at Heathrow and other airports from the early closing and general closing provisions of the main Act for Sunday trading. 92 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 34 7 (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 982 975 64 (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) 16 24 4 Total 1,022 1,033 75 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) 1 Unreasonable temperature (S.3) Inadequate ventilation (S.4) Ineffective drainage of floors (S.6) Sanitary Conveniences (S.7) 1 (a) Insufficient 7 5 1 (b) Unsuitable or defective 71 19 (c) Not separate for sexes Other offences against the Act (not including offences relating to Outwork) 1 Total 78 24 3 1 93 Late in 1972 there was reason to believe that the majority of traders operating in the Uxbridge Town Centre wished to trade for six days. A postal vote was arranged and the majority of the traders carrying on food businesses and the majority of those selling goods other than food preferred not to close their shop for half day. This does not affect the assistants' entitlement to a half day holiday on one week day a week but does permit the shop to remain open and the assistants to be given half holidays on different days. An order permitting persons operating shops in these classes of trades to remain open for six days of the week will be made by the Council to become operative early in 1973. The Sunday trading restrictions have again caused difficulty, due to the continued operation of a Sunday market on the car park of the Hayes Football Club and to some Sunday trading by local shopkeepers, mainly those selling "Do it yourself" articles, for which there is apparently a public demand. In all, 83 summonses were taken against offenders, 14 in respect of local shopkeepers, one occupier being prosecuted on three separate occasions and 69 against stallholders operating from the market. Nine of the summonses against stallholders were for obstruction, one was dismissed, the remainder fined from £3-£10. Six of the summonses alleging illegal sales were dismissed and the remaining 54 fined. The fines imposed were £3 with £1 costs. One case against a local shopkeeper arose from premises where purchasers in order to circumvent the law were becoming "club" members. The seriousness or otherwise accorded to offences against the Sunday trading provisions by the local magistrates may be judged by the fines imposed, in this case the fine was £1 with no costs. Recently the law has been changed to increase the maximum fine that may be imposed, indicating the Government have no intention of legalising all Sunday trading. However the fines imposed have rarely been to the previous maximum so this is unlikely to affect the local position. Unless effective action can be taken against the market organisers or the local organisation offering facilities and space for the market, the Sunday market will continue to operate. It should be realised that this market causes considerable inconvenience to nearby residents and that other factors in addition to infringements of the Sunday trading provisions of the Shops Act should be considered when deciding whether or not a market is desirable, even if these are not factors, which may be considered by magistrates when dealing with particular cases. AGRICULTURAL (SAFETY HEALTH & WELFARE) PROVISIONS ACT 1965 There are 97 agricultural units in the Borough. As in the case of factories when inspections are made under the specific legislation attention is also paid to other matters such as drainage, manure storage, rodent control etc. No statutory action was necessary to enforce this Act. NOISE Noise complaints continue to increase and 135 complaints, approximately 10% more than the previous year, were received. Twenty-five years ago it was possible to relate noise very closely to "the activity of a town". On the average weekday from midnight to midnight there would have been little movement until 5 a.m. then possibly some early risers and the activity would have gradually increased to a peak at about 9 a.m. would then level off until about 4 p.m. when there would have been a decline continuing until about 6 p.m. reducing still further with some minor peaks as people returned from the evening social activities and from about 11 o'clock onwards would reduce to meet the midnight level at the start of the period. This correlation between noise and activity is still relatively true but modern affluence and technology have increased the level of noise. On the domestic front to the vacuum cleaner has been added the washing machine, the refrigerator, the deep freeze, the food mixer and the central heating pump and boiler. The use of public transport has declined and the motor car offers door to door transport and noise. Modern technology has created many tools which are capable of complex and multiple undertakings with minimum supervision. They are however costly to produce, quickly become obsolete and therefore tend to be used continuously. This continuous use has somewhat changed the former pattern of activity and people are increasingly having to change their way of life and adapt to a 7 day, 24 hour working period; for many people a Sunday is now another weekday. If the noise climate is to be contained and reduced it will be necessary for people to decide what levels are acceptable and what sacrifices they are prepared to make. For example it may be agreed that an Englishman's home is his castle but does this mean he may 94 play his radio as loud as he likes or only so loud that it does not intrude into his neighbour's castle ? If it is considered that the radio should be turned down so that it does not intrude and that this entails no sacrifice, what attitude should be taken towards the noise created by a motor lawn mower, electric drill or powered hedge trimmer ? Aircraft It is hoped that the Government's scheme for the noise certification of aircraft will eventually reduce the aircraft noise level. Measurements were made of the noise created by the Concorde aircraft while landing and taking off during July. This original prototype was very much noisier than any plane which either landed before, or took off immediately after it, and it is to be hoped that the modifications to the plane will permit it to qualify under the noise certification scheme. During 1972 the question of nuisance from aircraft using Northolt aerodrome was raised with the Ministry of Defence. Some improvement in the sound protection during the ground testing of engines was provided. A suggestion that the Ministry should consider the provision of a sound insulation grant scheme for the houses in the vicinity of Northolt did not receive a favourable response, the principal reason being the limited number of daily flights in and out of Northolt, but an investigation to ascertain the extent and level of the aircraft noise is being carried out. Motorways and Main Roads Noise level measurements were made in the vicinity of the M4 motorway. The measured levels indicated that noise nuisance if assessed by the provisional standard recommended in the Wilson report which was based on the noise measured inside buildings would be a nuisance. This is the level which the Council had been recommended to adopt as a standard in considering Ringway 3 and other major developments. In July the Department of the Environment published "New Roads in Town" a report of the Urban Motorways Committee which made reference to noise and compensatory measures and sound insulation and in October a white paper was published "Development and Compensation—Putting People First". The method for assessing compensation is to be based on the noise level between 06.00 hours and midnight assessed as an average of the hourly level exceeded for 10% of the time known as the L.10 figure. The L.50 figure is the average noise level and the L.90 figure is the noise level exceeded for 90% of the time or the low noise figure. The measurements are made externally in front of the face of a building and allowing for the sound protection provided by the structure of a building having windows open for what would be reasonable ventilation will permit a noise level standard of approximately 5 to 10 dB/A higher than that recommended by the Wilson report. While both this fact and the fact that it may be necessary to use sophisticated equipment in order to record and assess the average hourly level for 18 hours is regretted, this positive step to assess and pay compensation to persons affected by new road noise is welcomed. It may well be that ultimately the acceptable noise standard may be lowered or the standard will be applied to roads built prior to 1969 or both and a positive step to an improved environment should not be over criticised because it failed to offer an immediate Utopia. THE HEATHROW AIRPORT—LONDON NOISE INSULATION GRANTS SCHEME During 1972 the British Airports Authority renamed the former London (Heathrow) Airport Noise Insulation Grants Scheme and gave it the title shown above. The scheme enables people living around London Airport in a defined area to receive financial aid to sound proof their houses. There are three main changes which came into operation on 14th September 1972: (a) the grant was increased to 75% of the cost of sound proofing works with a maximum of £206 (outer area) (b) a higher rate of grant (100% of £360) is now available to those closest to Heathrow who are worst affected by aircraft noise (inner area) (c) those people residing in the outer area eligible for a grant and to whom the higher rates of constant attendance allowance is paid by the Department of Health and Social Security, will under the revised scheme, be eligible for a 100% grant up to a maximum of £275. 95 The revised scheme also extended the period during which grants could be applied for and claimed. Applicants can now apply up to the 31st December 1974 and providing sound proofing works to which the application relates are completed before 1 st January 1976. The increased grants appear to be attracting more applicants and last year's figure of 22 grants is far exceeded this year. Details of applications dealt with are as follows: No. of applications received 140 No. of applications granted 140 No. of applications dealt with since the scheme started 1st January 1966 794 CONSUMER PROTECTION Toys (Safety) Regulations 1967 These regulations prohibit the use of celluloid toys, other than ping-pong balls and impose restrictions in relation to the lead, antimony, barium, cadmium and chromium content of paints used on toys. Periodical visits are made to toy retailers within the Borough and suspect toys are purchased and submitted to the Public Analyst for examination. Screening tests can also be carried out in the departmental laboratory and while this only indicates the presence of lead in excess of 10,000 parts per million, it is a most useful test as the majority of adverse reports received are in excess of this figure. Forty-three toys were submitted to this screening test, 3 of which were found to be unsatisfactory. Nineteen toys were submitted for analysis of which 6 were found to contain lead in excess of that permitted by the regulations. Details of these toys are given in the following table: Satisfactory Toys Unsatisfactory Toys Article Country of Origin Article Country of Origin Reason Wooden pull along train Foreign Building bricks China 56,100 parts per million Pb Musical pull along Xylophone slovakia Light magnetic China Yellow paint from lorry 107,200 parts per million Pb. Arithmetic blocks China crane Animal orchestra blocks China Piano book Foreign Yellow paint from metal bones 45,400 parts per million Pb Rubber toy Hong Kong Windmill Holland Wood blocks slovakia Zoo blocks China 9,100 parts per million Pb Wooden blocks Foreign HB 120 pencils China Drawing sets (2) Foreign Red pencil 25,280 parts per million Pb Drawing set Foreign School coloured paper England Coloured pencils Foreign Red pencil 26,680 parts per million Pb Paint brush Japan 119,400 parts per million Pb The building bricks, light magnetic crane and zoo blocks were examined at the request of parents whose anxieties had been aroused by the publicity which had resulted from the department's findings of lead in a toy sample taken in December. Only one of the articles was purchased within the Borough. Extensive enquiries were carried out by both this department and the other local 96 authorities concerned, but, as is so often the case, the articles were found to be part of an old importation and it was not possible to recommend legal proceedings in these 3 cases. Two drawing sets were found in each case to have a red pencil containing an excessive quantity of lead in the paint finish. This was also the case with a paintbrush imported from Japan. Two further paint brushes examined in the department's laboratory also indicated the presence of lead in excess of 10,000 parts per million. The presence of lead in the pencils and paintbrushes was viewed with particular concern and a general warning to the public was issued via the Council's Press Officer which was taken up in the national press, radio and television. Details were also sent to independent schools and play group organisers within the Borough and advice was given regarding the types of pencils and paintbrushes considered to be most suitable for use by children. As with all unsatisfactory toys the information was sent to professional bodies concerned with enforcement of the regulations namely the Association of Public Health Inspectors, the Association of Weights and Measures Inspectors and the Association of Shops Act Administration. The Toys (Safety) Regulations 1967 define a toy as meaning a child's plaything and whether or not pencils and paintbrushes come within this definition has not yet been established. Both articles were imported and again would appear to be old stock. Because of the tendency to chew pencils and paintbrushes, it is particularly important that the level of lead and other dangerous metals be kept to an absolute minimum. The control of rats and mice in accordance with the requirements of the Prevention of Damage by Pests Act 1949 together with the control of insects and other pests generally is carried out by a team of four operators, a foreman and a technical assistant. In addition to pest control work the operators also carry out drain clearance, assist in testing and transport of laboratory specimens, etc. Treatments in domestic premises for the eradication of rats and mice are carried out free of charge. Business premises are generally advised to avail themselves of the services of one of the specialists contractors but under certain circumstances, for example when control is necessary as part of the control of a block involving domestic property, treatment may be carried out and a charge made. Free disinfestations are carried out at domestic premises for insects of public health significance i.e. fleas, bed bugs and cockroaches. Infestations of animal fleas are not normally dealt with as a free service but advice on all insects and pests is freely given. Wasps are also eradicated free of charge. Although there was a slight reduction in the number of premises found to be infested with rats during the year, the number of premises infested with mice rose sharply, 674 compared with 490 in 1971. The department co-operated with the London Pest Unit of the Ministry of Agriculture, Fisheries and Food in a survey to determine the extent of rat and mouse infestations in the Greater London area. A detailed questionnaire was filled in relating to 1,000 premises of varying types. Details of the premises inspected found to be infested with rats and mice are contained in the following table: Type of Property Non-agricultural Agricultural 1. Number of properties in district 92,501 97 2. (a) Total number of properties inspected following notification 1,912 8 (b) Number infested by rats 1,251 8 (c) Number infested by mice 661 0 3. (a) Number of properties inspected for reasons other than notification 2,401 31 (b) Number infested by rats 1 6 (c) Number infested by mice 13 0 PEST CONTROL 97 Sewers Treatment of sewers is carried out with fluoracetamide when conditions permit. In other cases warfarin sewer bait is used. During the year 57 inspection chambers in various parts of the sewage system were treated. Squirrels and Foxes The nature of the Borough makes control of these animals particularly important. A charge is made for this service and all land under the control of the Borough is systematically dealt with, shoots being arranged under the control of a technical assistant. During the year 1,410 squirrels and 48 foxes were destroyed. Other Pests Measures are also taken against feral pigeons and stray cats when such steps are necessary in the interest of public health. As a result of trapping over the last two years the centre of Uxbridge is no longer troubled by a serious pigeon nuisance. Insect Pests There was a reduction in the number of insect pest complaints during the year, 652 as compared with 1.480 for 1971. This was laraelv due to the decrease in the number of waso complaints, 452 as against 1,336 for 1971. Details of these complaints are as follows: Wasps 452 Carpet beetles 7 Insect larvae 6 Ants 23 Cockroaches 17 Mites 7 Fleas 44 Flies 38 Silver fish 3 Bed Bugs 22 Lice 5 Other insects 5 Beetles 23 Total 652 PORT SANITARY ADMINISTRATION—LONDON (HEATHROW) AIRPORT While the Borough is the port health authority for London (Heathrow) Airport, the airport itself extends into the adjoining districts of Staines and Hounslow. During 1972 aircraft movements again increased and the number of passengers using the airport numbered 18,621,886 an increase of 14% over the previous year. Imported Food At the end of the year one of the two bonds in the central area transferred its operation to the cargo terminal in the Urban District of Staines and it is anticipated that no further commercial imports of food will take place through the remaining bond. The following food was inspected and found in good condition: Article lbs Article lbs Fresh Vegetables 70,252 Tinned Fruit 167 Fresh Fruit 49,935 Dried Turtle Meat 7,942 Food Hygiene During the year the enlargement of the Terminal 3 departures building was almost completed together with opening of the more spacious catering facilities for the public who will enjoy better service and the staff working therein have been afforded improved conditions. An aircraft catering 98 unit was extended permitting reorganisation of the whole system of production and storage in more hygienic conditions. The numerous food preparation premises include high-class restaurants, grill and griddle restaurants, snack bars, industrial and non-industrial canteens and aircraft catering establishments. Many of these units operate 24 hours of every day. The frequent changes in staff can lower the standard of hygiene temporarily and more changes are now taking place with the opening of additional hotels in the vicinity of the airport. Managements are anxious to meet the standards required and their co-operation continues. The responsibility for cleaning in many establishments is divided between the occupiers and the British Airports Authority who rely on contractual cleaners. Similarly the Authority engage contractors for some maintenance work which results invariably in delays in execution. In aircraft catering establishments, cold meals immediately after preparation are placed in cold rooms where the temperature is maintained below 50°F whilst awaiting despatch to aircraft. They are placed in insulated metal containers and on the longer flights to maintain a low temperature until served, dry ice is placed in containers except where galley compartments provided for containers are fitted with refrigeration. Some later type containers are constructed with built-in refrigeration plates which are plugged into refrigerator lines on the most modern aircraft. Freshly cooked hot meals are placed in special portable ovens which are connected to the aircraft electrical supply to maintain their temperature until served. This method particularly applies to short haul flights. Otherwise mainly frozen meals are supplied and reheated in convection or microwave ovens whilst the same types of ovens are used for the small proportion of freshly cooked meals served. All meals served on aircraft leaving the airport are stored and served from galleys. Water Supply Two companies supply the whole of the airport with mains water. Regular samples are taken from aircraft and submitted for bacteriological examination. 331 samples were taken during the year with the following results: Satisfactory Unsatisfactory From fixed tanks 158 8 From portable flasks: (1) filled in Borough area 32 4 (2) filled outside Borough area 44 52 (3) foreign filled 21 11 From bowsers 1 Modern aircraft are fitted with fixed tanks from which water is distributed to drinking points, galleys and washbasins. These are subjected to hyperchlorination at times of routine maintenance checks. Water is uplifted to the tanks by bowsers which are subjected to hyperchlorination weekly as a routine. The bowsers are filled with mains water specially provided from supply points and chloramine is injected automatically at this stage to leave at least 0.3 parts per million chlorine 30 minutes after treatment which will ensure that the water remains pure in the aircraft tanks and pipes. The water in the tanks becomes a mixture of varying sources and qualities as additional supplies are taken on board at foreign stations. A small number of the older types of aircraft rely on portable flasks for drinking water and in addition many foreign airlines carry iced water in flasks as an additional supply. As will be observed from the results obtained this type of supply is unreliable either by reason of ineffective sterilization of flasks or their contamination by incorrect handling in the filling process. Airlines are notified of 99 unsatisfactory results and the airline supplied with the majority of the flasks which were unsatisfactory has agreed, in spite of the cost, to dispense with the use of flasks and is providing proprietary brands of water in disposable containers. Vermin Control Following last year's more intensive survey successful treatments for rats on land were carried out by the British Airports Authority contractors. The same contractors are employed by most occupiers and carry out inspections on a routine basis for rodents and insects. The cockroach situation was extremely bad but maintainance of continuous treatment resulted in such an improved position that on routine inspections of catering establishments little evidence was found. Not only does the daily intake of catering supplies entail the continual risk of cockroach introductions but passengers' baggage and animals in transit are added hazards. In addition, flight cateiing units are also at risk when insects may be found in container equipment from pick-up points abroad. On the slightest suspicion of a rat or mouse being present in an aircraft hold the operating company immediately arranges for the whole aircraft to be treated with poison gas. OTHER SERVICES DEPARTMENTAL LABORATORY Facilities in the laboratory were further extended during the year to include a rapid method for the detection of lead and approximate indication of the amount in the range of 1.0% to 1.50% of lead and also to determine the presence of cyanide and fluoride in water. Laboratory facilities are invaluable in providing quick and positive identification of foreign bodies in food, insect identification and for supplementing the services available through the Public Health Laboratory Service and the Public Analyst. A summary of the tests and determinations carried out in the laboratory are set out in the following table: Bacteriological Examinations Type of Examination Total number of tests Swimming pool water 10 Ice cubes 4 Milk 24 Cream 2 Liquid egg 3 Other foods 4 Chemical examinations of food (pH, determination presence of metals etc.) 45 Identification of foreign bodies in food 40 Insect identification 80 Identification of mould growth 6 Identification of abrin beans 8 Full chemical analysis of water course samples 78 Fluoride determination mains water 63 Leaded toys 46 Atmospheric pollution: (a) sulphur dioxide determinations 2,430 (b) measurement of smoke concentration 2,430 Total 5,273 100 RIVER POLLUTION The attempt to improve the condition of the rivers in the Borough continues and in addition to the regular checks which are carried out to control oil pollution from the Uxbridge Industrial Estate, a concentrated effort was made to improve the condition of the Grand Union Canal at Harefield and where it flows west-east across the southern part of the Borough from West Drayton to Hayes. The first volume of "River Pollution Survey 1970" classified all the rivers in this Borough as grade class I, except for the canal and the River Colne where it flows with the canal at Harefield which were grade II. A survey of the canal was made to check all points of discharge into the canal including the effluent discharges and the points where water is abstracted from and returned to the canal for industrial purposes. A number of points of pollution were noted and with the exception of discolouration caused by the effluent discharged from the West Herts Main Drainage Works the persons were contacted and the pollution prevented. In volume II of "River Pollution Survey 1970" reference was made to the pollution of the River Colne by unsatisfactory effluent from a sewage disposal works. A total of 875 visits were made in connection with pollution of rivers, ponds and water courses and some of the matters dealt with are listed below: A plastic storage tank containing 1,500 gallons of sulphuric acid burst, and as the tank was not bunded, discharged into the surface water drainage. The company by the use of caustic soda and with assistance from the London Fire Brigade attempted to neutralise and dilute the discharge. There was serious contamination of the river and damage could have resulted to the sewers. There is no authority to require the provision of "bund" walling to enclose a storage tank and thus prevent the escape of chemical, including oil, if a tank burst. The British standard specification for the installation of oil storage tanks recommends the provision of a bund wall capable of retaining the tank capacity plus 10% i.e. to allow for any rain water which may be trapped within the bund, but this is a recommendation and cannot be enforced. Action can be taken to secure a penalty for contaminating both the Council's sewers or the river but it is not possible to enforce the provisions of works necessary to safeguard against the possibility of pollution in the event of an accident of this kind occurring. Oil pollution into Yeading Brook was traced back to a factory at Eastcote where apprentices were cleaning engineering equipment and pouring the waste into a surface water drain. This source of pollution has now ceased. It should be stressed that the expression "was traced back" is a brief and accurate description of what in practice is several hours work and a number of other possibilities had to be eliminated if the fish in the rivers were to be protected. A drum of chemicals spilled from a lorry at London (Heathrow) Airport and burst. The driver, a police officer and a passer-by all suffered from the effects of fumes and had to receive hospital attention but, fortunately there were no serious or lasting effects. It was again necessary for the fire brigade to hose down and pollution although heavily diluted would have got into the rivers. The chemical involved was only labelled by a trade name and there was some difficulty in locating the actual chemicals used in the preparation. Contamination of the surface water sewage system also occurred when a bulk tanker carrying perchloroethylene sprang a leak while parked in a car park in the West Drayton area. Investigation of the pollution of a stream in the Ruislip area revealed that foul water from the sinks in a nearby factory was being discharged into the stream. The main foul water drainage from the factory discharged into a cesspool. The cesspool which was emptied by the Council would have had to be enlarged. A contribution to the cost was made by the Council and all the foul drainage from the premises connected direct to the foul sewer. Regular and systematic patrolling of rivers and water courses by the environmental health staff is not possible and information from the public concerning pollution of the rivers is always welcome. LECTURES During the year groups of student midwives from Hillingdon group of hospitals visited the department to spend a day with the public health inspectors. Assistance was given with an in-training course for staff from the Health Control Unit at London Airport. Food hygiene lectures were given to domestic science pupils, members of women's organisations, and in connection with a special training course for food handlers which was organised in collaboration with the St. John Ambulance Association (Hillingdon Centre). 101 CHRONICALLY SICK AND DISABLED PERSONS ACT 1970 Section 6 of the Chronically Sick and Disabled Persons Act 1970 requires that when a notice is served under section 18/9 of the Public Health Act 1936 requiring the provision of sanitary conveniences at refreshment or entertainment premises, reasonable and practical provision shall be made for disabled persons. When assessing plan proposals for this class of building consideration is given to these requirements and where sanitary accommodation for members of the public is necessary, sanitary conveniences for the disabled are also requested to the standard set out in British Standard code of practice CP 96 Part I 1967. These provisions have or are being made at 5 new hotels and 1 motel. In some cases accommodation is provided by way of special adaptations to bedroom suites or by way of portable aids for use with the standard toilets. 102 SECTION IV Other Services 'Without health life is not life, life is lifeless."—Ariphron the Sicyonian Other Services HOUSING ALLOCATION—MEDICAL FACTORS The following table gives a summary of the applications for re-housing by the Council and for transfer of accommodation submitted over the last five years for assessment of the medical factors which are being put forward by the applicants to further a claim for priority consideration. Year New Applications Transfers Total Special recommendation or points No recommendation Total Support No support Total 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 1972 240 365 605 31 65 96 701 It will be seen that 701 housing cases were referred to the department during 1972 and in addition 28 other cases were considered under the Council's purchase of accommodation scheme making a total of 729 cases in all compared to 576 cases dealt with the previous year. Particular attention is drawn to the 605 applications for re-housing referred to the department which represents an increase of 50% over the figure for 1971 (415) which had itself been the highest total since the formation of the Borough in 1965. For many of the applications for re-housing further information has to be obtained from hospitals, health visitors, social workers, public health inspectors, etc. and this sharp rise in the number of new applications received, results in an increased work load for many of the department's staff. Of the 240 applications for re-housing in which it was possible to give support, 204 were awarded extra housing points while 36 were given "special" recommendations, i.e. the information available indicated that medical factors present were being seriously aggravated by existing accommodation and re-housing was recommended despite the fact that the application did not in other respects satisfy the criteria laid down by the Council in order to qualify for consideration. Of the 365 applications in which no recommendation was made 118 were considered to have medical factors present worthy of re-consideration at a later date when the application had been registered for one year and qualified for "pointing". Mention was made in the annual report of 1971 (page 105) of the Housing Committee's decision to dispense with the need for a general practitioner's certificate to be submitted in support of applications where priority on medical grounds was being sought. Applicants themselves were encouraged to disclose on a form designed for the purpose details of any condition which they felt was being aggravated by existing housing factors and during the year 225 applicants made use of this form. Many applicants however continued to seek support from their general practitioners and during the year g.p.'s certificates were received in support of 324 new applicants compared with 274 the previous year. Analysis of Medical Factors The table on the following page gives details of the medical conditions most commonly put forward when claims for priority consideration for re-housing or for transfer of accommodation are put forward. 105 Analysis of Medical Factors Medical Condition New Application Transfers Nervous Debility 146 36 Cardio-Vascular 116 14 Respiratory 89 11 Arthritis and Rheumatism 63 3 Physical Disability 53 12 Mental Illness or Subnormality 33 8 Other 105 12 Housing Needs of the Elderly Despite the sharp increase in the total number of new applications received, the number of applications submitted by persons of pensionable age was at 161, only 5 more than the figure for 1971. It was possible to give support on medical grounds in 102 of these cases, 21 of which received a "special" recommendation. During the year improvements were made in the system for collecting further information in relation to housing applications. With the kind co-operation of the Director of Social Services and his staff, social worker reports on cases already known to the social services department are made available in respect of families of housing applicants. The assistance of the department's nursing staff in respect of these cases not already known to other agencies of the Council has also resulted in further information concerning applicants and their families being made available more quickly than has been the case in the past. LONG STAY IMMIGRANTS The following table gives the number of advice notices received during the year from ports and airports relating to the arrival of immigrants in the Hillingdon area. Country issuing passport Number of notifications received during the year from ports and airports relating to arrival of immigrants Successful visits paid to immigrants during the year Commonwealth Countries Caribbean 6 3 India 41 29 Pakistan 17 12 Other Asian 10 9 African 163 109 Other 77 59 Total 314 221 Non-Commonwealth Countries European 19 16 Other 43 38 Total 62 54 Grand Total 376 275 106 MASS RADIOGRAPHY The Standing Medical Advisory Committee has recommended that the number of mass miniature radiography units should be reduced. Changes in policy with regard to the deployment of mobile units were implemented in the north-west metropolitan hospital region during 1972. The headquarters of the service was moved to St. Albans in December 1972 and the establishment of mobile units was reduced by two. Although it is planned that the routine three-yearly community and factory surveys will cease, a unit from the mass miniature radiography service did visit the Hayes area in March/April 1972 and the following table gives details of the places visited, number of persons X-rayed and the results obtained. Visit of Mass X-ray Unit to Hayes—March/April 1972 Site Number X-rayed 1969 visit Factories etc. 4,122 4,270 Public: Belmore Parade 726 Working Men's Club 822 Manor Parade 129 Kingshill Avenue 490 Bourne Avenue 297 Poplar Parade 252=2,716 3,652 Findings: Active T.B. 1 To chest clinic for observation 2 Healed T.B. 5 Heart conditions 10 Carcinoma 3 Sarcoid 3 Thyroid abnormality 1 Bronchiectasis 1 Pneumonia 7 CHEST X-RAY Static X-ray Centres Central Middlesex Hospital Acton Lane, Park Royal (nearest LTB Station—Park Royal) Monday to Friday 9.30 a.m.-4.30 p.m. Saturday 9.30 a.m.-11.30 a.m. West Middlesex Hospital Isleworth, Middlesex Monday to Friday 9.00 a.m.-5.00 p.m. 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 Police Station Forecourt (near Uxbridge Road Roundabout) Rickmansworth Weekly—on Mondays 2.45 p.m.-3.15 p.m. 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 1972. A problem drawn increasingly to the attention of the department is the elderly person who begins to act in an eccentric way so that neighbours and friends fear for her safety. The property and garden is often untidy but rarely a hazard to health whilst the elderly person is often reasonably mobile and showing no obvious signs of illness. Nevertheless the interior of the house leaves room for doubt about the person's ability to cope without help, although offers of assistance are frequently refused. Although approaches are made to various health and social agencies to resolve the problem either under this section or under the Mental Health Act the circumstances rarely justify such an initiative and there is often little that can be done except to observe a situation which is inherently a deteriorating one and to provide such support as the elderly person will permit. The concept of an observation register, first developed within the child health service, has been applied to elderly persons who may ultimately require action under Section 47 of the National Assistance Act. Although the register is not yet fully functional the assistance of health visitors, home nurses and public health inspectors is beginning to produce benefits. Reports are normally requested at three monthly intervals since any deterioration usually develops very slowly. Excellent rapport has long been established with the hospital geriatrician and his staff who are most helpful in a crisis, and who recognise the value of this early warning system. During 1972 there were 18 names added to the register, and 11 were removed. Of those on the register two were admitted to Council homes, two to geriatric wards and six died. At the end of the year a total of 23 names remained on the register. In the case of one couple the home nurse was experiencing great difficulty over the problem of the wife's incontinence. With the co-operation of the hospital laundry, and the environmental section of the health department a temporary incontinent laundry service was arranged. The sudden death of the husband a few days after the commencement of this service followed by the admission of the wife to a geriatric ward brought to an abrupt end an arrangement whose preparation had been necessarily time consuming. NURSING HOMES One hospital in the Borough is subject to registration under the Public Health Act 1936 and is visited by officers of the Department from time to time for advice and inspection. There are no private nursing homes in the Borough. NURSING AGENCIES The single nursing agency in the Borough was closed during the year. MASSAGE AND SPECIAL TREATMENT Premises used for the reception and treatment of persons requiring massage or other special treatment are licensed under the provisions of the Middlesex County Council Act 1944. They are inspected regularly by a principal medical officer. Included in this category are certain beauty establishments which hitherto have operated in conjunction with hairdressing salons. The cult of the sauna has blossomed with amazing rapidity throughout the world and seems to have a particular appeal for business men and travellers. Sauna baths are therefore becoming an essential part of the modern hotel service.One of the largest 108 national airports in the world lies within the Borough and is attracting a halo of luxury hotels, with the inevitable increase in licensed establishments. In view of this the requirements for licensing were reviewed and streamlined to allow the facilities to compare with international demands, at the same time retaining control over the traininq and qualifications of the staff and the general conduct of the establishment. Details of the number of premises licensed and the type of treatment offered are shown in the accompanying table: Treatment Carried Out Number of Premises Chiropody 10 Chiropody, physiotherapy 1 Physiotherapy, manipulative therapy 1 Beauty massage, electric treatment, radiant heat, steam or other baths, manicure, pedicure, electrolysis for face and limbs 5 OCCUPATIONAL HEALTH SERVICES The following table gives the details of medical assessments carried out during 1972 and for the previous four years. 1968 1969 1970 1971 1972 Total Number of Assessments 2,072 1,773 2,233 2,257 2,503 MEDICAL EXAMINATIONS Routine (i) Teachers (First appointment) 111 66 78 96 52 (ii) Students (On selection for Teachers Training College) 219 177 188 304 233 (iii) Requests from other Authorities 7 11 10 9 10 Other Staff Examined 398 323 240 259 142 Total number of Medical Examinations 735 577 516 668 437 Number Assessed without Examinations 1,337 1,196 1,717 1,589 2,066 % Total Assessed by Medical Examination 35% 32.5% 23% 29% 17.5% % Assessed by Examination when Routine Medical not required 23% 21% 12% 14% 7% 109 It will be noticed that although the total number of assessments carried out during 1972 was higher than for any of the previous years, the number of medical examinations (as distinct from assessments without examinations) was at 437 lower than for any of these years and brought the percentage figure of total assessed by medical examination down to 17.5% which is only half the figure for 1968. Although this reduction in the number of medical examinations carried out is partly explained by the smaller number of 14 T.T. forms (forms required by the Department of Education and Science for teachers and students), it will also be noticed that for those candidates for employment where discretion could be exercised with regard to the necessity for arranging a medical examination (examinations are compulsory for 14 T.T. candidates) only 1% of candidates were medically examined. The practice of requiring a chest X-ray examination for all candidates for employment whose duties would involve close and continuous contact with children was continued during 1972. Such employees are required to have a chest X-ray examination every three years and it has proved possible for details of chest X-ray requirements to be placed on the computer. At the time of appointment an indicator number is entered on the computer notification form and batches of these forms are forwarded at regular intervals to the Director of Finance & Treasurer. Starting in 1974 a list will be produced each month of all those members of staff in all departments whose chest X-ray examinations are then due and following receipt of a satisfactory chest X-ray report a further computer notification form will be completed so that the programme can be updated. PUBLIC MORTUARY The number of bodies received and post mortem examinations carried out during 1972 at the Council's mortuary in Kingston Lane, Hillingdon were: From Home Address: Residents of Hillingdon 224 Residents of other districts 12 236 From Hospitals in the Area: Residents of Hillingdon 415 Residents of other districts 372 787 From London Airport: Residents of other districts 23 1,046 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, and the Director of Health Services is the medical referee. 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 1972 4,140 110 The number of cremations, 4,140 was the highest on record at the Crematorium and continued the upward trend which was temporarily arrested in the previous year. It is one of the objectives of the Council to encourage cremation in appropriate cases. The proportion of cremations authorised as a result of a Coroner's certificate in 1972 was 33.1% compared with 30.5% in the previous year. In spite of the increasing number of cases cremated following the issue of a Coroner's certificate the need for appropriate enquiry in the remaining cases does not appear to diminish. In 1972 a total of 10 cases were referred for autopsy examination by the medical referee before the cremation could be authorised. The Joint Committee considered the report of the Committee on Death Certification and Coroners during the year and concluded that the office of medical referee should be retained but that a single medical certificate completed by a suitably experienced registered medical practitioner would be acceptable subject to certain safe-guards additional to those proposed in the Brodrick Report. The Joint Committee further concluded that the medical referee's current power to require an autopsy examination was of limited value unless he had the additional power to defray any medical expenses incurred by the examination. It was therefore resolved that Dr. Michael H. Bennett should be appointed consultant pathologist to the Crematorium. In fact it was possible to make arrangements with H.M. Coroner (Dr. J. D. K. Burton) or with the medical staff involved in the case for the necessary examinations to be undertaken in all ten cases during the year. In spite of the firm opposition of the medical profession to some of the proposals in the Brodrick Report concerning cremation, there was a notable tendency during the year for previously high standards of certification to be relaxed. The recommendation that present methods of certification be abandoned, have in some cases, made it more difficult to ensure that the present requirements of the Cremation Acts are strictly followed. It has never been possible to insist that only the Crematorium's own forms are used, and it was necessary to remind Funeral Directors during the year that the provision of two entirely separate medical forms although apparently accepted at some Crematoria were not suitable for use at Breakspear Crematorium. Occasionally such forms were received separately at the Crematorium and it was obvious from incidental enquiries that the doctor completing the second form had, in some cases, not seen the first form, although the current regulations require this to be done. The Committee on Death Certification and Coroners appears to have seriously underestimated the work of the present medical referee, and it would be unfortunate if, whilst necessary safe-guards to remedy this omission were being considered, current standards were allowed to deteriorate. 111 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 Health Centre, Park Lane, Harefield Every Tuesday p.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 a.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 Tuesday p.m. Ruislip Manor Clinic, Dawlish Drive, Ruislip Every Tuesday p.m. Every Wednesday a.m. Sidmouth Drive Clinic, Sidmouth Drive, Ruislip Every Thursday p.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 Health Centre, High Street, Yiewsley Every Tuesday and Wednesday p.m. Every Monday p.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 75 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 1 1 B5 Tuberculosis of Respiratory System M 3 1 1 1 F 2 1 1 B17 Syphilis and its Sequelae M c 1 1 B18 Other Infective and Parasitic Diseases r M 2 1 1 F 2 1 1 B19(1) Malignant Neoplasm, Buccal Cavity, etc. M 1 1 F 4 2 1 1 B19(2) Malignant Neoplasm, Oesophagus M 3 2 1 F 5 1 2 2 B19(3) Malignant Neoplasm, Stomach M 23 1 5 14 3 F 19 1 1 2 4 2 9 B19(4) Malignant Neoplasm, Intestine M 22 1 3 2 7 9 F 31 1 2 5 7 16 B19(6) Malignant Neoplasm, Lung, Bronchus M 133 3 19 36 51 24 F 33 1 3 12 13 4 B19(7) Malignant Neoplasm, Breast M F 41 6 7 12 10 6 B19(8) Malignant Neoplasm, Uterus F 19 1 5 2 7 4 B19(9) Malignant Neoplasm, Prostate M 9 4 1 4 B19(10) Leukaemia M 5 1 1 1 2 F 11 2 1 1 1 2 4 B19(11) Other Malignant Neoplasms M 74 1 2 10 23 18 20 F 71 1 8 19 17 26 B20 Benign and Unspecified Neoplasms M 1 1 F 3 1 1 1 B21 Diabetes Mellitus M 6 1 1 1 1 2 F 8 1 1 2 4 B46(1) Other Endocrine, etc., Diseases M 1 1 F 7 1 1 2 3 B23 Anaemias M 1 1 F 4 2 2 B46(2) Other diseases of Blood, etc. M F 1 1 B46(3) Mental Disorders F 1 1 B24 Meningitis F 1 1 B46(4) Multiple Sclerosis 2 2 F 1 1 B46(5) Other Diseases of Nervous System 10 1 1 2 3 2 1 F 4 1 3 B26 Chronic Rheumatic Heart Disease 5 1 1 2 1 F 13 3 4 6 B27 Hypertensive Disease 27 1 1 4 11 10 F 37 2 9 26 B28 Ischaemic Heart Disease 338 6 34 98 120 80 F 228 1 12 22 62 131 B29 Other Forms of Heart Disease 28 1 3 3 4 17 F 67 1 1 4 7 54 B30 Cerebrovascular Disease 84 1 4 11 31 37 F 154 1 3 13 42 95 116 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 B46(6) Other Diseases of Circulatory System M 40 3 3 12 22 F 58 1 3 12 42 B31 Influenza M 3 1 2 F 3 1 2 B32 Pneumonia M 67 2 1 1 7 18 38 F 101 1 2 1 5 8 84 B33(1) Bronchitis and Emphysema M 90 1 17 30 42 F 25 1 7 5 12 B33(2) Asthma M F 3 2 1 B46(7) Other Diseases of Respiratory System M 13 1 1 2 1 5 3 F 6 1 1 2 2 B34 Peptic Ulcer M 5 1 1 3 F 14 1 5 8 B35 Appendicitis M 2 1 1 F B36 Intestinal Obstruction and Hernia M 2 2 F 8 2 2 4 B37 Cirrhosis of Liver M 2 1 1 F 2 2 B46(8) Other Diseases of Digestive System M 9 1 1 2 4 1 F 16 1 1 3 11 B38 Nephritis and Nephrosis M 2 1 1 F 3 2 1 B39 Hyperplasia of Prostate M 3 1 1 1 B46(9) Other Diseases, Genitourinary System M 8 1 4 2 1 F 5 1 1 3 B41 Other Complications of Pregnancy, etc. F 1 1 B46(11) Diseases of Musculoskeletal System M 4 1 2 1 F 15 2 8 5 B42 Congenital Anomalies M 16 4 3 3 1 2 2 1 F 11 5 2 1 1 1 1 B43 Birth Injury, Difficult Labour, etc. M 7 7 F 6 6 B44 Other Causes of Perinatal Mortality M 3 3 F B45 Symptoms and III Defined M 5 3 1 1 Conditions F BE47 Motor Vehicle Accidents M 20 6 4 5 1 2 2 F 10 3 2 2 3 BE48 All Other Accidents M 15 1 3 1 2 2 1 3 2 F 8 1 1 1 1 1 3 BE49 Suicide and Self-inflicted Injuries M 10 1 2 6 1 F 3 2 1 BE50 All Other External Causes M 4 1 1 1 1 F 2 1 1 Total All Causes M 1,110 16 10 9 3 10 11 27 99 239 351 335 F 1,068 13 7 5 3 7 7 17 54 132 243 580 117 ATTENDANCES AT CHILD HEALTH CLINICS 1972 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. p.m. Laurel Lodge Mon. p.m., Thurs. p.m. Manor Farm Thurs. a.m. & p.m. Infants Born 1972 65 146 248 116 50 92 68 128 297 75 All other Attendances under 1 year 1,033 2,014 2,772 1,381 816 1,637 1,165 1,797 1,931 1,046 Children 1-5 years 1,114 1,560 1,493 1,332 802 1,434 1,061 1,004 1,535 651 Total Attendances 2,212 3,720 4,513 2,829 1,668 3,163 2,294 2,929 3,763 1,772 Consultations with Doctors 461 828 1,323 656 390 663 364 841 890 466 Number of Sessions 104 100 121 100 52 100 104 102 100 103 Average Attendance per Session 1972 21.3 37.20 37.3 28.3 32.1 31.6 22.1 28.7 37.6 17.2 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  Maurice Child. Carfax Road Tues. p.m. Minet Mon. p.m.. Fri. p.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 (Now replaced by Mobile) 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 1972 74 113 114 148 157 78 163 73 179 220 277 All other Attendances under 1 year 947 1,414 1,506 1,614 2,251 301 2,118 1,024 2,036 2,100 2,999 Children 1.5 years 840 800 1,020 1,871 1,410 385 1,043 779 988 819 1,453 Total Attendances 1,861 2,327 2,640 3,633 3,818 764 3,324 1,876 3,203 3,139 4,729 Consultations with Doctors 456 784 651 945 1,275 241 842 428 912 1,124 989 Number of Sessions 51 99 100 98 124 39 102 48 102 102 94 Average Attendance per Session 1972 36.5 23.5 26.4 37.1 30.8 19.6 32.6 39.1 31.4 30.8 50.3 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 46.2 118 ATTENDANCES AT MOBILE CHILD HEALTH CENTRES 1972 Barra Hall Circus 1st & 3rd Tues. a.m. Charville Estate 2nd. 4th. 5th Mon. a.m. Cowley 1st. 2nd, 4th & 5th Fri. p.m. Cranford Cross 1st & 3rd Weds. a.m. Glebe Estate 2nd & 4th Fri. a.m. Harlington 1st, 2nd, 3rd. 4th Ft 5th Mon. p.m. Hayes Baths 1st, 2nd. 3rd. 4th Ft 5th Weds, p.m Northwood, The Grange 2nd Ft 4th Thurs. p.m. Sipson 1st. 3rd & 4th Fri. a.m. Wise Lane Estate 2nd Ft 4th Weds, a.m Yeading 1st, 2nd. 3rd. 4th Ft 5th Tues. p.m. Infants Born 1972 33 18 51 15 25 63 58 27 24 31 57 All other Attendances Under 1 year 266 125 429 150 164 776 29 367 247 243 688 Children 1-5 years 295 126 368 130 287 473 93 209 215 167 527 Total Attendances 594 269 848 295 476 1,312 180 603 486 441 1,272 Consultations with Doctors 184 77 250 94 174 342 60 174 152 133 335 Number of Sessions 26 24 38 24 23 47 13 24 24 22 68 Average Attendance per Session 1972 22.8 11.2 22.3 12.3 20.7 27.9 13.8 25.1 20.3 20.0 18.7 Average Attendance per Session 1971 20.5 11.2 25.1 23.5 25.2 34.1 — 17.5 19.9 18.9 22.0 119 CHILDREN ON OBSERVATION REGISTER Category Year of Birth 1968 1969 1970 1971 1972 Pre-Natal Rubella or virus infection 1 6 3 Blood incompatibility 1 5 9 Ante Partum Haemorrhage 2 5 8 Toxaemia 2 20 33 X-ray 13 Thyrotoxicosis 1 1 Diabetes 1 1 5 Other complications of Pregnancy 1 3 4 Psychiatric illness 2 3 2 Peri-Natal Prolonged or difficult labour 21 167 202 Post Maturity 2 4 2 Birth Weight under 5 lbs 5 53 45 Gestation under 36 weeks 2 Foetal distress 2 49 104 Birth Asphyxia 3 Prolonged poor sucking 5 5 25 Post Natal Jaundice 8 26 55 Convulsions 2 5 9 Respiratory Distress 12 18 Cyanotic attacks Congenital Abnormality 35 33 45 53 51 Genetic Family History deaf or blind 1 2 2 9 14 Other 1 11 3 13 11 General Socio Economic 2 6 7 5 4 Other 11 11 14 2 1 Total 50 65 130 447 618 Grand Total: 1,310 120 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 1972 Total 1971 1972 197 1 1970 1969 1965-68 Others under 16 Diphtheria 88 1,873 741 90 305 30 3,127 3,209 German Measles 892 *892 1,553 Measles 1 1,090 642 158 181 13 2,085 2,202 Poliomyelitis 80 1,913 837 82 492 24 3,428 3,066 Tetanus 88 1,872 744 94 315 42 3,155 3,237 Whooping Cough 82 1,648 667 58 98 3 2,555 2,908 * This figure represents 54.6% of eligible school population. Re-inforcing Doses—Vaccine Year of Birth Total 1972 Total 1971 1972 1971 1970 1969 1965-68 Others under 16 Diphtheria 9 13 22 18 Tetanus only 1 1 3 15 159 179 277 Combined Dip./Tet. 12 28 30 1,511 1,550 3,131 5,765 Triple— Dip./Tet./W.cough 17 37 6 185 43 288 865 Poliomyelitis 1 42 62 46 1,578 1,362 3,091 5,279 121 DEATHS FROM CANCER Male Female Total 1972 1971 1972 1971 1972 1971 Malignant neoplasm, buccal cavity, etc. 1 5 4 1 5 6 Malignant neoplasm, oesophagus 3 5 5 1 8 6 Malignant neoplasm, stomach 23 29 19 21 42 50 Malignant neoplasm, intestine 22 28 31 42 53 70 Malignant neoplasm, larynx 2 2 4 Malignant neoplasm, lung, bronchus 133 102 33 26 166 128 Malignant neoplasm, breast 41 60 41 60 Malignant neoplasm, uterus 19 13 19 13 Malignant neoplasm, prostate 9 26 9 26 Leukaemia 5 10 11 11 16 21 Other malignant neoplasms 74 84 71 69 145 153 Totals 270 291 234 246 501 537 Rates per 1,000 of population Hillingdon All causes 2.13 Lung and Bronchus 0.70 122 DEATHS FROM CANCER OF THE PANCREAS Total QUARTER March June Sept. Dec. 1966 Hillingdon L.B. 20 4 6 4 6 Remaining London Boroughs 848 217 205 202 224 Greater London 868 221 211 206 230 1967 Hillingdon L.B. 21 3 10 7 1 Remaining London Boroughs 847 201 228 216 202 Greater London 868 204 238 223 203 1968 Hillingdon L.B. 14 6 3 5 Remaining London Boroughs 782 210 207 167 198 Greater London 796 216 207 170 203 1969 Hillingdon L.B. 19 5 6 5 3 Remaining London Boroughs 901 229 211 218 243 Greater London 920 234 217 223 246 1970 Hillingdon L.B. 19 5 9 3 2 Remaining London Boroughs 815 185 206 204 220 Greater London 834 190 215 207 222 1971 Hillingdon L.B. 27 4 7 9 7 Remaining London Boroughs 840 220 211 208 201 Greater London 867 224 218 217 208 1972 Hillingdon L.B. 31 3 14 8 6 Remaining London Boroughs 781 182 191 189 219 Greater London 812 185 205 197 225 123 PRIORITY DENTAL SERVICE STATISTICS Attendances and Treatment Children under 5 Expectant and Nursing Mothers First visit 1,206 101 Subsequent visits 1,317 156 Total visits 2,523 257 Number of additional courses of treatment commenced 180 17 Treatment provided: Number of fillings 1,437 132 Teeth filled 1,310 114 Teeth extracted 360 36 General anaesthetics 138 2 Emergency visits by patients 114 20 Patients X-rayed 56 30 Patients treated by scaling, etc. 694 52 Teeth otherwise conserved 134 Teeth root filled Inlays 1 Crowns 2 Number of courses of treatment completed during the year 883 55 Inspections Number of patients given first inspections 1,399 60 Number of patients who required treatment 1,048 55 Number of patients who were offered treatment 1,018 54 Prosthetics Patients supplied with full upper or full lower (first time) 7 Patients provided with other dentures 3 Number of dentures supplied 10 Sessions Number of dental officers sessions devoted to Maternity and child welfare patients (for treatment) 111 Total number of Dental Officer sessions 4,513 124 HOME NURSING AND MIDWIFERY STATISTICS Day Nursing Service Place where first treatment of year took place Number of persons treated during year Under 5 5 to 64 65 and over Total Patient's home 40 996 2,730 3,766 Health Centres 22 4 26 G.P.'s Premises 278 1,241 243 1,762 Residential Homes 5 50 55 Total 318 2,264 3,027 5,609 Total visits paid by Home Nurses—122,249, of these 392 were of over one hour's duration. Night Nursing Service Number of patients nursed 184 Number of visits paid by night nurses 4,179 Number of nights where a nurse has been placed in a patient's home throughout the night to give full care 177 Midwifery Service Number of domiciliary confinements 629 Number of confinements in the Duchess of Kent Maternity Wing conducted by domiciliary midwives 136 Number of patients confined in hospital and discharged to care of domiciliary midwives 711 Of these, number discharged before 5th day 126 125 HEALTH VISITING SERVICE Staff Establishment—excluding managers 55 Principal Nursing Officer 1 Senior Nursing Officers 3 Health Visitors—full-time 29 Health Visitors—part-time (full-time equivalent 8 7) 15 Clinic nurses—full-time 3 Clinic nurses—part-time 17 Health Assistants 3 Statistics Number of Cases Number of cases included in col. (1) seen at special request of Hospital G.P. Cases visited (1) (2) (3) 1 Children born in 1972 3,503 66 55 2 Other children aged under 5 7,297 40 20 3 Persons aged between 5 and 16 seen as part of health visiting (including those seen as part of school health service) 1,499 26 30 4 Persons aged between 17 and 64 1,021 29 39 5 Persons aged 65 and over 491 18 56 6 Households visited on account of tuberculosis 274 44 7 Households visited on account of other infectious diseases 221 13 8 8 Households visited for any other reason 602 15 12 9 Total 14,908 251 220 Number of persons included in lines 7-5 above who are: 10 Mentally handicapped 206 2 2 11 Mentally ill 103 9 13 126 127 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 1 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 1 1 1 2 9 1 2 1 1 1 1 16 Prematurity 5 1 1 1 1 1 10 10 Birth Injury 1 1 1 Resp. Distress Syndrome 1 2 3 3 Haemorrhagic Disease of Newborn 2 2 2 Pneumonia (All forms) 1 1 4 1 6 Bronchitis 1 1 Septicaemia 1 1 2 2 Cot Death 3 3 Asphyxia 1 1 Malabsorption Syndrome 1 1 Total 10 3 2 1 2 2 1 4 1 2 28 5 3 5 1 1 1 1 1 46 SECTION V Report of the Principal School Medical Officer for the year 1972 "Health and intellect are the two blessings of life."—Menander. Annual Report of the Principal School Medical Officer for the year 1972 Dr. J. Stuart Horner, M.B. Ch.B., 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 the calendar year 1972. The uncertainty which has surrounded the future of the school health service since the first Green Paper on the reorganisation of the National Health Service published in 1968, was resolved during the year by a statement that the personnel would be employed by the area health authorities, with the relationships between the transferred staff and the present local education authorities to be determined following recommendations by the Working Party on Collaboration. In November the publication of the National Health Service Reorganisation Bill made it clear that responsibility for the provision of special educational treatment would remain with the local education authority, whilst the present responsibility to provide facilities for the medical inspection and treatment of school children would be transferred to the Secretary of State for Social Services. This decision, which allows the development of a comprehensive child health service and which will permit closer relationships with medical and allied staff in the National Health Service generally than has previously been possible is welcomed although it is important to ensure that each local education authority is permitted to define the standard of service required. The total number of routine medical inspections completed during 1972 showed a reduction from the high figures of the previous year when children not examined earlier were also included. There was a marked increase in the number of special inspections and re-inspections as greater emphasis was given to the child with health problems. Many such children had previously been identified by school teachers and the service may be expected increasingly to concentrate in the future upon such children rather than upon the examination of large numbers of normal children. The working party of school medical officers completed its report during the year by recommending a more comprehensive examination at or near school entry with a more selective type of examination at later ages. It is now necessary to plan pilot projects to determine the practical difficulties associated with such arrangements, but in view of the tremendous changes which are currently taking place it would be prudent to introduce amendments to well established procedures slowly and with considerable care. During the year changes in the health services available for school leavers entering industry resulted in the creation of the Employment Medical Advisory Service, which will depend heavily for its medical advice in respect of every child upon information provided by the school health service. Thus decisions to abandon a school medical inspection at the end of the child's school career, would appear to be inopportune in view of the responsibility now placed upon the school medical officer to provide information about medical contra-indications to particular career choices. Nevertheless in certain cases it may still be more appropriate to obtain the required medical information by an extended interview with the school medical officer, rather than by a physical examination of every part of the school child. The trend towards an improved training of school medical officers and the provision of more complex diagnostic aids continued and a test of colour discrimination developed in the County of Hampshire and suitable for the examination of five-year old children was introduced as part of the routine examination. It has been customary to examine colour vision of children at the intermediate medical examination for many years, but this new test has allowed assessment of children at school entry. It is not yet known whether modern methods of teaching mathematics in primary schools may place the colour defective child at a disadvantage. By making this initial assessment it may be possible to obtain accumulating statistics which could prove helpful for research purposes, whilst the knowledge that a particular child who is having difficulty with the new methods also has apparent difficulties discriminating between similar colours, will be of great value to the class teacher. 131 Treatment Facilities The improvements in treatment facilities provided direct by the service and foreshadowed in the previous year's report were maintained, and there were dramatic increases in the number of children treated by the service. The success of the experimental enuresis clinic together with the considerable waiting list for treatment justified the opening of a second clinic during the year. The number of children treated at the orthopaedic clinic supervised by one of the school medical officers increased very significantly, and the staffing improvements in the speech therapy service were reflected by a 66% increase in the number of children treated. The appointment to the second consultant psychiatrist post at the child guidance clinic which was advertised at the end of the year will result in a considerable extension in the facilities available for children with behaviour disorders. It was apparent from comments by many school medical officers that the need for additional specialist advice in this field was particularly acute and thanks are due to the North West Metropolitan Regional Hospital Board for their interest and understanding of these problems. Dental Service The appointment of a second senior dental officer represented a further increase in the specialist expertise available to the dental services. During the year the chief dental officer obtained an honorary clinical assistant appointment at the London Hospital dental school whilst each of the two senior dental officers obtained similar appointments at University College Hospital. These appointments not only confirmed the high level of clinical expertise but also ensured that comprehensive facilities were available for Hillingdon children requiring advanced forms of dentistry. The number of dental inspections completed during the year increased by 1% but the percentage of children inspected who required treatment also increased so emphasising in particularly dramatic local form the problems presented by the current epidemic of dental disease in this country. Although the amount of treatment provided similarly increased often exceeding the additional proportion of treatment sessions available it can hardly be expected that the treatment services can meet known needs. The service in Hillingdon is seeking to provide more specialised forms of children's dentistry for those whose dental needs do not seem to be met by other dental services available locally. Since the latter are particularly well developed in this Borough this policy seems more appropriate than their duplication by the school dental service. Vermin Infestation The number of children examined by school nurses during the year again increased and the number of children found to be infested rose by 29%. The return of this condition, like the increased prevalence of scabies, is part of a national trend. Early identification and prompt treatment of these conditions which once appeared to have been completely eradicated remain the only practical solution. The continued vigilance of the school nurses in their conscientious attention to this important work is particularly to be congratulated. Health Education The appointment of a health education officer to assist Mrs. Mahy allowed the continued expansion of this important work during the year. A study day for teachers was over-subscribed and reflected the growing interest in health teaching in schools. One of the senior dental officers and the dental auxiliary assisted in the development of dental health programmes which were particularly well received in primary schools. Their emphasis upon practical participation helped to demonstrate to the children that health education is not merely a useful subject, it is also an interesting one. Special Education There is a wide-spread view amongst parents of handicapped children that placement in ordinary schools is to be encouraged and increased, apparently to the exclusion of provision in special schools. A doctrinaire approach to such a complex problem is totally inappropriate since 132 there are many occasions upon which transfer to a special school can be the only means of providing satisfactorily for the education of a handicapped child. A survey of physically handicapped children in ordinary schools was circulated by the Department of Education and Science during the year. It showed that a large number of such children were indeed attending ordinary schools and some of these children were severely handicapped. Nevertheless a significant number were considered to require additional help, and it was by no means clear that such assistance was available whenever it was required. The need for greater flexibility allowing handicapped children easily to transfer between the special school and ordinary school system at appropriate stages in their development seems likely to offer greater opportunities to the handicapped child than either despairing attempts to retain a child in an ordinary school when his handicaps are affecting adversely his education or retaining the child in a special school when, with a little ingenuity, his educational needs could be met more appropriately in open competition with normal children. I am most grateful to the Committee for their interest and support throughout the year. I am greatly indebted to the Director of Education together with the staff of the Education Department and the headteachers of the schools who so readily provide the help upon which much of our work depends. The Town Clerk and his staff have continued to provide much helpful advice and assistance. Finally my particular thanks are extended to the staff in the service to whose efforts the following pages bear witness. Yours faithfully, J. Stuart Horner, March 1973 Principal School Medical Officer 133 School Health Service Dr. J. W. E. Bridger (Principal Medical Officer) Part I MEDICAL INSPECTION IN SCHOOLS A local education authority has a duty under Section 48 of the Education Act 1944 to provide medical inspections of school children attending maintained schools in its area. Medical officers in department have responsibilities allotted to them in the school health service of the Authority to carry out periodic inspection of children in the schools; special examinations are conducted in the schools by arrangement with the Headteachers or in the Authority's clinics. All parents are given the opportunity of being present at every routine or special medical inspection of their children. Periodic medical inspections are carried out as follows: (a) On entry to infant school or nursery school, at the age of five years or under and this inspection to be carried out during the first year at school (entrance inspection). No further routine medical inspection will be undertaken until the intermediate inspection unless the child presents with a defect which needs observation or treatment. (b) An intermediate medical inspection is made in the last year of the primary school or the first year of secondary school education. (c) A medical inspection is made during the child's last year at secondary school, that is to say the school year in which the child attains its 16th birthday. No further inspections are made after this leaving inspection unless a defect is found to be present, which requires treatment or further observation. In addition to these routine medical inspections, special examinations may be made at any time in the child's school career at the request of the parent, school nurse or headteacher. The total number of routine medical inspections made during 1972 was 9,823. In addition to these, 7,697 special inspections were made making a total of 17,520. A comparison of the figures for routine medical inspection in 1971 shows that 3,236 fewer occurred during last year. The reason for this fall is to be found in the effect of the raising of the school leaving age from 15 to 16 years excluding a whole year group from the number of pupils requiring inspections in 1972. An increase in the number of special inspections was made during the year (7,697 compared with 6,670 in 1971). These latter inspections generally take longer to perform, demanding more of the doctor's time. During 1971 a questionnaire was circulated to each headteacher at a maintained school in the Borough requesting details of children in the schools who presented problems in physical or mental health or whose social background was under-privileged. A large response was obtained, some 1,700 children being brought forward for special medical investigation. Many of these children were already known to the service and were being observed or undergoing treatment in the school clinics, with general practitioners or at hospital. A number (1,034) was left to be inspected whose recent history was not known. This entailed the addition of these children to the lists for examination and this work occupied much of the available time in the summer and autumn terms of 1972. As has been reported previously, a working party recommended that a modified programme of medical inspection should be considered and this streamlining of the routine medical inspection programme was presented to the Education Committee and adopted by it, the result being to revise the timing of inspections beginning in the Autumn Term of 1972. It is a pleasure to record the increasing proportion of parents who attend medical inspection with their children. 76% of parents invited to the child's routine medical inspection were present and 71% of the parents invited to the special inspections. The value of the co-operation whrch is achieved by the meeting of parent and medical officer is immense and when the teacher can also be involved, the benefit to the child in its educational environment is greatly increased. The total number 134 of defects recorded as requiring observation or treatment was 3,309 among 9,823 children examined at routine medical inspections, i.e. 33.7%. An analysis of the figures for the various defects shows that four main medical areas are involved, namely defects of vision, hearing, speech, and orthopaedics. Among the children at entrance examination, the most important defects in order of frequency are: hearing, vision and speech; among the children seen at intermediate and leaver examinations however, these defects show a different distribution, i.e. vision, hearing, and orthopaedics. The obvious importance of hearing and vision in the education of the child and the fact that these two areas attract a large number of defects has emphasised the necessity of more frequent inspection in these fields. The Council has therefore decided to examine every school child in its maintained schools for vision every two years from entry and audiometrically every three years. An additional audiometrician has been trained and began work in September 1972 to supplement the work of the existing audiometrician, who has been testing children in the Borough since 1965. Speech defects are most numerous among children below the age of seven and are often only discussed or assessed for the first time at the entrance examination. Every medical officer is equipped with a speech screening test which identifies sounds which the child has difficulty in producing. Reference can then be made to an appropriate clinic where the speech therapist will assess the child, advise the parents and begin treatment where necessary. Personal Hygiene The London Borough of Hillingdon in implementing its powers under Section 54 of the Education Act 1944 has adopted the following procedure: Primary Schools A full inspection for cleanliness of person and clothing is to be conducted each autumn term in every school and re-visits to schools are to be made until an inspection of all 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 will 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, third and fourth year children will be inspected on exactly the same principle as outlined for the primary schools. The cleanliness and inspection of the fifth year children will be carried out at the same time as routine medical inspection which takes place during the school year in which a pupil attains the age of 16 years. There will be no further inspection of senior children unless cases of infestation are found in the group. If such infestation is found, the method of inspection adopted to combat further infestation will be left to the discretion of the Principal School Medical Officer. At any other time complaints of infestation of individual pupils will cause immediate inspection under the Section in the interest of the health and well-being of all school children. Cleanliness Inspections Regrettably, an increase in the number of children infested with head lice occurred during 1972. In all, 237 children were found to be infested for the first time in a total number of 64,486 inspections made. In spite of extra vigilance by school nurses, shown by the increase in the number of 135 inspections over last year, more children have become infested than in previous years. The figures demonstrate the trend. Year 1969 1970 1971 1972 No. of cases 68 112 184 237 There has been mounting evidence that the head louse over the past two or three years may be becoming resistent to the insecticides commonly used to cleanse the heads of children, and the nursing service has been experimenting with newer treatment such as "Malathion" in place of the previously successful D.D.T. and dieldrin insecticides. This lotion should not be used by other than trained persons because it is inflammable and poisonous. Since the nursing service can only inspect a school at intervals, it is important that one of the parents in a family should examine the heads of the children weekly and where infestation is present carry out energetic treatment of the whole family to eliminate this condition. 1971 1972 Number of cleanliness inspections 61,030 64,486 Number of children found infested for the first time 184 237 Skin Defects The proportion of skin defects found was similar to the previous year. The intermediate examination produced more children with skin defects than the other two groups. Many of the skin troubles are due to infections such as impetigo, various kinds of dermatitis, and verruca. This latter condition affects all ages of children, but is mainly brought to light among the junior and first year seniors when inspections prior to swimming reveal warts of the feet. Last year a form of treatment of verrucae was adopted in an endeavour to control the large number of children reported by headteachers to suffer from this condition. Results were obtained through the year from clinics using this treatment. Over a period of 8 months, from December 1971 to July 1972, 12 clinics treated 180 children with 136 successful results. Of the 44 unsuccessfully treated, 10 were seen later by chiropodists and the others applied for treatment elsewhere. Vision Defects Defects of the eyes account for 36.6% of all defects found at routine medical inspection. 1,023 children were discovered to have less than normal vision, 268 needing treatment at ophthalmic clinics, private opticians or hospital and 755 requiring observation; these latter were recalled for re-testing after varying periods of time. Ninety of the 268 children were entrants to school, 58 were the leavers, and the remaining 120 were scattered through the year groups. These figures indicate the necessity for close inspection of visual acuity throughout school life and the Council has adopted the recommendation that all children shall be so tested every two years. This will not necessarily reduce the number of children presenting with poor visual acuity, but the defect will be discovered more quickly. The lower incidence of squint among the children compared with 1971 and 1970, indicates that children with squint are being found and referred earlier. It is important that this defect is treated in the early months of a child's life to obtain maximum benefit from treatment. Delay inevitably results in the squinting eye being of little or no use to the child in later years. The routine vision testing of school children by experienced school nurses complements the normal vision testing at entrance, leaver and intermediate routine medical inspections. An additional vision test has been given at the age of seven for many years past and in September 1972 further vision tests were introduced for the nine and thirteen year-olds so that all children are now given a test at two year intervals. 136 The results are: Routine Vision Testing in Schools 1971 Number of Children tested 6,310 Number referred for opinion of school medical officer 261 Of these: 75 were referred to the school Ophthalmic Clinics 18 were referred for treatment via family doctors at request of parents 62 were referred for re-examination at school health clinics 12 were considered to have normal vision 67 were already having ophthalmic treatment 4 left the area while investigations were proceeding 23 are still awaiting examination by school medical officers Of the 75 children referred to the school Ophthalmic Clinics: 44 were prescribed glasses 12 were noted for re-examination 9 were discharged 10 are still under investigation 2 of the 75 were also referred to the school Orthoptic Clinic. The use of colour in the education of children has assumed some importance particularly for the very young; in some areas of teaching the ability to distinguish colours becomes crucial. Where a child has inherited colour vision defects, his understanding of the teaching material and the underlying principle of the subject may also be defective. It is essential then for teachers (and parents) to be aware of this disability and to vary the teaching accordingly. During the year a new screening test was introduced at the first routine medical inspection. The method depends upon the matching of colour strips in a series of simple tests. Any child who fails to pass this procedure is re-tested using a more sophisticated method distinguishing the type of colour deficiency. If this test is failed also, the parents and teachers are informed of the defect in the child's vision and the significance explained. Defects of Ears Next to the large number of children with visual difficulties come those defects of the ears and hearing, 11.8% of the total this year. This represents a welcome drop from the figures for 1971 (13.8%) and 1970 (12.8%). These figures are sufficiently large to warrant a close inspection of hearing function in children since a moderate loss of hearing can produce serious hindrance to a child's education. It has therefore been decided to increase the number of audiometric inspections, so that every child is routinely inspected every three years, i.e. in the child's sixth, ninth, twelfth and fifteenth year. An audiometrician was recruited and trained and began working in the autumn term of 1972. There are now two audiometricians employed on a part-time basis. Beside making routine inspections in schools, they are employed in special sessions in the school clinics where the school medical officers see children referred to them because of suspected hearing loss. When the child has been clinically examined and found to need treatment, advice is given or appointments made via the referring service to either a hearing clinic or an ENT surgeon. Defects of Nose and Throat Most of the abnormal conditions associated with the upper respiratory tract are infections and as might be expected are more common among the children at entrance examination (123). This figure is roughly four times the frequency found among the older junior children (33) which again is about four times that of the seniors (7). Essentially these infections are the greatest cause of school absences in the infant classes where the young children are exposed to a variety of microbial organisms with which they have to come to terms. The numbers of children seen with these conditions, however, tend to decline each year—7.4% in 1970, 5.3% in 1971 and 4.8% in 1972. Few 137 of the children appear to be left with any serious disability from these particular defects although persistently enlarged tonsils and adenoids may affect the child's hearing and sometimes speech in the following years. Speech defects The acquisition and development of clear verbal communication is recognised by everyone as an extremely important factor in the cultural and economic life of a person. All accept the faculty of speech as an expected continuous development in normal maturation from babyhood, into childhood, to adult stature. Every parent has thrilled to the first babblings of its infant child and has endeavoured to recognise purposeful sounds indicating the baby's gradual identification of people and objects in the world around it. This verbal development varies among children, and a degree of departure from the normal may require simple observation during the child's development over a longer or shorter period of time, or demand the assistance of a speech therapist. 240 children were reported as needing some help, the majority of these (204) being among the entrants. A further 34 were gathered from the intermediate inspections; two only being from the leavers, neither of whom needed active treatment. There has been a slight rise in the proportion of children with speech defect, 7.2% compared with 6.6% in 1971 and 6.3% of all defects in 1970. These figures may reflect a slightly better service being offered due to an increase in the number of speech therapy sessions available to the service. A fuller report on the speech therapy service is presented on page 155. Defects of lymph glands This rather anachronistic heading deals with palpable regional lymph nodes situated in strategic areas of the body, limbs, trunk, neck where enlargement of the nodes indicate acute or chronic infection or new growth involvement in the lymph area drained. Gross enlargement was only noted in 13 children. The proportion varies little from year to year—0.5% of all defects. Defects of heart and circulation The proportion of children presenting with possible heart defects remains the same as last year—2-1 % of all defects. Of 74 children noted 46 were among entrants; this dropped to 25 among intermediate examinees and only three in the leavers group. Among the infants, two were referred for investigation, the remainder requiring observation only. The presenting sign was usually a heart murmur, the significance of which must be carefully evaluated by the doctor. The evaluation of abnormal heart sounds presents particular difficulties for the school medical officer and as part of the programme of in-service training arrangements were made for one of the consultant paediatricians at Hillingdon Hospital to give a tutorial on the subject. Dr. S. M. Tucker was able to spend a whole morning with the medical officers explaining the features that might suggest the need for further specialist investigation and illustrating significant points by practical demonstrations on individual children. This session was most valuable not only for educational purposes but for the practical demonstration of close links between all doctors working with children upon which the future efficiency of the child health service depends. Defects of Lungs Sixty-five children were noted to have lung defects, a proportion of 1.9% of all defects. This proportion is much lower than last year (2.7%) and that of 1970 (2.5%). Twenty-three of the total of 65 children were among the entrants, this figure rising to 37 children offering themselves for intermediate inspection. This is a reverse of the usual figures obtained—probably an artifact due to groups of children being examined at different seasons of the year. Developmental defects The figures under this heading provide a consistent but small percentage of the total defects. Four children were sent for treatment of herniae; i.e. inguinal or umbilical. 104 children had some developmental anomaly i.e. absence of testis, absence of certain muscles, webbing of fingers or toes, presence of cleft palate etc. 138 Orthopaedic defects After defects of vision and hearing, this group attracts the greatest proportion of defects (8 8% of the total). This is smaller than last year's figure (12.4%) and that of 1970 (10.1 %). The importance attached to these disabilities is demonstrated by the establishment of an orthopaedic clinic to which children can be referred for advice and treatment. The headings of defects under this general orthopaedic grouping are: (a) Posture—The children seen at intermediate inspection provide the largest number in this section (18). This follows the pattern of last year's figures. (b) Feet—A total of 234 children were noted to have foot problems and the figure indicates the importance of careful surveillance from babyhood onwards of the child's feet. The proportion of foot defects unfortunately remains a fairly constant figure compared with other defects. Health education concerning the care of the feet is making very little impact upon those who are responsible for this field of a child's care. The fact that the figures of both entrants and intermediate examinees are similar (100 entrants, 107 intermediates) indicates that throughout the very important period of rapid physical growth of children, the same factors, year after year are producing defects of the feet. These are socks and shoes which become too small during growth of the child and inhibit the free movement of feet and toes. Frequent examinations of these articles of footwear are essential to avoid future deformity and pain. Defects of the Nervous System Twenty-three children were recorded as suffering from epilepsy of whom three were referred for investigation and treatment or for revision of treatment. The proportion of children with this condition remains at a low but constant level—0.7% of all defects in 1972. All of these children can be educated in normal schools, sometimes with some slight variation of the school regime to suit their particular needs. Providing full information is exchanged between parent, headteacher and doctor, few serious problems emerge during school life. Sixty-five children presented with other defects of the nervous system, 15 of whom were referred for treatment or investigation. These defects may cover a larger number of disabilities; weakness of limbs, or extremities, slight degrees of cerebral palsy, ataxia or some other dysfunction of the central nervous system. Psychological Defects There was a slight drop in the proportion of psychological defects noted this year—5.3% compared with 6.3% in 1971. There were fewer children recorded as having developmental defects compared with last year's figures, but there was a similar proportion presenting with problems of emotional instability. The former require careful assessment if their future educational needs are to be met in an appropriate environment; and the results of studies by teachers, educational psychologists and doctors of the children must be collated, and recommendations made to the Authority with that end in mind. Many of these children display other medical problems as well and the progress over the next few years of their physical and mental development will be recorded, and, where necessary treatment offered. The fact that all of these 28 children were noted among the entrants and intermediate groups indicates that this screening is successful in identifying the children early so that appropriate educational treatment may be quickly begun. The latter group of children, showing some degree of emotional instability, is still a comparatively large one—153 among all the groups which represent 4.5% of all defects. This figure is the same as last year. One half of all children so discovered were among the entrants to school and 10 of these were sufficiently disturbed as to warrant referral to the consultant child psychiatrist. Among the intermediate group of 66 children, 21 needed referral to the Child Guidance Clinic. It has been noted in former reports that hospital provision for severely disturbed children is still under discussion for this area; in the meantime the non-placement or unsuitable placement of even 139 one such patient can present enormous problems to the Authority, and can cause grave anxiety to the parents and deep heart searching of the public conscience. Scabies The organism causing scabies is a minute parasitic mite called Acarus Scabiei. The fertilized female burrows into the upper layers of the skin and deposits eggs in the small tunnel which she excavates. These burrows can often be seen as small sinuous lines in the skin, ¼ to ½ inch in length. Sometimes the burrow has a small vesicle or papule superimposed on it disguising the underlying lesion, or the infestation may show as a generalised rash over parts of the body. The patient becomes aware of the condition by the intense itching which is more pronounced after getting warm in bed. To relieve the irritation, the patient resorts to scratching which can damage the skin further and cause secondary infection and subsequent pustulation. The scabies mite chiefly invades the skin of the webs of the fingers, front of the wrists, elbows, arm pits, abdomen, buttocks, lower legs, ankles, and webs of toes. It is spread by direct contact of one person with another and like all infectious disease is no respecter of persons. After infection, itching may not be apparent for 2-3 weeks and this delay often makes contact tracing difficult. It is usually a family infection and all members of the family should be treated at the same time. There has been a significant rise in the number of children reported to be infested with scabies during the year. 49 such cases were diagnosed during 1972 and 39 visits to 29 schools were made to investigate contacts of these children. After a steady downward trend during the years 1969 to 1971 in Hillingdon, these figures are particularly disappointing in view of the thorough screening of many hundreds of children in an attempt to eradicate the condition from our schools. This rise in the number of scabies infestations reported is a national trend and vigorous measures are necessary to control it. All notifications of scabies are passed to the Deputy Medical Officer of Health who alerts the health visitor of the district in which the infestation has arisen and also informs the school health section whether a clinical investigation is necessary. The health visitor then visits the home to ensure that the whole family will accept treatment. The names of the children concerned and the schools and classes at which they attend are obtained. The school health section arranges for a team to investigate the contacts at the schools or classes to which the known infested children belong. The team consists of a medical officer in department who has received special instruction and training, a school nurse who prepares the children for examination and a clinic clerk who prepares letters for the parents and family doctors for any child found to be so infested. All children take home a stencilled note giving the reason for the inspection. Fresh cases of infestation are followed at home by the health visitor to explain the method of treatment which the family doctor may prescribe and the necessity for the co-operation of the whole family—adults and children. (Further details are recorded on page 179). EDUCATION (MILK) ACT 1971 Under the above act and accompanying regulations, free school milk is provided for pupils at junior departments in maintained schools on the following grounds: (1) Where a school medical officer certifies that the pupil's health requires that he/she should be provided with milk at school. This recommendation can be made at any time whilst a child is in a junior school. (2) Where a child achieves seven years of age between the end of the summer term and the following 31st August, then free school milk is provided for such a pupil in a maintained school until the end of the summer term following the seventh birthday. This would cover a child's first year only in a junior department. At the end of 1972, 1,082 pupils were receiving free school milk in junior departments of maintained schools. 140 School Health Service and Youth Employment Service The employment of school children is regulated by law and Local Authorities may apply restrictions by means of bye-laws. A child who is 13 years of age 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 stating that the school medical officer is satisfied that the work the child has to perform will not interfere with his health or education. The medical officer must consider whether the work is liable to induce undue or excessive fatigue, whether it is liable to induce some postural disability— excessive weight carrying, working in a cramped attitude, etc., or whether it is liable to take up too much of the child's leisure. 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 in 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. School Leavers and the Employment Medical Advisory Service The Employment Medical Advisory Service Act 1972 empowers the Government to set up an Employment Medical Advisory Service (EMAS) which will study and give advice on medical problems connected with employment. This Act comes into force on 1 st February, 1973. The arrangements at present made between the school health service and the youth employment service depend upon advice given to the local careers officer concerning any aspect of a young person's physical health likely to impose limitations on him/her in relation to possible work situations. The limitations are indicated on Form Y.9 or for a substantially handicapped young person, on Form Y.10. These forms are sent to the local careers officer and indicate to the careers officer that certain occupations would be unsuitable for the school leaver. In employment subject only to the Factories Act 1961, young people had to be medically examined by an appointed factory doctor within 14 days of starting work in a factory irrespective of whether or where they had been employed previously; also an annual examination had to be made whilst employed at the factory until the age of 18 years was reached. The appointed factory doctor had discretionary power to approach the school health service for medical information about a young person employed in a factory, but this was generally little used. As from 1 st February, 1973, the new arrangements will cover the medical supervision of young people entering any type of employment. The new arrangements relate to young people who have some departure from normal health, which might affect their choice of employment, whatever sort of job they had in mind. This new system will be based on the school health service's knowledge of the health of pupils and this will enable it to be selective. Only those young people so identified by the school health service will be brought to the attention of the EMAS. The system will be flexible and largely non-statutory, and to function properly, it will require close co-operation between the school health service, the careers officer and the employment medical adviser. Co-operation with family doctors will often be required also. Normally the careers officer will form the link between the school health service and the employment medical adviser. In the London Borough of Hillingdon medical information held by the school health service applies to children attending maintained schools as no arrangement exists for examining children in non-maintained schools. Medical examinations in maintained schools take place at the beginning of the last school year, to give careers officers and employment medical advisers ample time to advise the children who will enter employment for the first time. The school health service will send a copy of Form Y.9 to the careers officer where the child's medical condition shows a departure from normal health, to the employment medical adviser, and to the young persons general practitioner. Normally the pupil, and his/her parents or legal guardians will be told in general terms of any suggested conditions that may affect his/her choice of employment. In difficult cases it is expected that the school health service will consult with the employment medical adviser before Form Y.9 is completed, thus drawing on the employment medical adviser's knowledge of industrial conditions. For a substantially handicapped young person the same procedure will be adopted using Form Y.10. Since this form will contain medical details, the consent of the parent or guardian is necessary before the form can be issued. A specialist careers officer appointed by the Authority 141 has the responsibility of placing children who are on the handicapped pupils register in suitable employment. In order to place these children in a congenial work setting, a special liaison exists between the school health service and the specialist careers officer. Through the effectiveness of the Employment Medical Advisory Service, the introduction of the general practitioner and the employment medical adviser into the team will enhance the advice and the help that can be given to the handicapped school leaver. 142 Part II SPECIALIST SERVICES ROUTINE AUDIOMETRY Routine hearing tests were extended from the autumn term to children in the following age groups: (1) School year in which a child reaches 6 years of age. (2) School year in which a child reaches 9 years of age. (3) School year in which a child reaches 12 years of age. (4) School year in which a child reaches 15 years of age. Audiometry Results 1st January, 1972-31st August, 1973 (One operator) Number of children tested 4,894 Number found to have normal hearing 4,522 Number found to have a hearing loss 372 Of the 372 found to have a hearing loss: 117 were found to have a hearing loss in the right ear. 86 were found to have a hearing loss in the left ear. 169 were found to have a hearing loss in both ears. The 372 children were referred for examination by the school doctors with the following results: 41 were found to have normal hearing on clinical testing. 229 were noted for re-examination. 24 were referred to family doctors. 8 were referred to audiology units. 3 were already attending their family doctors. 11 were already attending audiology units. 38 were already attending hospital. 3 had left the area. 15 were still under observation. Audiometry Results 1st September, 1972-31st December, 1972 (Two operators) Number of children tested 5,474 Number found to have normal hearing 5,090 Number found to have a hearing loss 384 Of the 384 found to have a hearing loss: 120 were found to have a hearing loss in the right ear. 124 were found to have a hearing loss in the left ear. 140 were found to have a hearing loss in both ears. The investigation of these children is now proceeding and the results will be included in the annual report for 1973 when it is hoped to give figures covering four specific age groups. 143 CHILD GUIDANCE CLINICS I am grateful to Dr. R. P. M. Urquhart, Medical Director for the following report: The past year has been characterised by change in the Clinic, changes in staff and the awareness of impending change, both in organisation and in the provision of premises for work. While it has been possible for the staff to learn by collaboration and discussion what the established members and newcomers each had to offer and to develop the service provided, the lack of information or final decision on the part of government, local and national, as to the future of such clinics and the Uxbridge premises proved a source of considerable frustration. Through the repeatedly mentioned shortage of secretarial help, detailed statistics of the year's work are not available for comments. There has been, however, an impression that other agencies are more ready to recognise the usefulness of the clinic as a source for consultation over problems, as a more economical and effective approach in some instances than the referral of a child as the ostensible problem. We have welcomed direct approaches in this way from medical officers, health visitors, staff of the social services department and probation officers. Such an approach is also being used by teachers in certain schools, and this will be referred to more fully in next year's report, as it has only been developing in the latter part of the year. The potential of the clinic for teaching has been referred to in previous reports. While in-service training of students of the professions represented in the clinic is limited by lack of space, the psychotherapists have continued to make appropriate progress. At the end of the year we were informed that Miss R. Kerbekian had proceeded to the point where she could start seeing children individually in psychotherapy. The clinic has been used more this year than ever before to take part in the health department's courses for student nurses, and this has been a welcome opportunity to make the work of the clinic better understood. Dr. Urquhart spoke to a meeting of medical officers in the health department in April, and, perhaps partly as a result of this, we have had better contacts with them since, and easier discussion of children's problems by Clinic staff. The clinic has been fortunate in the new appointments made and taken up during the year. Mr. T. Ballantyne, psychiatric social worker, who had experience recently of working in a social service department, joined the staff on 1st January and has worked to understand his role in a new setting, at the same time furthering discussion of the scope of social work. The contribution of Mrs. N. Brice, who started work on the same day as an educational psychologist, has been stimulating also, bringing as she did a wide range of expertise in her own field. The psychotherapy side was considerably strengthened by the appointment of Dr. David Campbell, who had trained in the United States and since July has added a fresh perspective and flexibility in approach. We have to note with regret the loss in July of the services of Miss V. Hamilton, psychotherapist, whose sensitive clinical perception was matched by a scholarly grasp of theory. She had an important review article published in the British Journal of Medical Psychology. We greatly miss Mrs. Rosemary Brand, who made the difficult job of social worker to the maladjusted schools worthwhile and understandable to the schools and parents. She left in October to have a child. The retirement of Miss A. C. Dunne in July from the post of psychologist at the Hayes Clinic meant the loss of a widely popular and respected colleague, and we are not surprised that she has been pressed into working at clinics in Cambridgeshire. There has been more active clinical discussion during the year, and greater sophistication in the help offered to children and families. It has been possible to offer psychotherapy to some more severely disturbed children with evident benefit, and greater use has been made of family interviews. Dr. Urquhart was elected during the year to the Regional Committee of the Royal College of Psychiatrists, and also Chairman of the Tavistock Group of Clinic Directors. 144 SCHOOL DENTAL SERVICE Mrs. B. Fox, B.D.S.—Principal School Dental Officer Dental Staff Considerable progress has been made in many fields but temporary shortages of whole time dental officers has resulted in a lack of continuity of treatment and school inspections in some clinics. The shortage of house officer posts in the dental teaching hospitals has resulted in a number of graduates joining the authority on qualification but leaving after six months to return to hospitals as posts become vacant. In the long term this should result in a better child dental service if staff can be attracted back to the service when they have completed their term of postgraduate training. There are, however, a considerable number of problems with short term staff. This fact, albeit with the great emphasis now placed on preventive dentistry, has necessitated full use of postgraduate and in-service training facilities. It is hoped that these efforts to weld a team of staff together will mitigate the effects of a frequently changing staff on the children's dental treatment. The aim of the service must be to attract whole time staff who are sufficiently committed to spend a number of years with the authority. The Chief Dental Officer, Mrs. B. Fox, was appointed as an honorary clinical assistant in the Children's Department at The London Hospital Dental School. Mr. John Furniss joined the authority in April 1972 as a Senior Dental Officer. He was previously at University College Dental Hospital where he was Registrar in the Children's Department. Both he and Mr. J. G. Windmill (Senior Dental Officer) have been appointed honorary clinical assistants in the Children's Department at University College Dental Hospital. Handicapped Children Efforts have continued to provide a consistent and comprehensive dental service for children attending special schools in the Borough. Mr. Furniss has continued with some of his special interests in handicapped children and the dental service is now able to provide certain specialised forms of treatment previously only available in hospital. It has taken over two years to catch up with the backlog of treatment needs of these children. There are many complicating factors both social and medical. The proportion of time spent on their care far outweighs that spent on the average child. Children with complex medical conditions and those who are severely handicapped still need to be referred to a hospital so that they may be given full nursing after-care when recovering from a general anaesthetic. General Dental Practitioners It is pleasing to report that a closer liaison is being established with general dental practitioners in the Borough. Through occasional newsletters they are acquainted with new projects in the local authority service, new forms or leaflets given to parents and any areas of difficulty being encountered in the Borough. We are fortunate that our general dental practitioners provide a comprehensive service for large numbers of school children and are able to see them for routine check-up examinations. Children in this Borough are in a very fortunate position compared to the country as a whole, as regular treatment is available to them. School dental inspections in many parts of the Borough serve to remind parents that they should make a recall appointment with their family dentist. School Dental Inspections The number of children receiving a school dental inspection is still far short of the ideal situation. The school dental inspection is a screening process developed to select those children thought to be in need of treatment. The parents are invited to bring the child for a more detailed examination in the dental surgery at the clinic or to make an appointment with their own dentist. A small number of children with neglected mouths are still found at school inspections but it is frequently found that they have not accepted previous offers of treatment, or they have recently moved into the area. A 145 number of these children are found at special schools and close co-operation with the schools is resulting in a higher uptake of treatment. Frequently social problems are the major obstacle to overcome. Shortage and frequent change of staff at some clinics in the Borough has resulted in fewer children being inspected at schools. The problem is acute in Yiewsley and West Drayton as there is no dental clinic until the new Health Centre opens. Children from this area must travel to surgeries at Uxbridge or Laurel Lodge, Hillingdon. It has been our experience that many appointments made for children from these areas are not kept, possibly because of the travelling problems. Preventive Dentistry Much emphasis has been put on preventive dentistry both in the press and on television. This includes prevention of decay and the prevention of periodontal (gum) disease. Most parents know the harmful effect that sugar has on the teeth by causing decay. Very few realise that the sticky film of bacteria on the teeth, dental plaque, is also responsible for inflammation of the gums. This is usually mild in children but progresses to chronic gum disease in early adult life. Mild inflammation is frequently found in children at the age of five and in the majority of children in secondary schools. It can be cured by cleansing the teeth with a toothbrush. Few children do this effectively but dyes or disclosing solutions, which colour the dental plaque, can be painted on to the teeth to show the children where they have not cleaned properly. It is sufficient to clean the teeth once a day, if this is done thoroughly. Our findings show that it is rarely done well. Techniques for strengthening the teeth with fluoride gels and solutions have been developed in the United States and Scandinavia; they also complement the strengthening effect of fluoride which can be obtained in the drinking water. We are able to apply these to children's teeth in the dental surgery. These developments are very promising but are raising difficulties. No longer are children only visiting the surgery for fillings and extractions. Many parents are requesting preventive treatment, often for children who have few or no decayed teeth. Thus the number of children requesting regular appointments is rising rapidly. The service will not be able to meet these demands without employing more ancillary help. The dental surgery assistants have been teaching children to clean their teeth effectively and checking their progress with the disclosing solutions. It seems that this may be an effective method of reaching large numbers of children and emphasising the message that healthy gums are as important as teeth free from decay. In the future we hope to break the cycle of treatment of dental disease by continually repairing the teeth. This could be done most effectively by fluoridation of the drinking water. The dental health of children in the Borough is, on the whole, good but this is entirely due to the tremendous amount of reparative treatment carried out by dentists in the Borough. The majority are, of course, general dental practitioners. The amount of decay and gum disease does not seem to be decreasing. Regular detailed surveys of children's teeth will show whether this is a correct assessment. As more parents realise the importance of regular treatment and the school population increases more strains are put on the treatment services of both the local authority and the general dental practitioners. We are competing with other authorities for suitably qualified dentists and the demand far exceeds the supply. School dental service statistics are recorded on page 173. DENTAL HEALTH EDUCATION Bishop Winnington-lngram School Project An intensive three week programme of dental health education involving a class of 39 children aged 9-10 years was carried out at the above school at the begining of October 1972. The teacher involved in the project had been well briefed beforehand and supplied with all the relevant literature. The children concerned were mainly from upper middle class families. This was the first term that the children were being taught by project teaching methods. For most of the sessions a member of the dental health education unit visited the classroom and gave a short talk on the topic for the day. One project group would then concentrate on this topic 146 Dental Health Education at Dr. Triplett's School whilst the other project groups were concentrating on different topics. There were 6-8 children in each group. The topics concerned covered the whole range of dental health with extra emphasis on dental decay, periodontal disease, plaque, diet, oral hygiene and fluorides. Numerous projects and surveys were carried out by the children on such subjects as frequency of toothbrushing, types of toothbrushes and toothpastes. Calculations of amounts of different brands of toothpastes and a "Which ?" report on the best buy. Favourite sweets, amounts spent on sweets, experiments on the clearance of chocolate from the mouth. Geographical distribution of sugar beet and cane. Manufacture of toothpaste. Tooth anatomy, different animals and their teeth, dental experiences, painting pictures and posters, putting fillings into plaster models. Numerous other projects including the use of disclosing tablets and tooth brushing methods. A "feed-back" system was employed in which the children wrote about each day's activities. They also participated in question-times during which the teaching methods could be assessed and whether the children were able to grasp the concepts of certain of the more involved topics such as the role of plaque and the use of fluorides. A questionnaire has been evolved by the unit for use in the school's programme. This has a dual purpose in so much as it not only focusses on specific gaps in the individual child's dental health knowledge but when used at the start and finish of a projects programme it can aid in assessing the effectiveness of the teaching methods involved. The questionnaire also acts as an initial stimulant. The 20 part questionnaire includes 10 "knowledge" questions and 5 "attitude" questions. Knowledge and attitude scores can therefore be calculated and used in the assessment. All the children's mouths were examined at the start of the project and PMA scores (to measure gingival inflammation and level of oral hygiene) were calculated for the 6 maxillary anterior teeth. The teeth were then disclosed at this stage and the plaque demonstrated. This was followed by oral hygiene instruction. At the end of the project PMA indices were again calculated. These (and the questionnaires) will be checked again at three monthly intervals to try and assess the long term motivation. Similar projects have been requested by a further 16 of the Borough's junior schools. Results Statistical results of the measurements of pre- and post-project gingival inflammation (PMA scores) have been prepared by Mr. M. J. Southgate. (1) There were 39 children in the study and these have all been subjected to an intensive Dental Campaign. At the end, 34 have shown a decrease in % PMA while 5 have shown an increase. Mean change = -17.1 Standard Deviation ±14.70 10 children showed an average decrease (25.6%). 15 children showed an above average decrease (38.5%). The others showed little or no decrease in PMA. (2) There was a statistically significant decrease in the average percentage of PMA. Total significant decrease 64.1%. (3) Those with the highest PMA initially were not necessarily those who decreased the most. These initial results are quite promising and will be followed up at regular intervals. 147 DENTAL SURVEY OF FIVE YEAR OLD SCHOOL CHILDREN PILOT STUDY Many dental clinics in use at present were built in the late 1930's. The siting of those built before 1965 was relative to the needs of the area when it formed part of the county of Middlesex. A number of new health centres are being planned for future years and it is necessary to try and establish areas where the need for provision of dental services seems greatest. The distribution of general dental practitioners is uneven, there is a greater concentration in areas which are predominantly social class I and II. If it was possible to estimate what dental decay was present in children entering school and what proportion was being treated and by which service, planning of future local authority services could be much more efficient. It was decided to conduct a survey of children entering school to try and find this information' Methods The survey formed part of the routine school dental inspection and was performed by the dental officer concerned. Children who were 5 years of age but not 6 years in the academic year 1971-72 were examined. The selected schools were those included for inspection in the 1971-72 programme. The distribution in the Borough was uneven and weighted in favour of the north area. The most serious disadvantage was seen to be the large number of examiners. Unless examiners are trained together for such a survey and perform calibration exercises to reach a common understanding of the written criteria for the diagnosis of the dental conditions, a large degree of error is found. It was possible to discuss the criteria but not possible to carry out such calibration exercises and the interpretation of the results must be made accordingly. Examination Methods All examinations were carried out at school, usually in the school medical room. The subjects stood facing the window. Artifical light was usually available. These conditions were far from ideal but were typically those of a school dental inspection. The presence of dental decay (caries) was detected by mirror and probe examination. Diagnostic Criteria The criteria for the clinical diagnosis of caries was whether in the opinion of the examiner, the cavity required a filling. Each tooth which was decayed, extracted or filled was given a score of one. An estimation was also made of teeth considered so broken down that they required extraction. Incisors or front teeth were included in the survey as they are rarely shed naturally before the child is six. If the examiner was in any doubt whether a front tooth had been lost in an accident or had been shed naturally the tooth was not scored as missing. Thus the number of missing teeth would be simply an estimation of the number of teeth which had been extracted by a dentist. The index used to measure the amount of decay was d.e.f., where d is the number of decayed teeth, e is the number of extracted teeth and f is the number of filled teeth. An assessment of oral hygiene was made, whether in the opinion of the examiner it was satisfactory or unsatisfactory. Data Recording The findings were dictated to an experienced dental surgery assistant and recorded on individual charts. 148 Results The total number of children examined was 712 consisting of 352 girls and 360 boys. They attended eighteen schools. Table I shows the number of children examined in each school, the percentage of children who were free from decay and the average number of teeth each child had which were decayed, extracted or filled (d.e.f.). Dental Survey of five year old schoolchildren School No. of children examined % Caries Free % with Caries A verage d.e.f. Bourne House Nursery 7 71.4 28.6 0.86 Deansfield 54 68.3 31.7 0.9 William Byrd 14 57.2 42.8 1.6 St. Andrews 33 51.2 48.8 2.1 Glebe 36 47.2 52.8 2.03 Pinkwell 32 46.2 53.8 2.2 Ryefield 46 43.5 56.5 2.3 Grange Park Infants 56 42.5 57.5 2.3 St. Mary's 22 40.9 59.1 3.1 St. Bernadette's 32 40.6 59.4 1.8 Un-named 42 40.2 59.8 3.3 Field End 82 37.8 62.2 3.02 Grange Park Infants 46 37.0 63.0 1.78 Breakspear 37 35.1 64.9 1.84 Harlyn 33 33.3 66.7 2.36 Bourne 36 27.3 72.7 3.7 Dr. Tripletts 45 24.4 75.6 3.8 Harefield 49 22.4 77.6 3.5 Total examined 712 40.2 59.8 2.5 Dental Survey Females Males Overall Number 352 360 712 Number caries free 137 151 288 % caries free 38.9 42.0 40.2 Total d.e.f. 935 818 1,753 Average d.e.f. 2.6562 2.2722 2.4621 Variance 9.6003 9.1260 9.4086 Standard deviation 3.098 3.021 3.068 % Children who have had one or more teeth extracted 84 11.8 Children who had one or more teeth decayed 302 42.4 Children who had one or more teeth filled 223 31 3 149 150 D.E.F. Distribution No. d.e.f. teeth Female Male Overall 0 137 151 288 1 30 50 80 2 37 45 82 3 33 20 53 4 28 17 45 5 23 25 48 6 18 18 36 7 17 10 27 8 11 7 18 9 7 6 13 10 5 3 8 11 2 2 4 12 2 2 4 13 0 2 2 14 0 0 0 15 1 0 1 16 1 1 2 17 0 0 0 18 0 0 0 19 0 1 1 Total 352 360 712 Dental Cleanliness Standards of dental cleanliness were recorded as good, fair or poor. Those which were good are grouped as satisfactory and those which were fair or poor as unsatisfactory. 90 per cent of children were considered to have satisfactory oral hygiene and 10 per cent unsatisfactory. Discussion Great variation was found in the percentage of children who were caries free in different schools. Whether this represents a true difference or is a reflection of the differences between the examiners it is not possible to say. Different treatment patterns by dentists practising in the area is an additional complication. A tooth scores one point if it is a large filling or a "prophylactic" filling in a sticky spot on the tooth. It is disturbing to find 5 per cent of children who had eight teeth or more which were decayed, missing or filled. The examinations were carried out under far from ideal conditions. It was not possible to use radiographs (X-rays) which show up early cavities on hidden surfaces of the teeth. It is possible that we underestimated the amount of decay present. Conclusion The need for regular dental examinations of pre-school children is shown by the number of children entering school with decayed, missing or extracted teeth. To make a more accurate assessment of the true state of dental health of children in the Borough would require selected children to be examined by one examiner to eliminate examiner variability. 151 Acknowledgments I would like to thank the dental officers in the Borough for their help in compiling the data, in particular Mr. J. G. Windmill, Miss K. Goldberg, Mrs. E. Jackson and Mr. P. Kaye. Mr. M. Southgate, Statistician in the Health Department, gave advice on the presentation of the data and valuable help on the final processing of the data. ENURESIS CLINIC Dr. C. Jennings—School Medical Officer This experimental special clinic was begun in October 1971 for the treatment of enuretic children in the Borough. It is run on a weekly basis and is staffed by a medical officer in department, a clinic nurse and a clinic clerk. During the year 1972, the clinic had 83 patients on its list, 51 of whom were new patients. 17 of these 83 discontinued treatment for a variety of reasons; namely, 6 transferred to the Minet Clinic for Enuresis after it had been established, 3 moved from the Borough, 8 failed to attend regularly in spite of follow-up. The remaining 67 children continued treatment and 32 of them were able to be discharged as cured. This represents a success rate of almost 48%. The methods of treatment are varied with the age and temperament of the child. For the younger patients simple advice to the parents and encouragement to the child together with back-up devices such as keeping charts and diaries with small sketches were successful in three cases. The older children were given the alarms which awaken the child when the bladder begins to empty. The age range of patients attending the clinic is from 6 to 15 years, though few are treated before the age of 7 years. Among the 67 children who followed the full regime of treatment, 20 were girls and 47 boys, and the success rate was 10 girls and 22 boys roughly half of each group that was accepted for treatment. The time needed for treatment was from one week to as long as one year. The children are given monthly appointments until pronounced cured and then they may be seen again at a two or three monthly interval before a final discharge. A total of 32 alarms are held by the clinic of which 24 are in current use 8 being kept in reserve. Two booster attachments have been purchased for use by patients who are very deep sleepers. As more experience is gained of the problem of enuresis, a greater number of children can expect to be treated in a given time and a higher cure rate achieved. HEALTH EDUCATION IN SCHOOLS Mrs. P. Mahy, S.R.N., C.M.B. (Part 1). H.V. Cert., Community Care Cert., F.E. Teachers Cert., M.I.H.E., M.R.S.H.—Principal Health Education Officer Miss M. Beynon, Health Education Officer, joined the staff in September 1972. After an initial difficulty in introducing health education to schools within the Borough some progress has been made in 1972. A circular letter sent to Headteachers produced a good response. The policy is to involve parents whenever possible. To date, four parent teachers associations have invited the Principal Health Education Officer to speak at their evening meetings. An increasing number of schools are receiving regular visits from the Health Department's team of health educators. A pilot scheme of health education at Park Place School carried out by Dr. E. W. Jones and the Principal Health Education Officer proved successful. Following this, a teaching and visual aids session was given to the nursing staff of Park Place School, who have subsequently continued the programme. 152 In July the Principal of Uxbridge Technical College discussed with the Director of Health Services the possibility of introducing health education sessions into the college. Following liaison with Mr. E. Bartholomew a pilot scheme was drawn up and the talks commenced in September; it is hoped that all students will be reached. In conjunction with this, the existing counselling service for students would be reinforced by members from the Health Department who would give advice on health matters. The staff involved in the counselling service also participate in the talks and this is proving to be a very worthwhile project. During the year three requests were received by the Principal Health Education Officer to talk to groups of teaching staff, such as all the domestic science teachers, about health education. An interesting and lively evening resulted in more requests for health education in schools. Two schools also asked for talks to the teaching staff on specific aspects of health education, this has all proved to be most rewarding. After liaison with the Education Department it was agreed that health education study days for teachers should be arranged. The first such study day took place in November. Dr. J. Stuart Horner gave the opening lecture which stimulated discussion in three small seminar groups. The afternoon programme commenced with a talk by Dr. E. W. Jones which was followed by two films and a lively discussion. Further study days are planned and appear to be received with enthusiasm. The cooperation of the officers in the education department and the headmaster and staff of Hayes Grammar School which provided the first venue is much appreciated. In conclusion, one may safely comment that health education is increasing. More schools are asking for talks and the health education unit frequently acts in an advisory capacity and participates whenever desired. The year has shown promise and the members of the staff are developing the work rapidly as more talks are given by various members of the team. We are well aware that health education is essentially team work. Health Education in Schools and Colleges Talks given by No. of Talks Audiences Total Nos. reached Medical Officers 8 School children 30 7 College Students 75 3 Teachers 72 Nursing Staff 80 School children 660 Dental Officers 52 School children 474 Public Health Inspectors 2 School children 66 Health Education Officers 14 School children 316 23 College Students 185 5 Teachers 124 4 Parent/Teachers Associations 200 INTELLIGENCE ASSESSMENT School medical officers make tests of intelligence on certain pupils referred to them during the year for various medical and mental conditions. Frequently these children show lack of educational progress in an ordinary school and may need education in a special class or school where their abilities and aptitudes can be more fully developed. Special training must be given before these intelligence tests can be administered by medical officers. Two medical officers in department completed their training last year and two more need a further probationary period to complete their training. 119 intelligence assessments were made in the school health service in 1972. 153 ORTHOPAEDIC CLINIC Dr. A. Karim—School Medical Officer The Clinic, which was begun in 1971, has firmly established itself as a useful adjunct to the specialist services available to the school health and child health services. 127 children, pre-school and school children, were examined during 1972 for a variety of orthopaedic problems. The commonest of these were knock-knees, flat feet and weak ankle joints. 7 children were referred to the Consultant Orthopaedic Surgeon to the Borough for further investigation and treatment. Treatments of foot and ankle defects generally are divided into three main categories:— The first treatment group consists of young children, mainly toddlers and children in infant schools; these children are fitted with inneraze shoes which improve the posture; foot exercises are given regularly to enhance the muscle tone and power of the older child. The second treatment group consists of only seven children who have weak ankles and wear their shoes down badly on the outer surfaces. Insoles are fitted which support the ankle joint, correct posture and relieve pain in the foot. When regular foot exercises are carried out, improvement is noticeably quicker. The third treatment group is based upon foot exercises only which are supervised by the physiotherapist. Generally this method is not suitable for the pre-school child and improvement among the older school child is slow due to long standing postural defects of the feet and lower legs. PHYSIOTHERAPY SERVICE Mrs. J. M. Gilboy—Senior Physiotherapist Physiotherapy is the use of physical means to prevent injury, to treat both injury and disease and to assist the process of rehabilitation by developing and restoring the function of the body so that the patient may lead or return to as active and independent life as possible. The main method of treatment at Uxbridge Clinic is therapeutic movement or remedial exercise. As before, the bulk of patients attending the clinic are those with minor foot and leg defects for correction exercises. Fewer pre-school patients have been selected and attended for treatment during 1972 than in the previous year and more children of school age attended than in 1971. This year, more physically handicapped children in the higher age group have been referred for treatment or observation concerning their particular conditions from the Meadow School and Hedgewood School. Total number of treatments at Uxbridge Clinic for physiotherapy during 1972 565; an average of 2 sessions per week. Moorcroft School The number of treatments given at Moorcroft School during 1972 was 682. Certain of these treatments were grouped activities, but many were individual since a considerable number of the children are severely physically handicapped and must be treated separately. Three orthopaedic clinics were arranged during the year, one per term, at which Mr. P. I. Busfield, F.R.C.S. attended. These clinics enabled the parents, patients, surgeon and physiotherapist to be present together to discuss the child's medical problems in familiar surroundings. As a result, among the children presented for examination and advice, two were selected for surgery in the near future, and the management of the remaining patients decided upon. Home visits by the physiotherapists during the half-term and full-term holidays continued to be a most valuable feature of the general management of the severely physically handicapped 154 children attending the special care unit. This is sometimes the only opportunity of meeting the parents of the children. The visit enables the physiotherapist to assess the need for suitable basic equipment, to help the parents in coping with the child at home and also to offer advice concerning the child's day to day physiotherapeutic management. The physiotherapist advises on the suitability of furniture, such as chair and table sizes, correct wheelchair requirements or alterations needed to this equipment. Demonstrations are given concerning correct methods of teaching a handicapped child to walk and prevent bad posture; to teach new exercises which would be beneficial to the child and to reinforce the work done at the treatment Clinic in school time. Visits were made by the physiotherapists to the Disabled Lung Foundation, Kensington W.12, The Children's Prosthetic Unit of Queen Mary Hospital, Roehampton, and one physiotherapist attended a three day course on paediatrics at the Hospital for Sick Children, Great Ormond Street, W.C.1. The number of treatments at Moorcroft School during 1972=682; 5 sessions per week were given to the school. Westmead Clinic (Mrs. M. Bond—Senior Physiotherapist) In April 1972 it was decided to extend the provision of physiotherapy within the scope of the school health service to Westmead Clinic as at Uxbridge. Physiotherapy is now available for two sessions per week. To some extent this alleviates the ever increasing number of children attending at Uxbridge and also caters for the needs of children in the north of the Borough. Nevertheless it is still a fully integrated part of Dr. Karim's Orthopaedic Clinic at Uxbridge where the under-fives are seen as well as the greater number of older children. Both physiotherapists attend this clinic and children requiring treatment at either Uxbridge or Westmead are referred back to Dr. Karim at regular intervals. The selection of the children needing treatment between the two clinics means less travelling for most children and therefore minimal absence from school. The majority of treatments carried out at Westmead are for foot and lower limb defects— however slight, e.g. pes planus with or without the associated genu valgum; postural correction; pectoral and shoulder girdle mobility for respiratory conditions and/or associated postural defects. Active or passive stretching exercises are given for a number of reasons e.g. in case of torsion or tendon stretching. Frequently the involvement of the mother, or both parents is encouraged, and the importance of supervising home exercises is stressed—also where simple strapping is required to be done, as in over-lapping toes, between attendances at the clinic. Mothers are often advised concerning the type of footwear required prior to buying new shoes, or the fitting of calipers where worn, this latter usually applying to the handicapped child who is supervised in the home. The total number of treatments given during the period was 184. SPEECH THERAPY SERVICE Miss G. C. Donald—Senior Speech Therapist It is pleasant to report that there has been an improvement in the service that can be given to school children needing speech therapy in the Borough during 1972. A full-time speech therapist was recruited and took up post in January 1973 to reinforce the small staff of part-time therapists who had tried to give as wide a cover as possible in the preceding year. The following clinics now have speech therapists attending once or twice a week; Yiewsley, Uxbridge, Oak Farm, Laurel Lodge, Grange Park, Elers Road, Westmead, Ruislip Manor, Minet, Ickenham, Harefield and Northwood. In addition to these clinics, sessions are held in the special schools, Hedgewood, Meadow and Moorcroft. As a part of the session at Oak Farm Clinic, children from the autistic unit at Oak Farm School are treated or supervised. As the clinic facilities at Yiewsley are not easily accessible to all the children in that area, the speech therapist visits some of the schools to advise on treatment and management. Thus all maintained schools in the Borough have access to a speech therapist at least once a week during term time. 155 At present, 170 children are being given treatment weekly with 100 others being reviewed. The waiting lists at the clinics vary in different parts of the Borough; there is a total list of 60 children awaiting treatment—every child referred to a speech therapist is however, seen and assessed and a priority awarded. This year saw the re-introduction of a regular termly meeting of speech therapists which has proved to be an immense help in the discussion of difficult and unusual cases and problems arising from them. A joint meeting with doctors and educational psychologists proved to be a great leavener of ideas for future joint discussions and promotions. Among the topics brought forward were language poverty and reading problems; examination of the criteria for selection for a proposed language class; parent education in the importance of parent/child relationships with reference to children with poor linguisticability etc. The speech therapy service has welcomed six students from the London colleges of speech therapy for training with our own staff in the clinics and schools, observing the work done and applying their knowledge under supervision. It is hoped that the students will continue to visit from time to time, since they bring new ideas and can be of help with the problem of large caseloads. Also, the interest and experience of therapy in the school health service which they acquire during their apprenticeship frequently sets the pattern of their future professional employment. 156 Part III HANDICAPPED PUPILS Special education is provided under section 34 of the Education Act 1944 for all children ascertained in the area of a local education authority as being in need of it by virtue of handicapping defects of mind or body. There are many ways in which this education can be provided. The regime of an ordinary school can be varied for particular types of handicap allowing children to be integrated into the school, thus preventing the necessity of special school provision. For certain sight and hearing defects, a seating in a normal class can be chosen which is favourable for the child; exclusion from or limitations of certain types of education can be arranged to safeguard the child's health and security; or an ordinary school can be chosen which has certain advantages for the child e.g. a single storey school or a school with a fewer number of pupils or a school situated in a favourable position or site. Many ordinary schools have special units attached for the observation of pupils with mental or physical problems. Sometimes part-time attendance is permitted at an ordinary school whilst the child is attending a special school to allow a gradual resumption of normal education. Attendance at special remedial classes is arranged whilst the child attends an ordinary school. The possibilities in this area of education are large and the type of tuition given is tailor made for the individual. In association with the special variation of education given to the child, medical attention is also frequently required at a school or clinic. Children who are, for example, physically handicapped may need physiotherapy; or speech therapy; orthoptic treatment or psychotherapy. Close cooperation is required between the schools through the education department and the clinics through the school health service to ensure that maximum benefit is made of the facilities available to these children. Teachers need to be kept well informed on the medical progress of the child through regular (usually annual) assessment and by recommendations of the medical officers who are responsible for the group of schools in their areas. Where specific medical and/or mental defects are present which cannot be contained in an ordinary school, special schools are available to provide educational facilities under the categories laid down in the Handicapped Pupils and Special Schools Regulations 1959 of the Education Act 1944. These schools can be day or residential establishments. Certain categories of handicapped pupils attract larger numbers than others and where the numbers are sufficient, local authorities often provide the schools in their own areas. Such are schools for the educationally sub-normal, physically handicapped and maladjusted pupils established in this Borough. Similarly in categories where the number of handicapped pupils is smaller, units are set up in or adjacent to ordinary schools; again, in Hillingdon an autistic class for seven children is provided, and also a unit for the partially hearing child in a secondary school. Some groups of handicapped children are small in number and the facilities provided by one authority is shared by neighbouring education authorities to make a viable unit or school. To such categories belong the blind and deaf children, some of whom will need residential education because of the distances involved in travelling. Residential education may also be required for other groups of children because of the necessity of prolonged treatment or because conditions in the home or in an ordinary school environment are unsuitable or the residential school can supply a more beneficial and stable background at a critical time in the child's life. For those children who cannot attend any school because of very severe physical or mental disability, tuition is provided in the child's own home. The benefit to the child is however, very strictly limited; he has little contact with others of his own age and this restricts the educational process by depriving him of the stimulation and competition upon which all youngsters can thrive. The tuition given must be concentrated into a few hours per week in place of the developing educational process and progress enjoyed by the majority of children. Where possible, the child receiving home tuition is integrated as soon as medically possible into a special school or unit or into an ordinary school. On the handicapped pupils register in the London Borough of Hillingdon, there are 1,121 children, 675 boys and 446 girls. 244 new cases have been added in 1972. A number of children 157 are removed from the register each year, because of the family moving from the Borough to another area, having left school for employment, a disability causing ascertainment and inclusion on the register which has now been modified, improved or cured, or death of the child. Of these 1,121 children, 448 are educated in ordinary schools with special arrangements being made as described above. This figure is over one third of the total number of children on the register and indicates the degree of assimilation that is possible with an enlightened education staff. It is possible that this figure can be increased as architectural improvement and equipment for the handicapped within the ordinary schools improve. Integration into ordinary schools is already proceeding with delicate, epileptic, some maladjusted and a few physically handicapped, partially hearing and partially sighted children, although all these pupils have to be observed very closely in order to be sure that educational progress is being maintained in this situation. It is interesting to note some of the recommendations of the Vernon Report on the Education of the Visually Handicapped Child which was issued in 1972. These recommendations cover many fields of activity, including planning of educational services, consideration of children under five and the medical service up to school leaving age, the organisation of schools, the school curriculum, further education and occasional guidance, training of teachers and research. Many of the recommendations could equally apply to most handicapped children. The report suggests that all children should be screened for visual handicaps at child health centres as part of a general developmental assessment. At present, all health visitors in this Borough are trained to screen young children for visual competence. Another suggestion is that all visually handicapped children should be regularly re-assessed. All children on the handicapped pupils register are annually re-assessed by medical officers in department. It is recommended that visual screening of all children, including an annual test of visual acuity, should be part of the school health services in all primary and secondary schools and all special schools for other handicaps. School children in this Borough are to be tested for visual acuity every two years, although it is not possible to increase the number of these tests with present staff committments. However, an annual test should be the ultimate aim. The report urges the experimentation with the education of visually handicapped children in ordinary schools either in ordinary classes or in special classes within the ordinary school. Generally speaking many of the partially sighted children begin in the normal infant classes, where their special problems can be contained, but as the size of print in books becomes smaller the difficulties for these children increase. It should not be beyond the ingenuity of doctors and teachers however, to provide means to keep them at ordinary schools especially if places in the special schools for the partially sighted become harder to obtain. Handicapped Pupils Register for 1972 Category No. of Children Placed in No. of other children ascertained (See Separate Table) Total New Cases during 1972 Day Special Schools Day Special Classes Residential Schools Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls A—Blind 1 4 2 5 2 1 2 B—Partially Sighted 5 3 1 1 3 3 9 7 1 1 C—Deaf 6 1 1 2 1 8 3 1 D—Partially Hearing 3 2 7 10 11 12 21 24 4 3 E—Educationally Sub-normal 210 164 28 12 9 10 247 186 59 50 F—Epileptic 1 1 21 11 22 12 4 3 G—Maladjusted 38 9 7 24 7 5 1 74 17 23 9 H—Physically Handicapped 26 20 1 4 3 42 32 73 55 13 6 I—Speech Defect 1 36 19 37 19 4 J—Delicate 4 3 1 10 3 132 92 147 98 32 12 Multiple Defects 19 12 1 7 8 6 2 32 23 11 5 Totals 312 214 17 12 80 38 266 182 675 446 153 91 158 Handicapped Children under 5 years of Age A total of 131 children under the age of 5 years are recorded as being sufficiently handicapped as to need future special education. Each child is carefully examined medically and after information and reports have been gathered from many sources, parents, hospitals, doctors, health visitors, social workers etc., an assessment is made of the child's needs. Regular re-appraisal is necessary because of changing factors in the child's mental and physical progress to keep the assessment upto-date. Close contact is maintained with the school psychological service and the education department to ensure that placement of these children in the correct educational environment will be made at the appropriate time. 50 of the children (38% of the total) are noted to have a mental defect. During the year 76 mental assessments were made by the department's medical staff of children under the age of five years. Co-operation between the school health service and child health service is essential in the transfer of the handicapped pre-school child into a suitable educational setting at the most appropriate time. Handicapped Children under 5 years of age Category Year of Birth 1968 1969 1970 1971 1972 Total Defective vision 1 1 2 2 6 Defective hearing 3 4 1 1 9 Mental defect 11 8 10 4 1 34 Down's syndrome 2 2 5 3 4 16 Autism Cerebral palsy 4 1 2 1 8 Epilepsy 1 1 2 Heart disease 5 2 6 4 3 20 Spina bifida 4 2 1 2 9 Fibrocystic disease 1 1 1 3 Other physical handicap 5 5 8 2 4 24 Totals 33 27 33 20 18 131 (A) Blind Children In residential schools 6 In day special schools 1 Children ascertained in 1972 3 Pre-school children ascertained in 1972 0 The number of blind children on the handicapped pupils register in the Borough is very small —7 in all—5 boys and 2 girls. They are all between the ages of 5-16 years and the total number changes little from year to year. One boy is placed in a sunshine home as a day pupil; 4 children (2 boys and 2 girls) attend Linden Lodge S.W.19, which is administered by the Inner London Education Authority; one boy attends Worcester College for Blind; and one boy attends Dorton House School (London Society for Blind School). (B) Partially Sighted In residential schools 2 In day special schools 8 In ordinary schools 6 Children ascertained in 1972 2 Pre-school children ascertained in 1972 1 159 A total of 16 children, 9 boys and 7 girls are ascertained as partially sighted. Six of them, 3 boys and 3 girls are able to be educated in ordinary schools. Annual re-assessments of their progress and medical needs will decide their future placement if a change of education is necessary. Eight children (5 boys and 3 girls) attend the Inner London Education Authority's School for Partially Sighted at Hammersmith. One girl is placed at Linden Lodge School, S.W.19 and a boy is entered at Exhall Grange. (C) Deaf In residential special schools 3 In day special schools 7 In ordinary schools 1 Children ascertained in 1972 1 Two children (one boy and one girl) attend the Royal School for the Deaf at Margate and one girl attends the Woodford School for the Deaf, E.18. (D) Partially hearing In day special schools 5 In day special classes 17 In day nurseries 3 In ordinary schools 23 Children ascertained in 1972 7 After preliminary screening and examination at child health or school health clinics most children with a hearing loss are referred to the Heston Hearing Unit at Vicarage Farm Road, Hounslow. This Clinic is under the direction of Dr. L. Fisch, Consultant Otologist who has a staff of medical, educational, paramedical and social welfare officers to assist in the exacting assessment of the child and his/her educational and social needs. After the assessment and close consultation with the parents, the Principal School Medical Officer and the Director of Education, a recommendation is made for the child's educational future. As will be seen from the figures most will be able to be contained in ordinary schools, perhaps with some adjustment of their position in the class, or by the issue and use of a hearing aid. Others, depending upon the degree of hearing loss, will need the more sheltered and specially equipped classroom of the special school or a special class in an ordinary school. In the latter case, the children are integrated into the normal school for group and school activities, but receive more individual attention from a specially qualified teacher of the deaf in academic subjects. A peripatetic teacher of the deaf is employed to visit schools which have partially hearing pupils in thetr classes to discuss problems presented to the teachers by these children and to assess progress; she also maintains the contact with the home. Three children under the age of 5 years are placed in day nurseries on account of hearing disability. The children are thereby encouraged to communicate with others having normal hearing and speech, the enriched experience gained greatly assists them when schooling begins at ordinary or special school. (E) Educationally sub-normal pupils In residential special schools 40 In day special schools 374 In ordinary schools 5 Pre-school children placed in day nurseries 1 Pre-school children recommended for special school 10 Children recommended for special schools 3 Children ascertained in 1972 109 There are three schools for the education of the educationally sub-normal pupil within the Borough—Hedgewood School, Meadow School and Moorcroft School. Children who require residential special schooling are accommodated at various schools managed by other local education authorities e.g. Swaylands School, Penhurst, St. John's School, Brighton, etc. Forty children (28 160 boys and 12 girls) are receiving boarding education or education whilst in hospitals for the mentally sub-normal. One hundred and nine children were ascertained as educationally sub-normal during 1972 (59 boys and 50 girls); the total number of children in this category is now 433. This represents just over 1 % of the total school population for Hillingdon. Five children are in ordinary schools for a trial period and 4 have been recommended for special schools and are awaiting placement. Three children of compulsory school age are not attending school yet, but they have been recommended for special schooling and are awaiting placement at Moorcroft School where shortage of accommodation is particularly severe. The lack of space has forced the speech therapists and physiotherapists to accept very indifferent working conditions in order to try to treat the very handicapped children. Moorcroft School for ESN Pupils I am indebted to Mr. W. D. Nicholas, Headteacher for the following report: At the beginning of 1972 there were 124 children on the roll and during the year 13 left and 18 were admitted. The erection of a new classroom during the summer term made it possible to admit 11 five year-olds. Our contacts with other schools in the Borough have increased and we are now having regular visits from pupils from five secondary schools as part of their social studies course. Part of the policy of the school is to take the children out into the community as much as possible, and numerous visits were made in the locality and further afield. One of the highlights was a visit by the special care unit to Buckingham Palace to see the mounting of the guard. Some of our senior children have become familiar figures to the shopkeepers and public in Yiewsley and Uxbridge when they have gone on their regular shopping expeditions in preparation for lessons in cooking. Throughout the year we have sent groups of children on Tuesday afternoons to the Hayes Swimming Baths. During 1973 we hope to extend our contacts with the Adult Training Centre and on 12th January, our top two classes are having a social evening to which they have invited the residents of the Bourne Hostel and Slough Hostel and the trainees of the Moorcroft Adult Training Centre. We hope that by establishing closer links, the transfer of our children from school to work will be much easier. Our constant aim at the school is to encourage the acceptance of our children by the community. Meadow School, Royal Lane, Hillingdon Mr. Everett, Headteacher has kindly sent the following report: Our roll is 152 plus 10 from the Ruislip Gardens diagnostic class which has been very successfully held at this school for the last eighteen months. Once again we have enjoyed a very full year. All children in the school have taken part in a number of the many activities, such as camping, visiting theatres and exhibitions and travel abroad. Recently, a large majority of the senior schools helped in a successful production of "Oliver" which we presented at Christmas time to the old people of the neighbourhood. We are again grateful to the senior specialist careers officer who has advised and helped in placing our school leavers in employment. The full and successful year has been made possible by the hard work of my staff who have all given freely so much of their own time. I am most grateful. Hedgewood Day Special School for Educationally Sub-Normal Pupils I wish to thank Mr. 0. G. Best for the following report: Hedgewood School continues to increase in size. We now have 140 children on roll. 161 One of the most notable developments in 1972 was the introduction of the Duke of Edinburgh Award Scheme. The course was run by members of staff with the help of outside organisations and individuals who willingly gave their time. Ten boys and ten girls from the school gained the bronze award. This was most encouraging for all concerned and I am very grateful for all the people who helped the children in their achievement. Another development was the meetings we had in parent's homes. Parents can feel isolated with their slow learning children, but if they can meet and discuss problems that arise in their homes with other parents, they find this very useful. Teachers attend these meetings when they can. If parents can understand what is happening to their children in Hedgewood it helps the child. At these local parents meetings we have met some parents who never come to school. We held eight meetings this year which proved so popular that we are to carry on with them. In 1972 we started regular weekly horse riding instruction at the Charville School of Equitation, which is only five minutes walk away from the school. The lessons have been very successful and have been an attraction for children who on the whole are not very good at other sports. The School Council which started two years ago continues to meet weekly. Towards the end of the year our school was invited by the Borough road safety committee to take part in the training course organised by the assistant safety officer. The course was for moped riders, and eight of our pupils went on the six lesson course to learn the basics of riding a moped, maintenance, and the practical requirements of the highway code. After the course, which also included demonstrations, films and riding practice, the children were put through their paces in an unofficial test which was of a high standard. Four children passed, and were very proud of themselves. We have had a lot of success in swimming. This year four of our older boys obtained their intermediate life saving awards. We take 40 children swimming three times every week, and while our main aim is to teach them to swim, we have been very pleased with their achievements in gaining various swimming certificates and awards. In 1972 we have been successful throughout the school with 14 confidence awards, 12 for water safety, 4 for junior swimmers, 3 for elementary life saving, 4 for intermediate life saving, 7 for personal survival—Bronze, 8-10M awards, 6-25M, 2-100M, 6-200M, and 10-400M. At our end of term presentations, we had the honour of having Mrs. Judy Rowley (nee Grinham) to present the swimming awards and she brought along the gold medal that she won at the Melbourne Olympic Games to show the children. The ascertainment of the educationally sub-normal pupil presents an exercise in co-operation between members of various disciplines and the parents of the child. A child's educational difficulties may be identified at several points in its school career, but in the case of the child with very limited ability, the problem should be recognised early. Infant teachers are often reluctant to put a child forward for examination too early in its career, but evidence of learning difficulty is beginning to build up by the third school year at the latest. Educational psychologists, who are severally made responsible for groups of schools in the Borough, and the medical officers should be brought in to discuss the problems presented to the teachers. An investigation into the child's mental ability and general medical condition with special reference to hearing and visual acuity, is part of a general assessment and only after careful consideration of all the available reports and discussions is the child recommended for special education as an educational sub-normal pupil. (F) Epileptic In day special classes 2 In ordinary schools 32 Children ascertained in 1972 7 It is a remarkable fact that 32 of the 34 children ascertained as being epileptic and receiving medical treatment for this condition, can be contained in ordinary schools. A tribute must be paid to the headteachers who have such children in their classes and who accept the small but nevertheless disturbing risk of a major attack occurring in one of them and the subsequent upset caused to the other pupils and, possibly, the teacher. Modern drug treatment has very largely removed this possibility and the majority of children pursue a normal school curriculum with only minimal restrictions being applied to their physical education. 162 (G) Maladjusted In residential schools 31 In day special schools 47 In day special classes 7 Attending ordinary schools 6 Children ascertained in 1972 32 Ninety-one children are ascertained on the handicapped pupils register as maladjusted. This represents a fraction of the children who are referred to the child guidance clinics at Uxbridge and Hayes in the year. Many of these children are sent initially to school clinics for the school medical officer's opinion by headteachers who have had presented to them difficulties in the child's behaviour or attitude to school discipline and staff. Some of the emotional problems could no doubt be dealt with at this level provided that the school medical officer felt sufficiently competent in knowledge and experience to undertake a supportive role to the family and to give treatment to the child. Although contact with the Child Guidance Clinic is easy and direct consultation is possible with the child psychiatrist, it is frequently a matter of regret that individual work loads make close contacts very difficult to achieve. It has been suggested elsewhere that if the child psychiatrist could give more time to training, consultation and advice to the doctors in direct contact with children and their families thus broadening the scope of work available to the medical officer and relieving the strain on the Child Guidance Clinic of the big task of sifting through the cases presented to it, allocating priorities and arranging numerous investigations, a better and quicker service could be offered to these children and their families. There are two day schools for the education of the maladjusted pupil in this Borough. Chantry Special School Mr. Cambell, Headmaster has very kindly sent the following report on Chantry School: We had 43 on roll at the end of the year, 38 boys and 5 girls—24 new children joined us and 15 left during the year, 5 went back to normal school, the rest to work. Only one boy left not able to be placed in suitable employment. We now accept children aged 8 to 16 years including some very aggressive youngsters. The educational level ranges from the non-reader to the boy who has obtained seven "0" level passes. We have continued with our many out-door activities with successful camping, hostelling and canoeing trips. Our float in this year's Hayes Carnival earned us a first prize. This year our open evening was attended by most parents and many friends. Townsend House Day Special School for Maladjusted Children I am grateful to Mrs. J. M. Clarke for the following report: We had a considerable movement of children in this small school during the year. Overall 7 children were admitted and 8 left. The leavers were placed as follows: 2 boys and 1 girl returned to normal school 3 older boys were transferred to Chantry School 1 boy was transferred to Hedgewood School 1 boy was placed in a boarding school. Our roll at the end of the year was sixteen, 13 boys and 3 girls; this will gradually increase as there are a number of children under consideration for entry. We have had several staff changes this year, leaving us with one vacancy, but we are hoping to appoint a new teacher at the beginning of the Easter term. Despite staff changes we have seen some gratifying progress in the children in our care. The majority of the children have achieved considerable social adjustment. The withdrawn children have learnt to laugh and play with others whilst the aggressive ones have found a degree of self control, which has enabled them to reach a higher standard of attainment in their school work. We have been helped and supported in our work throughout the year by Dr. Urquhart and members of the child guidance team who are regular visitors to the school. 163 We have maintained a close contact with parents, for, apart from visiting the school, we have encouraged parents to join in our trips to the zoo and pantomime and most of the parents attended our Christmas party which helped to make it a very happy occasion for the children. (H) Physically Handicapped Pupils In residential schools 7 In day special schools 46 In day special classes 1 Attending ordinary schools 65 Pre-school children in day nurseries 1 Attending ordinary school but recommended for special school 2 Pre-school children recommended for special school 5 Receiving home tuition 1 Children ascertained in 1972 19 A total of 128 children are sufficiently severely physically handicapped to be entered on the handicapped pupils register. Forty-six of them (26 boys and 20 girls) are entered at one or other of the two special schools for physically handicapped children—St. Michael's School, Eastcote and Martindale School, Hounslow. Seven children, all boys, are entered at residential special schools. During the latter part of the year, it was decided that health visitors should pay a visit to the homes of children ascertained as physically handicapped. A total of 100 visits were made of which 43 were to the homes of those children in special schools when seven parents raised the need for aids (mainly in connection with enuresis) and one enquired about holiday facilities. The remaining 57 visits were made to the homes of children in ordinary schools but only three problems were raised by the parents; need for footwear (2) and rehousing (1). St. Michael's School, Eastcote has changed its status from that of a residential school for all ages to a day school for children of infant and junior age. This has resulted in a wider range of disabilities being accepted and also a lowering of the age of admission so as to include some nursery school children. It is hoped to begin a nursery unit in the near future to cater for the social, medical and educational needs of the very young physically handicapped child. The medical supervision of children at the school is undertaken by a visiting medical officer and physiotherapy and speech therapy is included in the educational programme so that the pupils derive the maximum benefit from both medical and educational treatment. The children suffer from a variety of handicaps, some are multiply handicapped, the major ones being stated in the following list: Cerebral palsy 11 Spina Bifida 8 Congenital heart disease 3 Pseudo-hypertrophic muscular dystrophy 3 Hemiparesis 2 Post road traffic accident 2 Asthma and eczema 2 Ectopia Vesicae 1 Neuroblastoma 1 Martindale School for physically handicapped children, Hounslow had accepted 16 children from Hillingdon. The principal disabilities are: Cerebral palsy 10 Congenital heart disease 2 Haemophilia 1 Rheumatoid arthritis 1 Three of the boys from St. Michael's School were transferred to ordinary schools in the Borough during 1972. Two of them were entered at secondary schools and their progress, medically and educationally is being watched with interest. There were a number of problems to face but the headmasters concerned welcomed the boys into their schools notwithstanding the possible 164 culties ahead and early progress is encouraging. The third boy was returned to his Junior School since his condition for entry into St. Michael's had much improved and his attendance there was no longer justified. St. Michael's School for Physically Handicapped Children, Eastcote Mr. Thornton has kindly sent the following report on this school: Since January 1972 St. Michael's has been operating as a day school, catering mainly for children of primary school age. Six pupils have left St. Michael's during the course of the last calendar year. Two boys, aged 12 were transferred to secondary schools; one boy, aged seven, to a primary school and one boy to Lingfield Hospital School. One boy was transferred to Shaftesbury Residential School and one girl was transferred to Martindale School, Hounslow. The number on the school roll has risen from 26 last year to 36, closure of the boarding unit having made extra teaching space available. St. Michael's now has a school library, which operates as a lending library to the pupils. Functions during the last academic year have included a party for staff, parents, pupils and younger brothers and sisters, held in St. Lawrence Church Hall; a sports day; a school fete; a fireworks party for staff, parents and pupils; the archery club championships and barbecue; a school Christmas party; Christmas concert and plays and a joint carol service with Newnham Junior School. We have also had educational visits to the Tower of London, Syon Park, Ruislip Woods and a local farm. The School Club Room Fund now stands at £3,300 and I hope to be inviting visitors to the opening within the near future. Our school film is now completed. This is the result of over four and a half hours of cine film shots during the course of the last 2½ years. It has been edited down to approximately one and a half hours running time and sound has been added. This film and the equipment used to shoot it and screen it all came from the school funds. The aims of the film are many and varied, but one of the most important is to inform parents, prospective parents and sections of the public who show interest. (I) Speech Defect In residential schools 1 In ordinary schools and receiving speech therapy 55 Children ascertained in 1972 4 The reduction of the number of children who are placed on the handicapped pupils register in this category compared with 1971 is to be expected following the discussion in last year's annual report (page 160). Before inclusion on the handicapped pupils register two criteria must be satisfied. Firstly the speech defect should produce a substantial handicap and be having or be likely to have a significant effect upon a child's education in school; and secondly the condition should be likely to be present for at least twelve months. The number of children referred to the speech therapists is no fewer than in previous years as has been notified in the report of the speech therapy service. There is a waiting list of children for treatment. Many of the speech defects are of a minor character usually a tardiness in acquiring certain sounds; otherwise the language of these children is usually normal. (J) Delicate In residential schools 13 Pre-school children placed in day nursery 5 In day special schools 7 Pre-school children recommended for ordinary school 1 In day special classes 1 Receiving home tuition 4 In ordinary schools with some variation of education 214 Children ascertained in 1972 44 165 This category includes all those children who by virtue of some defect of health require special education or a variation of normal education for their health and progress; and who are not included in any of the other categories. Such children may suffer from chronic bronchitis, bronchial asthma or other chest conditions; certain heart defects; rheumatic fever; haemophilia; diabetes mellitus, etc. It is the second largest category and the majority of the children are able to be educated in ordinary schools. Children in particular with bronchial asthma may need special education in a residential school; indeed over half the children attending Park Place School for delicate children suffer from this condition. The improvement in the health of the children so placed is not achieved without a great deal of help and encouragement (and sometimes anxiety) from the teaching and nursing staff of the residential schools and by careful supervision of a sometimes complex drug treatment by the medical staff. Park Place School, Henley-on-Thames This residential school for delicate boys at Henley-on-Thames is maintained by the London Borough of Hillingdon. I am grateful to Mr. Owen the Headmaster for the following report: We have 46 pupils on roll whose ages range from 11-17 years. Between Easter 1972 and the end of the year 22 boys left to enter day schools, further education or employment. The CSE results were encouraging. All 7 boys who took the course obtained passes some attempting 3 subjects. One boy regularly attended an "0" level course and 6 boys have followed a vocational course on one morning each week at the local technical college. Our two resident nurses, with the full support of Mrs. Mahy the Principal Health Education Officer and Dr. Jones, have undertaken the instruction and organised the discussions for the health education programme. This has proved extremely stimulating and beneficial. The school band has become well known locally through playing at different functions— they have also been invited to play for other special schools in the Borough. Badminton, basketball and canoeing have been added to the full range of activities which include photography cooking, enamelling, pottery, woodwork, natural history, football, cricket, swimming, amateur radio, chess, model making, rifle club, snooker, table tennis and a scouting group. Regular use has been made of the school mini-bus to attend sports fixtures and concerts and to make careers visits. Many hikes and weekend camps were arranged. A wet but successful fortnight's camp of 24 boys was held at Rydal in Westmorland. The scouts attended as helpers at both the cub and scout camps for the physically handicapped at Sidlesham and Sandhurst. Two camps for the school are planned for 1973—in Sherwood Forest and at Schmittbach on the German Frontier. An exchange visit (one week) with pupils from Ashe Hall Delicate School in Derbyshire has also been arranged. Multiple Handicaps In residential special schools 15 In day special schools 31 Pre-school children recommended for day special classes 1 Attending ordinary school 3 Pre-school placed in day nursery 2 Receiving home tuition 1 Children ascertained in 1972 16 Fifty-five children are reported to be multiply handicapped, but the primary handicapping condition is regarded from the educational stand-point as being the most disabling. The placing of multiply handicapped children requires frequent re-assessment by medical and educational staff to ensure that any variation in the child's condition is recorded and the appropriate steps taken to modify the educational placement accordingly. 166 Chronically Sick and Disabled Persons Act 1970 Through the operation of this act, a duty is placed upon local education authorities to provide special educational treatment for children suffering from three further conditions, deaf/blind, autism and early childhood phychosis, and acute dyslexia. Deaf/Blind Children As in 1971, there are three children who are assessed as being Deaf/Blind. Two of these children attend the Pathway's Unit at Condover Hall and the third child attends Moorcroft School for Educationally Sub-normal children. Autism and Early Childhood Psychosis Seven children are being educated in the autistic unit at Oak Farm School, Long Lane, Hillingdon. This special unit has a high teacher/pupil ratio in order to give the individual child the very personal interest and care that he needs. One of the essentials of treatment is to establish a close relationship and so enable the child to relate to the world outside. The development of communication is vital and this faculty is severely handicapped in nearly all of these children; communication through language is usually impossible because language is not understood. Tremendous patience and skill is demanded from teachers, educational psychologists, psychotherapists, and speech therapists. It will be noted that the unit is part of a normal school and the children have the opportunity of integration with normal school children. This reinforces the special skills applied to the child in the Unit and helps him to respond to the stimulus of a normal teaching and playground situation. Acute dyslexia There is no universal agreement concerning the definition of this term and its application to children with difficulties in reading, but most doctors tend to include children who have specific reading difficulties not related to low intelligence. Generally children who present with severe reading difficulties are assessed by education psychologists and a scheme of remedial teaching is worked out for the individual child. Special remedial classes are set up in the Borough at strategically placed schools where several children can be congregated and expert help be given. 167 EDUCATION (HANDICAPPED CHILDREN) ACT 1970 This Act made provision to bring into the educational system those children who have or would previously have been determined as being unsuitable for education at school. No child within the age limits for education is outside the scope of the educational system now. The following table covers all children for whom the London Borough of Hillingdon has some responsibility and provides factual evidence of steps taken to identify these children and any problems which they present in school or in the home. 97.16% of these children have been formally ascertained as handicapped pupils (category E-educationally subnormal) by the London Borough of Hillingdon Local Education Authority. Year Group Moorcroft School Leavesden Hospital Other Platings (see below) At Home Total On HPR (E) ESN No. Ascertained 1972 No. Examined 1972 Boys Girls Boys Girls Boys Girls Boys 1956 2 2 1 1 1 7 7 6 1957 1 4 1 1 5 1 13 13 1 10 1958 4 4 2 10 10 9 1959 5 1 2 2 10 10 8 1960 4 6 1 2 3 2 18 17 2 15 1961 9 2 1 1 13 13 1 10 1962 2 5 2 2 2 2 15 14 5 11 1963 8 10 2 20 20 13 19 1964 7 5 3 1 16 14 9 13 1965 7 7 1 2 17 16 10 13 1966 8 7 1 1 17 17 13 17 1967 6 9 1 1 17 17 10 10 1968 1 1 1 3 3 2 2 Totals 64 62 10 7 13 17 3 176 171 66 143 Other Placements Boys Girls Boys Girls Cell Barnes Hospital 1 1 Breakspear Centre, Watford 1 Binfield Park Hospital 1 Marlborough Day Hospital 1 Harperbury Hospital 1 Whittlesea School, Harrow 2 3 Goldie Leigh Hospital 1 Mandeville School, Ealing 1 2 St. Catherines Hospital 1 Clarendon School 1 St. Vincent's Hospital 1 Strathmoor Road School 1 Meadow Cottage Home 1 Autistic Society School 1 Larkwood Hall 1 Brighton Guardianship 1 Camphill Rudolf Steiner School 1 Grange Park Spec. Class 1 Hawksworth Hall 1 Townsend House School 1 John Capel School 1 Private School Placing 1 St. Christopher's School 1 168 Health Visitors Health visitors made 217 visits to the homes of these children during the year. As a result of these visits recommendations were made in 36 cases for the following matters to be further investigated: Holidays and temporary residential care 24 Aids and adaptations 13 Social work support 10 Rehousing 8 Residential care 5 Total 60 169 Part IV STATISTICAL RETURNS 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) 1968 and later 274 274 8 26 32 1967 1,551 1,546 5 30 146 170 1966 1,834 1,831 3 42 178 211 1965 244 244 10 33 40 1964 163 162 1 5 23 28 1963 129 129 8 11 18 1962 416 416 6 41 46 1961 1,524 1,524 44 81 121 1960 1,280 1,279 1 36 46 80 1959 465 465 15 31 45 1958 243 243 8 13 21 1957 and earlier 1,700 1,699 1 56 54 108 Totals 9,823 9,812 11 268 683 920 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 3,538 Number of re-inspections 4,159 Total 7,697 170 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) (3) (4) (5) (6) (7) (8) (9) (10) F. Re. F. Re. 4 Skin 11 15 7 1 20 27 38 43 25 28 86 186 5 Eyes: (a) Vision 90 422 58 71 120 262 268 755 135 156 133 282 (b) Squint 11 11 1 3 12 14 3 6 3 2 (c) Other 1 99 2 10 3 109 3 1 3 7 6 Ears: (a) Hearing 150 40 23 9 74 30 247 79 209 334 116 344 (b) Otitis media 5 21 1 7 6 28 4 3 15 (c) Other 4 11 2 5 5 11 11 27 18 11 19 63 7 Nose and throat 13 110 3 4 10 23 26 137 7 20 21 41 8 Speech 80 124 2 15 19 95 145 42 31 18 39 9 Lymphatic glands 1 11 1 1 12 1 2 10 Heart 2 44 3 4 21 6 68 2 5 10 38 11 Lungs 3 20 5 1 36 4 61 1 4 11 41 12 Developmental: (a) Hernia 2 4 2 2 4 6 1 7 (b) Other 3 27 10 10 54 13 91 5 7 17 66 13 Orthopaedic: (a) Posture 3 5 1 1 3 15 7 21 2 2 2 7 (b) Feet 10 90 8 19 19 88 37 197 60 18 110 263 (c) Other 4 13 4 5 15 9 32 4 2 7 60 14 Nervous system: (a) Epilepsy 8 1 3 11 3 20 1 3 20 (b) Other 8 26 2 4 5 20 15 50 5 14 9 21 15 Psychological: (a) Development 3 12 3 10 6 22 4 5 14 20 (b) Stability 10 66 1 10 21 45 32 121 24 32 23 56 16 Abdomen 1 15 1 5 13 2 33 2 2 4 17 17 Other 45 117 6 17 55 153 106 287 40 19 84 157 (T) Requiring treatment, 951 (O) Requiring observation, 2,358 171 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 10 Errors of refraction (including squint) 1,601 Total 1,611 Number of pupils for whom spectacles were prescribed 711 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 tonsillitis — (c) for other nose and throat conditions — Received other forms of treatment 13 Total 13 Total number of pupils still on the register of schools at 31st December, 1972, known to have been provided with hearing aids: (a) during the calendar year 1972 2 (b) in previous years 68 Orthopaedic and Postural Defects Number known to have been treated (a) Pupils treated at clinics or out-patients departments 174 (b) Pupils treated at school for postural defects 97 Total 271 Diseases of the Skin Number of pupils known to have been treated Ringworm—(a) Scalp — (b) Body — Scabies — Impetigo — Other skin diseases 54 Total 54 Child Guidance Treatment Number known to have been treated Pupils treated at Child Guidance clinics 180 172 Speech Therapy Number known to have been treated Pupils treated by speech therapists 527 Other Treatment Given Number known to have been treated (a) Pupils with minor ailments 4 (b) Pupils who received convalescent treatment under school health service arrangements 7 (c) Pupils who received B.C.G. vaccination 2,825 TABLE E—SCHOOL DENTAL SERVICE STATISTICS Attendances and Treatment Ages 5-9 Ages 10-14 Ages 15 and over Total First visit 4,027 2,644 588 7,259 Subsequent visits 7,088 6,017 1,137 14,242 Total visits 11,115 8,661 1,725 21,501 Additional courses of treatment commenced 598 189 35 822 Fillings in permanent teeth 2,639 4,666 1,230 8,535 Fillings in deciduous teeth 5,827 805 6,632 Permanent teeth filled 2,242 4,229 1,137 7,608 Deciduous teeth filled 5,827 761 6,588 General anaesthetics 760 401 45 1,206 Emergencies 557 228 56 841 Prosthetics Pupils supplied with full upper or full lower (first time) Pupils supplied with other dentures 1 2 3 Number of dentures supplied 1 2 3 Number of pupils X-rayed 1,733 Prophylaxis 4,335 Teeth otherwise conserved 456 Number of teeth root filled 81 Inlays 1 Crowns 51 Courses of treatment completed 6,049 Orthodontics New cases commenced during year 138 Cases completed during year 113 Number of removable appliances fitted 296 Number of fixed appliances fitted 13 Pupils referred to hospital consultant 22 Inspections First inspection at school, no. of pupils 20,267 First inspection at clinic, no. of pupils 4,570 Number found to require treatment 11,487 Number offered treatment 10,624 Pupils re-inspected at school clinic 1,802 Number found to require treatment 1,575 Anaesthetics Total number administered 1,206 Sessions Number of sessions devoted to treatment 3,689 Number of sessions devoted to inspection 160 173 TABLE F—ORTHOPTIC CLINIC Monthly Attendance Record New Patients Observation Treatment Total January 9 43 10 62 February 10 48 9 67 March 10 39 10 59 April 5 39 3 47 May 6 57 18 81 June 13 45 20 78 July 5 34 39 August 21 21 September 4 4 October 15 62 77 November 8 71 1 80 December 8 34 5 47 Totals 89 497 76 662 Total new patients 1972 Total attendances 89 Referred from school clinic 79 662 Referred from medical eye centres 10 Total patients discharged 25, including 6 transferred to other areas. Type of Case Convergent strabismus Including: (i) With amblyopia (ii) Requiring surgery (iii) Others 18 5 23 46 Divergent strabismus Including: (i) Latent (ii) Manifest 8 2 10 Anisometropia amblyopia 9 Heterophoria Nil Apparent (epicanthus etc.) 9 Children with family history of squint or vision defect found N.A.D. 15 174 TABLE G—HANDICAPPED CHILDREN NOT ATTENDING SPECIAL SCHOOLS OR CLASSES Category Pre-school but placed in Day Nurseries Pre-school but recommended for Attending ordinary School Receiving Home Tuition Of 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 Girls A—Blind B—Partially Sighted 1 2 1 1 1 3 3 C—Deaf 1 1 D—Partially Hearing 1 2 10 10 11 12 E—Educationally Sub-normal 1 3 7 2 2 1 3 9 10 F—Epileptic 21 11 21 11 G—Maladjusted 5 1 5 1 H—Physically H'cap 1 3 2 34 29 1 1 2 1 42 32 I—Speech Defect 3 33 19 36 1 9 J—Delicate 5 1 117 86 2 2 2 2 2 2 3 132 92 Multiple Defects 2 1 2 2 1 6 2 Totals 13 2 7 9 1 1 218 158 13 6 4 4 4 2 6 266 182 175 176 TABLE H—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 2nd, 3rd, 4th & 5th Friday in the month Monday to Friday Every Tuesday 1st Friday a.m. in the month Grange Park Clinic, Lansbury Drive, Hayes Every Tuesday a.m. Every Mon., Tues., Wed., & Fri. Every Monday & Friday a.m. Every Wednesday p.m. 2nd & 4th Thursday a.m. in the month Harefield Clinic, Park Lane, Harefield 1 st & 3rd Friday p.m. in the month Every Tuesday & Wednesday Every Tuesday a.m. 4th Friday p.m. in the month Harmondsworth (Old School), Moor Lane, Harmondsworth 3rd & 5th Thursday p.m. in the month Haydon Hall Clinic, Joel Street, Eastcote 1 st Thursday a.m. in the month Hayes End Clinic, Methodist Church Hall, Uxbridge Road, Hayes 1st Thursday a.m. in the month IckenhamClinic, Long Lane, Ickenham 1 st & 3rd Tuesday a.m. in the month Monday to 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 Wednesday 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 Premises School Health Sessions Dental Clinics Speech Therapy Ophthalmic Clinics Immunisation and Vaccination Minet Clinic, Coldharbour Lane, Hayes Every Friday a.m. Monday to 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 1st & 3rd Tuesday a.m. in the month Monday to Friday Every Monday & Thursday p.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 Monday & Thursday p.m. 2nd Friday a.m. in the month Ruislip Manor Clinic, Dawlish Drive, Ruislip 2nd & 4th Friday a.m. in the month Every Monday, Tues., Wed. & Thurs Every Tues., a.m. & Thurs., a.m. & p.m. Every Tuesday a.m. 1st Friday a.m. in the month Sidmouth Drive, Ruislip 2nd & 4th Friday a.m. in the month 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 Wednesday & Thursday a.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 Health Centre, High Street, Yiewsley Every Tuesday a.m. in the month To be arranged To be arranged 2nd, 4th & 5th Fridays p.m. Specialist Clinics are held at Uxbridge Clinic as follows: Orthopaedic—1st Friday p.m. in month. Physiotherapy—Every Monday and Thursday p.m. 177 ORTHOPAEDIC Sessions First Attendance Total Attendance Physiotherapy - Uxbridge 87 67 461 Specialist - Uxbridge 9 107 126 SPEECH THERAPY Elers Road 30 21 113 Grange Park 61 35 233 Harefield 30 2 166 Ickenham 38 20 167 Laurel Lodge 75 75 368 Minet 167 34 743 Northwood 70 39 299 Oak Farm 73 31 398 Ruislip Manor 120 40 764 Uxbridge 77 40 365 West Mead 88 38 422 HEALTH VISITORS/CLINIC NURSES/HEALTH ASSISTANTS Visits and Sessions for School Health Service Number of children visited 3,060 School health and follow-up sessions 500 Enuresis clinics 67 Hygiene inspections 505 Pre-medical examination sessions 396 Routine medical examination sessions 456 Health Education sessions 128 Health survey visits re pertussis 39 178 SCABIES 1972 Schools where Investigations made Date No. of Cases Cherry Lane Infant 7 January 1 Hedgewood 7 January 1 Townfield S.G. 10 January 2 Townfield S.G. 20 January 0 Providence Road 26 January 1 Providence Road 7 February 0 Greenway 16 February 2 Brookside 24 February 1 Providence Road 3 March 1 Providence Road 9 March 1 Ruislip Gardens Infants 10 March 1 Yeading J.M. 21 April 1 Longmead Infants 1 May 1 Hermitage 2 May 1 Evelyns 4 May 1 Meadow 8 May 1 Yeading J.M. 9 May 1 Heathrow 10 May 1 Minet Infants 11 May 1 Our Lady & St. Anselms 15 May 1 Heathrow 17 May 1 Hedgewood 15 June 1 Minet J.M. 21 June 1 Pinkwell Infants 27 September 1 Whitehall Infants 4 October 1 Charville Infants 10 November 1 Ryefield Infants 11 October 1 Ruislip Gardens J.M. 23 October 1 Townmead 16 November 2 Minet Infants 21 November 1 Minet J.M. 21 November 1 Lady Bankes Infants 21 November 1 St. Catherine's 30 November 1 Wood End Park Infants 4 December 1 Wood End Park J.M. 4 December 2 Townfield 6 December 4 Douay Martyrs 7 December 1 Longmead J.M. 11 December 3 John Penrose 11 December 4 29 Schools 39 Visits 49 Cases 179 Index Accidents 90 Agricultural (Safety, Health and Welfare Provisions) Act 1956 94 Aliens, Medical Inspection of 26 Animals—Diseases of Act, 1950 79 — Slaughter of Acts, 1933-1958 79 Ante and Post-Natal clinics 31,115 Atmospheric Pollution, measurement of 62 Attachment and Liaison Schemes 39 Audiometry 143 Autism 167 Bacteriological examination of food 76 B.C.G. Vaccination 45 Bonfires Industrial 61 Cancer, deaths from 122 Caravan sites 88 Cervical cytology 35 Chantry School 163 Chest X-Ray 107 Chief Public Health Inspector, Report of 59-102 Child Guidance Clinics 144 Child health centres 32 Child health centres attendances 118 Chimneys 61 Chiropody 36 Cholera Surveillance 21 Chronically Sick and Disabled Persons Act 102 Cleanliness inspections 135 Clearance areas and Individual Unfit Dwellings 80 Common Lodging House 87 Community Nursing Service 38-40 Computer Processing of vaccination records 46 Congenital Errors of Metabolism 31 Congenital Malformations 31 Consumer Protection Act 1961 96 Cream 66 Crematorium — Breakspear 110 Deaf/Blind children 167 Deaths—All causes 14 — cause of, statistics 116 Defects found at school medical inspection 171 Dental Service — Priority 40-42, 124 — School 145 Dental Health Education 146 Dental Survey of 5 year old children 148 Diseases of Animals Act 1950 79 Diphtheria Immunisation 121 Diphtheria 17 Drug abuse 51 Dust and Grit 68 Dysentery 17 Dyslexia — acute 167 Education (Handicapped children) Act 1970 168 Education (Milk) Act 1971 140 Employment of Young Persons Act 1958- 1964 92 Employment Medical Advisory Service 141 Enteric Fever 18 Enuresis Clinic 152 Environmental Health 55-102 Factories Act 1961 92 Factories —Inspections 93 — defects 93 Family Planning 34 Fertilizers and Feeding Stuffs Act 1926 79 Food and Drugs Act 1955 71 Food — complaints 69 — hygiene 74 — Imported Regulations 1968 77 — Inspection at London (Heathrow) Airport 98 — Poisoning 18 — Premises Inspection of 75 — Sampling 73 — Unfit, surrendered 69 German Measles — immunisation 121 Gypsies and other itinerants 88 Handicapped Pupils 157, 175 Handicapped children under 5 years 159 Health Committee 8 Health Control Unit, Heathrow Airport . . 21-28 Health Education 43 Health Education in Schools 152 Health Visiting Service 39 Health Visiting Statistics 126 Health Visiting Statistics — School Health Service 178 Hedgewood Day Special School 161 Holidays—Recuperative 51 Home Dialysis 51 Home Nursing Statistics 125 Housing — Allocation on Medical Grounds 105 — Certificates of Disrepair 87 — Clearance Areas 80 — Improvement Areas 81 — Improvement Grants 84 — Multiple Occupation 86 — Qualification Certificates 81 — Repair and improvement 81 — Slum Clearance 80 Hygiene — Personal 135 — of Food Premises 74 Ice Cream 66 Immigrants— Long Stay 106 — Commonwealth — Medical Inspection of 25 Immunisation 45 Immunisation Statistics 121 Infant Mortality 127 Infant Mortality, Trends in 15 Infectious Disease 17 Infective Jaundice 18 Insect Pests 98 Intelligence Assessment 153 Introduction 3-6 183 Laboratory—Departmental 100 Legal Proceedings 73 Lifts and Hoists 91 Massage and Special Treatment 108 Mass Radiography 107 Meadow School 161 Measles 18 Measles Immunisation Statistics 121 Meat 67 Medical Examination of Staff — Statistics 109 Medical Inspection — in School 134 — other 170 Mental Health Services 50 Midwifery Service 39 Midwifery Statistics 125 Midwives Act 1902-1951 31 Milk and Milk Products 64 Mobile Child Health Centre — Attendances at 119 Moorcroft School 161 Mortuary 110 Mothercraft and relaxation 31 Multiple Handicaps 166 Multiple Occupation 86 National Assistance Act 1948 — Section 47 108 Night Nursing Service 38 Noise 94 Noise Insulation Grants— London Airport 95 Nursing Agencies and Nursing Homes 108 Nursing Service 38 Observation Register 120 Occupational Health Services 109 Odours — Industrial and others 63 Offices, Shops and Railway Premises Act 1963 89 Orthodontics 173 Orthopaedic Clinic 154, 178 Orthoptic Clinic 174 Other Services 105-111 Outworkers 92 Pancreas — Carcinoma of 16 — Statistics 123 Park Place School 166 Pest Control 97 Personal Health Services 31-51 Physiotherapy Service 154 Poliomyelitis Vaccination — Statistics 121 Port Health London (Heathrow) Airport 21 Port Sanitary Administration, London Airport 98 Post-Natal Clinics 31 Poultry Inspection 68 Prevention of Damage by Pests Act 1949 97 Principal School Medical Officer — Report of 131-179 Priority Dental Service 40, 124 Pulmonary Tuberculosis 19 Pupils Treated at School Clinics 172 Rabies Vaccination 45 Recuperative Holidays 51 River Pollution 101 Salmonella Investigations 18 Sampling of Food and Drugs 73 Scabies 140,179 School Clinics and Sessions 176 School Dental Service 145, 173 School Health Service and Employment 141 Schools — Primary 135 — Secondary 135 Sewage Disposal 56 Shops Act 1950 92 Slum Clearance 80 Smoke Control Areas 60 Smoke Nuisances 61 Speech Therapy Service 155, 178 Squirrels and Foxes 98 St. Michael's School 165 Staff of the Department 9 Statistics 13-14 Swimming Pools 63 Tetanus, Immunisation Statistics 121 Toys (Safety) Regulations, 1967 96 Townsend House Day Special School 163 Treatment of School Children — Statistics 172 Tuberculosis 19 Uxbridge Central Redevelopment Area 88 Venereal Diseases 20 Vermin Control 100 Vision Testing — Routine 137 Water — Aircraft Drinking 99 — Private Supplies 56 — Public Supplies 55 Welfare Foods 34 Well Women's Clinics 35 Whooping Cough 21 Working Environment 89 X-ray Unit, Heathrow Airport 26 Printed by R. G. Baker & Co. Ltd., Farnham Common, Bucks., SL2 3PJ