LCC 67 LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1961 Published by the London County Council The County Hall, Westminster Bridge, S.E.I 1962 No. 4182 4s. Od. Postage extra Page 164, table (ii) - Work in various departments For "electrocephalograms" read "electrocardiograms" Page 166, Diagnostic Group tab?.e: The classification is a modification of the International Classification, designed "by the College of General Practitioners. Symptoms and ill-defined conditions: Para. 2, line 3 - for "electric cardiograms" read "electrocardiograms" Page 167, Diseases of the blood and blood forming Line 3 - delete "hypochronic; line 9 - for "60" read "65" LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1961 By J. A. SCOTT, o.b.e., m.d., f.r.c.p. county medical officer of health and principal school medical officer THE COUNTY HALL WESTMINSTER BRIDGE, S.E.I 3 CONTENTS London Administrative County—Vital Statistics (Summary) page 4 Vital Statistics 5 Infectious Diseases 14 Tuberculosis 23 General Public Health 34 Scientific Branch 40 Health Service Premises 43 Care of Mothers and Young Children 47 Domiciliary Midwifery 52 Health Visiting 54 Home Nursing 55 Home Help 57 Immunisation and Vaccination 58 London Ambulance Service 61 Prevention of Illness: Care and After-Care 65 School Health Service 73 Dental Services 87 Staff 91 Finance 94 Visitors to the Department 95 Reports by the Divisional Medical Officers 96 Appendices: (a) Mental Health in London in 1961 and the implementation of the Mental Health Act, 1959 112 (b) The Home Nursing Service in London 137 (c) Speech Therapy in L.C.C. schools 145 (d) South East London General Practitioners' Centre 161 (e) Statistics of work carried out by the Metropolitan Boroughs 169 (f) Staff of the Public Health Department 170 Index 171 4 LONDON ADMINISTRATIVE COUNTY VITAL STATISTICS, 1961 Figures in brackets are for 1960 Population: Area comparability factors: Males 1,494,000 3,180,000 (3,194,000 Births 0.90(0.90) Females 1,686,000 Deaths 0.96 (0.98) Number of marriages registered: 33,579 (32,677) Live births: Legitimate 52,420 (50,838) Illegitimate live births Illegitimate 7,632 ( 6,530) per cent. of total live births: 12.7(11.4) Live birth rate per 1,000 population: 18.9 (18.0) (adjusted rate 17.0 (16.2) ) Stillbirths: Legitimate 913(911) 1,103(1,052) Illegitimate 190(141) Stillbirth rate per 1,000 live and stillbirths: 18.0 (18.0) Total live and stillbirths: 61,155 (58,420) Deaths: Males 19,108 (18,534)37,915 (36,521) Females 18,807 (17,987) Death rate per 1,000 population: 11.9 (11.4) (adjusted rate 11.4 (11.2)) Deaths of infants: Legitimate Illegitimate Total Under 1 month 799 (761) 154 (125) 953 (886) 1 month to 1 year 295 (307) 34 (39) 329 (346) Total under 1 year 1,094 (1,068) 188 (164) 1,282 (1,232) Infant mortality rate:. (per 1,000 live births) 20.87 (21.01) 24.63 (25.11) 21.35 (21.48) Neo-natal mortality rate: .. „ „ „ „ 15.24(14.97) 20.18 (19.14) 15.87 (15.44) Early neo-natal mortality rate: „ „ „ „ 13.66 (13.04) 18.34 (16-39) 14.25 (13.42) Perinatal mortality rate: .. (per 1,000 total births) 30.54(30.42) 42.19(37.18) 32.03 (31.19) Maternal mortality: Rate per 1,000 Post- Other pregnancy live and abortion and childbirth Total stillbirths Deaths from sepsis 14 (9) — (—) 14 (9) Deaths from other causes 4 (2) 27 (15) 31 (17) Total 18 (11) 27(15) 45 (26) 0.74(0.45) 5 VITAL STATISTICS* Population Table (i)—Home population (a), 1952-61 (Figures in thousands) Year Mid-year estimate of population by the Registrar General, by age groups Average age (years) Total 0-4 5-14 15-24 25-44 45-64 65+ 1952 3,363 256 400 416 1,091 822 378 36.7 1953 3,343 244 413 410 1,072 826 378 36.7 1954 3,322 234 425 394 1,056 827 386 36.9 1955 3,295 230 421 391 1,037 829 387 37.1 1956 3,273 229 427 384 1,018 829 386 37.1 1957 3,254 230 425 383 974 843 399 37.4 1958 3,225 231 418 387 949 843 397 37.5 1959 3,204 236 409 394 925 842 398 37.5 1960 3,194 241 403 398 905 846 401 37.6 1961 M 1,494 127 202 190 444 388 143 35.7 F 1,686 120 194 214 449 451 258 39.2 3,180 247 396 404 893 839 401 3.5 (a) Resident civilian population, plus any British, Commonwealth or Foreign Armed Forces stationed in the area. There was a net loss of 14,000 in the population from the previous year's figure; in detail there was a rise of 6,000 at ages 0.4, a fall of 7,000 at ages 5.14, a rise of 6,000 at ages 15.24, falls of 12,000 and 7,000 at ages 25.44 and 45.64 respectively, whilst the population aged 65 and over remained constant. The rise in the number of pre-school children stems from the increased birth rate—see table (ii) below; the changes at ages 5.14 and 15.24 are linked with the movement out of the former age group of children born in the years of high fertility following the war— migration of young people into London also affects the 15.24 age group. The losses at ages 25.64 are probably due in the main to outward migration and the net effect of this loss in conjunction with the increased birth rate has been a marginal change towards a younger population—the average age having fallen by 0.1 year. Fertility Table (ii)—Live births and stillbirths, 1952-61 Year Live births Stillbirths No. Rate per 1,000 population No. Rate per 1,000 total births (live and still) 1952 51,443 15.3 1,000 19.1 1953 50,992 15.3 1,088 20.9 1954 50,745 15.3 1,029 19.9 1955 49,826 15.1 1,034 20.3 1956 52,171 15.9 1,070 20.1 1957 52,733 16.2 1,083 20.1 1958 54,152 16.8 1,102 19.9 1959 55,191 17.2 1,085 19.3 1960 57,368 18.0 1,052 18.0 1961 60,052 18.9 1,103 18.0 * The statistics given are based on the latest information available from the Registrar General: instances have occurred in the past in which figures have been subsequently corrected so that data for a previous year may differ from that published in the Annual Report for that year. 6 Live births—There were 68,619 live births registered in London in the year; after correction for residence the final figure of births allocated to London was 60,052, an increase of 2,684 over 1960, giving a birth rate of 18.9 per 1,000 population compared with 18-0 in 1960 and 17.2 in 1959. The post-war trend in London followed closely that for England and Wales until 1956 when the rise in the London rate preceded a similar rise in the country as a whole; in 1957 the two rates were again almost identical, but since then the crude London rate has continued to exceed the national rate. The major factor contributing to the increased birth rate, both local and national, appears at present to be the increased proportion of women of child-bearing age who are married. The two rates are not, however, strictly comparable because the proportion of women of child-bearing age in the population is greater in London than in England and Wales; adjusting for this difference by multiplying the crude rate by the Registrar General's area comparability factor for London births (0.90) the rate becomes 17.0. The crude birth rate for the past 10 years is shown in figure 1 below, together with the national rate and the adjusted birth rate. Figure 1 LIVE BIRTH RATELONDON (A.C.) AND ENGLAND & WALES, 1952-61 7 Illegitimacy— Table (iii)—Illegitimate live births in London (A.C.) and percentages for London and England and Wales, 1952-61 Year Illegitimate live births Illegitimate live births as a percentage of total live births London A.C. England and Wales 1952 3,607 7.0 4.8 1953 3,645 7.1 4.7 1954 3,615 7.1 4.7 1955 3,827 7.7 4.6 1956 4,434 8.5 4.8 1957 4,686 8.9 4.8 1958 5,343 9.9 4.9 1959 5,765 10.4 5.1 1960 6,530 11.4 5.4 1961 7,632 12.7 6.3 The percentage of illegitimate births in London has increased year by year for the past six years—one in every eight babies born in 1961 was illegitimate. Boroughs with notably high percentages were, in the West, Paddington (21.5) and Kensington (18.2), in the South, Lambeth (15.8) and in the North and East, Stoke Newington (16.4), Hackney (15.8) and Stepney (15.3). Nationally the rise in illegitimacy has been much slower than in London; the national percentage is now about half that for London. A complex of factors probably accounts for the phenomenal rise in London—proportionately more single women, a continuous influx of unmarried women, many of whom are already pregnant and the facilities which London can offer to an unmarried mother in the way of anonymity, ante-natal care and support from moral welfare organisations. Information as to the extent of some of these factors will only become reliably known when the results of the 1961 census are available. The table below gives details of women seen by the moral welfare organisations in the twelve months ended September 1961, from which it will be seen that 991 (30.1 per cent.) were pregnant on arrival in London and that in all 1,450 (44.1 per cent.) were not British. It should be remembered that these components of the illegitimate births are minima; the moral welfare organisations do not deal with all unmarried mothers, though doubtless they will tend to deal with proportionately more of the non-Londoners. Table (iv)—Unmarried mothers seen by moral welfare associations in London, 1st October, 1960-30th September, 1961. (Figures in brackets are for 1959-60) British (U.K.) Eire European West Indian Other Total Non-Londoners pregnant on arrival in London 468 (424) 308 (272) 49 (50) 137 (85) 29 (33) 991 (864) *Non-Londoners not pregnant on arrival in London 64 (71) 49 (87) 8 (8) 40 (33) 8 (3) 169 (202) Resident in London one year or more 1,306 (1,371) 434 (454) 92 (76) 260 (267) 36 (58) 2,128 (2,085) 1,838 (1,866) 791 (813) 149 (134) 437 (385) 73 (94) 3,288 (3,292) * Had lived in London less than 12 months before making contact with moral welfare association. 8 Mortality The total death rate at 11.9 per 1,000 population was higher than the previous year (11.4) and slightly above the average of the last decade. Leading causes of death—The leading causes of death in London in 1961 were as follows: Deaths Rate per 1,000 population Diseases of the heart 11,509 3.62 Cancer 7,782 2.45 Bronchitis, pneumonia* 5,155 1.62 Vascular lesions of the central nervous system 3,965 1.25 Other circulatory 2,027 0.64 Violent causes 1,701 0.53 Digestive diseases 1,224 0.38 Diseases of early infancy (international classification Nos. 760-776) 765 0.29 Congenital malformations (0—4 weeks) 152 Tuberculosis (all forms) 318 0.10 All other causes 3,317 1.04 Total 37,915 11.92 * Excluding pneumonia of the new born (under 4 weeks) which is included in ' Diseases of early infancy The ranking order of the leading causes of death remains unchanged from 1960. Heart disease was discussed in detail in my report for 1956, cancer in 1958 and bronchitis and pneumonia in 1960. Cancer—The cancer death-rate for all ages was 2.45 per 1,000 in 1961—a slight decrease from the previous year. Cancer is, however, largely a disease of the later half of life and in order to eliminate variations caused by a changing age/sex composition of the population rates for specific age/sex groups are shown below: Table (v)—Cancer mortality rates per 1,000 living, 1952-61 Age and Sex 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 Males: 0.24 0.12 0.14 0.12 0.11 0.14 0.11 0.09 0.10 0.12 0.11 25.44 0.45 0.46 0.41 0.40 0.43 0.37 0.42 0.40 0.38 0.37 45.64 4.19 4.28 4.31 4.50 4.51 4.55 4.52 4.46 4.75 4.52 65+ 15.50 15.69 15.29 15.-73 15.77 15.29 16.01 15.20 15.74 15.72 All Males 2.61 2.68 2.64 2.73 2.76 2.77 2.85 2.76 2.90 2.83 Females: 0.24. 0.07 0.07 0.06 0.07 0.09 0.07 0.10 0.07 0.07 0.07 25.44 0.47 0.51 0.43 0.45 0.50 0.47 0.52 0.51 0.52 0.50 45.64 2.85 2.85 2.85 2.93 2.77 2.97 2.71 2.63 2.82 2.72 65+ 8.77 8.73 8.39 8.43 8.75 8.34 8.50 8.18 8.44 8.02 All Females 2.02 2.04 2.02 2.08 2.12 2.16 2.15 2.09 2.20 2.11 All Persons 2.30 2.34 2.31 2.39 2.42 2.44 2.47 2.40 2.53 2.45 Lung cancer—The lung has become the principal site for cancer in males and the table below shows, for three age groups, the steep rise that has occurred in the last decade together with, for comparison, the corresponding figures for females. 9 Table (vi)—Deaths and death rates from cancer of the lung by age and sex, 1952-61 (Rates per 1,000 population) Year Age 25-44 45-64 65+ No. Rate No. Rate No. Rate Males: 1952 73 0.14 673 1.81 580 4.03 1953 81 0.15 734 1.96 614 4.26 1954 64 0.12 773 2.06 625 4.34 1955 62 0.12 810 2.14 651 4.55 1956 65 0.13 853 2.25 718 5.06 1957 37 0.08 891 2.31 723 4.95 1958 52 0.11 883 2.29 786 5.46 1959 61 0.13 907 2.34 788 5.51 1960 55 0.12 958 2.46 857 5.99 1961 44 0.10 883 2.28 832 5.82 Females: 1952 19 0.03 127 0.28 137 0.59 1953 18 0.03 119 0.26 139 0.59 1954 19 0.04 137 0.30 164 0.68 1955 13 0.02 151 0.33 174 0.71 1956 13 0.03 109 0.24 154 0.63 1957 19 0.04 142 0.31 176 0.70 1958 22 0.05 124 0.27 183 0.72 1959 22 0.05 134 0.29 157 0.62 1960 26 0.06 157 0.34 190 0.74 1961 24 0.05 151 0.33 184 0.71 The rates for males in 1961 are slightly below those of the previous year and for females they are about the same. Whilst these figures are encouraging it is too soon to read into them a halt in the upward trend of lung cancer. 10 Infant mortality Table (vii)—Infant mortality, 1961 Cause of death Age at death Total Rates per 1,000 live births Under 1 day 1 to 7 days 1 to 4 wks. 4 wks. to 1 yr. No. Male Female Total Male Female Whooping cough Leg. - . - - - - - - - Illeg- — - . Tuberculosis Leg. — — . 2 2 1 1 0.03 0.03 0.03 Illeg. — - . Measles Leg. — - 1 1 2 2 — 0.03 0.06 — Illeg. - - . Bronchitis and pneumonia Leg. 5 16 11 150 191 112 79 3.18 3.63 2.70 Illeg. 2 3 4 Gastro-enteritis and diarrhœa Leg. — - 2 15 18 9 9 0.30 0.29 0.31 Illeg. - - 1 Congenital malformation Leg. 56 47 38 84 236 95 141 3.94 3.08 4.82 Illeg. 3 4 4 Injury at birth Leg. 75 66 — - 169 102 67 2.81 3.31 2.29 Illeg. 20 7 1 Post-natal asphyxia and atelectasis Leg. 114 60 2 1 217 130 87 3.61 4.22 3.00 Illeg. 29 10 1 Haemolytic disease Leg. 13 8 — - 22 11 11 0.37 0.36 0.38 Illeg. 1 — — Immaturity Leg. 128 48 8 2 231 126 105 3.85 4.09 3.58 Illeg. 29 14 2 Convulsions Leg. - - . - - - - - - - Illeg. — — . Accidental mechanical suffocation Leg. - - 1 6 8 3 5 0.13 0.10 0.17 Illeg. — — 1 Other causes Leg. 35 45 20 68 186 120 66 3.10 3.89 2.26 Illeg. 15 3 — All causes Leg. M. 245 172 34 295 1,094 617 477 20 87 22.88 18.74 F. 181 118 49 Illeg. M. 50 22 4 34 188 94 94 24 63 24.35 24.92 F. 49 19 10 Total, 1961 .. 525 331 97 329 1,282 711 571 21.35 23.06 19.54 Total, 1960 .. .. 467 303 116 346 1,232 711 521 21.48 24.20 18.61 Leg. M. 228 163 56 307 1,068 614 454 21.01 23.58 18.31 F. 167 105 42 Illeg. M. 44 24 9 39 164 97 67 25.11 29.05 21.00 F. 28 11 9 The pattern of infant mortality remains much the same as in the previous year. The trend since 1952 is as follows: 11 Table (viii)—Infant mortality by cause, 1952-61 (Rates per 1,000 live births) Cause of death 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 Whooping cough 0.08 0.27 0.06 0.06 0.04 0.02 - 0.05 0.05 - Tuberculosis 0.04 0.14 0.08 — — — — 0.02 0.03 0.03 Measles — 0.06 0.02 0.10 — — — — - 0.03 Bronchitis and pneumonia 3.89 4.04 2.70 3.57 3.32 2.88 3.45 3.50 3.63 3.18 Gastro-enteritis 0.80 1.27 0.43 0.48 0.35 0.42 0.31 0.27 0.16 0.30 Congenital malformations 3.93 3.41 3.51 3.43 3.70 3.96 4.51 4.75 4.32 3.94 Injury at birth 2.82 2.71 2.34 2.59 2.64 2.98 2.27 2.46 2.55 2.81 Post-natal asphyxia and atelectasis 3.50 3.90 4.06 4.32 3.66 4.17 4.08 3.59 3.63 3.61 Haemolytic disease 0.72 0.53 0.55 0.58 0.61 0.51 0.44 0.51 0.54 0.37 Immaturity 4.20 3.98 3.70 4.67 4.10 4.27 4.69 3.86 3.71 3.85 Convulsions — — 0.02 — 0.02 — — — — — Accidental mechanical suffocation 0.17 0.14 0.12 0.06 0.21 0.23 0.13 0.16 0.09 0.13 Other causes 2.96 3.40 3.04 3.35 2.55 2.56 2.60 3.26 2.77 3.10 All causes 23 24 21 23 21 22 22 22 21 21 Mortality—A comparison with England and Wales for both neo-natal (deaths in the first four weeks) and infant mortality (deaths in the first year) is as follows: Year (Rates per 1,000 live births) Neo-natal mortality Infant mortality London England and Wales London England and Wales 1952 15.8 18.3 23.1 27.6 1953 16.1 17.7 23.9 26.8 1954 15.1 17.7 20.7 25.4 1955 16.7 17.3 23.2 24.9 1956 15.9 16.8 21.2 23.8 1957 16.3 16.5 22.0 23.1 1958 16.6 16.2 22.5 22.5 1959 15.7 15.8 22.4 22.2 1960 15.4 15.6 21.5 21.7 1961 15.9 15.5 21.4 21.6 As regards neo-natal mortality there were 953 deaths in London; of this number 597 occurred in premature infants. An analysis of the total number of premature births by birth weight and mortality is shown in the following table. Corresponding figures of domiciliary confinements are shown in the section on domiciliary midwifery on page 53. Table (ix)—Prematurity and mortality by birth weight, 1961. Weight Number Proportion per 100 live premature infants Died within 24 hours Survived 28 days Number Per 100 live premature infants Number Per 100 live premature infants 3 lb. 4 oz. or less 614 13.3 235 38.3 271 44.1 3 lb. 5 oz. to 4 lb. 6 oz. 811 17.5 73 9.0 671 82.7 4 lb. 7 oz. to 4 lb. 15 oz. 945 20.4 20 2.1 896 94.8 5 lb. 0 oz. to 5 lb. 8 oz. 2,263 48.8 24 1.1 2,198 97.1 All premature babies 4,633 100.0 352 7.6 4,036 87.1 12 Perinatal mortality—Comparative rates for perinatal mortality (stillbirths and deaths in the first week of life) per 1,000 total births are given below for London and England and Wales. Year London England and Wales Year London England and Wales 1952 32.6 37.5 1957 34.2 36.3 1953 34.7 36.9 1958 34.3 35.1 1954 32.8 38.1 1959 32.7 34.2 1955 34.8 37.4 1960 31.2 32.9 1956 33.3 36.7 1961 32.0 32.2 The causes of death in the first seven days of life are shown in table (vii) on page 10. It will be apparent from the preceding section that premature babies provided the major share. The cause of stillbirth, the other component of perinatal mortality, was not known until certification was introduced on 1 October, 1960 under the Population (Statistics) Bill, 1960. The following table gives the causes for 1961, but on the basis of the 1960 certificates only about two-thirds of them were certified by medical practitioners. Table (x)—Causes of stillbirth, 1961. Code No.* Cause Male Female Number Per cent. Number Per cent. Y.30 Chronic disease in mother 23 3.9 17 3.3 Y.31 Acute disease in mother 3 0.5 1 0.2 Y.32 Diseases and conditions of pregnancy and childbirth: (1) Ectopic gestation 1 0.2 — — (2) Haemorrhage 52 8.8 37 7.3 (3 and 4) Toxaemia 79 13.3 69 13.6 (5) Infection 2 0.3 1 0.2 Y.34 Difficulties in labour 57 9.6 39 7.7 Y.35 Other causes in mother 5 0.8 3 0.6 Y.36 Placental and cord conditions 151 25.4 110 21.5 Y.37 Birth injury 14 2.4 11 2.2 Y.38 Congenital malformation of foetus 59 9.9 80 15.7 Y.39 Diseases of foetus and ill-defined causes: (0-3) Diseases of foetus 20 3.4 27 5.3 (4—6) Other ill-defined or unspecified cause 128 21.5 114 22.4 Total 594 100.0 509 100.0 * International classification of causes of stillbirth. 13 Maternal mortality— Table (xi)—Maternal mortality, 1952-61 Year Live births and stillbirths Deaths in pregnancy or childbirth excluding abortion Postabortion deaths Total maternal deaths No. Rate per 1,000 total births 1952 52,433 35 15 50 0.95 1953 52,080 21 16 37 0.71 1954 51,774 28 6 34 0.66 1955 50,860 31 8 39 0.77 1956 53,241 16 11 27 0.51 1957 53,816 15 13 28 0.52 1958 55,254 14 19 33 0.60 1959 56,276 22 12 34 0.60 1960 58,420 15 11 26 0.45 1961* 61,155 27 18 45 0.74 * For the sixth year running none of the deaths in pregnancy or childbirth was due to sepsis; 14 of the 18 post-abortion deaths came under the category of'abortion with sepsis Summary tables—Tables summarising the more important of these vital statistics (a) by metropolitan boroughs and (b) showing the secular trend for the county are to be found on pages 17 and 18. Air pollution There were no particular foggy incidents in 1961. The table below shows for the past eight winters the average levels of pollution based on the seven recording stations described in appendix B to my report for 1956. Winter averages of air pollution Average daily readings of seven volumetric recording stations Winter ' Smoke' ' Sulphur dioxide' Ratio smoke ISO t (a) (c) ib) (c) (a:b) (c.c) 1954-1955 49 11.1 4.4 1955-1956 52 11.8 4.4 1956-1957 45 10.2 4.4 1957-1958 41 11.5 3.6 1958-1959 43 309 11.9 340 3.6 0.9 1959-1960 32 206 9.6 275 3.3 0.7 1960-1961 24 200 9.7 277 2.5 0.7 1961-1962 182 302 0.6 (a) Milligrams of black suspended matter per 100 cubic metres of air. (b) Acidic gases in parts per 100 million parts of air. (c) Micrograms per cubic metre. From 1 October, 1961 the estimation of smoke and sulphur dioxide was changed to a common unit, micrograms per cubic metre, to accord with the new system introduced by the Department of Scientific and Industrial Research. In order to provide a link with the figures quoted in previous reports the pollution data has been recalculated on the revised basis for the three preceding years and both sets of figures are shown. 14 INFECTIOUS DISEASES Notifications of infectious diseases for the years 1952-1961 are shown in table V.5, page 21, those for certain such diseases by age and sex for the 13 four-weekly periods of the year 1961 are given in table V.6, page 22 and deaths from infectious diseases are included in table V.3, page 19. Diarrhœa and enteritis—There were 20 deaths under the age of two years from diarrhoea and enteritis, compared with 16 in the previous year. This represents a rate of 0.33 per 1,000 live births and shows a continuation of the low figures of recent years. Diphtheria—There was a slight rise in notifications in 1961, from sixteen in 1960 to twenty-eight. Localised outbreaks occurred in Camberwell, Battersea, Kensington, Bermondsey and Deptford. Each of these episodes centred on a primary school (that in Kensington in a junior training centre for subnormal children). The pattern was that after the recognition of a single case of diphtheria widespread swabbing among the school and home contacts brought to light a variable number of infected persons, most of whom were carriers without symptoms. The intensive search for infected persons and the isolation of any cases or carriers enabled the infection to be eliminated from the area in each instance. There were three deaths from diphtheria and there was no evidence that any of these children had been immunised in the past. The fact that it has been possible to limit these outbreaks by the rapid institution of energetic measures has been due to the willing co-operation of the staff of the Public Health Laboratory at County Hall, who shared with the divisional staff a great deal of additional work while the outbreaks were in progress. Nothing that occurred during the year cast any doubt on the value of immunisation. The risk of contracting diphtheria is four or five times greater in the unimmunised than in the immunised and there was a tragic demonstration that diphtheria can still be a very serious disease in unimmunised children. The events described above have somewhat diverted attention from the continued improvement in the proportion of young children given their primary course of immunisation. Figures for infant immunisation in 1961 given elsewhere in this report give cause for some satisfaction. The local outbreaks during the year lead to a general determined effort to increase the number of boosting doses given to children in primary schools. Dysentery—During the year dysentery notifications fell to 1,812—the lowest figure for ten years. Whereas in recent years the number of cases occurring in children of school age has been roughly equal to that in the much smaller numbers of pre-school children, in 1961 the cases in school children were fewer in number than those in the age group 0 to 4 years. Enteric fever—Incidence continued at a low level; no notable outbreaks occurred. Most cases in recent years have been of the sporadic kind. Influenza—There was a rise in the number of deaths from influenza but incidence of the disease was not above the average. Leptospirosis—For the fifth successive year there was no case of leptospirosis reported among the Council's sewer workers. Measles—The customary biennial epidemic culminated in the early part of the year. Mortality remains at a low level. Trials of a new vaccine were carried out during the year. Although it gives substantial protection against the disease, its administration is followed in a high proportion of those receiving the vaccine by side effects (fever and skin eruption). These reactions make it most unlikely that the vaccine in its present form will become popular in this country while natural measles remains as mild a disease as it now is. The vaccine may have a place in the health programme of countries in which measles still has a high mortality. 15 Ophthalmia neonatorum—There was an increase in the number of notifications from 89 in 1960 to 100 in 1961, the rate (per 1,000 registered live births) changing from 1.36 to 1.46. Cases among children born to London residents totalled 70, a fall of three compared with the previous year; in 61 vision was unimpaired, five removed and four were still under treatment at the end of the year. Poliomyelitis—There was a considerable reduction in the number of notifications of poliomyelitis in 1961. Once again a marked feature of the epidemiological picture was the high proportion of cases found in the age group 0.4 years. This was 50.0 per cent, of all cases. Table (xii)—Poliomyelitis notifications by age, 1949-61 Year 0—4 years 5-14 years 15 years and over Total No. % No. % No. % No. 1949 356 53.3 173 25.9 139 20.8 668 1950 150 34.9 149 34.6 131 30.5 430 1951 27 24.1 45 40.2 40 35.7 112 1952 95 30.7 105 34.0 109 35.3 309 1953 116 35.0 104 31.3 112 33.7 332 1954 42 33.6 41 32.8 42 33.6 125 1955 334 34.8 391 40.7 235 24.5 960 1956 88 31.5 115 41.2 76 27.3 279 1957 103 31.8 131 40.4 90 27.8 324 1958 40 37.4 36 33.6 31 29.0 107 1959 108 51.4 66 31.4 36 17.2 210 1960 52 59.8 17 19.5 18 20.7 87 1961 22 50.0 12 27.3 10 22.7 44 It will be seen from table (xii) that a high proportion of cases in the 0.4 years age group has been recorded previously in 1949, 1959 and 1960. Cases were spread throughout the age group. The higher rate of incidence in the under-fives does not appear to be related to any difference between vaccination rates in this age group and the over-fives. The reason for the high proportion of cases in young children remains uncertain. As a result of scrutiny of the clinical and virological findings, a final diagnosis was made in respect of each notification. The diagnosis of paralytic poliomyelitis was made on clinical grounds, although virological confirmation was present in the majority of cases. A diagnosis of non-paralytic poliomyelitis was made only in cases in which poliomyelitis virus was present on the stool, or when serological evidence supported the diagnosis. Table (xiii) gives an analysis of the original notifications according to the final diagnosis. Table (xiii)—Final diagnosis of poliomyelitis notifications, 1961 Final diagnosis Notified as paralytic Notified as non-paralytic Total (all ages) 0-4 years 5-14 years 15 + years Total 0-4 years 5-14 years 15+ years Total Paralytic 19 2 6 27 - - - - 27 Non-paralytic — — — — 2 4 2 8 8 Not poliomyelitis (or not known) 1 3 2 6 — 3 — 3 9 Total 20 5 8 33 2 7 2 11 44 16 Table (xiv)—Vaccinal state of confirmed cases of poliomyelitis, 1961 Age Vaccinated* Not vaccinated Not known Total No. % No. % No. % No. % (a) Paralytic cases 0-4 years 3 16 16 84 19 100 5-14 ” — — 2 100 — — 2 100 15+ ” 1 17 4 66 1 17 6 100 Total 4 15 22 81 1 4 27 100 (6) Non-paralytic cases 0-4 years 1 50 1 50 2 100 5-14 ” 2 50 2 50 — — 4 100 15+ ” 1 50 — — 1 50 2 100 Total 4 50 3 38 1 12 8 100 * One, two or three injections. Of the four vaccinated cases with the paralytic form of the disease, one had received one injection and three (the children aged 0.4 years) had had two injections; none of the four had received a third injection. In the non-paralytic cases two had received three injections and the remaining two vaccinated cases two injections. It is estimated that by the end of the year 75 per cent, of children aged 0.14 years had received two injections of poliomyelitis vaccine, 56 per cent, three injections and 25 per cent, of the schoolchildren had had a fourth injection. Applying the figure of 75 per cent, to the child population at risk gives the following incidence rates for the paralytic form of the disease: Cases per Population million population 0-14 years Cases at risk Vaccinated 482,700 3 6.2 Not vaccinated 160,900 18 111.9 Thus the incidence rate in the unvaccinated children was about 18 times that in the vaccinated; in 1960 when the percentage vaccinated with two injections was 70 per cent, it was 13 or 18 times*. Smallpox—There was one case notified during the year in St. Pancras; this was in respect of a visitor to this country. Fortunately no secondary cases resulted. Whooping cough—After the increase in 1960 the figures for whooping cough returned to a low level in 1961, being the lowest yet recorded. For the first time no death from whooping cough was reported. * These alternative ratios were according to whether two cases whose vaccinal state was not known were included or excluded. 17 Table V.l—Vital statistics—Metropolitan Boroughs and the Administrative County of London, 1961 (a) Metropolitan Boroughs Estimated home population mid 1961 Live birth rate Death rate (all causes) Infant mortality (per 1,000 live births) Death rates Notifications of infectious disease Cancer Vascular lesions of C.N.S. Heart disease Other circulatory Pneumonia Other respiratory (excluding tuberculosis) Violence Dysentery Food poisoning Measles Pneumonia Poliomyelitis Scarlet fever Whooping cough Tuberculosis Crude Adjusted Crude Adjusted Paralytic Nonpara lytic Pulmonary Nonpulmo nary Division 1 Chelsea 48,490 13.5 10.3 15.0 10.8 24 2.80 1.84 4.39 0.99 0.76 0.95 0.78 0.80 0.02 11.63 0.16 0.021 — 0.08 0.49 0.39 0.04 Fulham 111,500 16.8 16.5 11.3 11.0 19 2.68 1.06 3.43 0.64 0.48 1.09 0.51 0.05 0.18 12.27 0.14 0.027 0.009 0.14 0.22 0.57 0.05 Hammersmith 108,010 21.3 20.2 11.5 11.8 17 2.56 1.20 3.59 0.57 0.55 0.98 0.60 1.06 0.37 10.99 0.41 — 0.009 0.23 0.19 0.81 0.14 Kensington 169,080 19.6 14.1 10.2 10.2 21 2.11 1.15 2.87 0.66 0.66 0.72 0.65 0.59 0.25 8.83 0.14 0.035 0.006 0.18 0.20 0.99 0.16 Division 2 Hampstead 96,990 17.8 13.5 10.1 10.0 16 2.31 1.05 3.20 0.55 0.63 0.62 0.53 0.16 0.13 11.27 0.20 0.041 0.031 0.39 0.26 0.56 0.16 Paddington 113,980 21.9 17.7 11.0 11.2 22 2.24 1.09 2.88 0.61 0.70 0.89 0.82 0.34 0.59 7.35 0.26 0.018 — 0.22 0.25 1.30 0.12 St. Marylebone 67,690 11.2 8.8 16.4 12.1 26 3.28 2.17 5.64 0.90 0.66 1.27 0.49 0.13 0.12 6.23 0.04 — — 0.19 0.16 0.59 0.03 St. Pancras 125,340 18.5 16.3 11.2 11.1 24 2.49 1.08 2.95 0.62 0.80 0.99 0.69 1.07 0.32 12.94 0.39 — — 0.42 0.31 1.09 0.08 Westminster, City of 86,680 11.9 10.0 11.2 11.1 22 2.58 0.90 3.43 0.76 0.61 0.78 0.72 0.31 0.23 9.17 0.05 - - 0.14 0.06 0.84 0-01 Division 3 Finsbury 33,020 18.8 17.1 10.7 10.6 31 2.70 0.94 3.24 0.30 0.42 1.15 0.42 2.45 0.85 12.51 1.61 - - 2.21 0.85 1.03 0.09 Holborn 20,520 10.5 7.5 11.8 12.4 46 2.68 1.12 3.36 0.63 0.97 0.58 0.63 0.10 0.19 5.95 0.10 0.049 — 0.24 0.34 1.07 0.10 Islington 227,170 24.0 21.8 11.4 11.1 21 2.32 1.13 2.93 0.72 0.87 1.32 0.53 1.10 0.49 14.55 0.19 0.004 — 0.67 0.29 1.05 0.10 Division 4 Hackney 163,180 22.4 21.1 11.8 12.6 23 2.59 1.13 3.58 0.66 0.55 1.24 0.38 0.32 0.17 15.39 0.29 0.006 — 0.57 0.21 0.61 0.07 Shoreditch 40,530 16.7 15.7 12.7 11.4 27 1.92 1.73 3.23 0.67 1.11 1.85 0.54 0.17 0.12 16.01 0.35 — — 0.59 0.30 0.64 0.02 Stoke Newington 52,180 24.9 22.2 10.9 12.5 27 2.20 1.19 2.99 0.54 0.57 1.11 0.54 0.67 0.29 17.50 0.21 — 0.019 0.38 0.29 0.88 0.06 Division 5 Bethnal Green 46,490 17.7 17.0 12.2 11.5 19 2.43 1.18 3.27 0.45 1.05 1.53 0.41 0.22 0.04 20.0 0.34 — — 0.77 0.28 0.71 0.09 City of London(b) 4,600 5.9 5.4 12.4 12.2 37 3.26 1.09 4.13 0.43 1.30 0.43 0.65 0.43 - 5.0 0.22 0.217 — 0.43 0.43 1.09 — Poplar 65,850 20.7 19.7 10.8 12.2 28 2.07 1.12 3.01 0.56 0.64 1.23 0.56 0.35 0.46 20.24 1.02 0.030 — 0.91 0.23 0.61 0.11 Stepney 91,710 20.4 18.6 13.1 13.4 22 2.56 1.06 4.00 0.56 1.06 1.56 0.60 0.52 0.26 20.70 1.28 — — 0.58 0.34 1.08 0.10 Division 6 Deptford 68,220 20.3 19.9 11.6 11.7 22 2.46 0.86 3.78 0.44 1.07 1.13 0.53 0.34 0.12 20.52 0.34 — — 0.51 0.67 1.42 0.04 Greenwich 85,240 15.4 14.8 10.9 11.9 23 2.43 1.06 3.48 0.42 0.77 0.87 0.46 0.41 0.26 21.35 0.06 — — 0.35 0.31 0.38 0.05 Woolwich 146,850 14.8 14.8 11.0 11.7 17 2.38 1.07 3.51 0.59 0.93 0.84 0.33 0.03 0.02 20.82 0.52 0.007 — 0.31 0.33 0.36 0.02 Division 7 Camberwell 173,980 19.4 18.2 11.8 11.6 19 2.41 1.40 3.39 0.69 0.74 1.10 0.53 0.17 0.18 15.74 0.20 — — 0.28 0.54 0.85 0.10 Lewisham 220,910 17.2 16.5 11.7 11.2 19 2.18 1.43 3.94 0.56 0.64 1.07 0.45 0.58 0.14 19.37 0.28 0.009 0.005 0.43 0.29 0.51 0.05 Division 8 Bermondsey 51,770 17.6 17.1 11.7 12.2 20 2.34 1.35 3.30 0.99 0.62 1.08 0.46 1.45 0.91 17.00 0.31 — — 0.66 0.37 0.70 0.06 Lambeth 221,960 22.1 20.1 11.6 11.6 22 2.61 1.18 3.23 0.55 0.81 1.09 0.52 0.57 0.07 15.60 0.28 0.009 — 0.52 0.54 0.57 0.08 Southwark 86,270 19.7 17.9 14.5 12.2 22 2.69 1.45 4.76 0.77 1.10 1.41 0.53 3.13 0.28 19.38 0.78 — 0.012 0.92 0.46 0.93 0.08 Division 9 Battersea 104,980 19.6 19.2 11.7 10.9 21 2.43 1.39 3.54 0.57 0.57 0.99 0.57 0.30 0.11 18.16 0.41 0.010 0.010 0.35 0.60 0.56 0.05 Wandsworth 346,790 17.1 16.4 14.0 10.5 20 2.53 1.50 4.91 0.72 0.94 0.95 0.50 0.27 0.26 14.21 0.62 0.003 0.003 0.31 0.55 0.49 0.06 London,1961 3,179,980 18.9 17.0 11.9 11.4 21 2.45 1-25 3-62 0.64 0.76 1-06 0-53 0.57 0.25 15.00 0.37 0.009 0.003 0.43 0.36 0.74 0.08 London, 1960 3,194,480 18.0 16.2 11.4 11.2 21 2.53 1-28 3-51 0.57 0.65 0-83 0-49 1.62 0.38 2.68 0.28 0.020 0.007 0.47 1.50 0.79 0.08 (a) Rates are per 1,000 home population, figures in italics are based upon fewer than 20 births, deaths or notifications. (b) Including Inner and Middle Temple. 18 Table V.2—Principal vital statistics—Administrative County of London, 1952-61 Year Annual rale per 1,000 living Annual mortality per 1,000 living Annual mortality— Infant (per 1,000 live births) Maternal (per 1,000 total births) Live births Deaths (all causes) Crude rate Adjusted rate Crude rate Adjusted rate Tuberculosis Cancer Vascular lesions of C.N.S. Heart disease Other circulatory disease Influenza Pneumonia (all forms) Bronchitis Other resp. diseases Violence Infants 0—1 Diarrhoea and enteritis 0—2 Pulmonary Non-pulmonary Suicide Road accidents Other violence 1952 15.3 13.8 12.0 12.1 0.28 0.03 2.30 1.27 3.55 0.62 0.05 0.61 1.09 0.12 0.1l (a) 0.07 0.22 23 0.8 0.95 1953 15.3 13.3 11.6 11.5 0.21 0.02 2.34 1.20 3.25 0.59 0.15 0.64 1.07 0.12 0.14 0.08 0.21 24 1.4 0.71 1954 15.2 13.3 10.7 10 .6 0.18 0.02 2.31 1.20 3.22 0.60 0.02 0.48 0.66 0.10 0.15 0.08 0.21 21 0.5 0.66 1955 15.1 13.3 11.5 11.4 0.16 0.01 2.39 1.25 3.37 0.61 0.05 0.63 0.88 0.1l 0.14 0.10 0.22 23 0.5 0.77 1956 15.9 14.0 11.7 11.7 0.13 0.01 2.42 1.27 3.46 0.59 0.04 0.67 0.96 0.1l 0.15 0.10 0.22 21 0.4 0.5 1 1957 16.2 14.4 11.4 11.3 0.12 0.02 2.45 1.19 3.34 0.56 0.12 0.65 0.83 0.10 0.15 0.09 0.21 22 0.5 0.52 1958 16.8 15.0 11.8 11.6 0.12 0.01 2.47 1.29 3.52 0.59 0.05 0.70 0.92 0.1l 0.17 0.11 0.22 22 0.4 0.60 1959 17.2 15.5 11.9 11.7 0.10 0.01 2.40 1.24 3.44 0.59 0.18 0.85 0.98 0.1l 0.17 0.12 0.23 22 0.3 0.60 1960 18.0 16.2 11.4 11.2 0.07 0.01 2.53 1.28 3.51 0.57 0.01 0.65 0.70 0.11 0.16 0.14 0.20 21 0.3 0.45 1961 18.9 17.0 11.9 11.4 0.09 0.01 2.45 1.25 3.62 0.64 0.08 0.76 0.87 1.06 0.16 0.13 0.24 21 0.3 0.74 (a) Deaths from motor vehicles and other road traffic accidents. 19 Table V.3—Deaths by cause— Administrative County of London, 1961 Cause Sex 0- 1 — 5- 15- 25- 45- 65- 75+ Total 1961 1960 1. Tuberculosis—respiratory m _ - 1 — 17 92 74 44 228 176 F - - - - 13 23 11 79 66 59 2. Tuberculosis—other m 1 - - - 1 3 3 2 10 9 F 1 1 1 - 2 6 2 1 14 25 3. Syphilitic disease m - - - - 2 24 26 13 65 62 F - - - - 2 7 16 22 47 56 4. Diphtheria m - - - - - - - - - - F - — 3 1 — — — - 4 - 5. Whooping cough m F - - - - - - - - — 2 1 6. Meningococcal infection m - 2 - - - 1 1 - 4 4 F 2 3 1 - - - - — 6 5 7. Acute poliomyelitis M - - - - - - - - - 2 F — — — - 1 — - — 7 — 8. Measles M 2 3 1 - - - - - 6 1 F - 3 1 - 1 - - - 5 - 9. Other infective, &c., diseases m - 1 2 1 3 13 6 5 31 45 F 7 1 4 2 5 13 4 7 37 27 10. Malignant neoplasm: Stomach M - - - 15 206 156 133 510 497 F — ~ - - 5 102 144 186 440 424 11. Malignant neoplasm: Lung, bronchus M - - - 2 44 883 568 264 1,761 1,870 F — — - — 24 151 99 85 359 575 12. Malignant neoplasm: Breast M - - - - - 4 - - 4 8 F - — — — 53 286 168 180 687 705 13. Malignant neoplasm: Uterus F - - - 1 34 133 76 52 296 309 14. Other malignant and lymphatic neoplasms M - 6 8 21 89 629 544 552 1,849 1,850 F 2 3 4 16 99 525 470 565 1,684 1,837 15. Leukemia, aleukemia m 3 8 6 5 15 32 19 12 100 112 F - 2 6 3 7 29 17 28 92 96 16. Diabetes m - - 1 1 3 15 27 26 73 72 F - - 1 — 3 30 61 80 175 745 17. Vascular lesions of nervous system M 2 - 2 5 31 342 471 684 1,537 1,600 F - 1 - 1 26 310 577 7,575 2,428 2,485 18. Coronary disease, angina M - - - - 120 1,471 1,146 1,073 3,810 3,857 F - - - - 12 373 860 1,475 2,720 2,677 19. Hypertension with heart disease m - - - - 1 54 80 115 250 254 F - - - - - 39 90 259 418 596 20. Other heart disease M 1 - 1 6 63 236 322 926 1,555 1,504 F - - - 4 58 255 428 2,011 2,756 2,583 21. Other circulatory disease M 1 - 1 - 20 207 245 357 831 738 F - 1 - 2 19 153 254 767 1,196 7,095 22. Influenza M 2 3 - 2 3 29 32 40 111 21 F 7 1 - 1 2 17 30 83 135 25 23. Pneumonia M 92 15 5 3 23 166 258 546 1,108 986 F 68 10 3 3 16 84 218 917 1,319 1,091 24. Bronchitis m 20 7 1 1 9 464 627 764 1,893 1,520 F 77 7 - 1 7 91 227 556 874 727 25. Other diseases of respiratory system M 3 2 1 5 13 66 66 65 221 252 F 4 3 1 1 2 35 32 59 137 700 26. Ulcer of stomach and duodenum M — - — - 7 84 78 85 254 282 F - - 1 - 2 24 39 70 136 146 27. Gastritis, enteritis and diarrhoea M 9 3 1 1 5 24 20 22 85 65 F 9 — - — 2 17 55 65 126 124 28. Nephritis and nephrosis M - 1 2 4 10 50 13 25 105 119 F - - 1 5 6 28 23 28 91 705 29. Hyperplasia, prostate M - - - - - 12 44 129 185 175 30. Pregnancy, childb., abortn. F - - - 11 33 1 - - 45 26 31. Congenital malformations M 95 15 11 6 7 21 8 2 165 196 F 141 13 1 4 16 15 4 2 196 200 32. Other defined and ill-defined diseases M 467 11 12 22 77 269 188 301 1,347 1,270 F 317 10 9 18 55 244 292 687 1,626 1,638 20 Table V.3 (contd.)—Deaths by cause—Administrative County of London, 1961 Cause Sex 0- 1 - 5- 15- 25- 45- 65- 75+ Total 1961 1960 33. Motor vehicle accidents M 1 7 14 66 64 49 37 43 281 307 F - 4 3 13 22 27 29 35 133 140 34. All other accidents M 11 17 25 37 90 115 53 63 411 359 F 14 16 5 9 15 45 59 162 325 247 35. Suicide M - - - 22 99 120 34 23 298 303 F - - - 10 61 100 30 23 224 199 36. Homicide, operations of war M 1 1 2 4 6 5 1 - 20 16 F - - - 1 4 2 2 9 9 ALL CAUSES M 711 102 97 214 837 5,686 5,147 6,314 19,108 18,534 F 571 79 45 107 610 3,165 4,289 9,941 18,807 17,987 Table V.4—Weather during 1961 (as recorded at Kew Observatory) Month Temperature Difference from Rainfall Difference from Sunshine Difference from Mean (a) Average (b) Total Average (b) Total Average (c) °F °F ins. ins. hrs. hrs. January 40.8 +1.1 2.45 +0.49 53.5 + 11.7 February 46.2 + 5.9 2.15 +0.60 66.0 +7.6 March 47.5 +4.7 0.16 -1.38 171.3 + 64.6 April 52.0 +4.5 2.06 +0.35 101.7 -47.5 May 53.8 +0.2 0.95 -0-80 232.6 +35.1 June 61.2 + 1.8 1.39 -0.59 241.5 +41.0 July 62.4 -0.3 1.20 -1.18 202.9 +7.4 August 62.1 +0.3 2.29 +0.05 166.9 — 18.1 September 60.8 +3.4 2.14 +0.15 130.-3 -10.6 October 53.1 +2.8 2.11 -0.40 123.1 +29.9 November 45.3 + 1.1 1.82 -0.52 63.3 + 12.1 December 39.6 -1.1 3.44 + 1.28 54.4 + 17.1 Year 52.1 +2.1 22.16 — 1.95 1,607.5 + 150.3 (a) Average of the daily means of 24 hourly readings. (b) Average over the 80 years ended 1950. (c) Average over the 70 years ended 1950. 21 Table V.5—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—Administrative County of London, 1952-1961 Year Anthrax Diphtheria Dysentery Acute encephalitis Enteric fever Erysipelas Malaria Measles Meningococcal infection Ophthalmia neonatorum Pneumonia Poliomyelitis Puerperal pyrexia Scabies Scarlet fever Smallpox Typhus Whooping cough Food poisoning Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Paralytic Non-par. Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate 1952 — — 18 0.005 1,704 0.507 21 0.006 25 0.007 467 0.139 22 0.007 31,055 9.23 82 0.024 202 (a) 3.36 1,908 0.567 204 0.061 105 0.031 1,860 (b) 30.38 535 0.16 5,263 1.56 5,587 1.66 612 0.18 1953 — — 11 0.003 2,639 0.789 18 0.005 45 0.013 408 0.122 89 0.027 27,046 8.09 98 0.029 161 2.76 2,434 0.728 235 0.070 97 0.029 1,712 28.72 527 0.16 3,425 1.02 — — — — 11,027 3.30 1,269 0.38 1954 1 0.0003 4 0.001 4,268 1.285 15 0.005 49 0.015 368 0.111 53 0.016 7,445 2.41 86 0.026 112 1.92 1,502 0.452 79 0.024 46 0.013 1,938 32.51 669 0.20 2,444 0.74 — — 1 0.0003 4,691 1.41 1,060 0.32 1955 — — 16 0.005 3,019 0.916 20 0.006 111 0.034 361 0.110 40 0.012 49,110 14.90 98 0.030 106 1.85 1,903 0.578 512 0.155 448 0.136 1,984 33.92 660 0.20 2,070 0.63 — — — — 4,709 1.43 1,530 0.46 1956 1 0.0003 11 0.003 6,392 1.953 54 0.016 73 0.022 297 0.091 31 0.009 9,651 2.95 94 0.029 83 1.39 1,633 0.499 183 0.056 96 0.029 1,792 29.49 703 0.21 2,198 0.67 — — — — 5,450 1.67 1,327 0.41 1957 — — 4 0.001 2,356 0.724 27 0.008 47 0.014 269 0.083 44 0.014 36,952 11.36 70 0.022 102 1.69 2,185 0.672 201 0.062 123 0.038 2,008 32.42 630 0.19 2,177 0.67 — — — — 3,982 1.22 1,189 0.37 1958 — — 38 0.012 4,502 1.396 38 0.012 42 0.013 257 0.080 10 0.003 16,664 5.17 81 0.025 132 1.99 1,735 0.538 80 0.025 27 0.008 1,680 24.85 635 0.20 2,716 0.84 — — — — 1,595 0.50 1,300 0.40 1959 — — 75 0.023 3,571 1.115 31 0.010 84 0.026 240 0.075 4 0.001 27,970 8.73 69 0.022 161 2.53 1,914 0.597 146 0.046 64 0.020 1,666 25.64 544 0.17 2,621 0.82 — — — — 1,607 0.50 1,639 0.51 1960 — — 16 0.005 5,161 1.616 23 0.007 51 0.016 229 0.072 10 0.003 8,561 2.68 71 0.022 89 1.36 882 0.276 64 0.020 23 0.007 1,416 21.20 498 0.16 1,500 0.47 1 0.0003 — — 4,794 1.50 1,229 0.38 1961 — — 28 0.009 1,812 0.570 18 0.006 32 0.010 204 0.064 26 0.008 47,620 15.00 67 0.021 100 1.46 1,174 0.369 29 0.009 11 0.003 1,486 21.27 463 0.15 1,361 0.43 1 0.0003 — — 1,146 0.36 783 0.25 (a) Rate per 1,000 live births registered in London. (b) Rate per 1,000 total births registered in London. Table V.6—Notification of certain infectious diseases—distribution by age and date of notification—Administrative County of London, 52 weeks commencing 2 January, 1961 Fourweekly periods 1961 Dysentery Measles Meningococcal infection Pneumonia Poliomyelitis Scarlet fever Whooping cough Paralytic Non-paralytic Ages Ages Ages Ages Ages Ages Ages Ages 0-4 5—14 15+ Total 0—4 5—14 15+ Total 0-4 5—14 15+ Total 0-4 5—14 15+ Total 0-4 5—14 15+ Total 0—4 5—74 75+ Total 0—4 5—74 75+ Total 0-4 5—14 15 + Total 1— 4 M 25 16 16 57 1,621 1,130 16 2,775 1 1 1 3 20 4 64 88 - - - - - - - - 13 34 5 52 52 37 2 92 F 23 11 21 56 1,492 1,035 46 2,578 3 1 1 5 70 5 75 90 1 — 1 2 — — — — 27 57 4 56 68 54 2 104 5— 8 m 40 24 20 84 2,839 2,794 43 5,686 4 - 1 5 12 8 172 193 2 - - 2 - - - - 20 42 7 69 45 18 - 63 F 38 15 34 87 2,713 2,864 55 5,639 4 7 — 5 75 8 756 179 - - - - - - - - 22 46 75 81 77 16 2 89 9—12 m 34 48 24 106 3,544 2,397 52 6,008 2 - 2 4 6 9 34 49 - - - - - - - - 17 47 1 65 28 15 1 44 F 38 44 31 114 3,463 2,367 70 5,909 7 — — 1 6 4 51 67 - - - - - - - - 14 47 2 57 51 31 4 86 13—16 m 47 31 10 89 3,016 1,753 65 4,840 1 5 - 6 6 7 39 52 1 - - 1 - - - 22 27 3 52 15 15 - 30 F 43 19 30 93 2,922 1,779 96 4,806 — 1 1 2 5 3 55 41 - - - - - - - - 29 44 5 77 25 27 7 47 17—20 m 56 17 13 86 1,364 610 44 2,024 3 - 1 4 4 4 14 22 1 - - 1 - 1 - 1 26 30 7 63 20 18 1 39 F 32 24 33 89 1,454 574 76 2,106 1 1 — 2 5 5 18 28 - - - - - - - - 24 43 4 71 28 12 2 42 21—24 m 41 25 17 83 784 386 27 1,197 1 1 - 2 8 4 26 38 - - - - - - - - 18 27 5 50 24 11 - 35 F 51 16 40 107 772 431 36 1,239 — 7 — 1 3 4 21 28 - - - - - - - - 16 29 3 49 18 14 — 33 25—28 m 25 24 27 77 402 210 16 629 - - - - 4 6 18 28 - - - - - - - - 16 32 2 50 22 9 - 31 F 27 15 31 75 399 223 18 641 3 — 3 6 1 2 13 16 1 — — 1 1 — — 1 13 31 2 46 17 9 1 27 29—32 m 57 15 13 85 210 93 4 308 3 - 1 4 4 4 13 21 - - - - - - - - 9 20 - 29 18 9 1 28 F 47 15 39 101 213 109 7 29 — — 1 1 2 - 12 14 2 — — 2 — — — — 9 29 1 39 27 70 2 39 33—36 m 53 13 14 80 114 37 7 158 - - - - 1 2 13 16 - - 2 2 - - - - 14 9 1 24 15 8 - 23 F 47 10 31 88 123 32 6 161 — — 3 3 1 1 72 74 1 — - 1 — — 1 1 12 9 4 25 22 13 — 35 37—40 m 20 4 11 35 58 15 - 73 1 - 2 3 4 - 8 12 - 1 - 1 1 1 - 2 12 17 1 30 27 10 - 38 F 20 9 15 45 63 21 4 88 - - - - - 1 11 12 1 1 1 5 - 1 — 1 7 24 2 33 30 8 — 38 41—44 m 37 9 8 54 50 26 3 79 1 2 - 3 7 3 13 23 - - 2 2 - - - - 22 31 1 54 17 12 - 29 F 20 15 19 56 66 26 3 95 1 7 — 2 2 — 77 75 2 — — 2 — — — — 74 52 2 48 18 75 7 54 45—48 m 17 14 15 46 48 13 1 62 2 -_ -_ 2 - 4 33 37 3 2 1 6 1 1 - 2 31 37 - 68 23 7 - 30 F 17 12 27 56 56 22 2 80 — — 7 1 7 2 79 22 2 — 2 4 — 1 — 1 27 57 3 68 56 75 — 51 49—52 m 21 13 4 38 35 17 2 55 2 - - 2 4 3 35 42 - - - - - 1 1 2 16 26 2 44 9 5 - 14 F 20 11 12 43 34 15 - 49 2 - - 2 4 5 36 45 - - - - - - - - 22 50 4 56 75 6 - 21 Total M 473 253 192 920 14,119 9,481 280 23,894 21 9 8 38 80 58 482 621 7 3 5 15 2 4 1 7 236 379 35 650 315 174 5 496 F 423 216 363 1,010 13,770 9,498 479 25,720 75 6 10 31 55 40 465 565 70 7 4 75 7 2 7 4 250 426 47 706 426 204 75 646 Notes: 1. Where the total figures are in excess of the sum of the age groups, the difference is due to cases ' age not known'. 2. The totals of these figures will not necessarily agree with the total notifications given in table V.J which relates to the calendar year 1961. TUBERCULOSIS Notification rates of pulmonary tuberculosis were slightly lower than in 1960 and the death rate followed the same general trend. The diagram on page 24 shows the trend of notifications, deaths and numbers on the registers of chest clinics over the last decade. Deaths from non-pulmonary tuberculosis are now so few that considerable random fluctuations occur in the rates from year to year and therefore are not shown in the diagram. The number of cases on the registers is now 35,208. Tuberculosis is still a serious infectious disease. This year, in adults it accounted for more cases than were notified of any other notifiable infectious disease. The 318 deaths from tuberculosis (all forms both sexes) include 210 deaths from pulmonary disease in men aged 45 years and over. Services provided—The services provided by the Council as local health authority for the care and after-care of tuberculous patients and the prevention of tuberculosis are summarised in table T.9. Care committees—The voluntary tuberculosis care committees associated with most of the 29 chest clinics in London continued their valuable work of assisting patients and their families financially or in other ways where help was not available from official sources. The Council's local tuberculosis care organisers (now renamed chest clinic welfare officers) act as secretaries to these committees. B.C.G. vaccination—The numbers of children vaccinated during the year under the Council's schemes for the B.C.G. vaccination of susceptible (tuberculin negative) child contacts of known tuberculous patients, diabetic children, thirteen-year-old schoolchildren, students at further education establishments and mentally subnormal persons at training centres are shown in table T. 11. Preventive measures—In addition to the B.C.G. vaccination schemes other preventive measures include the chest X-ray of all newly appointed staff who are likely to work in close and frequent contact with children, staff at the Council's training centres for mentally subnormal persons and of tuberculin reactors discovered among thirteen-year-old schoolchildren, students and others tested with a view to B.C.G. vaccination. Epidemiological investigations are made among the contacts of cases of tuberculosis notified in children, staff or residents in the Council's establishments. Similar investigations are carried out at secondary schools where the reactor rates disclosed by tuberculin surveys are significantly higher than the average for secondary schools in the area (table T.8). Tuberculosis contact scheme—In view of the small number of child contacts now needing to be boarded away from home, the placing of such children was taken over, as from 1 April 1961, by the Council from the Invalid Children's Aid Association, which had undertaken this work on the Council's behalf for over thirty years. 23 TREND OF TUBERCULOSIS LONDON A.C. 1952-61 24 Table T.l—Tuberculosis—Statutory notifications and deaths, Administrative County of London, 1952-1961 (a) Year Pulmonary tuberculosis Non-pulmonary tuberculosis Statutory notifications Deaths Statutory notifications Deaths No. Annual rate per 1,000 living No. Annual rate per 1,000 living No. Annual rate per 1,000 living No. Annual rate per 1,000 living 1952 4,713 1.40 933 0.28 518 0.15 86 0.03 1953 4,668 1.40 690 0.21 410 0.12 73 0.02 1954 4,231 1.27 596 0.18 410 0.12 62 0.02 1955 3,757 1.14 517 0.16 365 0.11 44 0.01 1956 3,602 1.10 423 0.13 327 0.10 32 0.01 1957 3,460 1.06 378 0.12 294 0.09 50 0.02 1958 3,103 0.96 379 0.12 305 0.10 41 0.01 1959 2,794 0.87 313 0.10 244 0.08 30 0.01 1960 2,519 0.79 235 0.07 250 0.08 34 0.01 1961 2,344 0.74 294 0.09 250 0.08 24 0.01 (a) Excluding posthumous notifications. Table T.2—Pulmonary tuberculosis—Notification and death rates per 1,000 living by age and sex, Administrative County of London, 1952-1961 Year Age 0-4 5- 14 15-44 45 and over All ages M F M F M F M F M F Notification rates 1952 0.65 0.70 0.53 0.61 2.16 1.90 1.88 0.43 1.73 1.11 1953 0. 84 0.85 0.69 0.65 2.01 1.80 2.09 0.42 1.76 1.08 1954 0.64 0.55 0.48 0.55 1.79 1.71 2.02 0.41 1.60 0.99 1955 0.56 0.42 0.39 0.48 1.65 1.48 1.82 0.41 1.45 0.86 1956 0..33 0.37 0.31 0.34 1.62 1.31 2.01 0.41 1.47 0.78 1957 0.43 0.40 0.30 0.32 1.60 1.27 1.92 0.38 1.44 0.73 1958 0.39 0.33 0.30 0.27 1.49 1.03 1.89 0.32 1.37 0.60 1959 0.47 0.43 0.24 0.28 1.30 0.95 1.66 0.32 1.21 0.57 1960 0.46 0.44 0.23 0.25 1.14 0.83 1.49 0.33 1.08 0.53 1961 0.34 0.45 0.23 0.29 1.00 0.79 1.45 0.30 1.00 0.50 Death rates 1952 - - - - 0.18 0.16 1.08 0.18 0.44 0.14 1953 002 0.,03 0.00 0.00 0.12 0.11 0.81 0.13 0.33 0.10 1954 - 0.03 - 001 0.07 0.10 0.74 0.12 0.28 0.09 1955 002 - 0.00 - 0.07 0.06 0.66 0.11 0.25 0.07 1956 - 0.02 - - 0.07 0.05 0.52 0.09 0.21 0.06 1957 - 0.009 - - 0.06 0.05 0.46 0.08 0.19 0.05 1958 - - 0.01 - 0.05 0.05 0.44 0.11 0.18 0.06 1959 0.02 0.009 - - 0.03 0.03 0.41 0.07 0.16 0.04 1960 - 0.03 - - 0.03 0.02 0.29 0.06 0.12 0.03 1961 — — 0.005 — 0.03 0.02 0.40 0.07 0.15 0.04 25 NOTIFICATION OF PULMONARY 1953-54, 1957-58, 1960-61 Figures 2 and 3 show a continuing fall during the last two years in the number of new notifications of pulmonary tuberculosis at ages up to 70 in men and in ages 15 to 45 in 26 TUBERCULOSIS, LONDON A.C. -THREE-YEAR MOVING AVERAGES women. In earlier years females showed a fall in all years up to age 55. The considerable improvement in the position as it affects older men is a very gratifying feature of current tuberculosis trends. 27 Table T.3—Non-pulmonary tuberculosis—Notification and death rates per 1,000 living by age and sex. Administrative County of London, 1952-1961 Year Age 0-4 5-14 15-44 45 and over All ages M F M F M F M F M F Notification rates 1952 0.198 0.168 0.275 0.173 0.144 0.233 0.070 0.085 0.141 0.165 1953 0.144 0.160 0.152 0.182 0.138 0.175 0.044 0.070 0.109 0.135 1954 0.142 0.149 0.139 0.187 0.128 0.176 0.069 0.071 0.111 0.134 1955 0.110 0.116 0.140 0.121 0.140 0.189 0.042 0.037 0.105 0.116 1956 0.111 0.089 0.078 0.095 0.109 0.176 0.048 0.058 0.084 0.114 1957 0.076 0.063 0.069 0.100 0.105 0.168 0.034 0.052 0.073 0.106 1958 0.126 0.116 0.075 0.083 0.108 0.148 0.047 0.066 0.083 0.104 1959 0.050 0.043 0.063 0.040 0.103 0.130 0.055 0.041 0.076 0.076 1960 0.065 0.051 0.029 0.030 0.133 0.136 0.038 0.041 0.079 0.078 1961 0.055 0.058 0.054 0.062 0.104 0.127 0.045 0.055 0.072 0.084 Death rates 1952 0.053 0.040 0.010 0.010 0.027 0.018 0.033 0.029 0.029 0.023 1953 0.024 0.076 0.005 0.010 0.017 0.017 0.025 0.029 0.019 0.025 1954 0.025 0.018 0.005 — 0.016 0.009 0.035 0.029 0.021 0.016 1955 0.008 0.009 0.009 0.005 0.012 0.004 0.021 0.024 0.014 0.013 1956 0.009 - — - 0.009 0.004 0.023 0.014 0.012 0.007 1957 0.008 0.009 0.009 0.005 0.011 0.004 0.030 0.027 0.017 0.014 1958 - - 0.005 - 0.012 0.004 0.026 0.021 0.015 0.010 1959 0.025 0.009 0.005 — 0.009 0.001 0.011 0.017 0.011 0.008 1960 0.016 - - 0.005 0.003 0.007 0.009 0.027 0.006 0.015 1961 0.008 0.017 — 0.005 0.002 0.003 0.015 0.013 0.007 0.008 Table T.4—Tuberculosis—Statutory notifications by age groups, Administrative County oj London, 1961 Form of tuberculosis notified Sex Number of notifications of new cases of tuberculosis by age Total all ages 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75+ Pulmonary tuberculosis M. 9 34 27 20 51 132 243 207 302 262 161 47 1,495 K 4 50 36 21 54 154 203 113 84 80 34 16 849 Other forms of tuberculosis M. 1 6 6 5 8 10 30 18 18 3 3 — 108 F. — 7 8 4 9 23 29 23 20 9 4 6 142 All forms of tuberculosis M. 10 40 33 25 59 142 273 225 320 265 164 47 1,603 F. 4 57 44 25 63 177 232 136 104 89 38 22 991 Table T.5—Tuberculosis—Deaths in Administrative County of London, 1961 Form of tuberculosis Sex Age at death Total all ages 0— 1— 5— 15— 25— 45— 65— 75+ Pulmonary tuberculosis M. - — 1 - 17 92 74 44 228 F. — — — - 13 23 11 19 66 Other forms of tuberculosis M. 1 — — — 1 3 3 2 10 F. 1 1 1 — 2 6 2 1 14 All forms of tuberculosis M. 1 - 1 18 95 77 46 238 F. 1 1 1 — 15 29 13 20 80 28 Table T.6—Statutory notification of non-pulmonary tuberculosis—Distribution according to site and age, Administrative County of London, 1961 Site of tuberculous lesion Numbers of notifications of new cases of non-pulmonary tuberculosis by age Total all ages 0-4 5-14 15-24 25+ Bones and joints 2 4 8 47 61 Abdomen 2 1 3 8 14 Peripheral glands 6 11 18 47 82 Meninges and C.N.S. 2 2 4 4 12 Skin and erythema nodosum 2 — — 1 3 Genito-urinary — 2 16 51 69 Other sites — 3 1 5 9 All sites.. 14 23 50 163 250 Table T.7—Patients on the registers—1952-1961 At 31st Dec. 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 Pulmonary: Males 17,336 18,475 18,897 19,300 19,715 19,946 20,308 19,553 19,380 18,759 Females 14,672 14,930 15,576 15,846 15,928 15,836 15,597 14,858 14,497 13,833 Other forms: Males 1,530 1,508 1,442 1,371 1,339 1,274 1,293 1,158 1,163 1,143 Females 1,850 1,820 1,709 1,704 1,710 1,709 1,674 1,555 1,527 1,473 Total 35,388 36,733 37,624 38,221 38,692 38,765 38,872 37,124 36,567 35,208 No. per 1,000 of population 10.5 10.9 11.3 11.6 11.8 11.9 12.1 11.6 11.4 11.1 Table T.8—Summary of investigations into tuberculosis ' incidents ' at Council establishments in 1961 Establishment Notified case Children Adults Tuberculin tested Positive reactors X-rayed Abnormal X-rayed Abnormal Day school Pupil 28 - - - 1 - Teacher 132 7 7 — — - Pupil 280 22 22 — 2 - Pupil 16 5 5 — — -— Secretary 17 4 4 — — — Pupil — — — — 1 — Teacher 23 4 4 — 16 — Pupil — — — — 134 2 Pupil 118 74 74 — — — Pupil — — — — 45 — Secretary 197 2 2 — 6 — Total (11) 811 118 118 — 205 2 Training centre Trainee 52 4 4 — — — College Lab. Technician . — — — — 4 — Grand Total (13) 863 122 122 — 209 2 29 Table T.9—Summary of services provided for tuberculous patients, Administrative County of London 1957-1961 1957 1958 1959 1960 1961 Clinic registers Total on registers at the end of the year 38,765 38,872 37,124 36,567 35,208 Work of local tuberculosis care organisers Patients assisted for the first time with: Beds and bedding 176 165 210 123 164 Clothing or footwear 734 571 558 500 421 Patients at the end of the year receiving: Extra nourishment 1,938 1,875 1,714 1,558 1,417 Home help service 528 467 465 462 412 Home care and treatment At the end of the year, patients: Awaiting admission to hospital 34 16 16 14 18 Under treatment in their own homes 329 238 143 140 123 Receiving attention by home nurses 371 368 331 283 244 Home visiting by tuberculosis health visitors— Total visits (including contacts) 80,302 78,953 86,680 77,861 83,585 Diversional therapy At the end of the year, attending classes at chest clinics 147 157 131 110 101 Receiving instruction in their own homes 259 262 200 180 150 Rehabilitation At the end of the year the Council was financially responsible for rehabilitants at: British Legion Village, Maidstone 29 30 19 11 13 Papworth Village Settlement, Cambridge 19 15 10 6 4 Enham-Alamein Village Centre, Andover 9 10 5 4 — Barrowmore Hall, Chester 1 1 1 1 1 Correspondence courses arranged through the British Council for Rehabilitation for patients undergoing prolonged treatment at home 20 14 10 9 6 At boarding open-air schools Children convalescent from tuberculosis: At the beginning of the year 8 6 1 — 2 Admitted during the year — — — 2 2 At the end of the year 6 1 — 2 3 Awaiting admission at end of year — — — 1 — Boarding-out of child contacts Children in nurseries and foster homes at the beginning of the year 172 136 94 79 53 Placed during the year 229 173 154 152 111 Boarded-out at the end of the year 136 94 79 53 34 Average number boarded-out at any one time 164 116 100 76 47 Boarding-out of child contacts for segregation during B.C.G. vaccination Children in nurseries and foster homes at the beginning of the year 4 3 9 3 2 Placed during the year 24 20 35 22 9 Boarded-out at the end of the year 3 9 3 2 2 Average number boarded-out at any one time 7 4 8 6 3 Hostels for homeless infective tuberculous men In residence at the beginning of the year 69 77 103 101 107 Recommendations approved during the year 60 81 63 74 51 In residence at the end of the year 77 103 101 107 103 30 31 Table TAO—Principal tuberculosis statistics—Metropolitan Boroughs and the Administrative County of London, 1961 Metropolitan Boroughs Estimated home population mid 1961 Pulmonary New notifications Deaths from tuberculosis Tuberculosis deaths per 1,000 population Pulmonary tuberculosis deaths per 1,000 population aged 15 and over Number of tuberculosis cases on clinic registers at 31.12.61 Cases on register per 1,000 population Tuberculosis of Meninges and C.N.S. Other nonpulmonary tuberculosis Total New notifications per 1,000 population Pulmonary Nonpulmonary tuberculosis Total deaths Total Percentage of pulmonary cases positive during 1961 Division 1 Chelsea 48,490 19 1 1 21 0.43 9 1 10 0.21 0.23 359 3.6 7.4 Fulham 111,500 63 1 5 69 0.62 3 1 4 0.04 0.03 1,206 1.1 10.8 Hammersmith 108,010 87 - 15 102 0.94 4 1 5 0.05 0.05 1,456 1.8 13.5 Kensington. 169,080 168 2 25 195 1.15 16 1 17 0.10 0.11 1,315 1.9 7.8 Division 2 Hampstead 96,990 54 — 16 70 0.72 1 — 1 0.01 0.01 979 4.0 10.1 Paddington.. 113,980 148 — 14 162 1.42 14 1 15 0.13 0.15 1,320 2.6 11.6 St. Marylebone 67,690 40 — 2 42 0.62 8 1 9 0.13 0.13 877 1.7 13.0 St. Pancras 125,340 137 1 9 147 1.17 9 — 9 0.07 0.09 1,119 2.1 8.9 Westminster, City of 86,680 73 — 1 74 0.85 7 — 7 0.08 0.09 844 6.0 9.7 Division 3 Finsbury 33,020 34 — 3 37 1.12 1 1 2 0.06 0.04 276 5.8 8.4 Holborn 20,520 22 - 2 24 1.17 1 1 2 0.10 0.06 262 3.3 12.8 Islington 227,170 238 1 22 261 1.15 22 1 23 0.10 0.12 2,450 1.5 10.8 Division 4 Hackney 163,180 100 1 11 112 0.69 12 2 14 0.09 0.09 1,736 2.1 10.6 Shoreditch 40,530 26 — 1 27 0.67 11 1 12 0.30 0.04 330 7.9 8.1 Stoke Newington 52,180 46 — 3 49 0.94 6 — 6 0.11 015 775 0.7 14.9 Division 5 Bethnal Green 46,490 33 - 4 37 0.80 4 — 4 0.09 0.11 737 1.7 15.9 City of London 4,600 5 — — 5 1.09 — — — 69 4.6 15.0 Poplar 65,850 40 — 7 47 0.71 10 — 10 0.15 0.20 591 2.4 9.0 Stepney 91,710 99 — 9 108 1.18 11 — 11 0.12 0.16 1,298 1.5 14.2 Division 6 Deptford 68,220 97 — 3 100 1.47 5 — 5 0.07 0.09 1,058 2.5 15.5 Greenwich 85,240 32 - 4 36 0.42 6 1 7 0.08 0.09 1,046 1.2 12.3 Woolwich . 146,850 53 - 3 56 0.38 19 19 0.13 0.17 1,634 1.4 11.1 Division 7 Camberwell 173,980 148 2 15 165 0.95 19 1 20 0.11 0.14 987 1.1 5.7 Lewisham 220,910 112 — 11 123 0.56 18 1 19 0.09 0.10 2,473 0.7 11.2 Division 8 Bermondsey 51,770 36 — 3 39 0.75 5 — 5 0.10 0.12 654 1.6 126 Lambeth 221,960 126 1 17 144 0.65 27 2 29 0.13 0.16 3,134 2.0 14.1 Southwark 86,270 80 — 7 87 1.01 9 1 10 0.12 0.14 1,461 2.1 16.9 Division 9 Battersea 104,980 59 — 5 64 0.61 12 1 13 0.12 0.15 1,050 2.1 10.0 Wandsworth 346,790 169 2 20 191 0.55 25 5 30 0.09 0.09 3,712 1.7 10.7 LONDON 3,179,980 2,344 12 238 2,594 0.82 294 24 318 010 0.12 35,208 1.9 11.1 Table T. 11—B.C.G. vaccination under L.C.C. schemes in 1960/61 1. Day schools— No. of schools visited 1960/61 (to 31.12.61) 371 No. of 13-year-old children at school *57,099 No. of consents *43,975 No. tuberculin tested *38,521 No. of reactors *3,377 = 8.8 per cent. No. given B.C.G. *35,050 No. vaccinated June, 1954 to December, 1961 177,690 2. Further education establishments (colleges, etc.) No. of establishments visited during 1961 35 No. tested 3,639 No. of reactors 2,138 No. given b.C.G. 1,489 3. Residential establishments— No. of establishments visited during 1961 3 No. of children tested 120 No. of reactors 20 = 16-6 per cent. No. given B.C.G. 99 4. Training centres— No. tested. 150 No. of reactors 24 No. given B.C.G. 126 5. Notifications of tuberculosis (all forms) in 14- and 15-year-old children in 1954 82 1955 (first full year after starting B.C.G.) 45 1958 38 1959 20 1960 31 1961 26 6. Tuberculosis contacts— No. of contacts given B.C.G. vaccination in London in 1961 5,084 No. of contacts given B.C.G. vaccination in London since inception of scheme in 1950 46,572 7. Diabetics— No. given B.C.G. in 1961 11 No. given B.C.G. since inception of scheme 79 * Divisional figures are shown in Table T.12 32 Table T.12—B.C.G. vaccination of schoolchildren in Administrative County of London, 1960/61 {seventh year)— Divisional figures to 31.12.61 Division No. of 13-yearold school children Total No. of consents Alleged contacts of known cases No. of children tested and read by B.C.G. units Children not dealt with because of refusal of consent or absence Positive reactors (among (4)) No. of negative reactors vaccinated by B.C.G. units Consents included in (2) No. Per cent. off. 1) No. Per cent. (1) (2) (3) (4) (5) (6) (7) (8) (9) 1 8,603 6,684 52 6,024 2,527 29.4 712 11.8 5,300 (12 negatives not vaccinated) 2 5,278 4,041 10 3,572 1,696 32.1 529 14.8 3,026 (17 negatives not vaccinated) 3 3,421 2,413 3 2,102 1,316 38.5 269 12.8 1,832 (1 negative not vaccinated) 4 4,892 3,903 105 3,323 1,464 29.9 296 8.9 3,018 (9 negatives not vaccinated) 5 6,897 5,153 27 4,403 2,467 35.8 445 10.1 3,950 (8 negatives not vaccinated) 6 8,384 6,953 119 6,177 2,088 25.0 294 4.7 5,881 (2 negatives not vaccinated) 7 8,054 5,807 161 5,013 2,880 35.7 291 5.8 4,700 (22 negatives not vaccinated) 8 5,756 4,248 111 3,841 1,804 31.3 230 6.0 3,611 9 5,814 4,773 54 4,066 1,694 29.1 311 7.6 3,732 (23 negatives not vaccinated) Totals 57,099 43,975 642 38,521 17,936 31.4 3,377 8.8 35,050 33 GENERAL PUBLIC HEALTH Housing The Council has set aside a small number of dwellings for the rehousing of families on purely medical grounds.The following table shows the cases dealt with in the five years the scheme has been in operation in its present form: 1957 1958 1959 I960 1961 Tuberculous persons Recommendations received 421 321 275 232 224 Nominated for rehousing 185 151 185 209 139 Recommendations not qualifying for rehousing 135 132 114 93 20 Under consideration at end of year 101 139 115 45 110 Persons with severe medical conditions Recommendations received 2,484 2,474 2,689 3,357 2,570 Nominated for rehousing 226 478 418 607 164 Recommendations not qualifying for rehousing 1,904 1,617 1,951 2,503 1,791 Under consideration at end of year .. .. 354 733 1,053 1,300 1,915 Work in connection with unfit houses during the past five years is summarised below: 1957 1958 1959 1960 1961 Slum clearance Areas represented as unfit for human habitation.. 90 77 27 48 34 Houses in such areas 2,409 1,830 660 1,356 932 Areas surveyed but not represented by the end of the year 81 11 13 39 90 Houses in such areas 2,004 312 641 1,291 2,869 Public local inquiries 28 36 37 42 12 Informal hearings 4 2 1 1 4 Orders confirmed) after inquiry or hearing 45 33 42 41 27 (ii) without inquiry or hearing (no objection received) 13 14 28 15 2 Orders not confirmed by Minister 1 1 3 1 - Confirmed order quashed on appeal to High Court - - - - 1 Improvement grants Surveys following applications to the Council .. 68 119 160 1,178 309 Searches following applications to metropolitan borough councils 158 103 346 572 595 Dangerous structures Premises scheduled as dangerous—searches made 1,094 1,229 1,013 * * * The functions with regard to dangerous structures were, by the London County Council (General Powers) Act, 1958, transferred to the metropolitan borough councils as from 1 January, 1960. / Public Health Laboratory The facilities at the Medical Research Council's Public Health Laboratory at the County Hall and the close co-operation with its staff have continued to be of great value. Milk sampling The following table shows the results of tests during the year on samples taken of milk arriving in London (the figures in brackets are those for 1960): 34 Designation Samples examined T.B. bacillus isolated T.B. bacillus NOT isolated Passed phosphatase test Tests not completed* Tuberculin tested (Farm bottled) 34 (49) - (-) 34 (47) N/A - (2) Tuberculin testedt 4 (4) - (-) 4 (4) N/A - (-) Pasteurised 17 (20) N/A N/A 17 (20) - (-) Total 55 (73) - (-) 38 (51) 17 (20) - (2) * Milk curdled or guinea pigs died before completion of test. † Samples from a residential school which has its own farm. Milk purchased for use in Council establishments: 1957 1958 1959 1960 1961 Liquid milk: samples taken by boroughs and county councils 1,162 947 910 589 306 number found to be unsatisfactory 3 7 11 - Dried milk: samples submitted to bacteriological examination 4 4 4 3 24* No samples contained more than 100,000 organisms per gramme, nor was staphylococcus aureus isolated. Sanitary inspection The public health inspectors dealt with the following matters in Council establishments: 1957 1958 1959 1960 1961 Reports of infestation by a variety of pests 178 190 207 274 221 Visits and re-inspections involved 294 347 472 506 409 Inspections of school meals centres 420 375 362 341 208 Investigations of illness following consumption of school meals 15 12 7 8 11 Occasions when the meal was found to be the cause 2 3 2 2 - Blind and partially-sighted persons During the year, 1,560 examinations—198 fewer than in the previous year—were made in connection with certification under the National Assistance Act, 1948, of blind or partially-sighted persons and 45 persons were found to be neither blind nor partially-sighted. In addition, 349 certificates were accepted from other local authorities, hospitals and private ophthalmologists—90 fewer than in the previous year. The percentage of new registrations recommended to obtain treatment was 53.9 per cent. compared with 57.7 per cent. in 1960. The results of examinations of persons newly registered during the year are given in tables (i) and (ii) overleaf. * Increased sampling was due to co-operation in the formulation of a British Standard for dried milk. 35 Table (i) Number of new registrations during the year with percentage recommended to obtain treatment Age Principal cause of defective vision Total Cataract Glaucoma Retrolental fibroplasia Other conditions 0-4 years 3 — — 6 9 5-15 years — — — 5 5 16-64 years 35 23 127 185 65-74 years 68 33 — 102 203 75 years and over 220 52 — 242 514 Age not known 3 - - 11 14 (a) Total no. of persons 329 108 - 493 930 (b) No. recommended to obtain treatment 205 89 - 207 501 (b) as percentage of (a) 62-3 82-4 - 420 53.9 Table (ii) Number of treatments recommended in respect of newly registered persons* No. of patients examined Treatments recommended Optical Hospital supervision None Medical Surgical Early Later If general condition permits Cataract 329 124 16 37 30 25 23 125 Glaucoma 108 19 21 3 8 2 3 77 Other conditions 493 286 53 6 7 4 25 148 Total 930 429 90 46 45 31 51 350 * Includes cases recommended more than one form of treatment. Persons recommended to obtain treatment are re-examined at intervals after the initial registration. The number of persons re-examined for this reason in 1961 is shown in Table (iii). Table (iii) Re-examination of persons recommended to obtain treatment Principal cause of defective vision Total Cataract Glaucoma Retrolental fibroplasia Other conditions No. of persons re-examined 168 42 1 293 504 No. found to have had treatment 136 42 — 157 335 Percentage treated 81.0 1000 — 53.6 66.5 As a consequence of successful treatment eight persons previously registered as blind were found, on re-examination, to be partially-sighted and nine persons previously certified as blind or partially-sighted were found to be improved to such an extent as no longer to justify registration. Figures for ophthalmia neonatorum are given on page 21. 36 Registration of nursing homes Table (i)—Registration and inspection of nursing homes 1957 1958 1959 1960 1961 Registered at beginning of year 39 38 37 34 33 New homes registered — — 1 — 5 Homes registered on change of keeper — 1 2 3 1 Registrations cancelled—voluntary closure or change of keeper 1 2 6 4 3 Registered at end of year 38 37 34 33 36 Inspections: medical officers 51 41 42 35 46 public health inspectors 96 50 63 84 122 Homes exempted from registration 39 38 38 40 37 Table (ii)—Accommodation in registered nursing homes at 31 December, 1961 Number of beds in homes Number of homes Maternity* Number of beds provided Total Others† Mentally disordered 25 or over 11 216 212 162 590 20 to 24 6 25 83 22 130 15 to 19 8 17 100 17 134 10 to 14 7 12 75 — 87 5 to 9 2 9 6 — 15 Under 5 2 — 6 — 6 Total 36 279 482 201 962 * Each bed is registered for a maternity, medical or surgical case. †Numbers include beds for medical and surgical patients which cannot be used if a maternity patient is accommodated in the same room. Mental nursing homes—When Part III of the Mental Health Act, 1959 came into operation on 1 November, 1960, the Council became responsible for the registration and inspection of mental nursing homes and of residential homes for mentally disordered persons. (Residential homes are registered by the Welfare department.) Eleven establishments formerly supervised by the Board of Control were notified to this department as likely to be affected by the provisions of the Act. All the establishments were inspected and after discussion with the keepers the following decisions were taken: Licensed house (Lunacy Act, 1890—Part VIII)—2: Both premises registered as mental nursing homes; one for patients liable to detention under the Act and the other for informal patients only. Certified institution (Mental Deficiency Act, 1913—sec. 36)—2: One institution registered as a mental nursing home for informal patients; the other establishment was not registrable under the Act. Approved home (Mental Deficiency Act, 1913—sec. 50)—1: This home was not registrable as a mental nursing home; it is being considered for registration as a residential home. Person having charge of a certified single patient (Lunacy and Mental Treatment Acts, 1890-1930)—1: Registration as a mental home was not appropriate; the patient remains in the person's charge in ' community care '. Person having care and control of mental defectives (Mental Deficiency Act, 1913— sec. 51)—5: One establishment registered as a mental nursing home to accommodate patients detained under the Act; in another the sole patient remains under the person's care in 'community care'. In the other three establishments the patients had left and no other mentally disordered patients were accommodated. 37 Welfare Committee establishments Medical supervision of homes under the control of the Welfare Committee was continued. These homes include large and small homes for the aged and infirm, accommodation for mothers and babies, and homeless families units. The medical problems arising in large and small homes for the aged and infirm was the subject of discussion at a conference of visiting medical officers held at County Hall in October under my chairmanship. The conference was attended by some twenty general medical practitioners who act as visiting medical officers of the homes. The Chief Officer of the Welfare department spoke of the overall increase in the numbers of old people resident in the Council's welfare homes and of the greater infirmity because of the rise in their average age. The number of people designated as chronic sick had also increased, in spite of the active liaison between visiting medical officers and the local geriatric units for the interchange of residents and patients as appropriate. Moreover, it was recognised that it was not humane to transfer an old person who had spent many years in a welfare home to hospital, even if there were sufficient beds available in hospitals in London. Nevertheless, their nursing care created staffing problems; the Public Health department had had some difficulty in recruiting ward sisters to supervise the nursing care and administration of drugs and there was an acute shortage of welfare assistants. The Principal Medical Officer (Tuberculosis) spoke of pulmonary tuberculosis among the elderly, in whom the incidence of the disease had not fallen as had been the case in the age groups under fifty-five years. He emphasised the value and ease of sputum examination and advocated an extension of arrangements for the routine examination of sputum of newlyadmitted residents with a productive cough and of other residents with winter sputum. These arrangements have since been put into effect. There are units for lone women with a new-born baby in two of the large welfare homes, where mothers may be resident for periods up to three months. The size of one of these units has been doubled in the past year. Carisbrooke House is a mother-and-baby home for single girls, who are admitted for six weeks before and six to eight weeks after delivery. Outbreaks of infectious disease have not been a problem in these homes except at the peak periods for confinements during March and April. The Welfare Committee also have a hostel for mothers-in-work with a baby. Mothers are admitted when the baby is six weeks old and may stay until the baby reaches the age of eighteen months. Three welfare assistants have been replaced during the year by nursery nurses appointed by the Public Health department. The sharp increase in the number of homeless families received by the Welfare department necessitated the setting up of further homeless families units within the large homes for old people, in addition to Newington Lodge and Morning Lane reception centre. The Public Health department advised on the adaptation of the accommodation for this purpose and on the steps to be taken to limit the spread of infectious disease, particularly Sonne dysentery and gastro-enteritis due to E. Coli. Many children had subsequently to be taken into care by the Children's Officer and were segregated in special units for short periods until free from infection. Three negative rectal swabs were required for each child, or the period of incubation of disease outlived, before transfer to residential nurseries or children's homes. It was found that 27 per cent. of children under five years of age had developed one or other of the diseases with which they had been in contact compared with only four per cent. among children over that age. It seemed likely in the light of experience that children over five years of age may be received directly into children's homes without undue risk, provided that reasonable observation by trained staff is maintained. Invalid Meals for London The Council for many years made an annual grant under section 28 of the National Health Service Act, 1946 to Invalid Meals for London, a voluntary body providing meals 38 for invalids and sick persons. Meals were supplied to those suffering from diseases which necessitated special diets which the recipients could not provide themselves nor obtain in an ordinary restaurant. In the great majority of cases the recipients of the meals were housebound and meals were delivered to them at their homes (in eighteen boroughs) by a transport fleet of 20 vehicles specially fitted with heated food-conveyors. Invalids living near and able to walk to the kitchens with dining-rooms attached (four out of the five) were served with meals at the restaurants. Towards the end of 1959 the Chairman of the voluntary body informed the Council that he felt unable to continue to be responsible for the work. His Executive Committee had authorised him to ask the Council to take over the service as soon as possible and, pending the completion of the necessary formalities, to make interim arrangements for the continuance of the service. The Council approved in principle the taking over of the service and, to enable the service to be maintained, approved the provision of financial and administrative assistance to Invalid Meals for London. The legal formalities were unexpectedly protracted and it was not until December, 1961 that the service was transferred to the Council. In the meantime, at the request of the metropolitan borough councils, provision had been included in the London County Council (General Powers) Act, 1961, to enable the borough councils to provide an invalid meals service or to make grants to voluntary bodies providing such a service. At the end of the year discussions were taking place with the Metropolitan Boroughs' Standing Joint Committee on the future running of the service. Details of the service provided is shown by the following figures: 1957/8 1958/9 1959/60 1960/1 1961/2 Meals served 174,011 167,134 172,637 180,291 196,695 39 SCIENTIFIC BRANCH The Scientific branch provides an advisory service to all departments of the Council on matters involving chemistry, physics and allied sciences. Similar service is provided, as required, to the metropolitan borough councils. In addition to statutory duties, the branch has important functions relating to health, safety and amenity. It is responsible for giving guidance on the efficient and economical use of material of all types used in the Council's service for construction, maintenance and consumption. The work is carried out in three groups of laboratories by a staff of 73. The headquarters laboratories at the County Hall cover the following main subject headings: (i) Air pollution, environmental radioactivity, ventilation. (ii) Noise and acoustics, fire precautions and investigations, industrial matters. (iii) Building materials and development work, floor maintenance, insecticides and fungicides, plastics, metals. (iv) Paint and decorative materials. (v) Fuel and boiler plant technology, heat insulation materials, drinking water, trade wastes. (vi) Detergents, laundries, swimming baths. (vii) Statutory, food, drugs, medical and general supplies. The Northern and Southern Outfall laboratories, situated at Beckton and Crossness respectively, are concerned with obtaining scientific data for the control of the sewage treatment process and ancillary plant together with research on projects potentially useful to the main drainage service. Samples totalling 63,187 were examined during 1961 in the course of analytical, experimental and research work. This record of samples does not include much of the consultative service given by the senior professional officers, which was not necessarily associated with laboratory work. A summary of the activities of the branch which have a direct or indirect application to the field of public health is given below. Full particulars are given in the annual report of the Scientific Adviser.* River Thames The condition of London's river is of special concern to the Council. In addition to effluents from the Council's own sewage treatment plants, there are sources of pollution from other sewage works, impure tributaries, trade discharges and contamination from shipping. To assess the condition of the water under varying conditions of fresh water and tidal flow, and to compare the state between seasons of the year and over periods of years, regular examinations are made involving chemical analysis of water taken from 26 points over a distance of 80 miles. The area examined extends from the upper limit of the tidal reaches at Teddington to the sludge dumping area at Black Deep in the outer estuary. The results are communicated to the Port of London Authority. The middle and lower reaches of the river showed general improvement when compared with conditions during the previous ten years, although low upland flow due to lack of rain during the late summer of 1961 caused deterioration in the upper reaches of the tidal river for a time. Improvement in the condition of the river off the Northern Outfall Works was attributable to operation of new plant at this works, which includes diffused air activated sludge units. Sewage treatment The treatment of sewage at both outfall works is the joint responsibility of the Chief Engineer and the Medical Officer of Health. Close daily collaboration is maintained between * Annual Report of the Scientific Adviser for the Year 1961, the London County Council, price Is. 3d. 40 our staffs and weekly conferences are held between the Scientific Adviser and the Divisional Engineer (Main Drainage), together with their senior officers, to discuss analytical results, operational practice and research projects. In addition to laboratory work undertaken to obtain the best efficiency from the treatment plant, full attention was given to matters of safety. For example, the utilisation of sludge gas involved daily safety tests at all potentially hazardous points in the digestion plant, power house and domestic boiler room. Trade waste discharges The Council exercises control under the London County Council (General Powers) Act, 1953 over industrial discharges into the London sewerage system. These discharges have increased in volume and complexity over recent years and continuous control is needed to exclude substances which would be hazardous or damage the fabric of the sewers. Detailed laboratory examinations were made on 2,795 samples of trade waste discharges, about one-third of this number being submitted by twelve metropolitan boroughs. In consequence of these examinations, officers of the Scientific branch and of the Chief Engineer's department visited many premises to discuss with the occupiers the problems involved in treating the discharges and to give advice. During the year a working party of the Council and of representatives of the metropolitan boroughs considered what further steps might be necessary to exercise a closer control on trade waste discharges in the county. The results of their deliberations were embodied in the London County Council (General Powers) Bill, 1962. Drinking water To ensure that the water supplies to Council establishments are of satisfactory quality, the Scientific branch carries out regular monthly inspections and samplings at those establishments where supplies are drawn from private wells. The water from these wells is chlorinated before use by means of automatic dosing plant. Samples of both the raw well waters and the treated waters are taken for bacteriological and chemical examination. If pollution is suspected check samples are taken at frequent intervals. At the request of the hospital management committees, the well supplies at some of the hospitals formerly under the control of the Council have continued to be regularly examined. Because of the excellent system of drinking water examination by the Metropolitan Water Board, samples are not examined direct from mains supplies but water from storage tanks is tested in many institutions to check the internal system and to ensure that tanks are periodically cleaned. Air pollution The Council continued its long-standing co-operation with the Department of Scientific and Industrial Research in investigating the incidence of air pollution, by maintaining regular observation of the degree of pollution of the atmosphere over the county. In recent years these measurements have acquired a special significance in reflecting progress in the implementation of the Clean Air Act of 1956. Results obtained by the daily volumetric method indicated a further reduction in the average pollution of the air during the year, as compared with the previous year, to the extent of about seven per cent. in smoke and four per cent. in sulphur dioxide, despite the occurrence in November and December of foggy periods which caused the average pollution during these months to be worse. Except perhaps in local pockets, the concentration of either of the two main pollutants never reached the level which would be regarded as ' smog ' ; the smoke concentrations, in particular, during fog reached little more than half the level which has frequently been exceeded in fogs of the past. 41 Environmental radioactivity For some years the branch has undertaken experimental studies to obtain reference data on environmental levels of ionising radiation and to determine the extent of any additions arising from the numerous applications of nuclear science. Matters dealt with during the year included radiological safety in the Council's dental clinics; the safe use of radio-isotopes and X-ray apparatus in colleges; the safety of the public at exhibitions; advice to the London Fire Brigade in assessing hazards at fires involving radioactive matter. Several applications were made by hospital, industrial and laboratory users of radio-isotopes for the discharge of wastes to the sewers and suitable provisions were made. Swimming baths The Council has under its control 23 outdoor baths, many for public use, and 24 indoor baths situated in schools and institutions. A number of baths are equipped with complete purification plant and all receive some form of chlorination treatment. Regular visits are made to these baths by officers of the branch for inspection and testing; samples are taken for bacteriological and chemical examination. As an example of the efficiency of treatment, the following were the figures obtained from 13 fully equipped public baths during the five months summer season, in which time about 850,000 people used the baths. The minimum measured clarity was 18 feet and the maximum was 160 feet. These baths vary from 100,000 to 1,000,000 gallons capacity and are emptied and refilled with mains water only once a year. Noise and acoustics There was an increase in the amount of work done under this heading, due largely to the growing awareness of the significance of noise in town planning. Measurement of the existing background noise levels was completed at two-thirds of the 500 sites selected for the London Noise Survey, which is being made in collaboration with the Building Research Station of the Department of Scientific and Industrial Research and the Town Planning division of the Architect's department. The Scientific branch made measurements at an additional 80 points to obtain information about sound effects from helicopters. In connection with the Council's extensive road building schemes the noise of fast moving traffic was studied; measurements were made at sites near fly-overs, inclines, roundabouts and junctions, and where shielding has been given by shrubbery. Estimates were made of the alteration in noise level to be expected through road widening. The extent to which traffic noise is attenuated in high buildings was studied. Acoustics measurements were made to test sound insulation methods in blocks of flats and also in connection with the design of ventilating systems for the new concert hall and art gallery to be built on the South Bank. 42 HEALTH SERVICE PREMISES Building programme Programme for 1962-63—As a result of the usual annual review of the five-year building programme, the Council approved a programme for 1962-63 providing for estimated expenditure amounting to £395,780, including acquisition of sites. Details of the schemes in the programme are given in table (i). General Details of works completed during the year, works in hand and works approved but not yet commenced are set out in tables (ii), (iii) and (iv). During the year freehold or leasehold interests in some properties were acquired; details are shown in table (v). Table (i)—Health Service building programme 1962-63 Health Division Premises Works proposed 1 Additional day nursery in North Kensington area. Conversion of standing property if acquired. 2 Sumatra Road welfare centre, Hampstead. Extension to existing building to provide additional facilities. 3 Additional day nursery in South West Islington area. Conversion of standing property if acquired. 3 Cromwell Lodge Hostel for tuberculous men, Hornsey. Annexe for occupational therapy. 4 Shoreditch Health Centre, Shoreditch Improvements to provide additional dental surgery accommodation. 4 Sun Babies day nursery, Shoreditch Improvements to heating and sanitary facilities. 4 Morning Lane, Hackney New elder boys' training centre to replace an unsatisfactory centre. 4 Additional child guidance unit in Hackney area. Conversion of standing property if acquired. 8 Loughborough Estate, Lambeth New maternity and child welfare and school treatment centre to replace unsatisfactory premises. 9 Sisters Avenue day nursery, Battersea Replacement nursery. 9 Additional child guidance unit in Putney/Wandsworth area. Conversion of standing property if acquired. Conversion of two premises for mental health hostels. Premises being sought. — Oval accident ambulance station, Lambeth. Rebuilding to accommodate additional ambulances. South Western general ambulance station, Lambeth. Provision of workshops and extra garage space. South Eastern general ambulance station, Deptford. Improvements to access, service bay and lighting. Russell Square accident ambulance station, Holborn. Adaptation and reconstruction. Table (ii)—Works completed in 1961 Health Division Premises Work involved MATERNITY AND CHILD WELFARE 2 Hallfield Estate, Paddington Provision of maternity and child welfare and school treatment centre in ground floor of housing block (built by Paddington Metropolitan Borough Council). 43 Table (ii)—Works completed in 1961—continued Health Division Premises Work involved DAY NURSERY 1 Ladbroke, Kensington Additional toilets and new heating and hot water systems. 1 Eridge House, Fulham Resurfacing of play space. 3 Scholefield Road, Islington Conversion of boilers to oil firing. MENTAL HEALTH 1 College Park training centre (elder girls), Letchford Gardens, Hammersmith. Adaptation of former maternity and child welfare centre. 4 Hackney training centre, Iceni Sports ground, Hackney. New junior training centre. 9 Clapham training centre, Clapham Manor Street, Wandsworth Adaptation of premises to form an industrial training centre. PREVENTION OF ILLNESS—TUBERCULOSIS 3 Cromwell Lodge hostel for tuberculous men, Hornsey. Provision of new boilers. GENERAL PRACTITIONERS' CENTRE AND CHILD GUIDANCE UNIT 7 South East London General Practitioners' Centre and Peckham Child Guidance unit, St. Mary's Road, Camberwell. Major adaptations to third floor to provide general practitioners' centre and improved accommodation for existing child guidance unit. LONDON AMBULANCE SERVICE - Eastern general ambulance station, Hackney. Improvement and re-allocation of accommodation and improvements to entrance. Table (iii)—Works in hand Health Division Premises Work involved MATERNITY AND CHILD WELFARE 6 Abbey Estate, Woolwich New maternity and child welfare and school treatment centre in housing block to replace temporary welfare centre on L.C.C. estate. 6 Burney Street, Greenwich Provision of maternity and child welfare centre in ground floor of housing block (being built by Greenwich Metropolitan Borough Council). 8 Keeton's Road, St. Crispin's Estate, Bermondsey. Provision of maternity and child welfare and school treatment centre in ground floor of L.C.C. housing block. 9 Plough Road, Battersea Provision of maternity and child welfare and school treatment centre in ground floor of housing block (being built by Battersea Metropolitan Borough Council). MENTAL HEALTH 6 Blackwall Lane, Greenwich Adaptation of existing building as an additional industrial training centre. 9 Putney Hill, Wandsworth Adaptation of premises as a mental health hostel. LONDON AMBULANCE SERVICE — Battersea accident ambulance station, Battersea Replacement of building destroyed by enemy action. 44 Table (iv)—Works approved but not yet commenced at end of 1961 Health Division Premises Work involved MATERNITY AND CHILD WELFARE 3 Barnsbury Estate, Islington New maternity and child welfare and school treatment centre in L.C.C. housing block to replace unsatisfactory premises. 9 Stormont Road, Battersea New maternity and child welfare and school treatment centre to replace unsatisfactory premises. DAY NURSERY 1 St. Quintin, Kensington Extension to existing building to provide additional places. 9 Upper Tulse Hill, Lambeth .. New day nursery in L.C.C. housing block to replace unsatisfactory premises. MENTAL HEALTH 3 Basire Street, Islington New junior training centre. 6 Maze Hill, Greenwich New junior training centre to replace unsatisfactory premises. 7 Brockley Rise, Lewisham New mental health hostel. 8 Draper Street, Southwark New day centre for the mentally ill to be constructed in L.C.C. housing development. Table (v)—Acquisitions and leases completed Health Division Property Interest obtained MATERNITY AND CHILD WELFARE 9 5 Stormont Road, Battersea, S.W.11 Freehold. DAY NURSERY 8 Coral day nursery, Windmill Walk, Lambeth, S.E.1. Indefinite tenancy (from Housing Committee). 9 23, Summerley Street, Wandsworth, S.W.18. Freehold. MENTAL HEALTH 6 33 Blackwall Lane, Greenwich, S.E.10 Freehold. 8 The Grange Tannery, The Grange, Bermondsey, S.E.1. Freehold. PREVENTION OF ILLNESS—INVALID MEALS 3 65 Essex Road, Islington, N.l Freehold. 4 159 Lower Clapton Road, Hackney, E.5 Leasehold. - 124 Churchfield Road, Acton, W.3 Leasehold. LONDON AMBULANCE SERVICE - Auckland Road, Battersea, S.W.ll .. Freehold. South East London General Practitioners' Centre—This centre, which opened early in 1961, provides family doctors in the neighbourhood with facilities, which they do not possess in their own surgeries, for the diagnosis and treatment of conditions not requiring full hospital investigation and treatment. It has an operations room where the general practitioner can perform minor surgery on his own patients, a well-equipped pathological laboratory, X-ray, dark and viewing-rooms and two consulting rooms. Nursing staff 45 carry out treatment on the doctors' instructions and there is co-operation with health visitors and other social workers. A common-room is available where there are books and other information for reference and where conferences, film shows and informal discussions take place. The centre is the first of its kind in the country to provide so wide a service to local general practitioners and has been established by the Council in collaboration with the South East Metropolitan Regional Hospital Board, the Camberwell Hospital Management Committee, the Nuffield Foundation and the Sir Halley Stewart Trust. An account of the first year's working of the centre is given in Appendix D. 46 CARE OF MOTHERS AND YOUNG CHILDREN The main features of the Council's services for care of mothers and young children remained as in previous years. Day-to-day administration of the services is the responsibility of the nine divisional health committees; details are given in the reports of the divisional medical officers. Changes in centres during the year are reported in the section on health service premises. Maternity and child welfare Particulars of sessions and attendances are given in the following table: Table (i)—Clinics for mothers and young children 1957 1958 1959 I960 1961 Ante-natal, post-natal and combined clinics: Number at end of year 118 112 111 109 109 Sessions per month 786 799 797 793 787 Ante-natal: First attendances 23,918 25,673 23,905 25,455 27,560 Total attendances 121,579 134,684 129,731 133,062 140,790 Percentage of pregnant women attending an ante-natal clinic 44 45 42 43 45 Post-natal: Number of women attending during the year 3,887 3,714 3,524 3,369 2,859 Child welfare clinics: Number at end of year 178 179 179 179 178 Sessions per month 1,990 1,991 1,957 2,034 2,057 Attendances under 1 year First 46,387 49,229 49,610 50,202 54,393 Total 613,147 611,057 606,042 578,250 599,930 Attendances over 1 year 183,538 177,283 152,627 163,845 169,023 Attendances at special toddlers clinics (not included in above) 40,848 38,940 38,361 37,533 38,203 Percentage of infants attending a centre at least once in the first year of life 86 88 89 88 90 Family planning—Advice on family planning is provided for married women for whom further pregnancy would be detrimental to health. 1958 1959 1960 1961 Attendances at sessions provided by the Council First 1,011 975 945 899 Total 4,392 4,260 4,337 4,226 Women referred by the Council to Family Planning Association 702 705 741 641 National welfare foods Average weekly issues 1957 1958 1959 1960 1961 National dried milk (tins) 19,839 15,791 15,328 13,817 11,647 Cod-liver oil (bottles) 5,191 3,620 3,469 3,442 2,623 Vitamin tablets (packets) 2,788 2,736 2,775 2,837 2,109 Orange juice (bottles) 48,925 31,360 30,412 28,864 18,514 47 Day accommodation for children Table (ii)—Day nurseries and child minders At 31 December 1957 1958 1959 1960 1961 DAY NURSERIES: Maintained 81 76 75 74 73 Grant-aided 5 5 4 4 4 Total 86 81 79 78 77 Places under 2 1,747 1,690 1,693 1,649 1,623 2-5 2,988 2,631 2,499 2,420 2,394 Total 4,735 4,321 4,192 4,069 4,017 COUNCIL'S CHILD MINDER SCHEME (Voluntary registration): Child minders registered 838 824 875 989 861 Children minded 954 973 1,039 1,187 993 NURSERIES AND CHILD-MINDERS REGULATION ACT, 1948: Private day nurseries registered (including part-time nurseries) 60 59 60 59 69 Places 1,701 1,742 1,620 1,595 1,840 Child minders registered 132 141 167 202 210 No. of children authorised to be minded 699 781 939 1,023 1,088 Occasional creches—These creches provide for the children of mothers attending a clinic or class on the premises and also give occasional relief to mothers who, for various reasons such as visits to hospitals, shopping, laundering and other domestic duties, wish to be relieved of their young children for two or three hours during the day; they also present an opportunity for an only child to associate with other children of similar age. At 31 December a total of 88 sessions a week was being held, providing for 1,610 childattendances weekly. Prevention of break-up of families It was possible during the year to provide caseworkers to undertake the support and intensive care of problem families in two more divisions, leaving only one without such workers. By 31 December nine full time social caseworkers were undertaking this work in the county and thirteen assistant organisers were working with one or two families each. As in previous years, the Council made a grant to Family Service Units in London towards the cost of their work with families in difficulty. The amount of the grant for the financial year 1961/62 (divided equally between the Health and Children's committees) was £12,715. During the year the Council agreed to make an annual grant for three years to the Family Welfare Association as a contribution towards their work with families with problems. The grant for 1961/62 was £1,000. Admission to maternity beds The shortage of maternity beds, especially in North West London, continued to cause anxiety throughout the year and the attention of the Ministry of Health was drawn to a continued increase in the number of women who had to be admitted to hospital in labour through the Emergency Bed Service because they had been unable to book a bed. Discussions on the subject took place with representatives of the Ministry, the North West Metropolitan regional hospital board and the teaching hospitals in the area. The Ministry 48 intimated that there were prospects of additional maternity beds being provided in North West London in the near future. In the meanwhile the Ministry asked the teaching hospitals to reserve 20 per cent. of their beds for emergencies and late-comers and not to book women, other than those needing hospital confinement on medical grounds in accordance with the criteria laid down in the Cranbrook Report, unless the local health authority had advised that there was a need on social grounds for hospital confinement. The Ministry also proposed that for this latter type of case hospitals or groups of hospitals should accept responsibility for all such cases from a defined area, it being left to local maternity liaison committees to agree on the allocation of areas of responsibility and the machinery for booking. A draft plan of catchment areas for the whole county is being drawn up for presentation to local maternity liaison committees. Detection of children suffering from phenylketonuria Following the pilot survey on the practicability of routine testing described by the divisional medical officer for division 3 in his report, arrangements have been made throughout the county for mass screening tests of babies to detect phenylketonuria, a rare inborn metabolic disorder which can give rise to mental defects. In addition more extensive tests will be made of children thought to be at special risk. Young children handicapped by impaired hearing In recent years certain factors which may arise during pregnancy, labour and early childhood have become recognised as potentially dangerous sources of deafness. In view of the vital importance of early detection, an index of children subject to a risk of deafness is kept in each of the nine divisional health offices. Arrangements have been made for hearing tests to be carried out in the maternity and child welfare service and for all new entrants to school to receive an audiometer test. General practitioners and hospitals have been asked to bring to the notice of the Council any children considered to be at risk. In September a joint circular on 'Young children handicapped by impaired hearing' was issued by the Ministry of Health (Circular 23/61) and the Ministry of Education (Circular 14/61). The services provided by the Council were already on the lines recommended in the circular and therefore discussions with metropolitan regional hospital boards and teaching hospitals were on the question of future planning in this field. Arrangements were in hand at the end of the year for consultation with the London local medical committee and the hospital authorities on the early ascertainment and follow-up of young children at risk of deafness. Mental health education In further development of the arrangements made for intensive training of medical officers and health visitors in mental health education, six additional case conference groups were set up for medical and nursing staff of the child welfare centres to receive training and guidance from psychiatrists and other professional workers attached to child guidance clinics. The co-operation of the hospital authorities in these groups has been a very great help. The aim is gradually to bring all child welfare medical officers and health visitors into the groups and to develop the case conference groups into a permanent consultative service under the leadership of the psychiatrist from the local child guidance unit. Residential establishments for young children Private residential establishments and those under the management of the Children's Committee are visited regularly by the Council's medical officers, who advise on hygiene and child health. A register is maintained of physically and mentally handicapped children and is reviewed periodically by a senior medical officer so that a handicapped child's special needs for medical or educational treatment can be anticipated. 49 D Adoption and boarding out Children in care who are being considered by the Children's Committee for adoption or boarding out are given a full examination by a general medical practitioner. These medical reports are scrutinised by a medical officer of the Public Health department. Should these reports reveal a medical defect or handicap in the child, or a history of inheritable illness in the natural parents, the Children's Officer is advised whether the child is medically fit for adoption or boarding out. In some cases, before the Children's Officer is given this advice, the prospective adopters are interviewed by the medical officer and an explanation is given of the implications of the child's defect or illness, or the probability of inheritance of disease from his parents. A report may be sent in some cases to the prospective adopters' family doctor. The number of children referred by the Children's Officer is shown below: 1957 1958 1959 1960 1961 1. Adoption cases: Suitable for adoption 178 167 228 267 257 Suitable for adoption subject to certain conditions .. 8 2 1 2 32 Unsuitable for adoption but suitable for boarding out 7 17 5 21 13 Withdrawn by Children's Officer 8 3 2 1 9 Under consideration at 31 December 4 1 2 5 4 205 190 238 296 315 2. Boarding out cases: Suitable for boarding out 310 320 290 447 438 Withdrawn by Children's Officer 7 3 3 6 5 Under consideration at 31 December 5 1 3 7 7 322 324 296 460 450 3. Unsuitable for either adoption or boarding out .. 3 3 1 — 1 TOTAL 530 517 535 756 765 Care of the unmarried mother and her child Moral welfare associations—Financial assistance is given to the five large moral welfare associations of the major religious denominations (London Diocesan Council, Southwark Diocesan Association, Westminster Catholic Social Welfare Committee (Crusade of Rescue), Southwark Catholic Rescue Society, Jewish Board of Guardians). 1957 1958 1959 1960 1961 Total grants £9,625 £12,531 £13,555 £12,800 £13,250 Number of expectant and nursing mothers advised.. 2,684 2,975 3,005 3,292 3,288 Nationality of mothers by normal residence London (Administrative County) Elsewhere Total British (United Kingdom) 1,306 532 1,838 Eire 434 357 791 West Indian 260 177 437 European 92 57 149 Other 36 37 73 2,128 1,160* 3,288 *991 were pregnant on arrival in London. Nearly one quarter of the total cases helped by the associations are girls from Eire. 50 Mother and baby homes—Voluntary organisations provide most of the mother and baby homes in London, supported by grants in aid from the Council under the National Health Service Act, 1946. One mother and baby home is maintained by the Welfare department together with two other units within their larger homes. 1957 1958 1959 1960 1961 Total grants £11,360 £10,476 £10,237 £8,865 £9,998 Number of voluntary homes receiving grant at 31 December 17 16 15 15 15 Number of expectant and nursing mothers admitted 1,141 1,191 1,072 1,136 1,171 A marked upward trend in the percentage of illegitimate births in London over the last five years has been commented on in this report (see page 7). There has also been an increase in the number of illegitimate pregnancies among girls under school-leaving age and girls still receiving full-time education. Although this increase must cause concern, it should be kept in perspective. The overall number of pregnancies in girls 13 and 14 years of age for England and Wales is not a large one (111 in 1960, the latest available figure) but the care of these young mothers presents special problems. I reported last year that, following a conference of departments and voluntary bodies concerned, it was arranged for a mother and baby home in South London administered by the Church Army to be made available for the sole use of young expectant mothers in receipt of full-time education, who would be referred by the Children's Officer. The home was opened on 1 April, 1961. A grant was made by the Health Committee for the adaptation of a room for use as a schoolroom and a full-time teacher was provided by the Education Committee. A special per capita maintenance rate was agreed by the Children's department, which maintains close co-operation with the staff of the home. An obstetrician in the maternity unit of a local hospital has undertaken the full maternity care of the girls admitted to this home and they are all admitted to the hospital for delivery. During the year 24 girls under 16 years of age were admitted to the home, one of whom left before the baby was born. The majority had entered the home at about the fourth month of pregnancy. Twelve babies were born during the year, of which five were taken into care and five went for adoption; one mother kept her baby and one baby was still in the home in 1962. Although the stay in the home can be prolonged post-natally, in practice most mothers have left at six to eight weeks after delivery. It is, perhaps, too soon to assess, in all its aspects, the value of this experiment in the care of young unmarried mothers having full-time school education in a home designed to meet their needs. Undoubtedly various modifications of the initial arrangements will be made in the light of experience, but a review of the work achieved in the first eight months is most encouraging. Child protection The visiting of foster children under the Children Act, 1958, and the inspection of the premises in which these children are living is undertaken for the Children's Officer by health visitors, who are designated as ' child protection visitors'. During 1960 the Children's Officer assumed direct control of the work in health divisions 5 and 8; in 1961 he assumed control additionally in health division 2. In the remaining divisions the number of children supervised by child protection visitors on 31 March, 1961 was 487. The Health Committee assumed the powers formerly exercised by the Public Control Committee in respect of sec. 11 of the Children and Young Persons Act, 1933, relating to the death or serious injury of children under the age of 12 years involving an insufficiently protected fire or heating appliance. Responsibility will be exercised by divisional health committees and divisional medical officers within the scope of the department's child welfare functions. Marriage guidance Grants totalling £6,900 for the year ending 31 March, 1962 were made to the London Marriage Guidance Council, the Catholic Marriage Advisory Council and the Family Discussion Bureau. 51 D* DOMICILIARY MIDWIFERY The duty to provide adequate domiciliary midwifery service is discharged through the Council's own midwives and those employed by district nursing associations and hospitals. Table (i)—Staff District midwives employed by 1957 1958 1959 1960 1961 The Council 87 87 89 94 94 District Nursing Associations (including supervisory staff) 44 48 45 46 43 Hospitals 39 40 46 43 40 170 175 180 183 177 Table (ii)—Domiciliary confinements attended 1957 1958 1959 1960 1961 Doctor present Doctor not present Doctor present Doctor not present Doctor present Doctor not present Doctor present Doctor not present Doctor present Doctor not present (a) Doctor not booked L.C.C. 172 3,325 201 2,899 232 2,761 178 2,197 83 1,069 D.N.A. 68 1,624 75 1,577 58 1,360 47 1,193 39 716 Hospital district 29 1,711 23 1,693 41 1,574 — — — — 269 6,660 299 6,169 331 5,695 225 3,390 122 1,785 6,929 6,468 6,026 3,615 1,907 (b) Doctor booked L.C.C. 996 1,548 1,135 1,966 1,340 2,405 1,563 2,848 2,237 3,759 D.N.A. 152 294 182 389 194 505 280 692 339 1,010 Hospital district 68 196 144 225 132 313 202 1,745 302 1,666 1,216 2,038 1,461 2,580 1,666 3,223 2,045 5,285 2,878 6,435 3,254 4,041 4,889 7,330 9,313 10,183 10,509 10,915 10,945 11,220 All hospital district cases are now shown as 'doctor booked', because all such cases are ante-natally under the direct care of a hospital doctor and medical aid during labour and the puerperium is available to them on call to the hospital. The difference in recording only partially accounts for the marked increase in the number of home confinements in which a doctor was booked for maternity medical services. The total increase was from 4,889 (45 per cent.) in 1959 to 9,313 (83 per cent.) in 1961, while the corresponding figures for 1956 were 2,722 (27 per cent.). Taking only those cases attended by London County Council and District Nursing Association midwives, the increase was from 4,444 (51 per cent.) in 1959 to 7,346 (79 per cent.) in 1961. Table (iii) 1957 1958 1959 1960 1961 Premature babies: Number 501 482 555 517 525 Per cent. of live births 5 0 4.6 51 4.7 4.7 Stillbirths: Number 87 89 100 79 85 Per 1,000 total births 8.5 8.4 9.2 7.2 7.6 The corresponding rates for domiciliary confinements for England and Wales in the year 1960 (the latest available) were for prematurity, 4.1 per cent., and for stillbirths, 8.7 per 1,000 total births. 52 Particulars of domiciliary premature live births are set out below. The difference between the total (559) shown in this table and the number (525) quoted above represents the number of cases attended by doctors and midwives independently of the Council's domiciliary midwifery service. Table (iv) Weight Number Proportion per 100 live premature infants Deaths in 24 hours Survivors at 28 days Number Per 100 live premature infants Number Per 100 live premature infants 3 lb. 4 oz. or less 33 5.9 14 42.4 13 39.4 3 lb. 5 oz. to 4 lb. 6 oz. 68 12.2 4 5.9 62 91.2 4 lb. 7 oz. to 4 lb. 15 oz. 84 15.0 1 1.2 80 95.2 5 lb. to 5 lb. 8 oz. 374 66.9 4 1.1 368 98.4 All cases 559 100 23 4.1 523 93.6 These figures, especially those relating to infants surviving at 28 days, compare favourably with those for all live premature infants born in the administrative county during 1961, (see table (ix), page 11). Table (v)—Inhalation analgesia administered 1957 1958 1959 1960 1961 % % % % / % Gas and air 351 87 17 88 9 87 8 86 7 84 Trilene 52/ 71 78 78 77 Each of the Council's midwives had been equipped with a portable trilene inhaler by the end of 1957. A marked reduction has resulted in the use of the more cumbersome gas and air apparatus which, nevertheless, is still delivered by the London Ambulance Service on a midwife's request for use when in her, or a doctor's, clinical judgment it is required. Midwives Act, 1951 Notifications received of intention to practise: 1957 1958 1959 1960 1961 As midwives 1,193 1,160 1,285 1,404 1,447 As maternity nurses .. 137 121 110 25 — As a result of amendments to the Rules of the Central Midwives Board, which became effective on 1 July 1960, the distinction between practising as a midwife and acting as a maternity nurse has been removed. In the past a midwife who acted only as a maternity nurse was required to notify her intention to practise as a maternity nurse but was not required to attend compulsory refresher courses. The meaning of the term ' practising midwife ' has been altered to include the former maternity nurse and, as a consequence of this change in definition, any midwife who wishes to attend maternity cases must notify her intention to practise as a midwife and attend compulsory refresher courses required by the Central Midwives Board. In accordance with section G of Rules of the Central Midwives Board, 149 midwives in the county attended a refresher course during the year. Fees to medical practitioners called in by midwives in emergency: 1957 1958 1959 1960 1961 Number of claims 2,479 2,626 2,653 2,350 2,603 53 HEALTH VISITING Home visits 1957 1958 1959 I960 1961 Expectant mothers: First 23,482 24,131 22,940 24,013 26,531 Revisit 21,994 23,213 23,161 22,546 23,934 Percentage of notified live and still-births. 43 42 40 41 43 Stillbirths 1,080 979 960 1,024 849 Children under 1: First 52,171 53,557 53,224 55,226 60,995 Revisit 169,760 176,428 173,932 168,669 172,964 Percentage of notified live births 98 96 95 96 101 Children 1-5 354,643 368,845 372,622 369,122 379,793 Care of old people 12,465 13,331 14,366 14,350 14,772 Miscellaneous 74,513 80,978 80,948 80,026 86,971 Unsuccessful 100,250 100,648 101,503 104,014 111,958 TOTAL 810,358 842,110 843,656 838,990 878,767 * The true percentage may be somewhat less, but it is not practicable to exclude from the year's figures a small number of immigrants and of children visited in the year but born in the previous year. 54 HOME NURSING (A special article, Appendix B, reviews the home nursing service in London since 1931.) Details of the work done by the 25 voluntary grant-aided district nursing associations who acted as agents for the Council are given below: Table (i)—Staff (numbers employed at 31 December)* 1957 1958 1959 1960 1961 State registered nurses 533 506 512 517 495 State enrolled assistant nurses 30 33 34 34 35 Total number of nurses employed 563 539 546 551 530 Male nurses (included above) 41 41 39 39 38 Full-time equivalent of nurses employed 522 496 507 508 492 Students 52 65 78 27 64 Male students (included above) 4 6 6 — 2 * Exclusive of supervisory staff. Table (ii)—Types of case nursed and visits paid Type of case Number of patients nursed Percentage total Average number of visits to each patient Total visits Medical 39,756 81.0 32 1,281,293 Surgical 5,434 11.1 41 221,543 Infectious diseases 220 0.4 12 2,536 Tuberculous 997 2.0 51 51,000 Maternal complications 1,396 2.8 6 8,547 Others 1,334 2.7 28 36,941 49,137 1000 33 1,601,860 The total visits for 1959 and 1960 were 1,763,296 and 1,690,084 respectively. Table (iii)—Types of treatment and location Visits for At patient's home Elsewhere (e.g., Nurses' Homes) Percentage of total visits Injections only 546,959 26,383 36 Injections plus other treatment 89,358 2,538 6 Other treatment only 930,413 6,209 58 1,566,730 35,130 100 The proportion of visits for 'injection only' fell during the year by two per cent. compared with reductions in the previous three years of four, five, and three per cent. respectively. Over the four year period there has been a fall of 14 per cent. Table (iv)—Long-term cases {i.e., those visited more than 24 times during year) Number Percentage of total patients nursed 10,236 20.8 The percentage of long-term cases shows an increase of two per cent. on the previous year. 55 Table (v)—Age distribution of patients Age No. of patients Percentage of total 0-5 years 2,236 5 5-64 years 19,256 39 65 years and over 27,645 56 49,137 100 There were fewer patients than in 1960 (51,325) and the proportion of patients 65 years and over increased by two per cent. Table (vi)—Nursing treatments and case load 1957 1958 1959 1960 1961 Number of completed treatments 56,395 53,359 49,299 43,118 41,010 Number of patients being nursed at end of year 13,749 12,099 11,352 11,118 10,898 Average case load per equivalent whole-time effective* nurse at end of year 27 24 23 24 22 *Allowing for holidays and sickness. 56 HOME HELP Statistics of the service provided during the last five years are shown in the following table. 1957 1958 1959 1960 1961 Cases assisted* 35,737 34,600 36,056 38,031 38,546 Applications deferred or refused because home helps were not available 25 25 13 23 18 Hours worked 4,896,000 4,651,500 4,919,200 5, 129,000 5,069,064 Home helps employed at end of year 3,388 3,529 3,706 3,830 3,896 Equivalent of whole-time stafff 2,116 2,033 2,150 2,242 2,164 Night helps for chronic sick patients‡ Applications met 44 55 40 28 17 No. of new families assisted! Child help (resident) 4 6 20 8 24 Early morning and evening help 153 197 200 244 257 Special help (problem families) 110 116 112 * 1957, number of times assistance given ;from 1958, number of households assisted. †From 1958 excludes staff on annual and sick leave. ‡These are included in total cases assisted. In the scheme for free home help service to women suffering from toxaemia of pregnancy, assistance was given to 107 cases, amounting to 6,977 hours of service. 57 IMMUNISATION AND VACCINATION During 1961 more children received a primary course of immunisation against diphtheria, pertussis and tetanus than in any year since the National Health Service came into being. These good results were offset to some extent by a decline in the number receiving a primary course of poliomyelitis vaccine caused, at least in part, by the shortage of vaccine supplies during the year. The number of infants vaccinated against smallpox in 1961 rose somewhat from the total of the previous year, although the figure was lower than the record level of 1959. The reasons for the decline in smallpox vaccination during the last two years are still somewhat obscure; a slight and temporary decline was to be expected when the new schedule of immunisations was introduced, but thereafter one might have expected a rise to a level substantially higher than ever before. The reasons for this continued unpopularity of smallpox vaccination require further study. The personal record card introduced in 1959 continues to be popular with both parents and staff. During reprinting the opportunity was taken to incorporate a section in which allergies and other personal idiosyncrasies can be noted for the benefit of those carrying out further inoculations. Space is also provided for a record of active and passive immunisation against tetanus alone. A separate sterile syringe and needle are provided for each injection. The arrangements for sterilization remained unchanged during the year. Diphtheria, tetanus, whooping cough— Table (i) 1957 1958 1959 1960 1961 Diphtheria immunisation: Primary course— Born in same year 8,281 10,644 14,102 20,203 20,990 Born in previous four years 28,687 23,301 26,125 28,980 32,276 Total under 5 36,968 33,945 40,227 49,183 53,266 Age 5-14 5,856 4,742 5,022 7,648 14,490 Reinforcing doses 39,268 38,725 33,237 40,511 87,758 Immunity Index 1-4 years 70.4 69.9 70.6 74.1 82.2 Tetanus immunisation .. 12,705 15,092 32,531 48,605 60,298 Whooping cough vaccination 35,648 34,133 38,917 48,539 54,064 The number of children referred to in table (i) who received multiple antigens is as follows: Table (ii) 1957 1958 1959 1960 1961 Diphtheria/whooping cough 19,464 7,623 4,925 1,536 722 Diphtheria/whooping cough/tetanus 12,405 15,092 32,382 46,650 52,927 Diphtheria/tetanus — — 42 1,734 5,860 The number of reinforcing doses of diphtheria toxoid given to children during the year was very much higher than during any recent year. This was the result of a deliberate attempt to improve the level of recent diphtheria immunisation in the children of primary school age following outbreaks of carrier infection in certain schools. The number of recall doses of diphtheria toxoid given to children at the age of 15-18 months is well below the level that is desirable. To some extent this has been due to the fact that this activity is timed to take place at about the same time as the third dose of Salk poliomyelitis vaccine, which had to be curtailed during the year because of shortage of vaccine. It is to be hoped that the number of doses of diphtheria toxoid (in the form of the triple prophylactic) given at this stage will increase in the current year, so that a sufficient level of protection against diphtheria can be carried over until the age of school entry. 58 Smallpox— Table (iii) 1957 1958 1959 I960 1961 Number vaccinated under 1 year 29,677 30,865 30,489 23,057 30,482 Percentage of live births 56 55 55 40 51 The fact that infant vaccination, in spite of a rise on the previous year, remains at a lower level than in 1959 has already been mentioned. The acceptance rate for infant vaccination is about 51 per cent. This level is about twice that of 1949 and present levels have been attained by a fairly steady improvement since compulsion was abolished by the National Health Service Act. In spite of this improvement, the acceptance rate for smallpox vaccination remains substantially lower than that for diphtheria and whooping cough immunisation. The reason for this must be found and steps taken to remedy it. Although the situation is much more favourable than it was ten years ago one must view with some concern the fact that half our children are growing up without being vaccinated. One of the disadvantages of such a situation was shown very clearly in the early weeks of 1962, when, as a result of importation of smallpox into the country, there was a huge public demand for vaccination. This resulted in large numbers of persons being vaccinated for the first time in adolescence and adult life, when the complications of primary vaccination are relatively common. Had they been vaccinated in infancy, their re-vaccination could have been carried out during the smallpox epidemic without discomfort or danger. One child, aged three years, developed generalised vaccinia six days after successful primary vaccination. The eruption developed at the sites of quiescent lichenified eczema and the child made a good recovery. A child who was vaccinated at the age of five months became ill seven days later. At the time of admission to hospital four days later there was a typical primary response, but the child was severely ill with signs of encephalitis from which he died within 24 hours of admission. At the post-mortem examination the diagnosis of encephalitis was confirmed. Poliomyelitis—The number of persons who have received protection against poliomyelitis is as follows: Table (iv) Number of persons who have received Two injections A third injection (cumulative total) A fourth injection Cage 5-14 years) In 1961 Since the commencement of the scheme Born in: 1957-61 48,164 618,501 463,518 1943-56 22,741 1933-42: Londoners 24,150 226,841 174,614 Others 2,150 58,887 47,395 1932 or earlier (under 40): Londoners 39,083 112,594 70,200 Others 4,929 21,067 15,827 Other priority groups (over 40) 2,306 24,324 14,146 TOTALS 143,523 1,062,214 785,700 98,809 Given by general practitioners and hospital doctors and included in the total above 52,940 288,963 218,430 16,199 59 Plans for poliomyelitis vaccination had to be curtailed during the latter part of the year because of the national shortage of Salk vaccine. During the year a fourth injection was given to a large number of children between the ages of five and 14 who had previously received the course of three injections of the Salk vaccine. The routine administration of the primary course of three injections to infants continued. There is an interval of at least seven months between the second and third injections and it is a matter for some concern that about a quarter of those receiving the first two doses do not return for the third. Figures given elsewhere in this report show that the additional immunity arising from the third or fourth doses is very considerable. Towards the end of the year thoughts turned to the possible use of the Sabin live poliomyelitis vaccine, which consists of attenuated strains of the three antigenic types of poliomyelitis vaccine and is given by mouth. It is known to be effective in giving a good antibody response. It has the advantage of not requiring injections. If given on a community basis to a high proportion of those under the age of 15 years, it not only provides individual protection but also stops the circulation of the virus in the community and thus reduces the risk of infection to the unvaccinated as well as the vaccinated. A decision was made to begin the routine use of the Sabin vaccine in the Council's clinics early in 1962. It is regrettable that the Ministry of Health has so far limited its use to those in the priority groups who have not received a full course of Salk vaccine. Its use as a measure of community protection is thus not possible. A new quadruple prophylactic is now being produced in this country, in which inactivated poliomyelitis vaccine is incorporated into the triple (diphtheria/tetanus/pertussis) prophylactic. Hitherto such an idea was not very attractive because it was known that early in life, when one would wish to give the triple prophylactic in order to protect against whooping cough, the response to poliomyelitis vaccine, particularly to Type I, is diminished. The new quadruple prophylactic has a fortified Type I poliomyelitis component in the hope that this difficulty will be overcome and its use will be studied with interest. Yellow fever vaccination—At the invitation of the Ministry of Health a yellow fever vaccination service is provided. This is operated by arrangement with the authorities of the centres mentioned below, who give vaccination and issue the appropriate international certificates. No charge is made to the public for this service. The numbers of persons vaccinated were: 1961 1960 Clinic No. 1. (Hospital for Tropical Diseases) 9,297 10,571 (Shipping Federation Clinic, King George V Dock) 2,762 809 Clinic No. 2. (Unilever House) 1,173 1,249 Clinic No. 3. (West London Centre) 3,682 4,031 16,914 16,660 60 LONDON AMBULANCE SERVICE The tables below show some aspects of the work of this Service and of its agency and supplementary services in 1961. Table (i) indicates that the number of emergency calls dealt with by the accident section, 4,738 more than in 1960, continue to increase; that 25,370 fewer patients were carried by the general section and 7,005 fewer by the agency and supplementary services. The decrease in the total number of patients carried is only two and a half per cent, or, on average, less than one patient per hospital per day. The total number of general section patients conveyed includes a number travelling long distances who complete the major part of their journey by rail. In 1961 this Service conveyed about 25,000 such patients to and from London railway termini. Most of these patients were conveyed at the request of other authorities; only 6,427 patients travelled under arrangements originated by this Service. Table (i)—Work performed by the directly provided service and by the agency and supplementary services, including both general and accident section work 1957 1958 1959 1960 1961 Patients: Accident Section 91,801 94,079 99,834 103,497 108,235 General Section 911,303 991,263 1,009,128 1,033,909 1,008,539 Total—directly provided service 1,003,104 1,085,342 1,108,962 1,137,406 1,116,774 Joint Committee 25,090 24,382 26,582 32,593 31,701 Hospital Car Service 201,436 201,161 193,523 189,337 183,231 West Ham C.b.C. 499 409 496 338 331 Total—agency and supplementary services 227,025 225,952 220,601 222,268 215,263 Total patients 1,230,129 1,311,294 1,329,563 1,359,674 1,332,037 Journeys: Accident Section 97,535 99,188 104,983 109,551 114,953 General Section 457,976 482,863 488,336 488,422 480,978 Total—directly provided service 555,511 582,051 593,319 597,973 595,931 Joint Committee 11,745 9,710 10,250 10,877 10,858 Hospital Car Service 71,556 70,724 69,672 58,441 61,294 West Ham C.B.C. 494 403 489 335 329 Total—agency and supplementary services 83,795 80,837 80,411 69,653 72,481 Total journeys 639,306 662,888 673,730 667,626 668,412 Mileage: Accident Section 485,431 495,913 524,009 556,390 605,904 General Section 3,687,353 3,982,374 3,980,327 3,960,964 3,928,746 Total—directly provided service 4,173,784 4,478,287 4,504,336 4,517,354 4,534,650 Joint Committee 430,373 394,145 411,823 441,468 435,851 Hospital Car Service 1,292,177 1,224,817 1,212,580 1,207,439 1,191,201 West Ham C.B.C. 5,052 4,953 5,121 4,061 3,850 Total—agency and supplementary services 1,727,602 1,623,915 1,629,524 1,652,968 1,630,902 Total mileage 5,900,386 6,102,202 6,133,860 6,170,322 6,165,552 61 LONDON AMBULANCE SERVICE, 1947-61 GENERAL SECTION, INCLUDING AGENCY AND SUPPLEMENTARY SERVICES 62 Perhaps the most important influence on the work of the Service resulted from a conference of representatives of members and staff of the Council, the four Metropolitan Regional Hospital Boards, the London Executive Council and the Teaching Hospitals Association. Meetings at hospital group level followed so that, with the close co-operation of hospital transport officers and of specially appointed uniformed visiting officers, there might be a more economic movement of ambulances and some reduction in the calls upon the Service. While it is gratifying to note that these co-operative efforts have met with some success in controlling the demand for ambulance transport, there is no reason to expect a general decline in the volume of work falling upon the Service. Indeed, the continuing development of out-patient treatment and of day hospitals and geriatric units, the increasing age of the population and the quickening turnover of hospital beds are all likely to result in the need for more and more ambulance transport. Table (ii)—General section 1957 1958 1959 1960 1961 Average mileage per patient 4.04 4.02 3.94 3.83 3.89 Average mileage per journey 8.05 8.25 8.15 8.11 8.17 Patients carried per 100 journeys 198 205 207 212 210 Table (iii)—Accident section Year Number of calls received Ambulance not required Average time to incident (in minutes) Average time from incident to hospital (in minutes) 1957 97,535 7,213 6.4 6.0 1958 99,188 7,746 6.5 5.7 1959 104,983 8,640 6.6 6.2 1960 109,551 9,644 6.8 6.4 1961 114,935 10,350 7.0 6.2 notes—1. These numbers include some urgent parturition cases and patients removed by general section ambulances when passing the scene of an accident. 2. Some accident calls are answered by vehicles from general stations, usually when an ambulance from the nearest accident station is not available. Table (iv)—Accident section—Source of calls 1957 1958 1959 1960 1961 Public and L.C.C. staff 66,039 68,134 72,793 76,705 81,755 Police 15,546 15,468 16,430 16,505 16,753 Midwives* 1,564 714 420 326 339 Doctors 6,781 6,815 7,092 7,522 7,964 Hospitals 1,917 2,032 2,021 2,186 2,045 Railway officials 2,775 3,030 2,931 2,896 2,868 Local callst 892 870 923 893 788 London Fire Brigade 841 928 1,067 1,055 789 Out county 1,180 1,206 1,306 1,463 1,634 Total calls 97,535 99,188 104,983 109,551 114,935 * Fewer calls for gas-and-air analgesia apparatus because of the introduction of trilene apparatus which is portable by midwives. †Made personally at ambulance stations. 63 Vehicles—By the end of the year 136 of the new type Austin ambulances were in service in replacement of Daimlers. Many modifications and improvements to the original prototype were carried out and research continued into the possibility of further improvement. The vehicle strength at 31.12.61 was: Large ambulances 249 Single stretcher, sitting case ambulances 62 Sitting case cars 30* Ambulance coaches 6 Mobile control unit for major accidents 1 Tenders 2 350 * Including four cars for the use of visiting officers. Staff—The service is under the supervision of an Officer-in-Charge and is staffed by 28 administrative and clerical staff, 77 ambulance control clerks and 859 uniformed supervisory and operative staff. Recruitment improved during 1961 and 185 new entrants successfully completed the three weeks induction course at the London Ambulance Service training school. However, wastage remained high and resulted in a deficiency of 40 ambulance driver/attendants at the end of the year. Award of resuscitation certificates—Three drivers were awarded the Royal Humane Society's resuscitation certificate during the year. First aid and diagnosis competition—An international competition, organised by the Casualties Union, was won by the London Ambulance Service team. The competition was in two parts, a first aid test and a diagnosis test; two cups, the Buxton International Trophy and the Dawson Cup, were awarded. Safe driving—66 per cent. of the 779 drivers who entered the National Safe Driving Competition held by the Royal Society for the Prevention of Accidents in 1960 gained awards, 20 per cent. were disqualified and 14 per cent. were accounted for by resignations and by exemption owing to prolonged sickness. Civil Defence In the course of the year the strength of the Ambulance and First Aid Section increased from 1,678 to 1,895—539 persons were enrolled but 322 persons resigned. The following courses were held during 1961: New entrants 6 First aid 3 Ambulance section—part 1 9 Ambulance section—part 2 8 Driving and maintenance 12 Officer selection 6 First aid practical revision 4 After a total of 991 hours' instruction by the British School of Motoring 34 volunteers passed the Ministry of Transport driving test. A total of 2,726 hours' driving practice on various types of ambulance was put in by volunteers holding driving licences and 222 tests were passed on such vehicles. Volunteers visit the Council's accident ambulance stations to see casualty work at first hand and the number of such attendances in 1961 was 544, covering 1,088 hours. Members of the Section took part in a number of exercises and displays: in addition, an internal competition between teams of the Ambulance and First Aid Section of the County of London Division proved of great value. 64 PREVENTION OF ILLNESS: CARE AND AFTER-CARE Chiropody A detailed account of the growth of this service was given in my report for 1960 (pages 78-82). The following tables show the attendances at the Council's foot clinics since 1957, with an analysis according to age groups for the last four years: New cases and attendances Year New cases Attendances Staff at the end of the year (in terms of whole units) 1957 8,149 166,987 44.2 1958 6,994 172,005 44.2 1959 7,074 169,847 46.2 1960 9,405 186,735 57.7 1961 10,379 196,788 55.6 Analysis in age groups of treatment given at clinics Group 1958 1959 1960 1961 Children 0-4 years 100 137 129 117 5-14 years 6,381 6,390 7,062 6,599 Males 15-64 years 14,805 14,442 14,766 14,076 65 years and over 15,435 15,410 17,613 19,675 Females 15-59 years 59,217 56,581 57,980 55,237 60 years and over 76,067 76,887 89,185 101,084 Total 172,005 169,847 186,735 196,788 Recuperative holidays Admissions to recuperative holiday homes 1957 1958 1959 1960 1961 Expectant and nursing mothers . 138 111 123 109 95 Other adults 2,510 2,289 2,457 2,175 2,183 Children under 5 not at school . 660 575 571 512 479 School and nursery school children 2,852 2,507 2,597 2,357 2,138 6,160 5,482 5,748 5,153 4,895 The Council maintains a recuperative holiday home at Littlehampton, Sussex, for 36 children from 3 to 8 years of age and leases another home at Bognor Regis, Sussex, for 44 children from 8 to 15 years old. Children who could not be accommodated in these homes, and all adults, have been placed in homes under private ownership or maintained by voluntary organisations. 65 B Venereal disease Treatment of venereal disease at London out-patient clinics Year New cases Total attendances Syphilis 5. Chancre Gonorrhoea Total venereal cases Total non-venereal cases M. F. M. F. M. F. M. F. M. F. M. F. 1952 811 490 91 3 5,625 1,176 6,527 1,669 16,920 5,632 220,871 100,420 1953 720 401 88 4 6,103 1,546 6,911 1,951 17,615 6,121 220,316 102,365 1954 651 340 64 2 5,816 1,422 6,531 1,764 17,875 6,304 219,258 100,554 1955 625 400 77 6 5,916 1,457 6,618 1.863 18,735 7,056 221,381 103,815 1956 691 493 72 4 7,468 1,718 8,231 2,215 19,802 7,468 222,695 101,034 1957 701 562 78 2 8,943 2,003 9,722 2,567 20,554 8,102 223,821 97,149 1958 733 490 66 3 10,619 2,307 11,418 2,800 21,906 8,857 215,934 89,407 1959 799 493 93 — 11,722 2,599 12,614 3,092 24,013 9,179 229,368 88,232 1960 908 410 68 2 13,077 2,905 14,053 3,317 26,494 10,647 240,303 96,113 1961 1,067 563 47 — 13,573 2,906 14,687 3,469 28,081 11,824 253,806 93,398 1957 1958 1959 1960 1961 Percentage of patients resident in County of London 81 82 83 81 83 Number of patients completing treatment and of defaulters— Syphilis—patients completing treatment— Males 828 631 579 526 572 Females 627 554 508 434 362 patients not completing treatment— Males 675 870 672 677 776 Females 294 292 336 431 390 Gonorrhoea—patients completing treatment— Males 4,938 5,237 4,941 5,700 7,800 Females 985 1,165 1,199 1,334 1,269 patients not completing treatment— Males 3,501 4,128 4,900 6,536 8,085 Females 900 1,161 1,312 1,485 1,550 Tracing of contacts of patients— Analysis of work undertaken by Council's welfare officers 1957 1958 1959 1960 1961 Contacts referred by hospitals, medical services of the Armed Forces and by local health authorities 384 297 246 282 188 Insufficient information for following-up 276 191 102 91 33 Contacts brought to treatment 27 43 57 72 67 Contacts traced but not brought to treatment 14 3 7 13 15 Contacts not traced 67 60 80 106 73 In addition the female welfare officers attended clinics at St. Paul's, St. Mary's, St. Thomas' and London hospitals and at H.M. Prison, Holloway and followed-up persons defaulting in attendance at these clinics. Health education During the year the Council was invited to submit evidence to a Joint Committee of the English and Scottish Health Service Councils (the Cohen Committee). This committee was set up to consider fresh fields for health education, having regard to recent developments in medicine; how far it is possible to assess the results of health education in the 66 past and what methods are likely to be most effective in future. As the Council's evidence was in the nature of a review of the department's activities in this field in recent years, the substance of the statement is reproduced here, with the addition of statistics for 1961, in place of the more usual limited annual review. As both a local health and education authority, the Council aims to provide a comprehensive educational programme in physical and mental health. It has been active in some degree in the field of health education since the inception of the school health service in 1905. What is health education—Health education may be defined as attempting to: (a) teach some of the underlying facts that will enable people to understand something of modern medicine and the function of their own bodies; (b) help people to appreciate the effects of heredity and environment on the community, their family and themselves; (c) help people to accept responsibility and to modify their attitudes towards health, disease and injury; (d) explain the health services to people in terms which they can understand, so that they are able to accept help in a rational manner. The emphasis of health education has changed over the years and can be thought of in three groups, inevitably mixed but still broadly separate: Environmental hygiene—sewage disposal, safe water, etc. The education of small and influential groups for a short time, i.e. till the service was created. Preventive medicine—the control of communicable diseases by immunisation and medical treatment. The need for quite large numbers of people, e.g. parents, to modify their attitudes for long enough to allow their children or themselves to be immunised. Positive health—the education of groups of people to modify their attitudes permanently, e.g. to change their diet, the way of rearing children, to give up smoking, in order to attain higher standards of physical and mental health. Co-operation in health education—Broadly, since 5 July, 1948 the Council has left health education on environmental hygiene to the metropolitan borough councils and has itself concentrated on the personal health services. There is the fullest co-operation with the metropolitan boroughs, e.g. the Council has provided stands and stewards for borough home safety exhibitions. In addition, there is a close link with the numerous bodies which have an interest, direct or indirect, in health education such as the Central Council for Health Education, Borough Safety Committees, the Royal Society for the Prevention of Accidents, the British Standards Institution, the National Association for Mental Health and the National Marriage Guidance Council. Financial assistance given by the Council in 1960/61 included: Central Council for Health Education £1,925 Royal Society for the Prevention of Accidents (Training Centre) £2,400 The Council looks to the voluntary bodies as the main source of posters and pamphlets. An executive committee to co-ordinate health education projects of common interest was formed early in 1961 by the liaison committee of medical officers of health of London and the Home Counties.* Its chairman and secretary are respectively chairman and secretary of the Council's Health Education Advisory Panel; the Medical Director of the Central Council for Health Education is also a member. Plans for a joint campaign to publicise polio vaccination, based on a poster display at London Transport Executive and British Railway stations in the area of the authorities, were rendered abortive by difficulties over the availability of vaccine and it was decided to postpone the campaign indefinitely. * Bedfordshire, Brighton, Buckinghamshire, Canterbury, Croydon, Eastbourne, East Ham, East Sussex, Essex, Hastings, Hertfordshire, Kent, London, Middlesex, Southend, Surrey and West Ham. 67 E* Organisation—Overall policy is decided by the Health Committee. There is a central Health Education Advisory Panel representing the main professional points of view both central and divisional, which also has the assistance of a senior teacher of a large secondary school. This panel deals with broad planning matters, particularly in relation to exhibitions, campaigns, media and the timing thereof. Matters for detailed consideration are referred to a working team of health visitors, under the chairmanship of a divisional nursing officer who is a member of the central panel. This team undertakes the appraisal of films and filmstrips, preparation and revision of lists of approved mothercraft equipment and practical steps for the preparation of visual aids. Each of the nine divisional medical officers is responsible for the day-to-day direction of health education activities and he is assisted by a representative panel of his staff. At the central office there is a small executive section which undertakes the co-ordination of departmental health education activities, liaison with interested bodies, press publicity, campaigns and exhibitions, the supply of equipment, films, filmstrips, literature and other aids, and the maintenance of a photographic and a general library on health subjects. Health education activities—These may be regarded as falling under three heads: (i) Day-to-day health education by medical officers, health visitors, etc. in the home or at clinics, on mothercraft, the need for prophylaxis, etc. (ii) Health education in schools in cleanliness, hygiene, biology, mothercraft, etc. This is the responsibility of head teachers but the school doctors and health visitors/school nurses afford any help requested. (iii) Individual campaigns or exhibitions which are in general centrally organised. These three aspects of the work are explained in detail below. The work of the field staff— Health education may be deemed to form part of almost any contact between field staff and the public, e.g. there are, each year, some 900,000 attendances at maternity and child welfare clinics, 1,750,000 visits by home nurses, 750,000 home visits by health visitors, 300,000 school medical examinations and possibly another 750,000-1,000,000 visits to the homes of schoolchildren by the 70 trained social workers and over 2,500 voluntary workers of the children's care committees (a service unique to London) to follow up findings at medical inspections, non-attendance for diphtheria immunisation, cases of problem children and mental health and moral welfare cases. Apart from this day-to-day contact with the public, a regular series of talks and discussions held mainly at welfare centres is the basis of field work. The variety and volume of the talks, arranged under the direction of divisional medical officers, is shown in the following tables. Health education talks—1961 Table (i)—Speakers Divisions 1 2 3 4 5 6 7 8 9 Total Medical officers 2 50 2 — — — 5 - 2 61 Nursing officers — — — — — — 1 — — 1 Health visitors and school nursing sisters 596 1,278 323 290 417 941 696 151 351 5,043 Domiciliary midwives 2 14 3 1 4 — 20 — — 44 Teachers/instructors 129 — — 110 53 — 20 — — 312 Fire prevention officer (L.F.B.) — — — 1 — — — 1 — 2 Lecturers from outside the Council's service—Nursing — 9 — 4 — — — 1 — 14 Other 16 47 15 5 — — 68 3 — 154 Total 745 1,398 343 411 474 941 810 156 353 5,631 68 69 Table (ii)—Subjects of talks and attendances Divisions 1 2 3 4 5 6 7 8 9 Total Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Care of mothers and young children 631 4,749 831 6,791 303 1,810 237 1,900 348 3,056 941 9,924 443 4,989 128 913 275 2,045 4,137 36,177 Care of older children 6 50 66 576 7 62 3 63 13 65 — — 48 673 1 100 7 42 151 1,631 General family health topics 5 35 184 1,663 2 22 3 57 15 127 — — 42 475 — — 28 208 279 2,587 Environmental hygiene 7 52 22 200 — — — — 1 6 — — 5 58 1 10 3 29 39 355 Infectious diseases and prophylaxis 23 243 72 540 3 15 3 17 25 219 — — 37 473 10 110 14 99 187 1,716 Prevention of accidents 16 139 48 408 2 33 1 19 10 85 — — 17 197 3 31 9 63 106 975 Smoking and lung cancer — — 6 27 — — — — — — — — 5 274 — — — — 11 301 Cancer education (other than above) - - - - - - - - - - - - 1 8 — — — — 1 8 Mental health - - 21 104 - - - - - - - - - - - - 1 8 22 112 First aid 5 45 13 153 10 60 2 39 2 20 — — 6 54 8 80 1 8 47 459 Other 52 489 135 1,103 16 98 162 3,131 60 412 — — 206 2,959 5 68 15 136 651 8,396 Total 745 5,802 1,398 11,565 343 2,100 411 5,226 474 3,990 941 9,924 810 10,160 156 1,312 353 2,638 5,631 52,717 Table (iii)—Audience groups Divisions 1 2 3 4 5 6 7 8 9 Total Expectant mothers 574 817 266 275 322 941 452 130 233 4,010 Mothers, mothers' clubs, etc. 167 500 77 136 152 — 343 10 117 1,502 Parent/teacher associations 5 1 — 6 Schools* — — — — — — 4 — — 4 Day continuation classes — 80 - - - - - - - 80 Voluntary organisations 4 1 — — — — 6 15 3 29 Total 745 1,398 343 411 474 941 810 156 353 5,631 * Lectures by medical officers. Health education in schools—This is the responsibility of head teachers. The services of divisional staff are, however, always available for advice and help in planning health education in schools and for giving special talks. Whilst a variety of discussions, talks and demonstrations are offered by the public health department and many schools do a great deal on their own, much more is needed, especially in boys' schools. The key to the whole matter, it is thought, lies in the emphasis given to health education in the training of teachers. Talks given by school health visitors at the invitation of head teachers range over a variety of subjects and numbered over 4.000 in 1961. Campaigns and exhibitions—Normally county-wide home safety and diphtheria campaigns are held annually, sustained for one and two weeks respectively. These campaigns have involved press advertisements in thirty-eight local newspapers, exhibition of films and filmstrips at welfare centres, etc. and films or slides at local cinemas, press, radio and television publicity, special shop window displays and printed slogans on correspondence envelopes used by the Council. Other campaigns are undertaken in response to requirements, e.g. poliomyelitis vaccination and mental health. In 1957 and 1959 exhibitions, in conjunction with the Royal Society for the Prevention of Accidents, were arranged at Charing Cross underground station on the themes of 'Danger at home' and 'Home, safe home', attendances being some 27,000 and 23,000 respectively. In co-operation with the Architect's department, special exhibits on home safety were also provided at the Ideal Home Exhibition at Olympia in 1960 and 1961. Displays on a number of health education subjects have been provided in the Council's own display centre at County Hall and in 1960 a 60-second film was made, in conjunction with local authorities in the Home Counties, which was shown on independent television networks. In 1959 an exhibition was held at County Hall to show what was being done after ten years of the National Health Service for the health of the people of London and the opportunities for young people in the health services for interesting and worthwhile careers in nursing and allied professions. The exhibition was presented by the Council and the four metropolitan regional hospital boards, in association with the London Executive Council and the Metropolitan Boroughs' Standing Joint Committee. As already indicated, the Council has participated in various exhibitions run by metropolitan borough councils. Displays on health education topics designed and executed by health visitors are a feature at welfare centres, in particular at three centres which have a shop window front and can therefore attract a wider public than those who would be attending the centres. 70 Health education material—As already mentioned, the Council mostly draws on other agencies for literature, but it has itself produced leaflets on such topics as lung cancer, oil heaters and general guidance to school leavers. To a limited extent some written material has been produced in foreign languages, i.e. Arabic, Bengali, French, German, Greek, Hungarian, Italian, Polish, Russian, Spanish, Turkish and Urdu, to meet local needs. The central office distributes over 400 different leaflets and booklets and some 250 posters and wall charts produced by related organisations. Over 900,000 leaflets, 90,000 bookmarks and 24,000 posters are used annually. Local distribution is mainly through the Council's own channels but the co-operation of the metropolitan borough councils is sought and obtained as regards their libraries, notice boards, etc. In addition to the large central library previously mentioned, smaller libraries are maintained at the nine divisional offices. There has been an increasing demand for films and filmstrips in the presentation of talks and discussions, as indicated in the following table of requests received from divisions: 1957 1958 1959 1960 1961 Films 270 325 364 473 675 Filmstrips . 477 446 977 1,094 955 The department's own library provided films on 199 occasions and all the filmstrips. In addition to those supplied centrally, divisions hold a number of filmstrips for exclusive local use. Assessment of results—In the day-to-day teaching and publicity, a most effective method has been the personal approach by talks to the individual or to small groups of people to whom the particular subject is of immediate interest, the lectures being supplemented as appropriate by posters, leaflets, flannelgraphs, films, filmstrips, etc. Though it is extremely difficult to assess the impact made on the particular public to which health education is directed, an attempt was made when a polio campaign was held in the Spring of 1960. An enquiry showed that of a sample of 2,116 who attended clinics for immunisation, the greatest response attributed to an advertising medium was due to posters and press advertisements. Results of the survey are shown in percentages* in the table below: Age group Medium T. V. or radio Posters Press adverts Leaflets Bookmarks None All ages 6.3 21.2 21.2 14.1 3.6 45.6 Born after 1942 6.2 15.2 15.2 8.9 2.1 64.5 1933-1942 6.3 22.2 22.2 19.5 4.0 40.1 Before 1933 and aged over 40 6.2 22.6 22.6 14.3 3.9 41.8 * In total these exceed 100 per cent. because some were influenced by more than one medium. A number of those who did not admit to having seen any publicity were influenced by spouses, parents or friends, who may themselves have been influenced by the publicity campaign. A further difficulty that cannot readily be resolved is the assessment of results. Though in the case cited above a demand for vaccination was provoked by publicity and some measure of its effect could be gauged, in many cases, such as in home safety campaigns, no immediate effect is apparent to judge from relevant statistics. There is, however, an indirect effect produced by such publicity by the Council in influencing the contents of television programmes and popular magazines, which have a wider and more direct appeal to the public. Training of staff in health education—An account of in-service training of staff will be found in the staff section of the main report. 71 The future—Health education has in the past been concerned largely with physical problems connected with nutrition, grooming, general care and protection from common dangers, particularly in relation to the young and the elderly. Current problems of adolescent promiscuity, rising incidence of venereal disease, lung cancer and smoking, immunisation, dental health of children, accident prevention, and emotional development and mental health spotlight the changing pattern of social needs which in turn will necessitate a change of emphasis in health education. Attention has been focussed recently on the subject of smoking and lung cancer, following the publication of a report by the Royal College of Physicians of London; the problems of achieving more effective health education in this field for children and adults are being actively probed in co-operation with representatives of the education service and my medical colleagues of the Home Counties. Personal approach, to individuals or groups, has been found to produce the most hopeful results within the limitations of the means of publicity which are available to local authorities. In contrast with advertising appropriations of commercial enterprises, the money spent on health education by local authorities is insignificant; the cost of production of films, television advertising and large-scale publicity by use of poster hoardings are in the main beyond their financial resources. Future intensification of health education activities will necessarily depend on the amount of money allocated and the availability of trained health educators. 72 SCHOOL HEALTH SERVICE Pupils on school rolls—In January, 1962 there was a total of 422,622 pupils on the day school roll; 230,134 in primary schools, 182,248 in secondary schools, 1,790 in nursery schools and 8,450 in special schools. In January, 1961 there were 428,591 pupils on the roll. Ministry of Education circular 14/61 and Ministry of Health circular 23/61—These administrative circulars, relating to young children handicapped by impaired hearing, in which local authorities were asked to review their existing services in consultation with Local Medical Committees and hospital authorities, are referred to on page 49. Medical inspection Details of medical inspections during 1961 are summarised and compared with those for earlier years in the tables below. Since 1958 periodic general medical inspections have been analysed by year of birth to conform with Ministry of Education requirements, but to facilitate annual comparisons the year of birth has been turned into 'age' (by subtracting year of birth from year of inspection) in the tables throughout this section of the report. The Council's revised scheme for the medical inspection of schoolchildren came into operation on 1 January, 1959 and one effect was to make the intermediate periodic inspections a year later in the child's school life. Consequently fewer inspections were carried out during 1959 than in 1960; in 1960 the normal pattern was resumed, but on the new time-table. It will be seen from the following table that intermediate inspections now are each spread over two age-groups because the school year begins in September. The number of children seen at periodic general medical inspections in 1961 was 38.7 per cent. of the school roll, compared with 35.2 per cent. in 1960 and 31.4 per cent. in 1959. Another effect of the revised scheme was to abolish nutrition reinspections and none is now recorded. Ordinary reinspections showed a fall of almost 7 per cent. from the 1960 figure and fewer 'special' inspections were carried out. It is of interest that of the 11,837 special inspections, half were requested by head teachers, nearly a quarter by school health visitors and one-eighth by parents. Periodic general medical inspections Age groups 1959 1960 1961 No. % No. % No. % 4 and less 7,660 5.6 7,674 5.1 7,939 4.9 5 29,317 21.6 27,435 18.2 28,558 17.4 6 7,069 5.2 7,511 5.0 8,314 5.1 7 13,278 9.7 9,744 6.5 9,356 5.7 8 8,540 6.3 19,322 12.8 20,684 12.6 9 3,128 2.3 3,227 2.1 4,204 2.6 10 1,817 1.3 1,897 1.3 2,078 1.3 11 15,424 11.3 10,549 7.0 10,096 6.2 12 8,744 6.4 19,634 13.0 20,148 12.3 13 2,896 2.1 4,884 3.2 6,103 3.7 14 8,204 6.0 9,418 6.2 10,277 6.3 15 and over 30,186 22.2 29,495 19.6 35,841 21.9 136,263 100.0 150,790 100.0 163,598 100.0 73 Non-routine medical inspections 1959 1960 1961 Reinspections—nutrition 3,622 — — Reinspections—other 97,401 80,631 74,618 Secondary school reviewals 2,771 1,785 1,908 Other non-routine inspections (see next table) 47,924 50,648 48,380 Total 151,718 133,064 124,906 Total inspections 287,981 283,854 288,504 Analysis of non-routine medical inspections Nature of inspection Number inspected Bathing centre inspections—scabies 28 Bathing centre inspections—other 128 Employment certificates 5,264 Licences for theatrical employment 468 School journeys 21,409 Recuperative holidays—prior to holiday 1,075 Recuperative holidays—on return 53 Candidates for higher awards 34 Nautical school entrants 149 Outward Bound and Adventure courses 159 T.B. contacts 30 Boarding schools for the delicate— Pre-departure inspections 130 On return 45 Other handicapped pupils— Statutory examination 1,072 Periodic special defect examination 5,126 Research investigations and enquiries 186 35,356 Specials, at request of: Head teacher—special book 1,618 Head teacher—others 4,585 School nurse—after health survey 1,208 School nurse—others 1,401 Divisional officer (Education) 895 District care organiser or care committee 642 Parent 1,488 11,837 All other non-routine inspections 1,187 Total 48,380 Pupils found to require treatment at periodic general medical inspections (excluding dental and infestation) Age groups inspected For defective vision (excluding squint) For other conditions Total individual pupils 4 and less 32 647 672 5 163 2,172 2,313 6 117 783 884 7 665 762 1,369 8 1,496 1,328 2,721 9 319 301 589 10 190 137 309 11 1,008 514 1,469 12 1,934 1,086 2,897 13 587 270 823 14 1,029 392 1,358 15 and over 3,807 1,121 4,748 11,347 9,513 20,152 74 Defects noted at routine medical inspections—The overall percentage of children referred for treatment of a defect was 12.3 in 1961 compared with 12.5 in 1960 and the comparative percentages for sex and age are shown in the following table. The percentage referred for vision defects has increased from 6.1 in 1959 and 6.6 in 1960 to 6.9 in 1961; for other defects it has decreased from 6.8 in 1959, 6.3 in 1960, to 5.8 in 1961; the increase in vision defect was of the same order for both boys and girls, but the decline in the percentages for other defects was greater for girls than for boys. Vision defects are dealt with in more detail in a later paragraph. For all defects in the age groups containing the largest numbers (viz., 5, 8, 12 and 15) boys aged 15 showed a marked increase over the 1960 figures and boys aged 12 also showed an increase, but to a lesser extent, both increases being accounted for almost entirely by the increase in vision defect. For girls there was no appreciable change. Percentage of children noted for treatment Age and sex All defects Vision defects Defects other than vision 1959 1960 1961 1959 1960 1961 1959 1960 1961 4 and less Boys 10.1 9.6 9.3 0.4 0.5 0.4 9.8 9.3 9.0 Girls 8.9 8.3 7.6 0.4 0.3 0.4 8.6 8.0 7.3 5 Boys 9.6 9.2 8.6 0.6 0.5 0.5 9.1 8.7 8.2 Girls 8.3 7.9 7.5 0.5 0.7 0.7 7.9 7.3 6.9 6 Boys 13.2 12.5 11.8 1.3 2.1 1.3 12.1 10.8 10.8 Girls 11.2 10.7 9.4 1.0 2.0 1.5 10.3 9.0 7.9 7 Boys 15.7 15.2 15.4 7.2 6.6 7.0 9.2 9.2 9.0 Girls 15.3 15.0 13.9 7.5 7.6 7.2 8.5 8.2 7.2 8 Boys 14.8 14.0 13.5 6.9 7.2 7.0 8.5 7.5 7.0 Girls 14.0 13.5 12.8 7.7 7.3 7.5 6.8 6.7 5.9 9 Boys 15.5 13.7 14.0 7.2 7.3 7.1 9.0 7.1 7.9 Girls 14.1 13.3 14.0 8.4 7.5 8.1 6.1 6.2 6.3 10 Boys 17.2 16.0 15.5 8.6 8.7 8.9 10.0 7.8 7.4 Girls 16.8 15.5 14.2 8.7 9.0 9.4 8.6 7.4 5.7 11 Boys 14.1 13.3 12.8 8.5 9.1 8.4 6.2 4.6 4.8 Girls 16.1 17.3 16.4 9.8 11.3 11.6 7.0 6.9 5.4 12 Boys 11.6 13.0 13.4 7.1 8.3 8.8 5.0 5.2 5.1 Girls 13.9 15.3 15.4 8.8 9.8 10.4 5.8 6.2 5.8 13 Boys 14.9 13.4 12.0 9.1 8.7 8.5 6.5 5.2 3.9 Girls 17.1 16.3 15.0 9.7 11.0 10.7 8.0 6.2 4.9 14 Boys 12.0 12.1 12.1 9.1 8.9 9.4 3.2 3.5 3.1 Girls 12.9 13.2 14.5 9.3 10.2 10.7 4.0 3.7 4.6 15 and over Boys 11.9 11.4 12.2 9.0 8.9 9.7 3.2 2.8 2.9 Girls 13.0 14.3 14.3 9.8 10.7 11.6 3.6 4.2 3.3 Total Boys 12.4 12.1 12.0 5.8 6.1 6.4 7.0 6.3 6.0 Girls 12.5 12.9 12.6 6.3 7.1 7.5 6.6 6.4 5.6 Total Both sexes 12.4 12.5 12.3 6.1 6.6 6.9 6.8 6.3 5.8 note: A child can be noted as requiring treatment of vision and another defect, hence the percentage requiring vision treatment plus the percentage requiring treatment of other defects exceeds the percentage referred for treatment of all defects. The following table shows the percentage of children of all ages noted for treatment or observation of the defects listed for the years 1959 to 1961. These percentages remain fairly stable over the period. The slight but steady decrease in the incidence of enlarged cervical glands continues. Enlarged tonsils and adenoids, lung disease and orthopaedic defects all show a continued decline since 1959, psychological defects an upward trend. 75 1959 1960 1961 Numbers examined 136,263 150,790 163,598 Percentages Skin diseases 1.22 1.22 1.19 External eye diseases 0.55 0.56 0.54 Defective hearing 0.91 0.85 0.90 Otitis media 0.67 0.56 0.51 Enlarged tonsils and adenoids 5.11 4.28 3.95 Defective speech 0.93 0.88 0.87 Enlarged cervical glands 0.89 0.68 0.63 Heart and circulation 0.88 0.83 0.87 Lung disease (not T.B.) 1.49 1.38 1.21 Orthopaedic defects 4.16 3.93 3.52 Defects of nervous system 0.39 0.43 0.43 Psychological defects 0.93 1.02 1.08 Anaemia 0.17 0.12 0.12 Enuresis 1.75 1.80 1.77 A child can be noted for more than one defect. A new method of recording, introduced on 1 January 1960, permits new defects discovered at special medical inspections to be related to the source of reference. The following table shows clearly how certain types of defect are most often brought to notice through a particular source of reference. Defects found at special medical inspections—1961 Head teacher School health visitor Referred by: Divisional officer (Education) Care committee Parent Number of pupils seen 6,203 2,609 895 642 1,488 Number of defects found 2,827 1,424 269 201 832 Number of defects per 1,000 pupils: Skin diseases 30 63 7 8 16 Defective vision 109 575 15 31 75 External eye diseases 21 40 3 8 29 E.N.T. conditions 92 102 27 30 126 Orthopaedic defects 51 57 16 12 33 Defects of nervous system 32 11 11 2 15 Psychological defects 291 24 35 40 52 Enuresis 17 29 1 28 46 Speech defects 53 23 — 2 25 Nutritional defects 15 31 8 19 22 All other defects 170 140 179 134 121 Attendance of parents and care committee representatives at periodic inspections—As in previous years the percentage of medical inspections at which a parent is present decreases as children get older. The overall percentage was 48.6, slightly lower than in 1960 when it it was 50.6 per cent. Care committee representatives attended 86.9 per cent. of all periodic general inspections. In the infant and junior school age groups the figure was over 90 per cent. but only about 80 per cent. in the secondary school age groups. This was due, no doubt, to the fact that care committees do not function in all secondary schools. 76 Attendance of parents and care committee representatives Age Group Number of pupils inspected Parent present % Care committee representatives present at inspection % 4 or less 7,939 90.9 82.3 5 28,558 87.7 94.6 6 8,314 79.1 95.8 7 9,356 71.8 94.4 8 20,684 70.1 96.4 9 4,204 59.2 96.3 10 2,078 51.9 95.2 11 10,096 37.7 75.8 12 20,148 31.8 82.9 13 6,103 24.7 79.9 14 10,277 10.3 82.1 15 and over 35,841 8.5 78.8 Physical condition of pupils The percentage of pupils whose condition was classified as satisfactory and unsatisfactory and the percentage who were noted as requiring treatment or observation on account of nutrition during 1961 are set out below, with similar figures for the four preceding years. This table suggests a continuous improvement over the five years, but the steadying of the percentage noted with a nutrition defect may mean that the end of this improvement is near. Physical condition Nutrition defect noted for Satisfactory Unsatisfactory Treatment Observation % % % % 1957 97.3 2.7 0.6 0.6 1958 98.1 1.9 0.5 0.6 1959 98.8 1.2 0.2 0.5 1960 99.0 1.0 0.2 0.5 1961 99.2 0.8 0.2 0.4 As indicated in my report for 1959, the newly introduced basis of tabulation by years of birth permits the comparison of samples of children of the same age group and is analogous to a 'follow-up' survey. The last three years' figures are: Percentage unsatisfactory physical condition Year of birth Year of examination 1959 1960 1961 1944 0.6 — — 1945 0.9 0.4 — 1946 1.3 0.6 0.4 1947 1.3 0.8 0.4 1948 1.2 0.9 0.6 1949 2.9 0.9 0.6 1950 2.0 2.2 0.6 1951 1.2 1.6 1.7 1952 1.4 1.1 1.5 1953 2.4 1.8 1.0 1954 1.4 1.8 1.2 1955 1.4 1.2 1.8 1956 — 1.0 0.7 1957 and later — — 0.8 77 School meals and milk The Ministry of Education asked for a return for a typical day of the total number of (i) day school children who had school dinners and (ii) children who had school milk. The day selected for the census was 26 September or the nearest normal school day thereto. The figures are set out below with those for 1960 in brackets. Type of school Number of children present Number who took school dinners On payment Free Total % Secondary 173,329 103,139 7,470 110,609 63.81 (173,092) (105,855) (7,237) (113,092) (65.34) Primary 205,994 109,150 12,382 121,532 59.00 (202,240) (103,145) (11,880) (115,025) (56.88) Special 5,585 4,411 1,098 5,509 98.64 (5,545) (4,473) (1,011) (5,484) (98.90) Nursery 1,509 870 87 957 99.17 (1,480) (933) (95) (1,028) (98.66*) 386,417 217,570 21,037 238,607 61.75 (382,357) (214,406) (20,223) (234,629) (61.37) * Percentage of 965 children, as 544 children attended half time and did not have school dinners. The Ministry was informed that 316,826 children in Council maintained schools took milk on the selected day(s) compared with 318,678 in September 1960. Of 28,891 children present in independent schools, 22,438 had milk under the scheme. The percentages for the several types of school for the corresponding days were: 1960 1961 Secondary 66.05 63.12 Primary 96.32 96.51 Day special 98.47 99.18 Nursery 98.51 98.67 Boarding 98.51 97.52 Independent 74.60 77.66 Vision Visual acuity standards expressed as percentages of the numbers of children whose eyes were tested are set out in the following table. For children not wearing spectacles the highest rate of referral for treatment is at age under 7 (entrants), but this is because vision testing at this young age is not general and tends to be confined to those in whom there is a suspicion of defective vision. In general, the referral rate for treatment is fairly consistent throughout the age range, i.e., development of defective vision is progressive with age, since those found to have defective vision at earlier examination and provided with spectacles will be excluded from this side of the table at subsequent examinations. For children already wearing spectacles the proportions referred for treatment increase with age, doubtless for correction of refraction. Of the children medically inspected 0.6 per cent. were noted for treatment of squint, the same as in 1958, 1959 and 1960. The percentage ranged from 1.3 in the entrant group to 0.1 in the leaver group. 78 Age group Boys Not wearing spectacles Wearing spectacles 6/6 6/9 6/12 or worse Referred for treatment 6/6 6/9 6/12 or worse Referred for treatment Under 7 82.0 11.0 5.3 7.8 0.6 0.5 0.7 0.3 7 78.2 12.0 6.2 6.4 1.1 1.0 1.6 1.3 8 80.9 9.5 5.7 5.7 1.4 1.0 1.5 1.4 9 80.7 8.7 6.3 6.0 1.8 1.3 1.3 1.3 10 80.9 5.9 8.2 7.5 1.7 1.0 2.3 1.8 11 80.9 5.3 6.2 6.0 3.5 2.1 1.9 2.5 12 80.3 5.1 6.2 6.0 4.3 2.1 2.1 2.9 13 80.4 5.2 6.1 6.2 4.7 2.0 1.7 2.3 14 80.5 4.0 5.8 5.5 5.0 2.3 2.3 3.9 15 and over 78.2 4.3 5.9 5.7 6.3 2.7 2.5 4.0 Total 79.8 6.3 6.0 5.9 3.9 1.9 2.0 2.7 Age group Girls Not wearing spectacles Wearing spectacles 6/6 6/9 6/12 or worse Referred for treatment 6/6 6/9 6/12 or worse Referred for treatment Under 7 78.8 12.2 6.5 9.1 1.1 0.6 0.8 0.6 7 76.4 13.1 6.5 6.6 1.1 1.3 1.5 1.3 8 79.2 10.6 5.5 5.9 1.4 1.5 1.7 1.7 9 77.2 11.2 7.0 6.9 1.2 1.5 1.9 1.4 10 79.4 6.5 7.5 7.2 2.3 1.7 2.5 2.4 11 75.7 6.6 7.4 8.0 4.4 3.3 2.6 3.7 12 77.6 6.5 6.5 7.0 4.5 2.6 2.3 3.4 13 77.2 6.0 6.9 7.5 4.5 2.7 2.6 3.2 14 77.1 6.1 6.6 6.6 5.8 2.9 2.5 4.1 15 and over 74.3 5.3 6.0 6.5 7.5 3.8 3.0 5.1 Total 76.7 7.5 6.3 6.8 4.5 2.7 2.7 3.4 note: The percentages of children referred for treatment differ slightly from those quoted in the defects for treatment table on page 75 in which the percentages were based on the number of children medically inspected. Personal hygiene As stated last year, the hygiene inspection of each child once a term was replaced in January, 1959 by an annual comprehensive health survey of each pupil, plus such additional health surveys as may be thought necessary or desirable at selected individual schools or departments. Also, from January, 1960 the use of Lorexane No. 3 shampoo was brought into use throughout the county under a revised cleansing scheme. However, since the type of action to be taken in any particular case is at the discretion of the school nurse/health visitor concerned, in the light of her knowledge of the family, it was decided that from 1 January, 1961 no attempt need be made to distinguish between 'first' and 'second' notices and that the distinction between 'verminous heads', 'nits only', and 'other verminous cases' be also discontinued. In consequence, the details of the findings at the 1961 surveys and the work done under the cleansing scheme are presented in a slightly different form from that used in 1960. 79 Health surveys—The number of comprehensive health surveys conducted in 1961 was only slightly less than that conducted in 1960, but there was a decrease of 56 per cent. in the number of selective health surveys. This is explained in large part by the fact that in 1960 examinations of children for athlete's foot, plantar warts and other communicable disease were included; whereas in 1961 they have been excluded from this figure and are shown separately later in the same table. No. found Pupils found to be verminous No. examined verminous % of No. examined Annual comprehensive health surveys* 323,800 2,899 0.90 (326,372) (3,028) (0.93) Additional health surveys* 189,216 3,327 1.76 (435,166) (5,413) (1.24) * 1960 figures in brackets. To assess the comparative level of infestation amongst schoolchildren, only the findings for comprehensive health surveys (each child seen once a year) can be compared with the former hygiene inspections (each child seen once a term). As will be seen in the following table, the percentage found to be verminous at comprehensive surveys fell considerably between 1959 and 1960 but has now stabilised at about the level of the latter year. Percentage found to be verminous Hygiene inspections Comprehensive health surveys 1955 1956 1957 1958 1959 1960 1961 1.35 1.26 1.25 1.27 1.25 0.93 0.90 The number of individual children found to be verminous in 1961 was 4,127, a reduction of 743 from the number in 1960. The average annual reduction from 1955 to 1959 was 450. Comparison with the earlier years of these figures and those of the percentage found verminous, tabled above, throws into relief the dramatic change brought about by the use of Lorexane. Details of the work done under the cleansing scheme are shown below. The new cleansing scheme itself is, of course, fundamentally different from past practice in its emphasis on children being cleansed at home by the parents and makes comparison with past years very difficult. It appears, however, that of the number found verminous at comprehensive and selective health surveys more than seven out of every ten were given a tube of Lorexane and the number of statutory notices issued showed a drop from 320 in 1960 to 62 in 1961. Cleansing scheme 1957 1958 1959 1960 1961 Advice notice only issued N/A N/A N/A 2,381 575 Advice notice with Lorexane No. 3 N/A N/A N/A 6,552 4,488 Number of pupils referred for further action N/A N/A N/A N/A 1,204 Pupils attending bathing centre voluntarily 6,183 5,527 4,552 1,628 735 Statutory cleansing notices issued 998 964 764 320 62 Pupils cleansed after service of statutory notice: voluntarily 243 240 259 84 18 compulsorily 704 628 458 197 37 Total 947 868 717 281 55 Bathing centres—The number of cases of infestation with vermin treated at bathing centres showed a reduction of 34 per cent. compared with 1960 and the number of treatments a reduction of 36 per cent. There can be little doubt that these reductions are directly attributable to the introduction of Lorexane. 80 1957 1958 1959 1960 1961 Scabies Pupils treated 697 768 660 637 514 Vermin Pupils treated 8,175 7,473 7,025 3,441 2,265 Treatments needed 13,787 13,647 11,799 4,345 2,764 Impetigo Pupils treated 2,433 1,478 1,187 1,020 1,033 Ringworm New cases 17 22 20 10 7 Employment of schoolchildren Medical examinations were carried out divisionally of 5,264 children with a view to the issue of employment certificates and 468 medical examinations were carried out at the County Hall in respect of employment under licence in public entertainments. Choice of employment The percentage of school leavers advised against particular forms of employment was 13.3 per cent. of those inspected, compared with 12.9 per cent. in 1960. For boys the figure fell from 14.6 per cent. in 1960 to 14.2 per cent. but for girls it rose from 11.1 per cent. to 12.3 per cent. As in recent years, normally acute vision headed the list of contra-indications followed by colour vision (boys only) and heavy manual work: Contra-indications Boys Girls Occupations involving: Heavy manual work 289 210 Sedentary work 10 32 Indoor work 3 8 Exposure to bad weather 141 140 Wide changes of temperature 107 83 Work in damp atmosphere 152 134 Work in dusty atmosphere 189 118 Much stooping 60 61 Work near moving machinery 101 103 Prolonged standing, much walking or quick movement from place to place 256 256 Normally acute vision 2,031 2,027 Normal colour vision 511 5 Normal use of hands 25 13 Work requiring freedom from damp hands and skin defects 47 38 Handling or preparation of food 70 56 Normal hearing 78 57 note: The total number of contra-indications is greater than the number of pupils with contra-indications since an individual may be noted for two or more contra-indications. Infectious diseases in schools When a pupil is absent from school, and the cause is either known or suspected to be due to infectious disease, the head of the school notifies the divisional medical officer and the borough medical officer of health. These notifications are uncorrected for diagnosis, but form the best available index of the trend of infectious disease in the school community; they are the only figures available in respect of diseases which are not statutorily notifiable. When the number of cases of infectious disease reported from a particular school indicates the possibility of an outbreak, special visits are made by a school health visitor and, if necessary, by a school doctor, in order to investigate the situation and take whatever control action is necessary. 81 F The numbers of cases of infectious diseases reported during 1961 and the preceding years are given below: 1957 1958 1959 1960 1961 Chicken-pox 4,496 8,901 5,399 8,357 5,895 Dysentery, diarrhoea or enteritis 414 1,170 1,148 1,557 669 German measles 2,081 2,549 1,325 631 3,891 Impetigo 301 265 192 194 187 Influenza N/A N/A N/A 229 127 Jaundice 75 11 19 253 493 Measles 13,039 5,045 9,326 2,544 14,343 Mumps 5,509 2,778 3,788 8,783 2,338 Ophthalmia and conjunctivitis 291 319 264 299 536 Ringworm (scalp) 8 13 13 8 10 Ringworm (body) 55 38 46 51 26 Scabies 61 61 57 76 78 Scarlet fever 1,037 1,251 1,264 721 634 Sore throat and tonsillitis 864 994 1,299 905 1,416 Whooping cough 1,372 485 508 1,454 395 Prophylaxis—The new system of recording medical inspection findings by years of birth permits an analysis of the percentage of school pupils, according to age, who have received prophylaxis, based on the findings at periodic general medical inspections. These figures may be compared with the separate estimates, prepared for the Ministry of Health, given on pages 58 and 59: Age group Number of pupils inspected % vaccinated against smallpox % immunised against diphtheria % immunised against whooping cough % vaccinated against poliomyelitis 4 or less 7,939 63.0 88.4 82.1 81.2 5 28,558 59.2 85.9 75.8 78.7 6 8,314 52.8 77.8 64.7 67.8 7 9,356 53.0 86.2 67.9 74.8 8 20,684 52.9 89.2 67.7 76.2 9 4,204 50.0 79.9 58.3 65.6 10 2,078 51.7 71.8 48.3 59.9 11 10,096 52.4 88.2 47.0 77.6 12 20,148 46.5 88.7 46.1 74.6 13 6,103 44.7 84.9 44.0 70.1 14 10,277 55.5 87.4 39.2 74.0 15 and over 35,841 53.0 88.2 36.4 79.7 Medical treatment of schoolchildren Treatment statistics—The number of sessions, new cases and total attendances at schoolchildren's clinics during 1961 (including sessions held in hospital premises) were as follows: Type of clinic Sessions New cases Attendances Minor ailments (nurse) 17,567 40,374 399,998 Minor ailments (doctor) 2,325 24,843 Special investigation 2,184 2,108 14,745 Dental 28,982 69,470 237,411 Vision 4,709 27,464 72,546 Orthoptic 2,014 1,348 7,641 Ear, nose and throat 604 2,673 6,376 Audiology 308 1,292 2,848 Rheumatism (supervisory) 135 75 880 Enuresis 186 169 889 82 Handicapped pupils New ascertainments—During 1961 the numbers of new ascertainments of pupils for special educational treatment were as follows: Day Boarding Blind — 5 Partially sighted 36 — Deaf and partially deaf 52 4 Delicate 455 246* E.S.N. 798 92 Epileptic — 1 Maladjusted 267 262 Physically handicapped 159 14 Speech defect l,179† 30† Dual defect — 65 * Including diabetic and E.S.N./delicate. † Including pupils attending special schools for other defects. Special educational provision—At the end of 1961 special educational treatment was being provided for over 12,000 pupils. The following table shows the main categories of handicap and numbers of pupils receiving full-time special education: Day special schools Boarding special schools Non-council boarding schools, hostels, foster-homes hospitals, etc. Total Blind – 66 36 102 Partially sighted 252 — 12 264 Deaf and partially deaf 254* 33 117 404 Physically handicapped 855 68 406 1,329 Delicate 1,374 135 123 1,632 Educationally subnormal 3,385 606 95 4,086 Epileptic † — — 26 26 Maladjusted 198 321 516 1,035 6,318 1,229 1,331 8,878 * Includes 82 pupils in partially deaf units. † A number of epileptic children (apart from those in ordinary school) are placed in schools for the delicate, physically handicapped or educationally subnormal. Educationally subnormal pupils—Section 57 of the Education Act, 1944 (as amended by the Mental Health Act, 1959) deals with the examination and reporting to the local health authority of children who are considered unsuitable for education at school, the review of cases previously reported to the local health authority and the cancellation of the report where the child on re-examination is found to be suitable for education at school. Details of the number of children dealt with under this section are as follows: Section 57 (as amended)—Unsuitable for education at school: 1959 1960 1961 Children not in any school 86 84 100 Children in ordinary schools 6 — 3 Children in special schools 97 57 68 Children receiving home tuition under section 56 of the Education Act, 1944 1 — 1 190 141 172 Section 51/A—Review of cases: Number reviewed 20 Still considered unsuitable for education at school 16 Cancellation of report 4 83 F* Children with impaired hearing—During 1961 a sixth peripatetic teacher of the deaf was appointed for work in audiology and auditory training centres, thus passing the half-way mark towards the approved establishment of ten. Routine audiometer testing—The numbers of children given 'rapid-sweep' audiometer tests during 1961 are as follows: Pupils given screening tests 50,332 Pupils failing screening tests given pure tone tests 3,749 Pupils failing pure tone tests referred to otologists 1,513 Speech therapy—By the end of the year 288 sessions a week were being held, 188 in 59 clinics and 100 in special schools. During the year 1,207 pupils were ascertained as requiring speech therapy, whilst 566 were discharged from treatment and 289 ceased to attend. The number of pupils under treatment at the end of the year was 3,536, whilst 179 were on the waiting list. A special article (Appendix C) reviews the history, growth and development of services for children suffering from speech defects over the past 50 years. Maladjusted pupils—At one of the Council's day schools for maladjusted children an experimental psycho-drama therapy group is being conducted. Although the experiment is in its infancy, the results so far are sufficiently encouraging for the continuance of the group, since some of the participants are already showing signs of a greater sense of reality and of using their intelligence more constructively. Child guidance units—Details of the work done during 1961 at the child guidance units maintained by the Council follow: Patients At 1 January, 1961 At 31 December, 1961 On waiting list: On waiting list: (a) awaiting first interview 218 (a) awaiting first interview 165 (b) interviewed and awaiting treatment 69 (b) interviewed and awaiting treatment 78 In attendance: In attendance: (a) active 410 (a) active 392 (b) under review* 425 (b) under review* 429 During 1961 During 1961 Applications received 862 Applications withdrawn 280 Cases closed 640 1,984 1,984 * Some cases are kept 'under review' for a time after active treatment has ceased; others are closed as soon as active treatment has ceased, any further visits, etc., being regarded as 'follow up'. During the year 165 closed cases were followed up. Student health scheme The experimental student health service, which was started at Barrett Street technical college at the beginning of the 1960/61 session (see page 112 of my report for 1960), was reviewed in July, 1961. There was no doubt that the students and staff valued the service and advice given by the doctor and that local contacts made (e.g. with hospitals, mass X-ray unit) were beneficial. In view of this satisfactory report, it was decided to extend the scheme to the City of Westminster and Brixton day colleges, although at the latter college the scheme was not fully implemented until the beginning of 1962. 84 The general conclusions reached, so far, by the medical officers and the college principals concerned indicate that the service is making a useful contribution to college life, particularly in the case of students from overseas and from other parts of the country, who seem to encounter difficulties in fitting into life in London. There is every reason for satisfaction in the way the service is developing. The following table gives statistics of the work done in 1961: Barrett Street College (Three terms) City of Westminster College (One term) No. of new students under 19 years returning questionnaires 198 147 No. invited for interview after scrutiny of completed questionnaire 83 36 No. of students seen by doctor: (a) following invitation—first attendances 55 31 —subsequent attendances 1 8 (b) voluntary—first attendances 89 17 —subsequent attendances 71 6 216 62 No. of students referred for treatment 78 17 No. of doctor's sessions 30 11 No. vaccinated against poliomyelitis 103 37 85 DENTAL SERVICES The Chief Dental Officer and Principal School Dental Officer reports as follows: School dental service In comparing results with those in 1960 not much change is observed. There were the equivalent of four fewer full-time dentists and 42 fewer treatment sessions a week. There was a slight increase, however, in the number of sessions devoted to dental inspections in schools. The number of children found at these school inspections to require treatment fell (for the fifth successive year) to 65.3 per cent.— a considerable improvement from the 1957 figure of 76.3 per cent. There is little doubt that this improvement indicates that more children than formerly are receiving dental attention of a reparative type, rather than a preponderance of extractions for pain relief. The indication is underlined if one looks at table (ii) 'additional number inspected at centres'. These patients are known to be mainly toothache and pain relief cases and the demands by such patients at our treatment centres has steadily fallen from 56,598 cases in 1957 to 19,778 cases in 1961. NUMBER OF INSPECTION SESSIONS AT SCHOOLS 86 NUMBER OF TREATMENT SESSIONS The reduction in staff produced a corresponding reduction in the totals of individual dental operations and in patients discharged, but it is gratifying to note in table (iii) a continued improvement in the number of permanent teeth conserved to those extracted. In the past ten years this ratio has improved from 3.86 to 9.10. General clinical observation throughout the year confirms the belief that children who attend the Council's treatment centres are now receiving a better service than formerly and it is expected that early official recognition of the necessity for revisional treatment will soon raise the standard still further. In 1961 it was still necessary to use a spread-over policy for dental attention throughout the school population but during the year increasing expressions on the part of parents of preference for 'private' treatment gave hopes for the possibility of routine revisional work for children who continue to attend our centres. It is a matter of concern that many parents who state their wish to have their children treated by their 'private' dentist do not see that the treatment is obtained; at subsequent inspections two out of every three children are still found to be in need of treatment. It is difficult to approach parents and urge provision of 'private' treatment. During 1961 much thought was given to exploring schemes for 'contracting in' or 'contracting out' of the Council's dental services by parents and means of improving the service for those who might 'contract in'. As far as possible, treatment sessions were held out of school hours to meet the wishes of teachers to prevent disruption of school instruction but staff response was low. With the same object in view, treatment centres were kept open during school holidays but attendance was lower than for school time sessions. 87 Table (i)—Staff and sessions 1957 1958 1959 1960 1961 Dental officers Number employed (i) full-time 44 42 35½* 36½* 36½* (ii) part-time 74 97 94 84 72 Total 118 139 129½ 120½ 108½ Full-time equivalent (i) School service 65.7 72.5 64.4 64.6 60.9 (ii) M & CW service 6.8 6.3 6 4.9 4.8 Total 72.5 78.8 70.4 69.5 65.7 Establishment (temporary) 95 95 95 95 95 Weekly sessions School service (i) by full-time dental officers 460 437 364 373 361 (ii) by part-time dental officers 263 361 355½ 337½ 308½ Total 723 798 719½ 710½ 669½ M & CW service (i) by full-time dental officers 46 41 29 31 32 (ii) by part-time dental officers 29½ 28 37½ 22½ 20½ Total 75½ 69 66½ 53½ 52½ Grand Total 798½ 867 786 764 722 * '½' full-time officer accounted for by appointment of half-time Assistant Chief Dental Officer Table (ii)—School dental service: Attendances and treatments 1957 1958 1959 1960 1961 Number of inspection sessions held at schools 1,354 1,952 2,177 2,473 2,514 Number of children inspected at schools by dental officers 120,440 196,573 215,637 244,630 246,803 Number found to require treatment 91,868 144,050 152,131 165,439 161,277 Percentage requiring treatment 76.3% 73.5% 70.5% 67.6% 65.3% Additional number inspected at centres 56,598 36,067 27,576 23,229 19,778 Total number found to require treatment 148,466 180,117 179,707 188,668 181,055 Total cases treated 102,568 97,300 82,448 77,781 69,470 Attendances 308,862 298,342 267,781 256,983 237,411 Ordinary treatment sessions 31,841 31,322 29,637 29,006 28,060 General anaesthetic sessions 1,594 1,431 1,180 1,049 922 Temporary teeth extracted 69,247 58,223 46,461 42,343 35,286 Permanent teeth extracted 18,273 19,342 14,973 14,467 11,072 Temporary teeth restored by fillings 45,509 40,994 39,861 38,164 37,533 Permanent teeth restored by fillings 117,148 122,558 110,934 109,586 100,755 Fillings in temporary teeth 48,477 43,176 42,656 40,996 40,350 Fillings in permanent teeth 131,071 136,811 125,053 124,821 115,294 Other operations: temporary teeth 58,021 54,884 49,109 43,889 38,682 permanent teeth 64,675 64,995 61,835 63,835 57,641 Local anaesthetics for extraction 14,404 13,320 12,354 12,165 9,919 Local anaesthetics for conservative treatment 10,718 13,964 11,667 13,082 12,844 General anaesthetics 34,019 30,861 24,367 21,753 18,101 Cases for whom immediate treatment was completed 10,415 10,566 9,414 8,407 5,317 Cases discharged as dentally fit 71,260 66,990 54,474 50,584 45,003 88 Table (iii)—School dental service: Average number of permanent teeth restored for each permanent tooth extracted 1952 3.86 1953 4.69 1954 5.32 1955 7.39 1956 6.50 1957 6.41 1958 6.34 1959 7.41 1960 7.57 1961 9.10 Orthodontics Reference to orthodontic centres continued, as in former years, to be limited by the relatively small numbers able to be accepted—about 800 patients—only a fraction of the discernible malocclusions in a school population of nearly half a million. Table (iv) shows a slight improvement, however, in 1961 compared with the preceding year. Table (iv)—School dental service: Orthodontic sessions 1957 1958 1959 1960 1961 Number of special orthodontic sessions 321 282 229 237 254 Number accepted at special orthodontic sessions 108 199 138 152 171 Number accepted at routine sessions 403 474 371 401 470 Number referred to hospitals 158 186 279 154 154 Total number of patients accepted or referred 669 859 788 707 795 Maternity and child welfare dental service For another year this service was kept at about 10 per cent. of the total dental services available. During the year new legislation, the National Health Service Act, 1961, exempted expectant and nursing mothers from the standard National Health Service charges for dental appliances. The local health authorities' dental service, under Part III of the Act of 1946, thereby ceased to be the only 'free' source of treatment for these patients and in consequence attendances fell. Many mothers also express preference for 'private' treatment. Staff fell by the equivalent of one full-time dental officer. Tables (v) and (vi) show the work done during the year. Table (v)—Maternity and child welfare patients: Attendances and treatments 1957 1958 1959 1960 1961 Number of sessions 3,293 3,135 2,764 2,592 2,300 Number of appointments offered 36,636 34,740 30,456 27,368 23,864 Attendances—by appointment 26,006 24,691 21,995 19,651 16,500 —other 1,717 1,539 1,122 1,060 894 Silver nitrate treatment 5,423 5,065 4,415 5,858 5,718 Fillings 11,310 11,491 10,031 8,716 7,399 Extractions 7,809 5,873 5,114 4,513 3,624 Dentures supplied—new full 508 422 380 351 327 —new partial 820 685 649 468 485 Number made dentally fit 6,010 5,014 4,784 4,165 3,255 89 Table (vi)—Breakdown of table (v) separating nursing or expectant mothers from children under five—1961 Total Nursing or expectant mothers Children (under 5) Number of sessions 2,300 — — Number of appointments 23,864 14,036 9,828 Attendances—by appointment 16,500 9,231 7,269 —other 894 313 581 Silver nitrate treatment 5,718 832 4,886 Fillings 7,399 3,941 3,458 Extractions 3,624 2,650 974 Dentures supplied—new full 327 327 — —new partial 485 485 — Number made dentally fit 3,255 1,279 1,976 Dental service in boarding schools and residential establishments There was little change in this field and it is still not possible to provide the level of service desired at these establishments. At all, however, some form of dental supervision and treatment was continued. Heads have authority to employ the services of local practitioners in cases of urgency. School for dental auxiliaries In 1960 a development of some importance was the establishment of a training school for dental auxiliaries conducted under the aegis of the General Dental Council. The Council is co-operating in this experiment. During the year some 25,000 children attending schools in the neighbourhood of the School for Dental Auxiliaries, New Cross were available for inspection by dental officers of the training school. The parents of children found to need dental treatment at these inspections had the choice of making 'private' arrangements, sending their children to the children's clinic at the School for Dental Auxiliaries or to one of the Council's dental surgeries. The nature of the treatment that can be given by dental auxiliaries is limited under the Dental Auxiliaries Regulations, 1961 and the Council seconded a full-time dental officer appointed to the Council's service for duty at the School for Dental Auxiliaries to undertake dental work beyond that permitted to the trainee dental auxiliaries. 90 STAFF The following statement shows the number of staff employed in the Public Health department at the end of the year (part-time staff are expressed as whole-time equivalents). The principal officers of the department at that date are shown in Appendix F. Types of staff Location Total Central office Divisional offices and establishments (a) Other establishments (b) Administrative and clerical (including ambulance control clerks) 232 640 78 950 Medical officers (c) 32 158 — 190 Dental officers 2 64 — 66 Scientific branch staff 34 — 18 52 Inspectors 14 — — 14 Medical auxiliaries (d) 41 154 18 213 Social worker grades (e) 24 350 11 385 Nursing and midwifery staff 10 1,763 242 2,015 Ambulance service operational staff — — 857 857 Manual workers, home helps, domestic grades, telephonists, etc. 9 3,305 21 3,335 Totals 398 6,434 1,245 8,077 (a) Including divisional health offices, home help offices, welfare centres, school treatment centres, training centres for the mentally sub-normal, etc. (b) Including residential schools and nurseries, Welfare department homes, recuperative holiday homes, ambulance stations, outfall works laboratories, central dental laboratory. (c) There are 132 visiting medical officers employed at residential establishments on a part-time basis whom it is not possible to compute in terms of whole-time staff. They have therefore been omitted from the table. (d) Including physiotherapists, speech therapists, dental surgery assistants, dental technicians. (e) Including psychiatric social workers, mental welfare officers, local tuberculosis care organisers, child care organising staff, etc., and workers in allied fields (e.g. home help organisers). Appointments and retirements—On 31 July, Mr. C. R. Geere, Administrative Officer of the department since 1947, retired after 41 years' service, his place being taken by Mr. D. J. B. Cooper, who had been Principal Clerk of Division B of the department. Mr. G. M. Howes was appointed to the latter position on 2 October, on transfer from the Clerk of the Council's department. On 3 March, Mr. A. G. Hellman, Officer-in-Charge, London Ambulance Service, retired on reaching the age of 65, his place being taken by Mr. F. A. Richardson, previously Assistant Officer-in-Charge. Medical examinations—Numbers of medical examinations of staff for various purposes, with the result of the examination, follow: 1957 1958 1959 1960 1961 Candidates fit for appointment 6,286 7,531 7,399 8,252 11,106 Candidates unfit for permanent appointment 285 401 343 250 560 Referrals (ill-health) 7,268 6,719 7,252 8,032 8,156 Permanently unfit to carry out their ordinary duties 245 323 331 418 641 Advice given (without examination) 1,378 1,621 1,595 1,034 1,386 Eligibility for spouse pensions 26 24 29 66 87 Staff casualties 240 315 309 289 863 Candidates for out-county authorities 65 100 111 84 121 Candidates examined for the Council by out-county medical officers of health 77 138 111 102 72 91 Food handlers—During the year 425 food handlers were referred for investigation because they had been in contact with or had suffered from certain infectious diseases. Bacteriological examination was arranged where appropriate. 1957 1958 1959 1960 1961 Contacts 107 137 167 205 118 Ill 270 266 302 419 307 Allowed to resume work after examination or fixed period of exclusion 360 388 451 578 406 Resigned — 9 8 23 16 Excluded from work and referred to own doctor for treatment 17 6 10 23 3 The three cases referred to their doctor had been found to have the following microorganisms: Condition Organism isolated Dysentery convalescent Shigella sonnei Gastric influenza with diarrhoea and vomiting convalescent Salmonella typhimurium Gastro-enteritis contact „ „ Staff training A feature of the year 1961 has been a marked expansion in volume and variety of the department's provision of training facilities for its professional staff. These facilities may be grouped as follows: Short courses and conferences—Some 450 professional staff of the department, from a wide range of services, attended 66 short courses and conferences arranged by outside representative organisations. These figures do not include the attendance of senior staff at conferences as official representatives of the Council. Because of the changes brought about by the Mental Health Act, 1959 and the fact that many new staff were recruited in this field, there was a particular demand for courses on various aspects of mental health. Refresher courses for medical and nursery staff— Regular refresher training, on the basis of attendance at a course of from one to two weeks' duration every five years for medical, health visitor, school nursing and midwifery staff, has continued to be provided through professional bodies such as the Society of Medical Officers of Health, the British Postgraduate Medical Federation, the Royal College of Nursing, the Women Public Health Officers' Association and the Royal College of Midwives. Refresher courses for day nursery staff continued to be provided at the North Western Polytechnic. Training for qualifications—In July, five of the department's social workers completed one-year university professional courses for which they had been granted leave with pay and in September a further five proceeded on leave for the same purpose. In addition, two senior mental welfare officers were granted leave with pay for a pioneer two-year course in general social work at the North Western Polytechnic, set up following the recommendations of the Younghusband Report. The University of London Institute of Education, Battersea College of Technology and the Royal College of Nursing continued to provide theoretical instruction for the Council's health visitor students, 49 of whom were undergoing training at the end of the year. Approximately 40 per cent. (i.e., 198) of the health visitor students successfully trained since 1948 and appointed to the Council's service as health visitors were still in the service at the end of the year. The Council's day nursery students, 190 of whom were undergoing training at the end of the year, continued to receive their theoretical instruction at Wandsworth Technical College, the Borough Polytechnic or the North Western Polytechnic. 92 Evening institute classes—The Council pays the fees for attendance of officers at evening classes when it appears in its interest to do so. During the year 42 health visitors attended courses providing instruction in the care and use of slide, film-strip and cinematograph projectors (which apparatus is in use for health education purposes in child welfare centres) at Goldsmiths' College and Wandsworth Technical College and 99 health visitors attended courses in teaching techniques at Garnett College. An evening institute course of one year's duration leading to the examination for the Certificate of the Examining Board for Dental Nurses and Assistants was completed by 12 dental surgery assistants and a further ten assistants commenced a similar course in September. In-service training—For large numbers of professional officers, training needs can sometimes be met more precisely and at less cost to the Council by courses arranged within the department. During the year this policy has been followed extensively as the following summary shows: A course on recent developments in mental health, consisting of ten evening lectures supplemented by visits to hospitals for the mentally disordered was provided. The course was repeated twice to permit the attendance of most health visitors, social and family case workers and junior mental welfare officers in the department. Altogether, approximately 600 officers (including some social workers from the Education and Children's Officers' departments) attended one of these courses. An advanced course of ten weekly sessions in 'discussion methods' was arranged for 18 selected health visitors. A three-day residential refresher course for 51 day nursery matrons was held in country surroundings outside the county. A course for medical officers in current techniques for the early detection of deafness in young children was provided at the Province of Natal centre on two consecutive Saturday mornings. A four-day course for assistant home help organisers was arranged, talks followed by discussion being given by nine of the department's professional and administrative officers, with a further general session devoted to summing up the course. Short courses for 27 day nursery cooks were arranged at the North Western Polytechnic. 'Post-entry' training for members of the administrative and clerical staff, pursuant to the Council's policy in this respect for all departments, has continued during the year. 93 FINANCE Capital—The total capital expenditure on the health services of the Council in the year ended 31 March, 1961 was £206,739, details of which are as follows: £ Ambulance stations—erection 3,249 Health centres—adaptation and equipment 25,719 Maternity and child welfare centres—acquisition and erection 695 Hostels and training centres—acquisition, adaptation, erection, etc. 177,076 £206,739 Maintenance—The gross cost of the various services in 1960-61—including central administrative and debt charges—and the contributions recovered from recipients of the services were: Service Cost Amount recovered in contributions £ £[/'###] Ambulance service 1,234,655 — Day nurseries 1,056,074 150,053 Domiciliary midwifery service 269,397 — Foot clinics 84,698 * 16,813 General health services (including health education) 66,458 — Health centres 34,279 — Health visiting 410,089 — Home nursing 546,651 — Home help 1,291,517 68,843 Maternity and child welfare 894,413 75,630 Mental health 445,295 16,603 Prevention of illness, including care and after-care of tuberculosis 407,289 10,402 School health 1,079,118 — Vaccination and immunisation 199,907 — 8,019,840 338,344 *Excluding central administration. The net cost of the services, before allowing for Government grant, expressed in terms of rate in the £ was 17d. 94 VISITORS TO THE DEPARTMENT During the year 634 visitors were received through the central office—of whom 426 came from overseas. Individual overseas visitors included the Speaker of the Federal Assembly of Nigeria, a member of the Malayan Parliament, the Ministers of Health for Mali, the Western Province of Nigeria, and Yugoslavia, the Minister of Social Service for the Leeward Islands, the Deputy Director of Health for Western Australia and 56 doctors, two dental officers, nine members of central and local governments, 14 central and local government officers, 35 social workers, 15 nurses, one university lecturer, five teachers, eight journalists, seven speech therapists, one architect, three hospital administrators and 17 students. Parties included delegates from eight countries to a World Health Organisation seminar in medical rehabilitation, a civic party from Zehlendorf, West Berlin, a group of youth leaders from Guinea, 100 delegates to the European Congress of the European League of Societies for the Mentally Handicapped and members of the Fourth Japanese Medical Survey Tour. Altogether visitors were received from 56 overseas countries. Other visitors were received at divisional offices, Woodberry Down health centre, the London Ambulance Service headquarters and the Council's training centres for mentally subnormal children. The health centre was visited by 1,216 people, 211 (including 84 students) from overseas and 1,005 (905 students) from the United Kingdom; the Ambulance Service headquarters received 188 visitors and training centres 767 visitors, including 536 students. Facilities were again provided for medical, nursing and social science students to study the health services. Courses of ten or twenty visits of observation and talks were arranged for 104 post-graduate students preparing for the Diploma in Child Health. Members of the department's nursing staff gave talks to student nurses at hospitals and programmes were arranged to enable 3,892 of these students to gain practical experience. Talks by members of the staff and/or visits of observation and periods of attachment were also arranged for students from the following training centres: Health visitor students Battersea College of Technology Royal College of Nursing Surrey County Council University of Southampton Speech therapy students Central School of Speech and Drama Kingdom-Ward School of Speech Therapy Oldrey-Fleming School of Speech Therapy Speech Therapy Training School of the West End Hospital for Neurology Other students (medical, nursing, teaching and social science) Battersea College of Technology Battersea Training College of Domestic Science King Edward's Hospital Fund for London— Course for Overseas Hospital Administrators National Association for Mental Health North-Western Polytechnic Queen's Institute for District Nursing Royal College of Nursing Royal Institute of Public Health and Hygiene University of London— Bedford College Institute of Education London School of Economics and Political Science London School of Hygiene and Tropical Medicine Queen Elizabeth College Women Public Health Officers' Association 95 REPORTS BY THE DIVISIONAL MEDICAL OFFICERS (A statistical summary of work done in the divisions will be found at the end of this section.) DIVISION 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington Dr. Bertha E. A. Sharpe reports: Diphtheria—Early in the year there was an outbreak of diphtheria involving the Kensington training centre, with places for 100 mentally handicapped children aged from 5 to 15. Although the number of children is relatively small, the centre is attended by severely subnormal children from a large part of North London. On 7 February one of the children was diagnosed as suffering from diphtheria. A medical team immediately examined and swabbed all those attending or visiting the centre, including all staff, meals service personnel and other close or likely contacts. About 60 per cent. of the children had been immunised in the past and were given a booster dose of diphtheria prophylactic. Those not immunised were given a protective dose of anti-toxin and the first of a course of immunising injections. Swabbing was extended to absentees, to all family contacts of those attending the centre, to the older girls attending North Kensington training centre, some of whom shared transport with children from the Kensington centre, and to the classmates of siblings of positive cases. The search for possibly infected children included certain parties and social groups known to have been attended by infected children during the period in which the infection might have been transmitted. Swabbing of the children at the centre continued at 48-hourly intervals. There were 16 clinical cases in all; six in Islington, five in St. Pancras, two in Hammersmith and one each in Paddington, Kensington and Westminster. Unfortunately there were three deaths (all children from Kensington training centre); four clinical cases and nine carriers received hospital treatment, of these one clinical case and two carriers lived in this division. As usual, there was the closest co-operation both with the borough medical officers concerned and with other divisional medical officers, who were notified daily of centre absentees living in their areas. Because of the wide area from which the centre was attended the County Medical Officer of Health informed all general medical practitioners in London of the outbreak. As a result of the publicity which accrued there were increased attendances at immunisation sessions and additional facilities were provided in divisional establishments. During the last two weeks of February 2,412 persons were immunised, as compared with 657 in the corresponding fortnight of 1960. In the course of the investigation health-visiting staff in the division visited some 200 homes and took more than 500 swabs; some 700 swabs were taken in the training centre and about 3,000 were taken throughout the division. Vaccination against poliomyelitis—Instruction was received early in the year that a fourth injection was to be offered to parents for children entering school between their fifth and twelfth birthdays. It was decided that as far as practicable the whole age group eligible should be vaccinated before the summer season when the risk of contracting poliomyelitis is greatest. With the co-operation of heads of schools two vaccination teams visited each school in the division and by the end of the summer term 10,458 fourth injections had been given. 96 Maternity and child welfare services—The mothercraft and home-making classes for North Hammersmith (two) and North Kensington (one) continued their useful function. Attendances were small at one of the Hammersmith classes held in a church hall; there was a marked improvement, however, when this class was transferred to Glenthorne Road welfare centre. Chiropody—An additional fourteen sessions for the priority classes were authorised but it was not possible to utilise all of these before the end of the year, when 93 weekly sessions were being provided. Day nurseries—Following the annual review of day-nursery accommodation it was decided to reduce the number of approved places at Dalling Road nursery by seven to 55 places. The percentage weighting on the register of two other nurseries was increased with the object of securing fuller attendance. Additional creche sessions were instituted at Glenthorne Road, Lancaster Road and St. Quintin welfare centres. School health service—An experiment in holding clinics out of school hours began this year. One special investigation clinic is held every five weeks on a Saturday morning and a vision clinic is held weekly in the evening. Average attendances at the Saturday clinic are not yet as high as those at the morning and afternoon clinics at the same centre (53.7 per cent. as against 70.1 per cent.) but the experiment has been under way for only five months. The average attendance at the vision clinic is 48.3 per cent. as against 59.6 per cent. at morning clinics at the same centre. The evening sessions have only been held since September. These sessions are used mainly for children of secondary school age and are particularly useful for those who are working for examinations. During the year the withdrawal of organisers from vision clinics in school treatment centres was completed. The work is now done by the sister at the clinic and a clerk, the overall supervisory responsibility remaining in the divisional social workers' office. Physiotherapy—On the retirement of the whole-time physiotherapist the Divisional Health Committee decided to discontinue physiotherapy sessions, in view of the alternative facilities available for treatment and a continuing decrease in demand. Mental health—Good attendance at a meeting of general practitioners and social workers, held as part of the divisional activities connected with World Mental Health Year in 1960, encouraged the holding of a meeting in May, 1961 arranged jointly with the Kensington and Hammersmith branches of the British Medical Association. It was held by courtesy of the Physician-Superintendent at St. Charles' hospital, Kensington and eighty-seven people attended, including general practitioners, hospital medical officers and consultants, and psychiatric and other social workers from Banstead and Springfield hospitals and the Earl's Court child guidance unit. Talks by the Superintendent of Downview and Banstead hospitals, a general practitioner and the divisional mental welfare officer on their experience of the working of the new Act and on recent developments were followed by a keen and informed discussion. The meeting provided an excellent opportunity for establishing closer contacts and exchanging views, and it was encouraging to hear that representatives of services and professions so closely concerned with the working of the Act were alert to the difficulties that arose and had so clear an idea of the intentions of the Act and how they might be effected. The part-time services of an occupational therapist, who had previously been employed solely on work with tuberculous patients, were utilised to give instruction and occupation to a house-bound mentally ill person. Although this patient had to return to hospital at the end of the year, two other patients were being given these services with good results. 97 G As part of an experimental scheme for the reception of groups of severely subnormal infants, specially chosen as being likely to benefit from attendance at a day nursery, arrangements were made to set up a unit to accommodate not more than nine such infants at Grove House day nursery. Notwithstanding some difficulty in recruiting suitable nursing staff, the first children were received in October. Difficulty was also experienced in arranging for attendance because of lack of suitable public transport, but it was found possible to give some assistance in this respect and at the end of the year there were eight children on the register, with a daily attendance of four. A rearrangement of the accommodation for the training centres for the severely subnormal in the division was effected. The elder girls, formerly at Branstone Street, North Kensington, moved into the premises at College Park, North Hammersmith, a former welfare centre specially converted for them, whilst the elder boys' centre housed in a church hall was moved to the Branstone Street premises. As a result, each of these centres now has very much better facilities for its work. During the year the girls at College Park training centre took part in a scheme for carrying out suitable work for industrial firms and received the first payment for the work they had done before the Christmas holiday. Liaison with other bodies—The Council continued to be represented on the maternity liaison committee for the Chelsea, Fulham and Kensington hospital groups. Professor McClure Browne of the Obstetric and Gynaecological department of Hammersmith hospital has continued to hold meetings for local general practitioners and the Council's ante-natal medical officers working in the division. Dr. C. W. Kesson, consultant paediatrician of St. George's hospital, has arranged talks for health visitors and for medical officers. The two discussion groups led by Dr. Felix Brown, Medical Director of the Earl's Court child guidance unit, and Dr. Erskine, psychiatrist of the West London Hospital, continue to be well attended by child welfare doctors and health visitors. A meeting of hospital almoners, health visitors, superintendents of district nursing associations, tuberculosis care organisers, home-help organisers, and divisional staff was held; much useful discussion took place on the services provided by the Council which can be of use to persons attending or being discharged from hospitals. Regular meetings were held with the medical officers of health of the metropolitan boroughs in the division. DIVISION 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and the City of Westminster Dr. H. L. Oldershaw reports: Maternity and child welfare—The birth rate in the division continues to increase although it is below the county average. A high proportion of all live-born infants are brought to the infant welfare centre in their first year of life and the percentage of expectant mothers in the division who receive ante-natal care at the Council's clinics is above the county average. Three evening sessions are held for expectant mothers at work who find it difficult to attend sessions during the day. Ampthill Square maternity and child welfare centre, St. Pancras, closed at the end of the year on the expiry of the lease. The clinic activities were transferred to Somers Town and other nearby welfare centres. Day nurseries—The demand for places has continued at about the same level for several years and the level of occupation remains high. 98 Prophylaxis—To ensure that immunisation is completed an intensive follow-up procedure has been instituted and reminder letters are sent to mothers. Following the experimental use of the Paddington hospital syringe service, disposable syringes were introduced during the year and have proved satisfactory. Health visiting—Great demands are still made on the time of the health visitor and the pressure has increased because recruitment has not kept pace with resignations and retirements. Health education—This has formed a feature of the work and is reflected in the high attendance at ante-natal and other educational classes for mothers at the centres. Mental Health—Co-operation with the Tavistock Clinic and welfare centres has been maintained and three mental health education discussion groups are held in the division. These are attended by psychiatrists, psychiatric social workers, doctors and health visitors. The first year of the working of the decentralised mental health services has shown the new organisation has worked well and integration with the other services provided by the division continues. The division has a very substantial share of all referrals in the county under the Mental Health Act, 1959, with a high proportion of cases referred for compulsory admission. Despite the pressure that this branch of work imposes on the mental health team, developments in other fields have taken place. Every chance is seized of contacting other social worker and public health agencies and opportunities for informal case discussions are made available whenever required. The community care service in the subnormal field has been well maintained. A new special clinic for diagnostic as well as supportive work is held by Dr. Alexander at the Harrow Road welfare centre. This clinic has become well established and enables the service to cover far more of the division than was formerly the case. Some expansion of the community care of the mentally ill has been undertaken. In addition to the work of the psychiatric social worker, the visiting of mentally ill patients in their homes is being undertaken by mental welfare officers and it is in this field that future developments are anticipated. A good liaison has been established with the psychiatric clinics of local hospitals and the out-patients' departments of the catchment area hospitals. The importance of the patient's private doctor in matters relating to mental health is clearly recognised in the new Act and divisionalisation has enabled local practitioners to get closer to the mental welfare officers. Many doctors now know the divisional staff personally and are able to use their services freely on an informal as well as a formal basis. Prevention of break-up of families—The work in connection with the prevention of neglect and ill-treatment of children in their own homes has increased greatly. During the year sixty-three families came before the divisional co-ordinating machinery as presenting particularly difficult problems. In addition twenty-seven families have been reviewed on one or more occasions. These conferences are very well attended and many people, both from statutory and voluntary organisations, speak of their value. There are now two full-time family case workers in the division and one social worker is doing part-time case work. The largest number of referrals come from health visitors. More cases, however, are now being referred by outside agencies—including borough council housing departments. 99 G* DIVISION 3, comprising the boroughs of Finsbury, Holborn and Islington Dr. W. G. Harding reports: Phenylketonuria— A pilot survey was conducted to establish the practicability of routine testing of all infants for phenylketonuria and the amount of extra effort by health visiting staff which would be required. The survey was based on two child welfare centres, the Province of Natal, Holborn and East Islington. The children tested were those born during a six months period to mothers resident in the areas of the two welfare centres or who moved into the areas. Testing was by application of paper strips impregnated with reagents ('Phenistix') made available by the manufacturer. Two tests were carried out; the first as early as possible after the tenth day of life and the second about five weeks after the first. Health visitors were told to carry out the tests as far as possible during the course of their normal contact with mother and child at home or in the clinic. Arrangements were made for urine showing a doubtful test result to be retested in a hospital biochemical laboratory. Of 582 births referred to the two centres, tests were carried out on 530 infants. In the Province of Natal centre area 90 per cent. of the first tests were completed by the end of the third week of life and in the East Islington area, a larger and more difficult one, the corresponding figure was 75 per cent. Overall, 36 babies (6.8 per cent.) could not be tested until they were at least seven weeks old and no second test was arranged for them; others left the area after the first test and 458 were available for the second test. Only three doubtful results were found, but on retesting the urines were found to be normal. The majority of the tests were carried out without difficulty, either at home or in the centres, but special arrangements for additional home visits or centre appointments had to be made in some instances. For the first tests 222 special home visits were made and for the second tests 169. Altogether 129 infants out of 530 needed one or more special home visits for the first test and 107 out of 458 needed at least one special visit for the second test, a total of 391 extra visits. A hard core of 85 infants—well below 10 per cent. of all—required between two and eight special visits, amounting to a total of 239. The most frequent reasons for special visits were the absence of a wet napkin or failure to keep an appointment. It was estimated that if all infants born in the county were to be tested once only some 17,000 additional visits would be necessary, equivalent to the time of approximately two wholetime health visitors. With an incidence of phenylketonuria as low as between one in 25,000 to 50,000 and bearing in mind the many other important tasks performed by health visitors, it could be argued that special visits should not be devoted to this sole purpose. Equally it could be argued that, because the consequences of non-detection are so serious, every effort should be made to ensure that no case is missed. A more economical case-finding routine would be the follow-up of families of known cases, comprising not only the testing of live siblings of diagnosed cases but also blood tests of any further siblings shortly after birth. The search on these lines should be extended into the next generation and as far as first cousins. Such selective testing would need a national register of all 'high risk' families, with the attendant problems of exchange of information between authorities concerned. A full account of this pilot screening survey was published in 'The Medical Officer' of 21 June, 1961 (CVI, 51-53). Maternity beds—The difficulties in obtaining maternity beds, especially for patients in social need of hospital confinement, continued throughout 1961 and in many instances beds were secured only through the Emergency Bed Service when labour commenced. Fortunately, the helpful arrangement described in last year's report, whereby the Royal Free hospital allocated ten beds directly to our welfare centres for cases in urgent social need, continued. 100 Mothercraft and home-making class—Since 1957 the Divisional Health Committee had explored the possibility of establishing a mothercraft and home-making class for selected mothers who would benefit from this instruction, but the problem of finding social agencies who could spend time on liaison work in persuading mothers to make regular attendances and to keep the instructor in touch with developments with families could not be resolved, although all the voluntary organisations interested were in favour of the scheme in principle. In 1961, however, the Islington Family Service Unit offered to provide accommodation for a class of about six mothers and to undertake the necessary liaison work. Owing to limited space it was not possible to provide a creche on the premises to mind children of mothers attending the class, but the Health Committee agreed that such children could be looked after free of charge during the training sessions in the nearby Canonbury Place day nursery. The class commenced on 21 November. Mothers attending have all been recommended by intensive caseworkers who introduce mothers to the class at their first attendance, and, when possible, attend with them for the first few visits. The mothers need continuous encouragement to attend and voluntary helpers who collect most mothers in their own cars make an important contribution to the running of the group. Attendances at the sessions varied between six and three mothers. Health education for expectant mothers—The attention of hospitals with maternity units was drawn to health education facilities for expectant mothers available in the Council's welfare centres and an invitation was issued for hospital-booked expectant mothers to attend. A more definite link between the hospital service and welfare centres was developed between the Royal Free hospital and the West Islington and Leage Street welfare centres. A pamphlet setting out the regular mothercraft and relaxation exercise classes in the welfare centres in the division and inviting mothers attending the ante-natal clinic at the hospital to attend the centre nearest their home was issued over the names of the obstetrician and myself. At Leage Street welfare centre a weekly evening session for relaxation exercises and parent-craft teaching was arranged for both welfare centre and hospital patients. Short talks and discussions on understanding childbirth, or relaxation exercises, are followed after a break for tea by parent craft discussions or films and fathers have been invited to take part in some of the latter together with their wives. Attachment of a health visitor to a group practice—From 30 October a health visitor was attached to a group practice in Central Islington. This practice is run by three doctors in purpose-adapted premises. The arrangement is an experimental one and the intention is that the health visitor will be available for home visiting, advice to and health education of all families with children under five years of age on the list of the group practice. All these families are given the option of continuing to attend their welfare centre. The doctors concerned run ante-natal and child welfare sessions and record their findings on the Council's forms. The health visitor assists with these sessions exactly in the same way as in the Council's own centres and also runs a relaxation and mothercraft class on the practice premises. First impressions of the experiment have been encouraging; attendances at clinic sessions have been good and many mothers have expressed satisfaction with the scheme which is likely to strengthen co-operation between the general practitioner and local health authority services. Employment of coloured home helps—The number of coloured residents in the division has been increasing for some years and they now represent a significant proportion of the total. During 1961 a special effort was made to encourage the employment of coloured home helps. They have proved to be able workers and have been found to be popular, both with the households they visit and with the other home helps. In the future, it may be expected that they will contribute in greater numbers to the flow of recruits needed for the home help service. 101 Remedial foot classes—Four remedial foot classes for schoolchildren were started in 1951 and under the direction of Dr. W. K. Steel and with the co-operation of head teachers they had increased to 20 in 1961. They are held three or four times weekly, lasting 15-20 minutes for 12 to 16 children. Teachers who volunteer to conduct these classes attend a course of lectures and demonstrations held by Dr. D. M. Baker at the Physical Education College, Nottingham Place, and Dr. Baker visits the classes at least once a term. A remedial gymnast also visits to help the teachers with any difficulties. Children are usually recommended for the classes by school doctors, but some referrals come from general practitioners. The defects chiefly found are flat feet and valgus ankles, the wrong type of footwear has also to be dealt with, parents being advised on this matter. One term of classes may be sufficient with some children but two or three terms may be required in bad cases. During 1961 the number of children attending the classes was 617; of these 395 were newly admitted to the classes. DIVISION 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports: Woodberry Down health centre—Still further developments in the use of accommodation at the health centre occurred during the year. There are now seven general practitioners practising at the centre, one of the six original practitioners having been joined by a partner. The psychiatric social club now meets weekly instead of fortnightly and provides a varied programme of discussions, films and social activities. The area Children's Office was moved to the centre in March, occupying the accommodation of the former sub-office together with an additional room which was needed to house the increase in staff. The Welfare department's class for the rehabilitation of physically handicapped persons now meets four times a week instead of twice, thus enabling a larger number to attend this popular class. Another activity of the Welfare department, the training class for the young blind, was moved during the summer to a more convenient location in South London. Mental health—The mental health officers' first full year of operations on a divisional basis was completed without untoward incident. The team has settled well and established a good relationship with general practitioners, hospitals and the various social agencies in the area. Nearly 600 cases of mental illness were dealt with during the year and the community care service was developed as fully as possible having regard to the day-to-day pressure of work upon the staff. A new training centre, purpose-built, was opened in Ickburgh Road, Hackney in June to accommodate 120 subnormal children between the ages of 5 and 16 years. Clifton Lodge, a day centre for the rehabilitation of patients recovering from mental illness which accommodates 40 patients, was opened in July, 1960. Initially conventional occupational therapy was undertaken at this centre, but since the beginning of June, 1961 industrial work has been undertaken with the willing co-operation of local firms. This has proved an incentive for regular attendance, as the patients undertaking the work gain financially by the payment of an allowance up to a maximum of three shillings a day. Health education—Meetings of staff involved in health education continued to be held to discuss and co-ordinate the work in this field and to select topics for monthly publicity efforts. Local maternity liaison committees—These were established in 1960 by both hospital management committees of the hospitals providing maternity beds in the division. A health visitor attends the Bearsted Memorial hospital weekly to see the mothers during the lying-in period and some of the patients who are confined at this hospital attend the Woodberry 102 Down health centre for ante-natal care and mothercraft instruction. There have been four meetings during 1961 of the Hackney Group liaison committee. Chiropody—The shortage of chiropodists limited the number of sessions held during the year to an average of approximately 71 a week. The number of sessions held at the Salvation Army Goodwill Centre in New North Road was increased from two to four weekly. Occasional crèches—These continued to be held at six centres. Premises—Facilities at Hoxton school treatment centre, other than the dental service, were transferred to the Shoreditch health centre in preparation for the conversion of the building for use as a child guidance clinic. In June, the Hackney training centre in Ickburgh Road was opened and in December the Clapton training centre closed, the girls being transferred to the Bethnal Green training centre. Prevention of break-up of families—There were five meetings of the divisional co-ordinating committee and fourteen intermediate case conferences at which 47 families were discussed. As in 1960 the largest number of requests for discussion of families came from the Housing department which referred 25 cases, 24 of these on account of rent arrears which might lead to eviction. Special investigation clinics—New attendances decreased very slightly as compared with 1960. The number of obese children referred was approximately 17 per cent. of the total. The ring-a-bell alarm apparatus for cases of enuresis continues in use. Loan of equipment—The demand for home nursing equipment continues and during the year under review 138 commodes and wheelchairs were issued on loan, in addition to various other items such as mattresses, hospital beds, quadruped walking sticks, etc. A further eight fireguards were also loaned to necessitous households, making a total of 22 fireguards on loan at the end of the year. DIVISION 5, comprising the boroughs of Bethnal Green, Poplar and Stepney and the City of London Dr. G. O. Mitchell reports: Divisional co-ordinating committee—Four meetings of the committee and twenty-four intermediate case conferences were held during the year; the latter included two meetings held for a review of families with children under five years of age visited currently by the N.S.P.C.C. Nearly eighty cases were considered, the largest group (20) being those referred for persistent non-payment of rent; four of these were referred by a metropolitan borough and 16 by the Council's Housing department. Eight new families were referred to the case workers in the division and five of these, in addition to 11 families referred in 1960, were visited regularly. A further seven new cases were referred by the committee to the Family Service Unit and their case workers visited these. Mental health—The divisional special advisory clinic for mentally-backward children under five years of age was attended by 38 children, of whom 13 were present for the first time. During the year 633 patients were referred to the mental welfare officers for investigation, of these 343 were admitted to psychiatric hospitals, 63 being over 70 years of age. Arrangements for a number of informal admissions were made by general practitioners direct with the hospitals concerned; for patients admitted under certificate there was a satisfactory liaison between the general practitioner, the consultant and the mental welfare officer. 103 Aged patients continued to present the greatest problem as so many of them were in a physically bad condition as well as being mentally ill. The psychiatric social worker gave intensive case work to 69 patients. Educationally subnormal children, particularly school leavers, were encouraged to join clubs and recreational institutes. Six children visited the home at Seaford opened recently by the 'Buckets and Spades' Society; no charge was made to the Council and the children were given every possible care by the matron of the home and the voluntary helpers from the Society. Recuperative holidays were arranged for many patients who were mentally ill. The Bethnal Green training centre closed on 9 June, 1961, in order that the premises could be adapted for an elder girls' training centre together with a special care unit for junior children. The new centre was due to open early in 1962. Prophylaxis—In May a fourth poliomyelitis injection was introduced for children about to enter school and for schoolchildren between the ages of five and eleven years. All eligible children living or attending school in the division were offered the fourth injection during June and July; all seventy-six primary schools in the area were visited by poliomyelitis teams during the last six weeks of the summer term. Health education—At two welfare centres film shows were held during the evenings, for which special invitations were sent to expectant mothers and their husbands. The response was gratifying and the highest attendance on any one evening was 46. Ante-natal services—In order to improve liaison, arrangements were made for a member of the health visiting staff to attend the weekly ante-natal booking clinic held at St. Andrew's hospital. This arrangement has worked very successfully. Day nurseries—In December, Old Church Road day nursery, Stepney, was closed. The premises are again to be used as a nursery school. The parents of children accommodated in the day nursery were offered alternative placings in other nurseries in the division. Bathing centres—The sole remaining ad hoc bathing centre was closed on 30 March and bathing facilities on a reduced scale were provided elsewhere. The number of schoolchildren needing cleansing at bathing centres continued to fall considerably; in 1961 there were 217 cases compared with 673 in the previous year. DIVISION 6, comprising the boroughs of Deptford, Greenwich and Woolwich Dr. F. R. Waldron reports: Accommodation—As an addition to divisional headquarters, premises at 74 Deptford High Street were occupied in February. These house the divisional mental health team, the Deptford home help office and a food sales point. The 'shop window' is used for topical displays by health visitors who form the divisional health education group. Maternity services—Despite co-operative efforts in applying priorities, the demand for maternity beds increased during the year, especially in the Greenwich and Deptford districts. Inevitably, some cases were referred to the Emergency Bed Service. Both maternity liaison committees in the division have discussed this problem at their meetings. Fifteen general practitioner obstetricians in the Woolwich and Greenwich district continued to attend ante-natal centres. In December steps were being taken to offer similar facilities to doctors in Deptford and to extend the facilities in the Greenwich, Eltham and 104 Woolwich areas. Although the formation of such schemes is not without difficulty, it is evident that they form the best available basis for team work in the supervision and care of the maternity case. Mental health—It became possible in February to accommodate the mental health team close to divisional headquarters. Although staff shortages have, until recently, slowed down expected progress, great strides have nevertheless been taken. The increasing number of persons coming under community care reflects in some measure the case work dealt with. In addition, excellent contact has been made with family doctors, consultants, and statutory and voluntary social workers in the area. The team has integrated at all levels with the existing divisional staff. Special 'mental health' groups were established at the beginning of the year in Woolwich, Eltham, Greenwich and Deptford. Each was composed of health visitors, social workers and doctors under the leadership of a consultant psychiatrist. They met periodically to discuss problems arising in the mental health field with emphasis on community care and prevention. Poliomyelitis vaccination—A great effort on the part of divisional health staff and colleagues in the education service resulted in the majority of the 5-11 years old age group receiving their fourth injection before the summer holidays. Diphtheria—A case living in Camberwell and attending a Deptford school was found just before the summer holidays. Fifteen carriers were discovered and removed to hospital. In September it was found that the carrier state had recurred in one child and further treatment was required. It is felt that the fact that no overt case resulted could be attributed to the high degree of immunity in the local child population. The intensive investigation required by this incident reflects great credit on the school medical and nursing staff and the district health visitors. Every co-operation was given, as usual, by the heads and staffs of the schools involved and the borough health department. The Devonport and Public Health laboratories had to deal with and report upon up to 600 swabs on several occasions at short notice. Chiropody—Considerable difficulty was experienced during the year in maintaining the divisional chiropody service in the face of an acute shortage of chiropodists. While every effort was made to deploy available staff in such a way as to secure an even geographical spread of the service throughout the division, some reduction in the number of weekly sessions was inescapable. Although the temporary suspension of sessions at certain centres inevitably resulted in increased waiting lists, the staff continued to make every effort to meet the special needs of persons in the priority classes. Occasional crèche—In response to what appeared to be a reasonably strong local demand, an occasional crèche was opened on 19 April at the Creek Road welfare centre, Greenwich. Attendances at the creche have, however, been much lower than anticipated and efforts continue to be made to stimulate mothers living in the locality to take advantage of the facilities available. Prevention of break-up of families—The co-ordinating committee continued to meet regularly to consider policy and subjects of common concern as well as measures to help particular families, the allocation of social case workers and of specially trained home helps. In addition, 28 intermediate case conferences were held, at which a number of departments of the Council and the majority of other statutory and voluntary agencies in the area took part to a greater or lesser degree. Voluntary workers—On average nine voluntary workers assisted each week at various infant welfare sessions; I am most pleased to acknowledge their generous service. 105 DIVISION 7, comprising the boroughs of Camberwell and Lewisham Dr. Ann Mower White reports: Premises—The South East London General Practitioners' Centre was opened officially on 16 February, 1961, in adapted premises in part of the Queen's Road Centre, St. Mary's Road, S.E.15. The Bellingham welfare centre, opened in September, 1960 in the Estate Community Centre, Bellingham Green, S.E.6, attained some publicity in the local press. Initial attendances were poor and the possibility of its discontinuance was raised in the Divisional Health Committee early in the year. Representations for its retention were made in the local press and by the end of the year attendances had sufficiently improved to justify continuing the centre. It was regrettable to note an appreciable increase in unauthorised entries to centres and day nurseries. Such entries used to be frequent in the early post war years, when short supply foodstuffs were an attraction; of late they had become rare. During the year there were ten entries, mainly into nurseries. There were minor thefts, probably the work of juveniles, and in two instances wanton damage of foodstuffs and materials. The police investigated each entry. Diphtheria—An outbreak of diphtheria centred in a school in North Camberwell had commenced in mid-December, 1960, as described in my report for that year. Home swabbings had been carried out for the pupils of the two classes affected; in the New Year swabbings were extended to cover other pupils from the school and special immunisation sessions were held at the school during the holidays. When the school reopened, swabbing and immunisation was continued systematically, over 950 injections being given. Further positive carriers were discovered and their contacts were followed up in conjunction with the borough medical officer of health. Two other schools were involved through contacts but they produced only one further positive swabbing, which was non-toxic. Precautions were taken with all pupils discharged from hospital to ensure that they showed a further negative swab result before returning to school. In all, 37 children were admitted to hospital, of whom 13 were clinical cases. As previously reported, the organism (C. diphtheria mitis) that caused this outbreak produced some severe attacks of the classical type, and one little girl aged seven years died on 7 January, 1961; she was unimmunised. The outbreak received much publicity in the press, radio and television news; as a result attendances at immunisation sessions throughout the division increased considerably. There was a further mild outbreak among the pupils in the nursery class and infants department of the same school, which lasted from 1-24 July, 1961. The divisional staff carried out swabbings and immunisation at the school and the borough council took similar action with home contacts. A further outbreak caused by a different type of organism made itself known early in May, 1961 in a school in the Dulwich area of Camberwell, the same routine of swabbing and follow-up was operated as in the previous outbreak. Because of a home contact, a class at a senior girls school in Peckham was also swabbed. Five cases of diphtheria were reported—two pupils at the original school, one senior girl contact, one parent contact and one pre-school child contact. None proved serious. There were also 14 carriers. The incident was closed early in June, 1961 when all swabbings had produced two negative results. Day nurseries—The number of places at Shaftesbury House day nursery was reduced from 50 to 35. The upper floor was thus released for use by young subnormal children, as described below. At the other nurseries there has been a consistently high level of occupation. The pressure has been felt particularly in the four Camberwell nurseries and proposals are in hand to increase their accommodation, as part of the replacement schemes for Peckham Park Road and Wyndham Road nurseries. 106 Occasional crèches—There has been a steady growth in this service and good use has been made of the sessions provided. Eleven sessions are held in six premises, three of which are rented. One new creche was opened during the year. Chiropody—Growth of the service has been limited by the supply of chiropodists. Although the full establishment of 66 sessions was not attained, there was sufficient recruitment to enable an experimental re-arrangement of sessions to be introduced at the end of the year at the Sangley Road foot clinic, Catford on the following lines: Old New 9.30 a.m.—12.30 p.m. 8 a.m.—11 a.m. 2 p.m.—5 p.m. 11.30 a.m.—2.30 p.m. 5.30 p.m.—8.30 p.m. 3 p.m.—6 p.m. 6.30 p.m.—9.30 p.m. The object is to enable more sessions to be worked at each clinic. Enquiries from the public suggest that there are many who welcome the earlier morning and lunch-time sessions, which fit in with their shopping and other activities. Health education—A planned programme of health education activities was carried out at centres and schools, and talks and lectures were given to interested bodies, e.g. parentteacher associations. A small exhibition was staged at the divisional office to stress the causes of home accidents and means of prevention. The exhibits were prepared by the divisional health education team, supplemented by material loaned by the Gas Board and an insurance company. About 200 people attended. Prevention of break-up of families—The work of the divisional co-ordinating committee increased during the year, as did the number of families referred to the intermediate committee. The families with heavy arrears of rent provided the greatest number of those referred; these had been notified both from the London County Council and borough council housing departments. Two full-time and one part-time case workers were allocated to the division in November; between them they undertook intensive work with 17 families. Mental health—The services which devolved on the division late in 1960 continued to be absorbed and much development took place, both in the emergency arrangements for the mentally ill and in the community care for the subnormal and mentally ill. A mental welfare officer attends the psychiatric day hospital, St. Olave's hospital, Bermondsey, to assist in the co-ordination of the hospital and local authority social work for patients who attend from Camberwell and Lewisham. Dover Lodge hostel for mentally subnormal girls was closed from May until July owing to the resignation of the warden. The six resident girls were dispersed to residential work, other hostels and lodgings. With the appointment of a new warden, a new intake of girls was admitted gradually. All are in employment. Their leisure is well organised to include attendance at local evening institute and church activities, where they participate in dressmaking, 'keep-fit', dancing and badminton. Special features of the training centres for subnormal pupils were the opening of an experimental holiday play centre at the Lewisham centre, at which permission was also given for the holding of a weekly evening club for 20 young persons under the aegis of the Lewisham Society for Mentally Handicapped Children. The friendly interest of local residents in the pupils manifested itself in a number of gifts of money to be used for outings and special equipment. The division co-operated in the Health Committee's experiment to provide, in association with a day nursery, for the care of severely subnormal infants under five years of age. A vacant floor was brought into use at Shaftesbury House day nursery, for up to nine infants. These were specially selected by a medical officer from the County Hall mental health section, on the recommendation of the divisional medical officer after consultation with the health visitors and mental welfare social workers. Eight children were admitted for a six months' experimental period. The early weeks of the scheme showed promise that it was meeting a real need of the parents and that the children themselves were responding to the care provided. 107 DIVISION 8, comprising the boroughs of Bermondsey, Lambeth and Southwark Dr. W. H. S. Wallace reports: Maternity and child welfare—The maternity and child welfare clinics have continued to be well attended. Increasing demands for help from families with social and domestic problems have thrown a heavy burden on health visiting staff. The rising birth rate and the increase in the number of immigrants have resulted in much extra work for the centres and a greatly increased demand for maternity beds. The home conditions of the immigrant population in particular are frequently poor and home confinements are not possible. The hospitals have been most helpful and, in spite of heavy pressure, have managed to find beds for all mothers requiring hospital confinement on medical or social grounds. Day nurseries—The demand for day nursery accommodation remains about the same as last year. There has, however, been a considerable increase in the demand for the occasional crèches that have been provided at some of the welfare centres. Additional sessions were provided at the Barley Mow and St. Anne's centres and a new creche was opened at the Rose McAndrew centre during the year. Infectious diseases—Three cases of diphtheria occurred in schoolchildren in Bermondsey during the year. Bacteriological tests were carried out on all the children in the schools concerned and the immunisation campaign was carried on intensively. No further cases were traced. School health service—The health of schoolchildren has remained good and the incidence of minor ailments has continued to decline. A further decline has taken place in the incidence of rheumatism. Attendances at rheumatism supervisory sessions have been dropping steadily in the division for some years and during 1961 only one new case was seen. As it was no longer necessary to maintain a supervisory session, as such, at St. Thomas' hospital the session is now working as a general investigation session, on the lines of special investigation clinics in other parts of the division. Special efforts have been made to ensure that all children with any defect of hearing are discovered and that every provision is made for them. There are at present 124 children on the deaf register and these cases are regularly reviewed. A treatment organiser attends the hearing aid distribution centre at St. Thomas' hospital. Mental health—The mental health team has made a satisfactory start in the development of services for the mentally disabled, though progress has been tempered to the staffing position for much of the year. There has been a steady rise in the number of people referred and the 3,778 visits and interviews undertaken indicate the effort made by a small staff to meet the needs of the community. A psychiatric social worker joined the team for three months and this enabled the division to start a closer working relationship with the day hospital at St. Olave's hospital. The mental welfare officers have been much encouraged by the helpful co-operation they have received from general practitioners and the medical staff of the area mental hospitals and out-patient clinics. The Institute of Social Psychiatry opened another rehabilitation centre in the division, Crossways, and the West London Mission opened St. Luke's Hostel, Wincott Street, S.E.11 for the after-care of alcoholic patients. Co-ordinating committee—The co-ordinating committee continued to do valuable work. The number of case conferences continues to increase annually, reaching a total of 57 during 1961. These conferences have proved most valuable in co-ordinating the work of those visiting the homes and agreement on the designation of a key worker has frequently helped to eliminate multiple visiting. 108 DIVISION 9, comprising the boroughs of Wandsworth and Battersea Dr. J. T. R. Lewis reports: The work of the division has proceeded normally throughout the year and we seem to have been as busy as ever. My colleagues and I never seem to be short of problems but it is difficult to convey accurately the extent, variety, and not seldom the complexity of the work. The following somewhat bare recital instances some, but by no means all, of the non-routine matters dealt with in 1961. Premises—In conjunction with the modernisation by Battersea Borough Council of Chatham Hall, a separate annexe was built to provide a doctor's room and waiting room for the welfare centre conducted from the main hall. This has improved the facilities at this busy centre. Diphtheria—Shortly after the commencement of the Easter holidays, a boy from Falconbrook Infants' school, Battersea, was diagnosed as suffering from diphtheria. A second case and 37 carriers were discovered later. The process of swabbing all contacts was made much more difficult because of the school holidays, but nevertheless was successfully carried out from six schools. On one of the peak days over 500 children and adults each had two swabs taken and 363 persons received either a primary or booster injection of diphtheria antigen. Prophylaxis—To enable eligible children aged 5-11 years to receive a fourth injection of anti-poliomyelitis vaccine before the summer holidays a special programme was organised and 7,524 children were inoculated. Maternity and child welfare—An occasional crèche was opened for one session a week at William Harvey centre on the Ashburton Estate, Roehampton. Bathing centres—Due to the general improvement in the standards of health education and hygiene and the issue of Lorexane shampoo for use in the home, the number of attendances for cleansing at the two bathing centres in the division dropped from 2,147 in 1959 to 1,123 in 1960; in consequence cleansing sessions were reduced by five a week. Mental health services—In the first full year's working since the Mental Health Act, 1959 came into operation, community care began to expand in a variety of ways. In April, a social club on one evening a week was opened for psychiatric patients either discharged from a mental hospital or who might, with sufficient domiciliary support, be discharged. The meetings give opportunities of discussing difficulties in an informal, friendly atmosphere with a psychiatrist and one of the Council's social workers. The success of this venture has been outstanding and it undoubtedly is a pioneering effort which may well prove to be one of the most fruitful ways of helping the mentally disordered in the community. A scheme was started in February with the object of giving occupation and instruction in their own homes to mentally ill persons. To some younger patients this can be a step to a psychiatric club or rehabilitation centre and then possibly to employment. The more elderly patient has been helped towards a more normal life in the community. This small incipient service, consisting of three sessions a week, has been welcomed by hospital doctors and general practitioners. Clapham industrial training centre was opened in April with accommodation for over 100 men and boys. Balham training centre, vacated by the older boys who were transferred to the Clapham centre, was modified and improved to provide occupation and training for 60 older girls and women formerly using a centre held in a church hall. 109 Liaison with general practitioners and hospitals—Close association has been fostered in all aspects including case work and two specific measures of co-operation may be instanced. A session in the programme of the local division of the British Medical Association, held at a welfare centre, was devoted to the community care of the mentally disordered. About 50 general practitioners and consultants met members of the divisional health team. Secondly, arrangements were made for the Council's social workers to attend the fortnightly clinical conferences held at Tooting Bec hospital. A weekly clinic conducted by a psychiatrist from Tooting Bec hospital for out-patient treatment of the mentally ill was started at Putney health centre in January. Staff— Dr. T. A. Plumley joined the division in March as deputy divisional medical officer. 110 Statistical summary 1961—health divisions Health division 1 2 3 4 5 6 7 8 9 Total Health division 1 2 3 4 5 6 7 8 9 Total Estimated population—mid 1961 437,080 490,680 280,710 255,890 208,650 300,310 394,890 360,000 451,770 3,179,980 Foot clinics Births and associated mortality Sessions 4,238 1,040 4,022 3,671 291 6,586 2,526 3,965 1,866 28,205 Live births 8,147 8,349 6,292 5,631 4,082 4,877 7,176 7,519 7,979 60,052 Total attendances 30,690 6,622 27,466 26,789 2,022 51,203 15,097 24,481 12,418 196,788 Rate per 1,000 population 18.6 17.0 22.4 22.0 19.6 16.2 18.2 20.9 17.7 18.9 Deaths under 1 month 118 140 106 97 75 75 99 117 126 953 Day nurseries Rate per 1,000 live births 14.5 16.8 16.8 17.2 18.4 15.4 13.8 15.6 15.8 15.9 Number of places at 31 Dec. 634 975 349 379 275 55 279 634 437 4,017 Total attendances 133,151 219,866 79,380 86,209 56,467 12,349 62,466 146,786 89,889 886,563 Deaths All ages 4,964 5,707 3,185 3,004 2,542 3,337 4,640 4,438 6,098 37,915 Child minders Rate per 1,000 population 11.4 11.6 11.3 11.7 12.2 11.1 11.8 12.3 13.5 11.9 Statutorily registered 31 Dec. 37 13 21 15 7 48 40 2 27 210 Children minded (authorised no.) 127 81 99 58 18 276 213 18 198 1,088 Health visiting Voluntarily registered 31 Dec. 143 143 105 71 50 120 124 90 15 861 Effective visits 108,197 117,810 67,381 58,848 59,477 76,634 93,645 108,367 76,450 766,809 Children minded 183 146 127 87 55 139 127 106 23 993 Staff at 31 Dec. W/T equivalents 47 57 39 43 31 38 53 51 54 413 Home help Welfare centres Households attended 4,392 4,793 3,040 4,478 3,036 3,661 5,686 4,666 4,794 38,546 Children— Households attended per 1,000 population 10.0 9.8 10.8 17.5 14.6 12.2 14.4 13.0 10.6 12.1 Sessions 2,787 3,899 2,740 1,737 2,063 2,874 2,987 3,151 2,591 24,829 Total attendances 88,341 121,968 80,804 66,125 59,431 83,503 96,747 98,637 111,600 807,156 Age 0-1: first attendances % of live births 86 92 91 88 86 96 92 88 97 91 Home nursing Total visits 212,902 229,666 135,698 127,226 117,802 190,461 199,685 206,582 181,838 1,601,860 Expectant mothers— Visits per 1,000 population 487 468 483 497 565 634 506 574 403 504 Sessions 1,587 1,614 1,200 368 330 1,373 1,650 644 749 9,515 First attendances 4,377 5,266 4,287 1,794 648 3,107 3,107 2,703 2,271 27,560 School health service % of live and still-births 53 62 67 31 16 63 43 35 28 45 Medical inspection, routine, special, reinspection 35,536 30,231 29,031 20,713 27,062 34,585 38,165 29,503 42,169 286,995 Total attendances 21,112 22,954 19,659 8,629 4,993 20,113 17,406 13,361 12,563 140,790 Health surveys 75,890 104,081 50,578 34,017 39,804 98,155 72,766 48,286 86,228 609,805 Prophylaxis Hospital/specialist clinics— Poliomyelitis— New cases 3,913 3,844 3,838 2,697 3,188 3,493 3,834 2,490 4,432 31,729 Two injections Total attendances 8,244 11,088 13,225 6,714 7,363 8,610 9,323 9,087 14,678 88,332 born 1957-61 6,519 6,747 4,879 4,277 3,058 4,293 6,303 6,077 6,011 48,164 born 1943-56 2,592 3,069 2,256 3,165 1,428 1,746 2,696 3,015 2,774 22,741 Dental services born 1933-42 4,069 5,454 2,709 1,973 2,675 2,012 2,533 2,536 2,339 26,300 Schools— born 1932 or earlier and under 40 years 5,013 7,597 3,821 3,203 5,372 3,884 5,254 5,208 4,660 44,012 New cases 7,247 8,451 6,566 11,254 7,502 5,794 6,673 7,934 8,003 69,424 New cases per 1,000 population age 5-14 167 195 190 333 249 131 118 158 133 175 over 40 years 224 815 134 161 43 344 374 67 144 2,306 Total 18,417 23,682 13,799 12,779 12,576 12,279 17,160 16,903 15,928 143,523 Total attendances 26,326 32,517 20,549 33,881 23,348 18,125 22,315 28,802 28,238 234,101 Third injections 13,060 24,289 14,992 11,726 13,759 12,218 16,617 13,538 19,432 139,631 Maternity and child welfare— Fourth „ 10,458 9,989 9,589 10,831 11,101 14,080 13,898 10,945 9,805 98,809 First treatment 656 483 393 948 215 291 190 295 220 3,691 Total attendances 2,957 2,649 3,387 3,858 1,186 1,157 553 853 821 17,421 Smallpox—Vaccinations 4,877 5,597 4,395 3,590 2,010 3,585 5,245 4,280 4,966 38,545 Re-vaccinations 328 861 319 505 181 401 465 351 448 3,859 Diphtheria—Primary course 8,861 8,374 7,113 5,315 4,492 5,906 9,288 9,627 8,882 67,858 Reinforcing injections 11,278 11,265 4,571 5,824 6,811 9,689 11,814 17,548 9,292 88,092 Whooping cough—Primary course 6,749 6,790 5,857 4,595 3,406 4,913 7,524 7,092 7,138 54,064 Reinforcing injections 3,726 2,707 2,225 2,120 1,570 3,650 4,713 2,624 3,576 26,911 Tetanus—Primary course 8,269 7,306 6,330 5,084 4,187 5,423 8,194 7,877 7,628 60,298 Reinforcing injections 4,431 2,948 2,766 2,345 1,974 4,356 5,025 3,470 3,910 31,225 111 APPENDIX A. MENTAL HEALTH IN LONDON IN 1961 AND THE IMPLEMENTATION OF THE MENTAL HEALTH ACT, 1959 Introduction In that part of my Annual Report for 1957 which dealt with the mental health services, particular emphasis was given to the findings of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency which were welcomed by the Council as providing an imaginative charter for a comprehensive mental health service. There was no doubt that the former legislation no longer reflected modern attitudes towards persons suffering from mental disorders and the drastic revision of the whole legislative structure introduced by the Mental Health Act, 1959, which came into operation on 1 November, 1960, underlined the concepts now accepted by many of the general public, as well as by those who are directly concerned with the care of mentally disordered patients, that mental illness and mental subnormality should be regarded in the same way as physical illness and physical disability. The main principles upon which the new Act were based were: (a) that as much treatment as possible, both in hospital and outside, should be given on a voluntary and informal basis; (b) that proper provision should be made for the residual category of care where compulsion is necessary, either in the interests of the patient or of society; (c) that the emphasis in mental care should be shifted, so far as possible, from hospital care to care within the community. The Act provides for the establishment of a comprehensive community care service by local health authorities to meet the needs of all types of mentally disordered persons not requiring hospital treatment. This includes— (a) provision of residential accommodation; (b) provision of centres for training and occupation; (c) exercise of functions relating to persons placed under guardianship; (d) provision of day centres, social clubs, recuperative holidays and short-term care; and (e) visiting and general welfare of patients in the community. In common with other local health authorities, the Council was required, in accordance with Ministry of Health circular 28/59, to submit its proposals for implementing the new legislation. The account which follows gives specific details of these proposals and indicates to what extent it has been found possible, up to the end of 1961, to put them into effect. The present mental health services are also described in relation to the progress which has been made in recent years and reference is made to the tasks which still face the Council. Historical developments Services for subnormal and severely subnormal persons—Social work for persons now classified under the Mental Health Act, 1959, as 'subnormal' or 'severely subnormal' has continued in London since the Mental Deficiency Act, 1913 came into operation, when social workers employed by the London Association for Mental Welfare undertook the supervision of such persons living in the community on behalf of the Council. A nucleus of officers designated as Mental Deficiency Act 'Inspectors' was appointed directly by the Council and was based at the County Hall to carry out initial enquiries for the ascertainment of new cases; to exercise compulsory powers; and to be responsible for the supervision of, and general social work for, persons placed under guardianship. 112 The work of the London Association for Mental Welfare was taken over by the Council in 1930 and the social workers continued to operate from four local offices. The work of the inspectors remained separate and centralised until 1955; these officers were then allocated to the local offices with the object of integrating the social work in this field and a senior organiser with over-all responsibility was appointed. This arrangement, whereby a group of social workers was engaged exclusively on mental deficiency work, continued until the mental health services were re-organised in 1960. The Council recognised that the provision of centres for the training and occupation of mentally defective children and adults living in the community afforded the means of achieving their fullest possible development and social adaptation. Occupation centres (now referred to as training centres) were first provided by the London Association for Mental Welfare, with financial assistance from the Council, in 1923. The Council took over the running of these centres in 1931, when there were 18 small centres providing accommodation for about 300 persons, although only three of these operated on a full-time basis. By the outbreak of war in 1939, when the centres had to close, about the same number of persons were being accommodated in 12 larger centres. It was not possible to start reopening the centres until 1948 and most of the centres then had to be accommodated in hired premises which it was realised were far from satisfactory. The period since 1948 has been one of rapid expansion to meet an increasing demand for places, as well as planning to improve the standard of accommodation in use. By the time the Council's proposals under the Mental Health Act, 1959 were formulated, although much remained to be done, the training centre service had been expanded to provide places for 1,250 persons in 21 centres (including one industrial centre); some of the least satisfactory hired premises had been replaced; some specially adapted Council-owned premises had been brought into use and the first two specially designed centres had been opened. Services for mentally ill persons—Social workers for the mentally ill were employed by the Council in its mental hospitals before the first mental health course for the training of psychiatric social workers was instituted in 1929, following which fully trained social workers were employed in the mental observation wards at the Council's general hospitals and subsequently at the county mental hospitals. When the hospitals were transferred to the Ministry of Health in 1948, under the National Health Service Act, 1946, these social workers were retained in the hospital service. Community care services for the mentally ill were started in 1943, at the request of the Ministry of Health, by the National Association for Mental Health for ex-service personnel who had been discharged on psychiatric grounds. Responsibility for this work, which from 1948 was extended to civilians, was assumed by the Council under section 28 of the National Health Service Act, 1946; the work at first was carried out by the National Association for Mental Health and the Mental After Care Association acting jointly as agents for the Council. In 1953 the Council took over direct responsibility and in 1960, when the mental health services were re-organised, there were five psychiatric social workers, including one senior, working from the County Hall under the general direction of the consultant psychiatrist employed by the Council as its adviser in mental health. Mental welfare officers—The emergency removal of mentally ill persons to observation wards and hospitals was for many years the responsibility of the Boards of Guardians. This work, which was taken over by the Council in 1930, was first performed in the newlyconstituted Public Assistance department; in 1948 it was transferred to the Public Health department, the relieving officers so employed being re-designated as duly authorised officers and transferred to the department to form the nucleus of the staff of mental welfare officers. From then until 1960, these officers were employed almost exclusively on the work of taking the initial proceedings in providing care and treatment for persons suffering from mental illness. Whilst these workers did not come within the category of social worker and although the organisation and nature of their duties precluded continuity of 113 contact with the mentally ill and their relatives, the work called for a high standard of integrity, tact and sympathetic understanding. This work, unrelieved by other duties, made great demands both physically and mentally on the officers concerned. Organisation and staffing Before the Mental Health Act, 1959 came into operation, the responsibility for the Council's mental health services rested with the Health Committee and the services were administered centrally from the County Hall. Mental welfare officers, employed as duly authorised officers under the Lunacy and Mental Treatment Acts, and psychiatric social workers for community care work with the mentally ill were based at the central office under the supervision and guidance of the part-time consultant in mental health. The medical work arising from the operation of the Mental Deficiency Acts was carried out by medical officers on the central staff and the bulk of the social work in this sphere was carried out from four district offices each under the control of a local organiser with the general supervision centrally of a senior organiser. Decentralisation of staff and services—As from October, 1960, the bulk of responsibility for the day-to-day operation of the mental health services was delegated to the nine divisional health committees and the staff of the services then existing were allocated to the divisions. The three categories of mental health worker were thus brought together and a mental health social worker team was set up in each division under the immediate direction of a Divisional Mental Welfare Officer responsible to the Divisional Medical Officer for the day-to-day operation of the local services. A Principal Mental Welfare Officer was appointed to the central staff to supervise and co-ordinate all mental health social work and to act as the chief professional adviser to the department in this field. The remaining members of the team included a deputy to the Principal Mental Welfare Officer, deputy divisional mental welfare officers, senior mental welfare officers, mental welfare officers, assistant mental welfare officers and psychiatric social workers. The background, training and experience of the members of the divisional teams varied widely. A number were qualified psychiatric nurses, others held social science qualifications, some were recruited from other fields of social work and included recruits from other departments of the Council. The bringing together and pooling of this varied knowledge and experience has been invaluable. The Council had been considering for some time the desirability of extending the work of mental welfare officers to include community care. The opportunity was therefore taken to reduce specialisation in the various branches of the mental health services by giving the staff the opportunity to widen the scope of their duties beyond those in which they had particular experience, the ultimate aim being to weld an integrated organisation of social workers within the mental health field. Certain aspects of the work were retained under direct central control where it was clear that provision on a wholly self-contained basis for each division would be uneconomical, e.g. the provision of hostels and day centres. Similarly, a number of medical examinations of mentally subnormal and severely subnormal persons continue to be dealt with centrally, either because they required the services of a particularly experienced medical officer or because they did not fall to be dealt with by a particular division. Responsibility for giving medical evidence to courts in respect of subnormal and severely subnormal or psychopathic patients, for the submission of evidence required by Mental Health Tribunals and for obtaining hospital beds for subnormal and severely subnormal persons was also retained at the centre. As part of the general devolution of responsibilities for the mental health services to Divisional Health Committees, responsibility for the day-to-day administration of training centres, including the maintenance of premises, supplies, the arranging of visits, centre functions and general staff administration passed to the divisional medical officers at the 114 end of 1960. Planning and the formulation of policy, the supervision of training, general control over admissions, the exclusion and transfer of trainees, the allocation of industrial work to centres and the arranging of transport and home teaching were retained as central responsibilities. Under the guidance of a principal medical officer, the training centre service is supervised centrally by the Organiser of Training Centres. The Industrial Manager, whose responsibilities include the obtaining and allocation of industrial work to adult centres, is also based at the County Hall. Supervisory staff at the centres are appointed and allocated centrally, whilst the engagement of subordinate staff and general day-to-day administration is handled divisionally. Staff establishment—In 1961 the Health Committee reviewed the divisional staffing structure which had been agreed consequent upon the reorganisation of the service. It became evident that the staff had been working under extreme pressure as a result of increasing demands. Considerable credit is due to the divisional mental welfare officers and their deputies for the leadership which they showed and to all the staff engaged in this work for their conscientiousness during the difficult time of transition to the requirements of the new legislation and the change-over from a centralised to a locally run service. The Committee agreed (subject to a further review before 1 April, 1963) to increase the establishment by 18 additional positions. The total approved divisional establishment at the end of 1961 was 95; which comprised nine divisional mental welfare officers, nine deputy divisional mental welfare officers, 24 senior mental welfare officers, 15 mental welfare officers (redesignated mental welfare officers, Grade I), 27 assistant mental welfare officers (redesignated mental welfare officers, Grade II), nine psychiatric social workers and two escorts. Recruitment to the grade of psychiatric social worker proved difficult and at the end of the year although there were 11 qualified psychiatric social workers on the staff only four were engaged solely on case work, the remaining seven occupying more senior positions. In 1959 the staffing of training centres followed a formula fixed several years before, namely a supervisor and one assistant supervisor for each 15 (or substantial part of 15) trainees except the first 15, with attendants as necessary, subject to the proviso that the over-all ratio of staff (supervisory and attendants) should not exceed one to ten. A slight strengthening of the supervisory staffing of the larger centres has since been found desirable and in 1960 an additional assistant supervisor for each centre with 100 or more trainees and an extra assistant supervisor for each older girls' centre were authorised. The number of staff employed in the training centre service at the end of 1961 was 134, comprising the Organiser of Training Centres, the Industrial Manager, 22 supervisors, 71 assistant supervisors, 36 attendants and three home teachers. Staff training—The Council's proposals to the Ministry envisaged an extension of arrangements for in-service training, both basic and refresher, for social workers in the mental health services, in conjunction with the recognised training bodies where appropriate and otherwise as necessary. The main object was to broaden the field of interest and activities of the staff in the various aspects of mental disorder and to keep their knowledge up to date. It was also proposed that there should be increasing participation by suitable social workers in general and advanced courses of full-time study. The pressure on available staff in maintaining an expanding service and, in particular, the need to provide sufficient senior officers for duty at the County Hall outside normal office hours to deal with emergency work hampered the efforts made to provide training facilities. Nevertheless, selected mental welfare officers attended all or some part of a series of lectures on mental health organised at the County Hall for health visitors; others attended a 115 H week's intensive course arranged especially for them at Bexley, the Maudsley and Springfield psychiatric hospitals respectively. Weekly conferences held at some of the hospitals afforded good training facilities for staff who could be spared from their normal duties. There was also a number of organised visits of observation to various hospitals. Arrangements were made for some of the more senior officers to attend conferences and residential week-end schools. Three officers attended a three-week course for mental welfare officers and four others attended a special course for social workers for a half day each week extending over a period of about six months. About 24 officers attended evening courses during the year, the Council paying the fees, on such subjects as abnormal psychology, human relations, marriage guidance, casework principles and problems of old age. The policy of seconding suitable officers to full-time courses was continued and during 1961 one officer so seconded completed the Mental Health Course and another commenced. Two officers were also seconded to take the first two-year 'Younghusband' course. Much remains to be done in promoting the further training of social workers in the mental health services so as to equip them to apply constructive casework principles to their work and to give them every opportunity of keeping abreast with new and changing ideas. The continuance of in-service training of the training centre supervisory staff for a recognised qualification and a possible cadet training scheme for school leavers were suggested in the Council's proposals relating to the training centre service, but no action had been taken at the end of the year to vary existing staff training arrangements pending the publication of the report of a sub-committee of the standing Mental Health Advisory Committee on the Training of Staff of Training Centres for the mentally subnormal. Eight members of the supervisory staff successfully completed the two-year part-time course for the diploma of the National Association for Mental Health for teachers of the mentally handicapped which ended in 1961. Thirty-five members of the staff held the diploma at the end of the year. Medical and diagnostic services Since the inception of the Mental Health Act, 1959, the medical services concerned with the diagnosis, supervision and care of the mentally disordered have continued to expand. The increased responsibilities placed on the Local Health Authority, the varying legal procedures to be adopted according to the type of mental disorder from which a patient suffers and the abolition of the Board of Control laid emphasis on the need for accurate diagnosis and specialised medical supervision by doctors specially experienced in this branch of medical practice. The Council maintains a team of medical officers, working full time under a principal medical officer, which specialises in the field of mental subnormality. These specialist medical officers are based centrally at the County Hall and are responsible for the more difficult and complicated clinical work arising from the Local Health Authority's duties under the Act. At the request of the divisional medical officers, they are also available for carrying out diagnostic examinations in the divisions, where the routine medical examinations for mental subnormality and the medical supervision of children and adults at training centres are now carried out. The central medical staff also have responsibilities for carrying out special examinations at the request of the Courts or the Prison Medical Service; for exercising any necessary medical supervision in relation to subnormal persons under guardianship or receiving community care and for undertaking special examinations in difficult cases involving very young children or multiple handicaps. The initial diagnosis of mental illness in adults remains largely in the hands of general practitioners, with the usual facilities for reference to hospital consultants when desirable. 116 The Council's mental health social workers, however, are available to general practitioners for visiting persons suffering from mental disorder and, if necessary, for making arrangements for their admission to hospital, either under compulsory procedures or informally. In my report for 1959 I gave a comprehensive account of the psychological services for children in London, in which references were made to the child guidance services and to preventive mental health work in the maternity and child welfare services. Further reference to these subjects will be found on pages 84 and 49 respectively in this report. Diagnostic clinics—The Royal Commission on the Law relating to Mental Illness and Mental Deficiency urged the need for a diagnostic service for severely subnormal and psychopathic patients and indicated that the initiative in organising such a service should generally lie with local health authorities. Diagnostic clinics have been set up in all divisions in London where parents and relatives of mentally subnormal children can obtain advice and help. These clinics were primarily designed to cater for children under the age of five years, rather in the nature of special maternity and child welfare clinics for parents who, because of their child's obvious mental abnormality, were unwilling to bring them to the ordinary clinic. It was soon evident, however, that the clinics were filling a real need and their number and scope were extended until at present they offer a very similar service to the out-patient department of a hospital, where a patient can not only be diagnosed and the nature and severity of mental disorder explained to the parent but where 'follow-up' examinations can be arranged and the various facilities available for the care, education and training suitable for each individual case indicated and necessary arrangements made. These diagnostic clinics are staffed by specialist medical officers, all of whom are approved under section 28 (2) of the Act as having special experience in the diagnosis or treatment of mental disorder, and are also attended by mental health social workers and health visitors. Facilities for consultation with the senior consultant staff at the County Hall are readily available and consultation with other specialists can also be arranged. Admission to hospital and guardianship The Council's mental welfare officers provide a continuous service, available through the 24 hours of each day, to receive and act upon calls received from general practitioners, hospitals, police, the public, etc. During office hours such calls are received and dealt with divisionally, but outside normal office hours a nucleus of staff is maintained on duty at the County Hall to deal with any emergency arising in the London area. During 1961, 5,750 persons who were alleged to be mentally ill and in urgent need of care and control were referred to the Council's mental welfare officers for investigation, of whom 4,141 were removed to hospital. About one-tenth (550) of the cases were referred between the hours of 9 p.m. and 9.15 a.m., which was less than half of the number referred during those same hours in 1957, when the proportion was about one-sixth of the total cases referred. Not all these cases were so urgent as to require a visit the same night, but of 467 cases visited 346 were admitted to hospital; no immediate action was found to be necessary in the remaining 121 cases. Hospitals serving the area—Only two of the nine psychiatric hospitals which admit mentally ill patients from London are within the county area, i.e. Springfield hospital, Tooting and Tooting Bec hospital. The remaining seven are Bexley hospital, Bexley; Banstead hospital, Sutton; Cane Hill hospital, Coulsdon; Horton hospital, Epsom; Long Grove hospital, Epsom; West Park hospital, Epsom; and Friern hospital, New Southgate. In addition five of the London general hospitals, i.e. St. Clements, St. John's, St. Francis, St. Pancras and Fulham, provide emergency wards for the admission of patients for observation. At the end of the year 210 beds were provided at these general hospitals for such cases and mental welfare officers arranged the admission of 1,442 patients to these wards during 1961. 117 H* There are 21 hospitals which admit subnormal and severely subnormal persons from the county area; two in London and 19 out-county. The Council continues to act as the normal channel for applications for admission to these hospitals, to assist in the assessment of priorities and in the provision of medical and social reports. Such patients are normally received in hospital on an informal basis. Difficulties persisted throughout the year in obtaining beds, particularly for children. The position was aggravated by the closing in July of the Fountain hospital to all children except those living within the area of the South West Metropolitan regional hospital board, although the hospital continued to accept children from other regions of London for short term care. During the year 234 subnormal or severely subnormal patients were admitted to hospital and at the end of the year 148 children under 16 and 47 patients over this age were awaiting admission, of whom 34 were regarded as being in urgent need. The comparative numbers of patients awaiting admission at the end of 1959 were 193 children under 16 and 50 patients over 16, of whom 87 were in urgent need. Informal admission to hospital—Hospital care under the Mental Health Act, 1959 is now available to all mentally disordered persons who are willing to receive it, with no more restriction of liberty or legal formality than applies to persons who need such care because of other types of illness or disability. Patients can be admitted to hospital informally providing they are not unwilling and can be treated suitably without powers of detention. The Council's mental welfare officers are not, of course, concerned with the large majority of informal admissions of mentally ill persons to psychiatric hospitals, but in 1961 about one-fifth of all removals of such patients dealt with by mental welfare officers were arranged informally. Compulsory admissions to hospital—The Act embodies a new code for compulsory admission to hospital of mentally disordered patients; it makes provision for applying compulsion only in the case of such patients who cannot be persuaded to enter hospital voluntarily but for whom hospital care is essential. It is necessary for an application for compulsory admission to hospital under the provisions of section 25 (admission for observation) or section 26 (admission for treatment) to be completed by a mental welfare officer or the nearest relative supported by two medical recommendations. In the case of an emergency admission under section 29, a mental welfare officer or any relative may make the application and only one medical recommendation (made if practicable by a practitioner who has previous acquaintance with the patient) is required in the first instance. During 1961, 903 persons were admitted to hospital for observation under section 25, 116 for treatment under section 26 and 1,841 were the subject of emergency admissions for observation under section 29. The police alone retain the power to remove to a place of safety without a medical certificate any person who appears to be mentally disordered and in immediate need of care or control in a place to which the public have access. Such a person may be detained for not more than 72 hours for the purpose of enabling him to be examined by a medical practitioner and to be seen by a mental welfare officer and of making any necessary arrangements for treatment or care. During 1961 mental welfare officers were concerned in the compulsory removal to hospital of 232 such cases. Power is given to the Courts to make orders for the compulsory admission to hospital or guardianship in respect of certain offenders or children or young persons found to be in need of care or protection or beyond control; provided that the court is satisfied, on the evidence of two doctors, that the offender or child or young person is suffering from mental disorder of a nature or degree which warrants his detention in hospital for medical treatment or his reception into guardianship and that in the circumstances the making of such an order is the most suitable method of disposing of the case. The Council's central medical staff are concerned in the examination and submission of evidence in relation to such 118 persons who are suffering from subnormality or severe subnormality and any necessary reports on the patient's home and social conditions are furnished by the mental welfare officer. During 1961 the Council's staff were called upon to give evidence in the case of 56 adults and 11 children and young persons and were concerned in the compulsory removal to hospital of 167 persons as the result of Court orders. Guardianship—Guardianship of mentally subnormal persons under the Mental Health Act, 1959 replaced (with some differences) the provisions for guardianship under the former Mental Deficiency Acts. A local health authority can now itself act as guardian and guardianship may now also be used as a form of control over mentally ill and psychopathic patients who do not need to be in hospital. Up to the end of 1961 this form of control for mentally ill or psychopathic persons had, however, not been used. In most cases it is possible for mentally disordered persons to receive community care without being subject to the legal control of guardianship over their place of residence and everyday life, but a small number of patients in the community still require control for their own welfare or for the protection of others. The procedure for placement under guardianship follows the same lines as that for securing compulsory admission of a patient to hospital. Applications to the Council for securing care under guardianship are made by the nearest relative or by mental welfare officers and must be accompanied by two medical recommendations (as in applications for admission to hospital), but in these applications reasons must be given why the patient cannot appropriately be cared for without powers of guardianship. The powers conferred are those which would be possessed by the guardian if the authority or the person concerned were the patient's father and the patient was under the age of 14. Guardianship in relation to subnormality or psychopathic disorder is limited to persons under the age of 21 years, but there is no such age limit in the case of severe subnormality or mental illness or in relation to patients who are the subject of court orders. The guardian is required in general, so far as is practicable, to make arrangements for the occupation, training or employment of the patient and for his recreation and general welfare and to ensure that everything practicable is done for the promotion of his physical and mental health. Under the new Act a 'responsible medical officer' was required to review all persons remaining under guardianship on 1 November, 1960, in order to classify under the Act the form of mental disorder from which they were suffering and to decide whether it was necessary for them to remain under guardianship. There were 92 London cases under guardianship on 1 November, 1960, of whom 51 were discharged from guardianship and continued in community care on an informal basis, three were admitted to hospital and 38 were continued under compulsory guardianship. It was decided that, save in exceptional circumstances, the Council should itself seek to undertake the function of guardian in all cases where this form of control was appropriate for mentally disordered persons under its care and that the Council's whole-time medical staff who have been approved for the purposes of section 28 of the Act should be authorised as 'responsible medical officers' in relation to these functions. Such officers act for the Council under the provisions of regulation 24 (1) of the Mental Health (Hospital and Guardianship) Regulations, 1960. Six members of the Health committee were appointed to exercise the power to order the discharge of a patient from guardianship, a power which is also given to the nearest relative. Approval of medical practitioners for the purpose of compulsory removals and guardianship—One of the two medical recommendations required for the compulsory admission of a mentally disordered person to hospital or reception into guardianship must be given by a practitioner approved by a local health authority as having special experience in the diagnosis or treatment of mental disorder; the other certificate is normally given by the patient's general practitioner. Before approving a medical practitioner a local health authority must consult a professional advisory panel for its area (appointed by regional 119 hospital boards); any two members so consulted must be satisfied that the medical practitioner possesses the necessary special experience before the local health authority approves him. Approval of a medical practitioner is for five years only and may be renewed only after compliance with the foregoing procedure. A doctor so approved may act in any part of England and Wales. The advisory panel in London consists of 23 members who, up to the end of 1961, had considered 268 applications of which 246 (including 12 from doctors in general practice) had been approved. Residential accommodation The provision of residential accommodation for certain mentally disordered patients now in hospital and for others who need to be admitted to hospital in the absence of such provision is potentially the most onerous task which the Council faces in developing its mental health services. Whilst recognising its ultimate obligation under the new Act to provide such accommodation for a very large number of persons for whom the special facilities of the hospital services are not essential, the Council decided to proceed with the provision of hostels on a broad basis of priority for certain classes, for whom the need was considered to be particularly marked. An initial programme was formulated on the principle that one hostel of each of a number of types for which a prima facie need existed should be provided; the need for further hostels of each type was to be examined in the light of experience. Considerable assistance in the provision of residential accommodation for elderly mentally infirm persons and for mentally disordered children in care is given by the Welfare Committee (in accommodation provided under Part III of the National Assistance Act) and by the Children's Committee (in homes provided under the Children Act, 1948) respectively. The categories of persons for whom hostel provision is being made in the initial stages through the health services and the progress made by the end of the year towards the implementation of the programme are shown below: (i) Persons discharged from psychiatric hospitals and considered likely to benefit from rehabilitation; other persons needing a period of hostel care to avoid admission to hospital. A large residential property in Putney has been acquired to accommodate 23 persons; the necessary adaptations were in progress at the end of the year with a view to occupation in mid-1962. Work on a similar purpose-built hostel for 60 residents for which a site has been acquired in Lewisham, is expected to start at the beginning of 1963. (ii) Young persons of both sexes leaving residential schools for the maladjusted and needing extra care and guidance. A search for suitable sites, or buildings for adaptation was proceeding at the end of 1961. (iii) Subnormal and severely subnormal children requiring short-term care to avoid hospital admission at times of particular domestic difficulty. Accommodation is to be incorporated in a purpose-built junior training centre for which a site has been acquired in Bermondsey. (iv) Employable subnormal male persons requiring long-term care. Negotiations were in progress at the end of the year for the acquisition of a site in Paddington. (v) Mentally disordered children requiring long-term care but not needing specialist medical treatment or training or continual nursing attention. A search for a suitable site, or building for adaptation, was proceeding at the end of the year. 120 Dover Lodge hostel—The Council established the first hostel of its kind in the country at Dover Lodge, Wood Vale, S.E.23 in 1955. This hostel accommodates up to 13 mentally subnormal girls who, normally, have no homes or whose home background is unsatisfactory. The girls are usually leavers from schools for the educationally subnormal and the hostel serves a useful purpose in training the girls to become self supporting members of the community. Suitable employment is found for them in the locality. During 1961, 18 girls were resident at the hostel and eight remained in residence at the end of the year. Three girls were placed in lodgings during the year; three in resident employment; two in other hostels; one absconded and one returned home. Voluntary organisations—In addition to the direct provision of hostels the Council intends to continue and, where necessary, extend the placing and maintenance of suitable mentally disordered persons in hostels and homes under the control of voluntary associations and with private persons. Use has been made of homes maintained by such voluntary organisations (principally the Mental After-care Association) for the long term and short term care of persons suffering from mental illness. At the end of 1961, 136 such persons were being maintained at homes owned or sponsored by the Mental After-care Association, seven at hostels of the Jewish Board of Guardians, five at Parnham House (National Association for Mental Health) and two at Winston House, Cambridge (S.O.S. Society). Patients at these homes are maintained by the Council and contribute towards the cost according to their means. With regard to the placing of mentally subnormal persons, the practice was continued of using private homes and hostels run by voluntary associations where this form of care was considered appropriate, including placings in convents and other training establishments run by religious communities and placings through the Guardianship Society, Brighton. Use was also made of two hostels (one for boys and one for girls) established by the National Association for Mental Health, where mentally subnormal children are trained to undertake paid employment and to fit them for life in the community. At the end of the year 139 mentally subnormal persons were being maintained by the Council under these and other similar arrangements. Short term care—The provision of short term care for mentally subnormal persons in hospitals or private homes approved by the Council's medical staff has grown considerably since it was first authorised by Ministry of Health circular 5/52. During 1961, 427 persons were placed under these arrangements for periods normally not exceeding eight weeks (compared with 376 in 1959). These facilities have been greatly appreciated by parents and relatives of children and adults, many of whom, while not willing to place them in hospital or elsewhere on a long term basis, have been relieved without cost for short periods from the strain of home care. The Guardianship Society, Brighton has nominated a number of foster mothers who are willing to care for mentally subnormal persons for a short period and so give them a holiday at the seaside which, in many cases, would not otherwise have been possible. Hostel for alcoholics—The Council contributes 90 per cent, of the net cost of maintenance towards the running, by the West London Mission, of a hostel in Lambeth for the aftercare of alcoholics. This hostel, which was opened on 1 July, 1961, provides after-care for a maximum of 40 patients who have received psychiatric treatment and who are under the continued supervision of psychiatrists. During the first six months, to the end of 1961, 66 men had been admitted to the hostel and 30 discharged; 16 of those discharged were considered to be failures because of short-stay or refusal to co-operate, the remaining 14 had made reasonable progress so far as is known. There has been close co-operation with the agencies referring the cases. Twenty men were admitted from Pentonville Prison psychotherapy group, the majority of whom did not return to drink. As complete rehabilitation is, to a large extent, dependent upon the availability of support and supervision after active treatment, the provision of this hostel meets a real need, particularly for those who have no homes of their own to go to after treatment. 121 Recuperative holidays—Recuperative holidays are provided for persons recovering from mental illness. During 1961, 143 persons were given holidays for two to three weeks in recuperative holiday homes compared with 128 in 1960. Training for mentally subnormal and severely subnormal persons Proposals for future development—In 1960, when the Council submitted to the Ministry of Health its proposals for the development of the mental health services, 21 centres were provided for the training of mentally subnormal and severely subnormal persons, with places for 700 children of school age, 295 for older girls and women, and 275 for youths and men—a total of 1,270 places. Of the nine junior training centres, two were purpose-built, four were in adapted premises and the remaining three were accommodated in church halls. Only three of the twelve adult centres were in buildings owned or leased exclusively by the Council. The proposals envisaged the following future developments in the training services for these categories of mentally disordered persons: (i) replacement of centres in church halls and other unsuitable premises by purposebuilt centres or by premises specially adapted for the purpose and the provision of additional centres to cater for the increasing demand from both children and adults; (ii) provision of special care units for children who require extra attention because of physical handicap or other difficulty; (hi) reduction in the general admission age of children to training centres from five to three years; (iv) provision of some form of holiday minding service or the opening of centres for longer periods, to afford additional relief for parents of children attending the centres; (v) introduction of sheltered industrial work for both men and women attending adult training centres; the expansion of industrial training centres; and the introduction of a system of payments for work done; (vi) provision of a part-time service at adult training centres, or otherwise, for older handicapped persons who are unable, unwilling, or unsuitable to attend a full-time training centre; and (vii) an increase in the number of home teachers and the frequency of their visits. Premises—Developments towards the replacement of unsatisfactory training centre premises and the provision of additional places, which have already taken place since the Council's proposals were formulated, include the opening in Hackney of a third purpose-built junior centre with places for 120 children; the opening in Wandsworth of a second industrial training centre with 100 places, including workshop accommodation for 40 trainees; the opening of an additional adult centre in Islington with 40 places for older girls and women; and the replacement of an adult training centre for females in specially adapted premises in Hammersmith. As a result of these changes it was possible to discontinue the use of three unsatisfactory church halls for training centre purposes and at the end of 1961 the number of centres had been increased to 22 and the total number of places available by 135 to 1,405. The provision of new premises has been hampered to some extent by difficulties in acquiring suitable sites, but at the end of 1961 the following projects were in hand— (0 the adaptation of premises in Greenwich to provide an additional industrial centre for 36 males; (ii) the erection of two new junior centres, each with 112 places, in Greenwich and Islington respectively; (iii) the provision of a new building in Hackney to provide an industrial training centre for 120 males; 122 The Training Centre Service Special coaches bring juniors and older girls to the centres. A new junior training centre opened in Hackney during the year. Juniors at work and play at the new Hackney centre. Laundry work and cookery play a prominent part in the training of the older girls. In the new industrial training centre for older boys and men in Wandsworth, training includes woodwork, using power tools, and the chopping and packaging of firewood. Simple paid industrial work being carried out in adult training centres. (iv) the acquisition of a site in Bermondsey on which to provide a new junior centre with 112 places, an adult training centre for females and one for males (with provision for industrial training and also residential accommodation for severely subnormal children). In addition, special attention was being given to the possibility of obtaining more satisfactory premises to replace an adult centre for females in south-east London and to acquiring suitable premises for an additional such centre in south-west London. This programme, which it is hoped will be completed within five years, will enable more unsatisfactory premises to be vacated and more places to be provided. Training of children—Training for children between the ages of five and sixteen is provided in nine junior training centres which are open during ordinary school hours and are run as closely as possible on the lines of schools. Pending the opening of new and larger centres, lack of places has precluded any general lowering of the minimum age for admission, i.e. five years. As a first step, however, towards the ultimate aim of accepting children from the age of three years, it has been possible to lower to four years the admission age at two centres serving west and south-west London, whilst children of this age may be admitted to other centres in special circumstances. In furtherance of the Council's intention to provide training for subnormal children at an early age, specially staffed and equipped units have been set up for this purpose on an experimental basis in two of the Council's day nurseries. The units were opened towards the end of 1961 and the results of the experiment are awaited with interest. Powers are given under the new Act to compel the attendance at training centres of children of school age who are unsuitable for education at school. The great majority of parents welcome the opportunity of sending such children to the centres and up to the end of 1961 it had not been found necessary to resort to legal action to enforce attendance. Provision has been made in the design of each new junior centre planned for the future for a special unit for 12 mentally disordered children who suffer from an additional handicap or have behaviour difficulties which would otherwise render them unsuitable for training centre attendance. Although it will be some time before the first of these specially designed units is ready for occupation, it has been possible to adapt vacant accommodation, at one of the older girls' centres in north-east London, to provide a unit for 12 handicapped children which was to be opened early in 1962. Since 1960 a special grant has been made by the Council towards the cost of staffing a unit for severely subnormal spastic children run by a spastic centre in west London, which is attended by some London children. Following the Council's proposal to afford additional relief to the parents of children attending junior centres, as an experiment four junior centres were kept open as play centres for four weeks of the 1961 summer holiday period. Although attendances were somewhat disappointing, this additional service was much appreciated by those who were able to take advantage of it and it has been decided to continue with the scheme during the summer holidays in future years. It was not considered practicable to provide special transport to the play centres and it is clear that difficulty in travelling to such centres prevented many children from attending. Special attention will accordingly be given, in future, to the selection of centres as play centres which are easily reached by public transport. Training of adults—Adult centres provide accommodation for persons from the age of sixteen, the social training given in the junior centres being continued; the trainees are encouraged to make the most of their limited capabilities and to achieve a measure of independence. There is more emphasis on the production of useful articles, carpentry and other crafts being taught to the older boys and the older girls receiving instruction in domestic crafts such as cookery, laundry and needlework. On one afternoon a week the trainees hold their own clubs, in which the activities include table tennis, billiards, playing their own gramophone records and—for the girls—dancing. Regular sports activities are also arranged at the boys' centres. 123 To stimulate industrial activity, an industrial manager was appointed in 1961 to negotiate orders for, and generally supervise, industrial work. Until that time this work had been confined to the single industrial centre, where woodwork articles, mainly for the Council's Supplies department, were produced; industrial activities have now been extended to other adult centres, so that as many as possible of the trainees have an opportunity of doing work for which they receive a proportionate share of the income received by the Council. There is no doubt that this development has been welcomed by the trainees who have shown themselves capable of quite a wide variety of simple work. It has been particularly gratifying that very severely subnormal adults who were previously considered quite unemployable have been able, as a result of the careful planning of jobs and their breakdown into simple stages, to play a useful part from which they derive an obvious satisfaction. So far work has been provided for seven centres and has included the assembly of lamp holders and brush and comb sets, sewing gas mantles and the stuffing of soft toys. The opening in 1961 of the second industrial training centre, with workshop accommodation for 40 trainees, was a significant step in the expansion of the arrangements for industrial training. Considerable power-driven machinery was installed and it is hoped to be able to produce a wide range of woodwork articles both for the Council's own use and for outside sale. The range of goods so far attempted includes tidy boxes, wooden toy bricks, toy blackboards and easels, ironing boards, swing seats and duckboards. Since autumn 1961, the two industrial centres have been kept open for a slightly longer day to bring them more into line with industry; for the same reason, instead of being open only for the periods of the school terms, they are now closed for only four weeks a year. At the end of 1961 each trainee at an industrial centre was receiving a daily payment of two shillings, a figure calculated on the annual profits at that time. Medical and ancillary services—All persons attending junior and adult training centres receive an annual medical examination and chest x-ray (subject to parental consent); annual mental re-examinations by medical officers experienced in mental subnormality are being introduced. Dental treatment and speech therapy are provided as necessary for children attending the junior centres. Trainees age 12 and over receive a B.C.G. examination. Meals—Mid-day meals are supplied cheaply (free in necessitous cases) at all centres by the School Meals Service, the food being conveyed to the centres in containers from conveniently situated school kitchens. It has recently been decided that in all new centres with 100 or more places meals shall be cooked on the premises and special provision for kitchen accommodation has accordingly been incorporated in the design of the centres for which plans have been completed. Free mid-morning milk is supplied to all trainees up to the age of sixteen. Transport—Special coach transport is provided for all junior and older girls' centres, twenty-seven coaches being in use at the end of 1961. In the case of the older boys, the making of their own way to the centres, by public transport if necessary, is felt to be an important part of their training for community life and for this reason they are not provided with coach transport. Where older boys are incapable of making their own way to their centres unescorted, guides are provided for them. Individual transport has recently been authorised for a small number of older boys who suffer an additional physical handicap which would prevent their travelling by public transport; at the end of 1961 four boys were being conveyed to and from their centres under this authority. Special activities—A seaside holiday for about 200 trainees at a holiday camp on the south-east coast has continued to be a popular feature. Trainees attending the camp are supervised by volunteer members of the centre supervisory staffs under the direction of the Organiser of Training Centres. The holiday is provided free of charge or at a reduced cost for those trainees who are in need. Day outings to the seaside and other places of interest 124 are organised during the summer out of amenity funds and transport is provided for regular outings to London parks for trainees attending centres which have no open space within easy reach. Home teaching—At the time of the Council's proposals under the Act, two home teachers were employed to give instruction and occupation to mentally handicapped persons who were prevented by an additional physical handicap from attending training centres. About 40 persons were being visited in 1959. A third teacher was appointed in 1960 and although the number of persons receiving teaching remains roughly the same, it has been possible to increase the amount of attention devoted to each one. There was a small waiting list for home teaching at the end of 1961, but the transfer of some home teaching cases to special care units should mean that the present staff will shortly be able to satisfy the needs for this service. General comment—Although the full implementation of the Council's proposals must await the bringing into use of new premises providing extra places—and the availability of some of these is still some way off—nevertheless, the period since 1959 has been one of steady development. In the case of every proposal except that for the special daytime care of older subnormal persons—the need for which is now becoming more evident although, hitherto, it has not been regarded as a first priority—solid progress has been made towards the ultimate goal. Rehabilitation, training and occupation of mentally ill persons In its proposals for the development of day centres for mentally ill persons the Council placed emphasis on rehabilitation rather than occupation and proposed to provide such centres as may be necessary and practicable, both directly and through approved voluntary bodies on a grant-aided basis. Similarly, it proposed to give support to the running of social clubs by voluntary bodies and to make such direct provision as may be necessary. With regard to psychiatric day hospitals, the intention was to participate in the provision of such units as were considered appropriate within the limits of its statutory functions, generally by making available the services of occupational therapists and social workers. Clifton Lodge day centre—The Council's first day rehabilitation centre, at Clifton Lodge, Hackney, was opened in July, 1960. The centre is intended primarily to cater for the rehabilitation of persons who have been suffering from some form of mental illness, with a view to their ultimate return to full community life. The provision of occupation for persons with a permanent psychiatric disablement is secondary to this. During the first twelve months only traditional occupational therapy was available but by June, 1961 a start was made on industrial work obtained through the co-operation of local firms. Originally, the majority of patients were referred from the main psychiatric hospital serving the area but increasing numbers of referrals are now being received from other sources. The centre, which provides accommodation for both sexes, can accommodate up to 40 persons. There were 56 admissions during 1961 and 26 remained on the register at the end of the year. In the latter half of the year most patients were engaged in groups on remunerative work, including folding Christmas cards, thonging moccasin shoes, fixing ornamental beading to dressing tables, machining sleeve linings, assembling jewellery and stripping down meters and light engineering parts to recover materials. A system of ex-gratia payments at fixed rates was introduced on 1 July, 1961, which had regard to the net income. No payment is made for the first month, 2s. a day is paid for the second month and 3s. a day thereafter. These payments, which are kept under review, have proved an incentive to the patients to attend regularly and to undertake, quite readily, many different kinds of work. 125 The following table analyses the discharges during the year; 10 of the persons leaving were admitted in 1960 and 33 in 1961. Obtained outside employment 4 Admitted to Government training centre 2 Admitted to hospital 7 Left the district 1 Unsuitable for further attendance 9 *Self-discharged 20 Total 43 *About half of these patients took their discharge within two days; the remainder within two weeks. The relative number of persons discharged to work or for further training is, of course, governed by the type of case referred and, as the centre has only undertaken industrial work for a comparatively short time, it is too early to assess results. Large numbers of patients do, of course, receive rehabilitation whilst in hospital and the potential demand for rehabilitation centres for patients only requiring out-patient treatment or treatment from their general practitioners may not necessarily be high. Patients whose mental state does not enable them to undertake individual work, even under sheltered conditions, are not normally accepted for admission to Clifton Lodge, but there may well prove to be many who can continue to do useful work at the centre but who cannot go the further stage and work under ordinary factory conditions. Steps are taken to prevent deterioration in the condition of the patients by ensuring that they take any tablets prescribed whilst attending the centre and regular visits are made by one of the Council's psychiatric social workers, working in close liaison with the supervisor. The Council plans to open a further centre in the Elephant and Castle area during 1963. Institute of Social Psychiatry day centres—Since 1949 the Institute of Social Psychiatry has provided a centre, the Blackfriars rehabilitation centre, for the rehabilitation of mentally ill patients and the Council has contributed 90 per cent. of the approved cost of attendance of London patients. It was considered unfortunate that, because there was only one centre, it was necessary for long-term patients to be treated in association with those who were recoverable. In May, 1961, however, the Institute opened a second centre, Crossway rehabilitation centre, which was also grant-aided by the Council on the same basis as Blackfriars. This centre has been adapted to cater for recoverable patients who are capable of simple industrial work and there is special emphasis on work routine and work tolerance, with a view to the patients' eventual rehabilitation in the community. All patients taking part in the work programme at the centre are paid by the hour at a uniform rate, the rate varying according to the income to the centre from the remunerative work being done at the time. At the Blackfriars centre, which caters for the more withdrawn, long-term patients, the emphasis is on group activities and resocialisation in the group, thus encouraging the patients to live a fuller life outside the centre. During 1961, 66 persons resident in the London area were admitted to these two centres. At the end of the year there were 50 London patients on the registers, 42 having been discharged during the year, 15 to take up employment or to attend government training centres; 10 were admitted to hospital, 12 were self-discharged and five were discharged for other reasons. Social clubs—Since 1948 the Council has contributed 90 per cent. of the approved cost of attendance of London patients at the psycho-therapeutic social clubs run by the Institute of Social Psychiatry, of which at the end of 1961 there were nine in London, including a drama group and a youth club. The average weekly attendance at these clubs was 18. The clubs meet one evening a week under the guidance of a psychiatrist and a social therapist. 126 In addition, the Council gives financial assistance towards the cost of two clubs run by psychiatric hospitals for patients in their catchment areas (average weekly attendance at these is approximately 18) and to a club run by the psychiatric department of one of the London teaching hospitals, which has a weekly attendance of 40 and above. Another psychiatric hospital holds its club in one of the Council's health centres, free of charge. St. Olave's psychiatric day hospital, which is run in conjunction with the Council, has its own associated social club with an average weekly attendance of 30. The Council runs two social clubs of its own, at each of which the average weekly attendance is about 15. One is in division 9 where there is no other club, the other is run in association with the Council's rehabilitation centre at Clifton Lodge. The existing clubs are well attended and, although they are all able to accommodate more patients, there would appear to be scope for new clubs in areas where, as yet, no clubs exist. The present clubs can cater for a maximum of 695 patients weekly. Psychiatric day hospitals—The Council co-operated with the South-East Metropolitan regional hospital board, the Bermondsey and Southwark hospitals group and the Cane Hill hospital management committee in the establishment, from 1 July, 1960, of a psychiatric day hospital at St. Olave's hospital. The Council assumed responsibility for the provision of occupational therapy for those patients in the day hospital who would benefit from it. This entailed the appointment of an occupational therapist, the provision of equipment and materials and the attendance of a social worker. The occupational activities were organised on a wide basis to include, among other things, handicrafts, group discussions and music appreciation. In addition, the Council makes an annual grant towards recreational activities of the patients, such as tennis, net-ball and ballroom dancing, which are considered to be of a therapeutic nature. It is reported that experience of the working of the day hospital has been very encouraging. It has been possible to treat all types of psychiatric illness in patients who have been able to travel daily from home and it has been found that a number of patients, who would otherwise have needed in-patient treatment, have been catered for satisfactorily as day patients. A further day hospital for psychiatric patients was established at St. Clement's hospital, towards the running of which the Council's services have contributed. Experimental scheme of rehabilitation—In 1960 the Council agreed to give substantial financial support to the Institute for Group and Society Development, to undertake a limited experiment in health division 4 in establishing community care services for patients discharged from Long Grove hospital. This experimental scheme consisted of preparing patients in hospital against the time of their discharge and in preparing their relatives and other members of the community to receive them back. Group sessions with patients and relatives, at which hospital staff (medical, social worker and nursing) joined in, were held initially at the hospital and later at a centre in the catchment area. Rehabilitated ex-patients and their relatives were enlisted to help in the scheme by providing temporary foster homes, acting as escorts, joining in social activities etc. The experimental scheme proved to be of great value in pointing the way in which group therapy could be developed as an aid in the rehabilitation of hospital patients. Towards the end of 1961 it was decided, however, that it would not be right to continue the inevitable overlapping of functions with the Council's own divisional mental health team which the scheme entailed. It was therefore agreed that from 1 June, 1962 the development of the scheme would be carried on within the framework of the Council's divisional mental health services. Occupation and instruction at home—A limited experiment has been conducted for some time in division 9, utilising the part-time services of an occupational therapist who had previously been employed solely on work with tuberculous patients. The therapist devoted three sessions a week to the home teaching and occupation of mentally ill patients and has reported progress with chronic patients. The experiment is reported to have fulfilled much 127 of its promise and the scheme has been welcomed by hospital doctors and general practitioners. The experiment was later extended to division 1. Thirteen persons were benefiting from this service at the end of the year and consideration was being given to an extension of the arrangements to include other divisions. Social work in the mental health service The Principal Mental Welfare Officer reports: The menially ill—As applied to mental illness, preventive care in a broad sense covers a very wide field in which all public health and other social services are involved, from the maternity and child welfare clinics to the old people's welfare committees, from the school to the housing office. It is usual to distinguish between preventive and after-care work, but this is often an artificial distinction, for the mental health social worker concerned with community care, as with all after-care, aims at preventing a relapse. It must be emphasised that the community care service for both the mentally ill and the subnormal is a permissive one, in that the person concerned and/or the relatives have a right to refuse to accept it: there is no question of a power to enforce, even where this may seem very desirable. The only exception to this rule is where the patient is the subject of a compulsory order, which may be during a period of up to six months on leave of absence from hospital or where a guardianship order is in existence, but these together represent a very minute proportion of those receiving community care. It follows that for the service to be effective the mental health worker must aim at securing the goodwill and maximum co-operation of all concerned. This calls for qualities of sympathy and understanding coupled, of course, with the right degree of detachment. It requires the capacity not only to listen but to withdraw at the right moment and also the willingness to work as hard as is required at any given moment. The work is therefore physically and emotionally demanding. The mental health team bears the brunt of this but other social workers in the department are inevitably confronted by mental health problems with which they must deal, not least the Council's health visitors who do a great deal of therapeutic value in the course of their work. Referrals to the service come from many quarters and the numbers are, as might be expected, steadily increasing. The community has, of course, always carried a heavy burden of mental illness but until comparatively recently the load was lightened by long term incarceration, sometimes for a lifetime. With changed attitudes and—more important -modern methods of treatment (including the use of new drugs), and the decrease in the use of compulsory powers, the average stay in psychiatric hospitals is now very short. On return from hospital, many, although 'cured', do require the supportive help of somebody who understands without judging and with whom they can make a good relationship; this of course frequently applies to the relatives as well as to the patients. In most cases the sense of stigma attached to hospital admission is still very real and the social worker is able to play a part in offsetting this. In some cases community care involves frequent and lengthy visits over a period; sometimes long supportive telephone conversations in times of crisis. So far as possible those cases requiring special skills are dealt with by the psychiatric social workers but the bulk of the work inevitably falls to the mental welfare officers. Where there is a psychiatric social worker employed as such, he or she is available for consultation if mental welfare officers so wish in cases of special difficulty. In four divisions the divisional mental welfare officer is a qualified psychiatric social worker. Any possible steps to prevent further breakdown or to assist rehabilitation are taken. These may include persuasion to attend a day centre, an out-patient clinic, a day hospital or perhaps an evening club; it may mean arranging a recuperative holiday or making special contact with the employment exchange or the National Assistance Board or any other assisting agency. It may also include finding a hostel vacancy. The social worker is frequently in a position to recognise early signs of 128 potential breakdown (which may be due to failure to continue drug treatment or increase of family stress or any other factor) and may, by timely liaison with the general practitioner or out-patient clinic, be able to avert the necessity for in-patient treatment. One effect of the new Act, with the consequential expansion of the community care service, is that inevitably a great variety of people with mental health problems are referred from many sources. For a number of these no very constructive help is possible but it is nevertheless impossible to shelve responsibility entirely, except in a very limited number of 'hopeless' cases. For the remainder, time and energy is often spent fruitlessly but unavoidably. A number of mentally ill (also subnormal) adults find their way into London from the provinces; some of these have spent earlier years in psychiatric hospitals. Before the establishment of a community care service, many floated more or less happily from lodging house to lodging house, only coming to the notice of the authorities if they appeared before the Courts; a number are now referred to the mental welfare officer. In some cases it is possible to help constructively but many have well established wandering habits and have become unemployable. Frequently they are not sufficiently ill mentally to be made the subject of compulsory orders and there is a tendency to wander in and out of hospital voluntarily. This is also the pattern of life of many of the mentally disordered who are Londoners and the burden is shared by all agencies, voluntary or otherwise, concerned with the homeless and destitute, including of course the Council's Welfare department. Bodies such as the Salvation Army and the Church Army provide temporary and sometimes permanent havens for them and co-operate with the mental health workers in efforts at rehabilitation. The severely subnormal—Mental welfare officers remain in close touch with all severely subnormal children and also the small number of children who are not severely subnormal but are reported under sec. 57 of the Education Act, 1944 (as amended by the Mental Health Act). By visits to the homes they are in a position to assess the situation and to recommend short term care in times of crisis or when the family need a rest from the demanding care of such children. It is also the function of the officers to explain more permanent hospital care to enquiring parents and to help them to come to terms with the problem whilst awaiting a hospital vacancy—frequently a very long wait. They play an active part in explaining the value of training-centre training and in persuading any reluctant parent to agree to the child attending. They also attend medical examinations at the centres and in most cases arrange for any necessary treatment. A number of officers attend centre open days; these affording valuable opportunity for fostering good relationships with the family and liaison with centre staff. Closeness of contact is usually maintained by mental welfare officers through the adolescent and adult years of the severely subnormal person, when the problems frequently become accentuated by the illness and increasing age of the parents. The subnormal—The majority of cases coming within this category are those who have attended schools for the educationally subnormal, leaving at 16 years of age. Most of these boys and girls are capable of unskilled or semi-skilled employment and the majority live at home. An after-care service is offered to the parent, just prior to the boy or girl leaving school; if accepted, visits are paid to the home at fairly regular intervals or as the need arises, until the mental welfare officer, the parent, or perhaps the boy or girl feels that this is no longer necessary. The amount of help required depends as much, if not more, upon the degree of stability of temperament as of that of subnormality. The service is partly advisory and the social worker may have to deal with any general or specific matters affecting the young people's welfare. This covers a wide range, from pocket money to income tax, from matters affecting employment or recreational activities to how to deal with potential delinquency. More concrete help is given as the need arises; this may take the form of limited financial help, arranging holidays or attendance at clubs, sometimes making alternative living arrangements when the home situation breaks down. 129 Although friendly supervision is discontinued at about the age of 18 (unless active assistance is still required), a number come to notice again at a later stage, sometimes some years later, when further help is required. This may arise from such factors as homelessness following the death of a parent, appearance before the courts, illegitimate pregnancy or sometimes problems following on marriage. In all such cases, any possible help or guidance is given. This also applies to those subnormal persons returning to the community after a period of hospital care, when efforts are made to assist rehabilitation. The maladjusted school-leaver—After-care of the children leaving the schools for the maladjusted is now the responsibility of the public health department. Some of these children require little if any follow-up, having made a good adjustment during the last months at school; others require help in varying degrees from placing in suitable lodgings to arranging attendance at a psychiatric clinic or admission to hospital. The service includes giving supportive help to the family, landlady or hostel staff as the case may be. With children who are in the Council's care there is liaison between the mental health social worker and the child care officer as and when the need arises, the mental welfare officer taking over normally at the age of 18 if continuing help is required. This applies also to the subnormal. Hostel placing: Dover Lodge—The main bulk of the social work connected with this hostel for up to 13 sub-normal girls in work falls mainly on the division in which it is situated, although mental welfare officers from other divisions play their part where they have a special relationship with the girls or their families. Close contact is maintained with the hostel and it falls to the lot of the social worker to find alternative placement when girls are ready to leave or are found unsuitable for retention there. The role of the social worker includes close co-operation with the Youth Employment service, child care officers and, of course, the staff of the hostel on anything concerning the general well-being of the girls; this includes employment conditions, recreational activities, holiday arrangements and general social training. The girls admitted to Dover Lodge are almost invariably those with either no home or homes into which they cannot fit satisfactorily. They are often lacking in a sense of security and sometimes with consequent delinquent tendencies. As a result, what may appear prima facie to be a disproportionate amount of the social workers' time and effort has to be spent on work at this hostel. This will probably apply also to future hostels, whether for the mentally ill or the subnormal. Hostels of voluntary bodies—The foregoing applies, to a lesser extent, to those boys and girls maintained in hostels run by bodies such as the National Association for Mental Health, the Church Army, etc; while the mental welfare officer is not quite so involved during the stay at the hostel, there is usually a great deal of community care work to be done subsequently, sometimes for many years on any one particular case. One such lad, since leaving the hostel, has been placed by the mental welfare officer concerned four times in lodgings, once in resident employment, three times in other employment and twice in other hostels. Each of these placings represents much time-consuming effort on the part of the social worker and this pattern seems likely to continue. The educational role of the mental health team—One valuable effect of divisionalisation of the service has been the closer contact and liaison with general practitioners, outpatient clinics, day hospitals, health visitors and other social workers, and the various social agencies, with the resultant exchange of ideas and information and improved mutual understanding. The mental welfare officers have actively participated in the meetings held at divisional level to which general practitioners and others were invited. During the year the Principal Mental Welfare Officer, her deputy and the divisional mental welfare officers (in some cases their deputies or the psychiatric social worker) have given talks on mental health to various local groups, including health visitors and other social workers, mothers' meetings, branches of the Society for the Mentally Handicapped, Rotary clubs and groups concerned with old people's welfare, etc. 130 In the wider field talks have been given to the mental health students at the London School of Economics; to students at the Royal College of Nursing; at the course for training centre teachers and regularly at the nurses school of the Maudsley Hospital. During the year officers have met various interested visitors from abroad to explain and discuss with them the Council's mental health service. It can be said that the educational role of the mental welfare worker is an important one in view of the need to promote a greater understanding and acceptance of mental disorder; this is fully appreciated by the mental welfare staff. Statistics Statistical tables detailing the work of the mental health services during 1961 are set out below. Various salient features of this work are discussed and certain comparisons made with 1959 (the last complete year before the operation of the Mental Health Act, 1959). Total number of referrals—The total number of mentally disordered persons referred to the mental health social workers during 1961 was 8,258, of which 7,158 were referred as 'mentally ill' and 1,100 as 'subnormal' or 'severely subnormal'. In 1959, persons so referred numbered 8,110, including 7,241 'mentally ill' and 869 'subnormal' or 'severely subnormal Sources of referrals—Table (i) gives a detailed analysis of the sources of referrals in relation to (a) mentally ill persons (other than those specifically referred for community care), (b) mentally ill patients referred specifically for community care and (c) mentally subnormal and severely subnormal patients. About 40 per cent. of the referrals under (a) were received from general practitioners, 12.9 per cent. from police or courts, 14.8 per cent. from psychiatric sources (compared with 8-9 per cent, in 1959). The proportion of such referrals from hospital wards and casualty departments without prior referral to psychiatrists fell from 19 per cent, in 1959 to 10-8 per cent, in 1961. Of mentally ill patients referred specifically for community care about one third were referred from hospitals, one fourth from other Council services and one tenth from general practitioners. Table (i)—Sources of referral of all cases Mentally ill Subnormal and severely subnormal Total With a view to hospital admission Community care No. % No. % No. % No. % Psychiatric hospital or ward 467 81 398 283 104 9.5 969 11.7 Psychiatric out-patient clinic or day hospital 147 2.6 67 4.8 7 0.6 221 2.7 Psychiatrist at general ward, casualty dept., etc. 236 41 - - - - 236 2.9 Non-psychiatric referrals from hospitals 619 10.8 38 2.7 65 5.9 722 8.8 General practitioner 2,312 40.2 140 9.9 16 1.5 2,468 29.9 Police or Court 741 12 .9 7 0.5 29 2.6 777 9.4 Other medical sources 77 1.3 28 2.0 111 10.1 216 2.6 Non-medical sources: Patients' relatives, neighbours, etc. 173 12.3 - Education Service 107 7.6 570 51.8 Other Council services 1,151 20.0 224 15.9 2,649 32.0 Government agencies 51 3.5 Voluntary organisations 110 7.9 198 18.0 Miscellaneous 65 4.6 5,750 100.0 1,408 100.0 1,100 100.0 8,258 100.0 131 I Applications with a view to removal to hospital of mentally ill persons—Mental welfare officers received 5,750 applications for visits to persons alleged to be suffering from mental illness, with a view to arranging admission to hospital. The applications concerned 4,839 persons, 581 being referred on two occasions and 145 on three or more occasions; 58 per cent. of the applications related to females and 42 per cent. to males. These numbers show a reduction of 1,130 applications (739 individuals) compared with 1959. Table (ii) gives details of the initial action taken on these applications and also the final disposal. No further action was found to be necessary in 21.9 per cent. of all cases investigated, compared with 23 per cent, in 1959. Table (ii)—Initial action and final disposal of mentally ill persons referred to mental welfare officers with a view to removal to hospital Initial action Final disposal No. % No. % Informal admission 899 15.6 2,306 40.1 Compulsory admission: For observation (sec.25) 903 15.7 - Emergency admission for observation (sec. 29) 1,841 31.9 - - For treatment (sec. 26) 116 2.0 497 8.6 By police (sec. 136) 232 4.0 - - Court order 147 2.6 156 2.7 Absent from hospital without leave (sec. 40) 3 0.1 5 0.1 Psychiatric out-patient clinic or day hospital 170 3.0 170 3.0 General ward for physical care 43 0.8 66 1.2 Community care from general practitioner, Welfare dept., etc 109 1.9 110 1.9 No further action 1,258 21.9 2,285* 39.7 Other action 29 0.5 29 0.5 Not known - - 126 2.2 5,750 100.0 5,750 100.0 * Includes 933 discharged after a period of observation, 68 deaths and 25 withdrawn or absconded. Admission to hospital of mentally ill persons—Arising from the applications referred to in the preceding section, 4,141 mentally ill persons (71.9 per cent. of the total number referred) were admitted to hospital. Table (ii) analyses the numbers of patients removed compulsorily to hospital under the various sections of the Mental Health Act, 1959 and shows the number of formal admissions. The proportion of compulsory removals for observation (the majority) or for treatment was high and much use was made of sec. 29 of the Mental Health Act. A further analysis in table (iii) shows the position for the two age groups—under 65 years and 65 years and over. 132 Table (iii)—Hospital admissions dealt with by mental welfare officers informally or under sees. 25, 26 and 29 of the Mental Health Act, 1959 Initial disposal to hospital Final disposal to hospital Under 65 years Over 65 years Total Under 65 years Over 65 years Total No. % No. % No. % No. % No. % No. % Informal admission 668 22.0 229 32.4 897 23.9 1,783 80.0 515 91.3 2,298 82.2 Compulsory admission: For observation (sec. 25) 685 22.5 215 30.5 900 24.0 - - - - - - Emergency admission (sec. 29) 1,583 52.1 250 35.4 1,833 49.0 - - - - - - For treatment (sec. 26) 103 3.4 12 1.7 115 3.1 447 20.0 49 8.7 496 17.8 Total 3,039 100.0 706 100.0 3,745 100.0 2,230 100.0 564 100.0 2,794 100.0 It will be noted that the major use of sec. 29 was in relation to those under 65 years of age but that about two-thirds of the '65 and over' age group who appeared to need psychiatric hospital care, even temporarily, were removed compulsorily. Prior to the full introduction of the Mental Health Act, 1959 there were voluntary patients and some informal admissions, whilst others were admitted under three-day orders, urgency orders, temporary certificates or sec. 14/16 of the Lunacy Act. Voluntary patients are now referred to as informal patients and sections 29, 25 and 26 replace the various orders and certificates stated above. Although, in the case of patients under 65 referred to mental welfare officers, there was a reduction in the proportion of compulsory admissions, i.e., from 89.4 per cent. of total cases removed in 1959 to 78 per cent. in 1961, the reverse took place in the age group '65 and over i.e., a rise from 63 per cent. to 67.6 per cent. Reasons for this require further investigation, bearing in mind also that whereas the proportion of total cases seen by mental welfare officers which resulted initially in informal or compulsory admission to hospital was the same for the under 65's in 1959 and 1961, it rose from 60.9 per cent. in 1959 to 65 per cent. in 1961 for the elderly group. Bearing in mind the comments on initial disposal, particularly with regard to the elderly, the comparative percentages for patients retained in hospital under compulsion (table iii) were as follows: Under 65 65 and over % % 1959 31.9 31.2 1961 20.0 8.7 These comparisons show that in 1961 there was a major reduction in the percentage of elderly persons retained in hospital compared with the increased initial compulsory rate already referred to. These factors will be taken into account in carrying out the further investigation referred to above. Admissions to the five emergency wards in general hospitals within the county area fell from 2,977 in 1959 to 1,442 in 1961. The increase in the statutory period of observation from 17 to 28 days introduced by the new Act and the numbers of patients now admitted informally to these wards with no restriction on their period of stay have affected the position, in that increasing numbers of patients are now being admitted for observation to psychiatric hospitals outside the area, often remote from their residences. There were 1,750 patients so admitted in 1961. 133 I* Community care—Persons suffering or suspected to be suffering from mental illness referred specifically for community care through the mental health services during 1961 totalled 1,408, compared with 361 such persons in 1959. Table (iv) shows the action taken relating to these referrals. Table (iv)—Disposal of cases suffering or suspected to be suffering from mental illness referred specifically for community care during 1961 No. % Hospital care: Informal admission 32 2.3 Compulsory admission 6 0.4 Psychiatric out-patient clinic or day hospital 20 1.4 Community care of mental health service 1,113 79.1 Other community care, e.g., Welfare or Children's dept., general practitioner, probation officer, etc. 61 4.3 No further action 176 12.5 No. of persons involved 1,408 100.0 At the end of 1961, 1,321 mentally ill persons and 4,732 mentally subnormal or severely subnormal were receiving some form of community care. Table (v) analyses the various types of care being given, from which it will be seen that 5,724 persons were being visited by mental health social workers, 304 were being provided with residential accommodation and 1,430 were receiving training at day centres or in their own homes. Table (v)—Persons receiving community care at 31.12.61 Type of care received Mentally ill Mentally subnormal or severely subnormal Grand total Under 16 years Over 16 years All ages No. % No. % No. % Residential home, hostel, convent, etc. 165 15 1.1 57 1.7 72 1.5 237 Boarded out - 4 0.3 63 1.8 67 1.4 67 Home training 13 18 1.4 22 0.6 40 0.8 53 Attendance at day centres for mentally ill 85 - - - - - - 85 Attendance at social clubs for mentally ill* 67 - - - - - - 67 Training centres for subnormal and severely subnormal - 719 55.1 573 16.7 1,292 27.3 1,292 Receiving visits from m.w.o. or p.s.w. 1,132 1,267 97.0 3,325 97.1 4,592 97.0 5,724 Other types of community care 12 23 1.8 29 0.8 52 1.1 64 No. of persons involved 1,321 1,306 100.0 3,426 100.0 4,732 100.0 6,053 *Some patients who are not included were attending clubs which receive financial or other help from the Council. Referrals of mentally subnormal and severely subnormal persons—Of the 1,100 mentally subnormal and severely subnormal persons referred to the mental health services during the year (table (vi)), 127 (11.6 per cent) related to children who had been found unsuitable for education at school and 443 (40.2 per cent) were school-leavers. Residential 134 modation was provided in 36 cases and in 102 cases arrangements were made for attendance at a training centre. At the end of the year 1,267 children under 16 years and 3,325 persons over 16 were being visited by the mental health social workers. Table (vi)—Mentally subnormal and severely subnormal persons referred during 1961 Disposal of cases No. % Hospital care 49 4.5 Community care of mental health service: Residential home, hostel, convent, etc. 36 Attendance at training centre 102 926 84.1 Receiving visits from mental welfare officer 904 Other types of community care 30 Other community care, e.g., Welfare or Children's depts., general practitioner, probation officer, etc. 22 2.0 No further action 86 7.8 Miscellaneous 17 1.6 1,100 100.0 Conclusion From the foregoing paragraphs it will be apparent that the Council has given very careful consideration to the duties placed on local health authorities by the Mental Health Act, 1959; that real progress has been achieved in improving and expanding the services for the care and training of mentally disordered persons in the community; and that the implementation of future proposals, already planned, will go some way towards meeting the recommendations of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. As the number of mentally disordered persons living in the community increases, however, the demand for the facilities provided by the Council will inevitably grow and the development of the mental health services to meet this demand will place increasing responsibilities on the Council. In the immediate future it will not be possible, for various reasons, e.g. shortage of staff and difficulties in obtaining sites and buildings, for the Committee to meet all its obligations under the Mental Health Act, 1959. As already stated, one of the most onerous tasks facing the Council is the provision of residential accommodation. It is unlikely that sufficient accommodation can be provided for some years to come to permit of appropriate care being given for the large numbers of persons, both in hospital and in the community, for whom the special facilities of the hospital services are not essential. In the meantime, it is hoped that hospital authorities will be forbearing in avoiding too rigid an interpretation of the duties now placed on local health authorities in this regard. There is no doubt that the efficiency of a local health authority's mental health services depends upon close co-operation both within the authority's own services and with outside agencies. Mutual consultation and exchange of information and ideas are essential if the fullest development is to be achieved. In London arrangements have been made for the divisional medical officers to establish links with the psychiatric hospitals and general practitioners serving their areas, by means of visits by medical staff and social workers to the hospitals and of local meetings of general practitioners to which the physician superintendents of the hospitals have been invited. Achievement of the maximum degree of personal contact with hospital staffs has been hampered to some extent by the location of the psychiatric hospitals, most of which are a long way from their London catchment areas. The future provision of psychiatric beds in general hospitals would not only be of benefit to relatives in avoiding long journeys to visit patients in out-county hospitals but would also have the great advantage of fostering closer relations between the staff of hospitals and the 135 Council's mental health social workers. Nevertheless, a good understanding between the two sides has been established and as more trained social workers become available it is hoped to foster closer relations with the hospitals. An informal joint advisory committee of officers, whose members are drawn from the various hospital, consultant and general practitioner interests, was set up in 1960 to advise on the development of the mental health services, including co-operation with other bodies concerned and has served a very useful purpose. The co-operation of voluntary agencies concerned in the field of mental health has also been invaluable in the developments so far achieved and it is the Council's intention in its future planning to foster further cooperation with and assistance from these agencies. The Council's plans for the future provide for a continued expansion in the community care of mentally disordered persons for whom such care is appropriate, with the ultimate aim that all such persons should receive the necessary care and supervision in their own homes or in day or residential establishments according to their particular need. 136 APPENDIX B THE HOME NURSING SERVICE IN LONDON Introduction—It is exactly thirty years since Dr. Margaret Hogarth produced her comprehensive report on home nursing in London*—thirty years which have seen far-reaching advances in the practice of medicine, a shift in the age distribution of the population and vast improvements in the living and working conditions of the people. Another major change has been the development of the personal health services as well as the availability of free medical and nursing service to all, with specialist consultation when necessary. These changes have completely altered the pattern of district nursing. When the National Health Service Act, 1946 came into force the structure of the home nursing service in London remained the same and in 1961 the service was still provided by voluntary associations. The work of these associations is co-ordinated by the Central Council for District Nursing in London, which was set up in 1914 for this purpose. From 1948, when the Council became responsible for the service, the Central Council has acted as the Council's intermediary with the associations. Except in the case of the Catholic Nursing Institute, the Council since 1948 has paid an increasing proportion of the approved expenditure of the district nursing associations; since 1954 this has amounted to 93 per cent. The total grant disbursed through the Central Council for District Nursing in 1960/61 was £531,786; in addition the Council made a deficiency grant of £7,000 to the associations. The home nursing service in London is provided by 25 district nursing associations, which in the main still base their work on residential staff homes; 20 are affiliated to the Queen's Institute of District Nursing. The Ranyard Nurses, together with an affiliated association (Norwood) cover a large part of London and have traditionally employed nurses working from their own homes in the areas of practice. Two other associations not affiliated to the Queen's Institute are the Nursing Sisters of St. John the Divine, who work in the areas of Poplar and Deptford, and the Catholic Nursing Institute in Southwark, which receives from the Council an ad hoc grant of £900 a year. Both these associations work from residential homes. A further independent association, Stoke Newington, is non-residential. A detailed list of the associations will be found at the end of this article. Staff- Staff employed by district nursing associations at 31st December, 1961 Wholetime Parttime Total Superintendents 25 - 25 Assistant superintendents 18 10 28 Senior nurses 2 - 2 State registered nursesdistrict trained 334 32 366 not district trained 93 36 129 427 68 495 Male nurses (included above) 38 - 38 State-enrolled nurses 22 13 35 Nursing auxiliaries - 2 2 Since the National Health Service Act, 1946 came into force, one of the changes in staffing has been the entry into the domiciliary nursing field of the male nurse and the state-enrolled nurse, both of whom are now well established as highly valued members of the staff. The Council's view is that the ratio of one state-enrolled nurse to five stateregistered nurses might ultimately be reached—the present ratio is one to 14. *Survey of District Nursing in the Administrative County of London. 137 There has also been a considerable change in the attitude of the nurse herself towards her work, which she now tends to regard more as a professional career than a vocation. Hence the nurse with a private life of her own no longer looks to the district nursing associations to provide accommodation in a residential home. By the end of 1961, excluding superintendents and midwives, only 81 nurses (16.6 per cent.) were living in district homes. The bicycle has remained the normal means of transport of the home nurse in London but cars have been made available by the Council, in the first instance to associations undertaking midwifery and later also to other associations for the use of superintendents and other stalf. In some cases where local conditions warranted or when unusually large areas had to be covered, as is often the case with the male nurse, car allowances have been paid to nurses who have used their own cars. Mileage allowances are paid to any nurse who uses her own scooter and crash helmets provided by the associations have ranked for grant. Midwifery and maternity nursing—Ten district nursing associations undertake domiciliary midwifery as agents of the Council, employing 43 midwives for the purpose. This number includes the supervisory staff who do relief work for the practising midwives within the association. Reciprocal relief is also supplied by the Council's own midwives. In 1931 four teaching hospitals in London arranged for district nursing associations to nurse midwifery cases after home delivery by medical students. These arrangements have long since disappeared, although since 1960 the Metropolitan District Nursing Association has again taken medical students from Charing Cross hospital to their patients on the district. The nursing organisations were also called upon thirty years ago to nurse cases of puerperal fever and maternity complications referred from the domiciliary midwifery service. Only the occasional pyrexia of unknown origin is now referred from the domiciliary midwifery service. On the other hand, there has been a growing tendency for maternity hospitals to discharge patients 48 hours after delivery because of the tremendous demand for beds; in London this is far in excess of the 70 per cent. recommended by the Cranbrook Committee. It has for long been the practice for hospitals to refer patients discharged before the tenth day to the superintendents of district nursing associations, as each has some stalf with the qualification of the Central Midwives Board who can be deployed to nurse these cases under the guidance of the general practitioner. With ever-increasing pressure from the maternity hospitals the Council, having in mind the necessity for the pre-selection of cases for early discharge, has tried out pilot schemes with Hammersmith, St. Mary's and Lewisham hospitals of acceptance of cases for maternity nursing by the Council's own midwives. By the end of 1961 it was decided to recruit part-time relief midwives to the Council's stalf, in the proportion of one to six full-time midwives. These part-time midwives will provide relief to cover the extended holiday period awarded by Whitley Council and the week-end off-duty period for each midwife once per month proposed by the Council, and will take over the nursing of maternity patients discharged before the tenth day from maternity hospitals. When the full number of part-time midwives has been recruited, the district nursing associations not undertaking midwifery will be relieved of the duty to take maternity nursings. Training—The Queen's Institute of District Nursing at 12 district homes and the Ranyard Nurses have provided general district nurse training for many years. The Council has now adopted the shortened courses recommended in the majority report of the Working Party on the Training of District Nurses, 1953. In this connection it is perhaps interesting to reflect that Dr. Hogarth in her report in 1931 said 'six months seems a long period of training for a nurse who has completed three years' hospital training, and more often than not has in addition taken her C.M.B. certificate involving another period of six months'. In 1961 the Queen's Institute of District Nursing and the Ranyard Nurses combined to give a joint theoretical training at two district homes, the nurses taking their practical course on the district as before; 64 nurses had district nurse training during 1961. 138 Ten district nursing associations, nine of which are affiliated to the Queen's Institute of District Nursing, provide three months' district experience for pupil midwives taking Part II midwifery training. Two of these associations, the Camberwell District Nursing Association and the independent Nursing Sisters of St. John the Divine, are approved Part II training schools and for the present have been able to give their pupils six months' district experience. The Council has authorised the attendance of superintendents and of home nurses at appropriate refresher courses run by the Queen's Institute of District Nursing, the Ranyard Nurses and the Royal College of Nursing each year. Since 1955 the Council itself has run a two-day course and subsequently five-day courses for home nurses in London, alternating with Ranyard Nurses for this purpose. Statistics—The associations make quarterly statistical returns to the Council. There has been a steady decline in the last few years in the number of patients nursed and in the visits paid. The following table shows the work done in the last five years. Work done by district nursing associations in London, 1957-1961 1957 1958 1959 1960 1961 Staff- Total number of nurses employed 563 539 546 551 530 State-enrolled assistant nurses (included above) 30 33 34 34 35 Whole-time equivalent 522 496 507 508 492 Visits— Type of case— Medical 1,647,319 1,563,599 1,427,302 1,351,815 1,281,293 Surgical 210,477 211,261 218,895 232,988 221,543 Infectious diseases 1,807 907 1,766 1,506 2,536 Tuberculosis 82,620 71,012 69,309 59,415 51,000 Maternity complications 5,441 6,710 7,461 7,626 8,547 Other 43,957 40,064 38,563 36,734 36,941 Total 1,991,621 1,893,553 1,763,296 1,690,084 1,601,860 To patients' homes for— Injections only 968,506 856,840 718,335 614,053 546,959 Injections and other treatment 108,715 111,555 102,037 85,571 89,358 Other treatments only 880,504 890,540 904,752 953,950 930,413 Average number of visits— To each patient 30 30 31 33 33 By each nurse 3,815 3,818 3,478 3,327 3,256 Patients— Types of care— Medical 56,091 52,222 47,464 41,914 39,756 Surgical 6,126 5,937 5,928 5,735 5,434 Infectious diseases 276 142 214 144 220 Tuberculosis 1,742 1,395 1,269 1,134 997 Maternity complications 714 862 982 1,047 1,396 Other 2,220 1,558 1,511 1,351 1,334 Total 67,169 62,116 57,368 51,325 49,137 Average case load per equivalent wholetime effective* nurse at end of year 27 24 23 24 22 Completed treatments 56,395 53,359 49,299 43,118 41,010 Long-term casest— Number 14,598 11,769 11,225 9,628 10,236 Percentage of total patients nursed 21.7 18.9 19.6 18.8 20.8 *Allowing for holidays and sickness. Visited more than 24 times during the year. 139 Interchange of information between general practitioners and the home nursing service— There are two entirely distinct but equally important aspects of the interchange of information between these two services. One relates to the availability of local health authority services and how they can be obtained. This is covered by the issue from time to time of an information booklet to, among others, all general practitioners in the county, with a local appendix which gives details about the services in each division. In the same way and in the same format the Welfare department issues information on the welfare services for the handicapped. The other aspect covers the means of direct communication between the family doctor and the nurse on individual cases. Here the traditional pattern persists. The doctor establishes communication by telephone with the nurse at the district home or office and leaves written instructions on the case at the patient's house. The nurse enters her report on the same sheet. The old method of leaving notes in local shops has, however, completely disappeared. In all associations every case must be nursed under the care of a general practitioner and not more than two visits of observation may be paid before a doctor is called in. Each nurse is now responsible for her own case records on standard cards, which were designed in 1957 by the Public Health department in consultation with the Central Council for District Nursing. The changing pattern of home nursing—What are the salient changes in the work of the home nurse during the last thirty years? In the first place she now serves all sections of the community, in contrast to her predecessor in 1931 who provided nursing mainly for the sick poor—'and only in exceptional circumstances, as when a doctor made a very special request for the services of a certain district nurse, did a district nurse attend a patient able to pay the usual five shillings a visit for a private nurse'. Another important change brought about by the National Health Service Act, 1946 has been the gradual breaking down of the isolation of the home nurse and the recognition of her place with the health visitor, the midwife and the home help in the local authority team. This integration has been helped by the fact that the divisional medical officer is a member of the committees of the district nursing associations in his area and by the setting up of divisional home nursing committees. In 1955 the Council also appointed a supervisor of midwives with special liaison duties in connection with the home nursing service. A principal medical officer and the Chief Nursing Officer sit as observers on the executive committee of the Central Council for District Nursing in London. In a service so largely financed from public funds the home nurse has been able to draw readily on up-to-date equipment, unlike her predecessor in 1931 who often spent hours on the improvisation of containers, making of bags, etc. In the past, too, the home nurse had to depend solely on voluntary resources for many essential needs of her patients. In an era of full employment, patients are better housed and in the main are able to provide for themselves the linen, blankets and even food which once the home nurse had to try to bring to them. However, the demand for specialised nursing equipment to be used in the patient's own home has, if anything, increased with the growing complexity of medical and nursing procedures. The Council makes grants for this purpose to the British Red Cross Society, which maintains medical loan depots in certain parts of London. At the request of the family doctor, the Council also supplies hoists and other lifting aids, wheel-chairs, cardiac beds, walking aids, etc., free of charge. A nominal deposit (returnable) is required for each article borrowed. A permanent exhibition of gadgets and other aids for the handicapped is maintained by the Welfare department of the Council and is open to all general practitioners, Council's staff or relatives of handicapped persons for advice and guidance on the supply or making of these aids. In addition, adaptations and special fittings have been installed in patients' homes by the Welfare department. 140 District nursing associations have co-operated with the Council in the experimental use of disposable syringes and incontinence pads. It is not possible to estimate from small scale experiments how much staff time and work could be saved by the introduction of disposable equipment on a large scale, but it is evident that over a long period some saving is to be expected. The introduction of sulphonamide therapy and antibiotics have replaced the long treatments for abscesses, whitlows or excision of carbuncles which were once the daily task of the home nurse—and puerperal fever, then the commonest cause of maternal death, is now almost unknown on the district. In 1961, of 1,566,730 home visits paid by home nurses in the county, 546,959 (35 per cent.) were for injections only; a further six per cent, were for injections and other treatment. These included injections of mersalyl which have banished the water-bed which had to be refilled every two weeks, the treatments by paracentesis and the care of pressure points to prevent the bed-sores, to which the oedematous patient with chronic nephritis or cardiac failure was so prone. Pneumonia in 1931 meant poultices, steam kettles and the anxiety of the 'crisis'. The treatment of diabetes, too, is becoming less exacting of the nurse's time. Many new patients, including children, now learn to give their own injections and some older patients can be satisfactorily maintained on oral treatments, so that the nurse in these cases takes on a supervisory role. The most striking change, however, in the day-to-day work of the home nurse has been the shift in the age range of her patients. Age distribution of patients nursed at home 1931 1961 % % 0- 5 years 19.5 5 5-14 years 20 39 15-65 years 42 Over 65 years 18.5 56 The general improvement in the hygiene and health of children brought about by the maternity and child welfare and school health services is reflected in the marked decline in 1961 in the number of children who have needed nursing care at home. One reads, almost with incredulity, that in 1931 home nurses gave many rubbing treatments to children with rickets, having received special training in this technique at Guy's hospital. Modern drug therapy for worms has replaced the enemata of infusions of quassia. The infectious diseases of childhood have been largely brought under control by immunisation programmes, so that the severe complications which were then treated by inhalations, steam kettles and poultices have almost disappeared from district practice. There were, too, babies suffering from ophthalmic infections or pemphigus referred from the domiciliary midwifery service. Otorrhoea was commonplace and home nurses in London attended school treatment centres each morning to treat these cases, a daily attendance of 70 children at one centre— mostly with otorrhoea and some eye affections and sores—having been recorded. The London County Council in 1931 maintained centres throughout the county for the operative treatment of tonsils and adenoids, where children were retained for two nights before being sent home for nursing care by the district nursing associations. In addition, many children had operative treatment in hospitals outside the Council's scheme and these children were sent home the same day for nursing care at home. In 1961 these centres for tonsillectomy, like the special hospitals for severe cases of ophthalmia neonatorum or bone tuberculosis, had long since disappeared. The 2,236 children under five years of age treated by the home nursing service in 1961 represent only 5.4 per cent. of the total case load. 141 Children treated by the Metropolitan District Nursing Association in 1961 Children under five years of age Injections Schoolchildren Injections Disease No. only No. only Diarrhoea and enteritis 1 — — — Other diseases of digestive system 5 - — — Boils, abscess cellulitis, other skin infections 3 — 2 1 Diseases of bones and organs of movement 1 — — — Circumcision 6 — — — Burns and scalds 4 — — — Inflammatory C.N.S 1 1 — — Infectious diseases 5 - 1 — Otitis media 16 25 4 7 8 3 Other ear 9 1 1 Pneumonia 4 1 — — Bronchitis 9 6 1 4 1 Tonsillitis 11 6 2 — Pharyngitis 1 37 - - — Enlarged glands 2 1 1 — Other respiratory 10 6 — — Total 88 26 15 5 Age analysis— Under 1 year 18 Age 5 14 1 year 19 6 1 2 to 4 years 51 - — Total 88 15 It is interesting to note that cases treated were almost all acute illness. If the home nursing service is no longer concerned to any great extent with paediatric nursing, this is more than offset by the rise in the demand for home nursing of the elderly. In 1931 there were 321,000 persons over 65 years of age living in London; by 1961 this number had increased by 25 per cent, to 401,000. However, prolonged expectation of life has brought an increasing liability with advancing age to degenerative diseases and associated deformities. While there was no real evidence that families were less willing to look after their old people in 1961 than they were thirty years ago, smaller families have meant fewer young people to look after them and economic opportunity has taken the young away from home. It is recognised that it is the home nurse, with her colleague the home help, who has made it possible for many old people, who would otherwise have had to go into residential homes, to remain much longer in the community. In her daily work with the elderly sick the home nurse gets the patient up as early as possible, tries to preserve function however limited this may be and helps the patient to do whatever he is capable of doing. Comprehensive statutory and voluntary services have been made available throughout the county for the rehabilitation of the elderly sick, to counteract loneliness and to bring colour and interest into the patient's life. The home nurse has worked closely with the health visitor to bring these services to the patient. In other age groups the home nurse has attended mainly acute illness and has been especially helpful to the general practitioner in carrying out diagnostic procedures in the early stages of illness. Nursing visits to the home traditionally have had an educational value, for the occurrence of illness brings to the relatives a ready receptiveness of the means of prevention, teaches them to take temperatures and carry out other simple nursing procedures and to observe the signs of change. Relationships within the family are no less important and the home nurse may have to use her influence to prevent over-coddling, to calm the patient who has to be isolated of his fear of loss of affection, or to give relatives 142 some basic knowledge of the disease so that they can understand the patient's special needs. Terminal cancer has often been nursed at home and in these cases the home nurse has had not only to help the patient but also to support the relatives in their distress and allay their fears. A special branch of the home help service was set up in 1952 to provide sitters-in for two nights each week, to allow relatives the opportunity to sleep. The demand has been surprisingly low, only 17 home helps were provided under this scheme in 1961. The Marie Curie Foundation also provides sitters-in for these cases on the request of the family doctor. The shift of emphasis from hospital to the community care of mentally disordered patients, since the Mental Health Act, 1959 came into force, has already had some repercussions on the home nursing service. Senility was commonly a reason for repeated visits by the nurse. Home nurses, too, have been called in to supervise the administration of drugs to mentally ill patients discharged to their own homes, particularly in the first weeks when relatives have not been able to cope or have gone out to work. Clearly the responsibility for the care of mentally ill patients on discharge from hospital is laid on the general practitioner, but it is still an open question whether he should call on the new divisional mental welfare officers or the home nurse to help him in this task. Conclusion—Undoubtedly the home nurse of today has a different but no less valuable role than her predecessor of thirty years ago. The standard of nursing is high and health education, always an essential part of every home visit, has become increasingly important. The home nursing service has always been closely integrated with the general practitioner service. Today the home nurse in London is also firmly established as a member of the local health authority team and has co-operated at field level with the hospital service in the continuity of care of patients discharged early to the general practitioner and home nursing services. This close integration, so well begun, deserves the highest praise, for we have now moved from the concept of limited services for the few to a vast network of community services for all. No service can any longer work effectively in isolation. 143 DISTRICT NURSING ASSOCIATIONS IN LONDON (a) Affiliated to Queen's Institute of District Nursing Brixton 47 Tulse Hill, S.W.2. Camberwell Halsemere Road, S.E.5. *Charlton & Blackheath 50 Vanbrugh Park, S.E.3. East London Nursing Society 7-9 Stainsby Road, E.14. Fulham 56 Harwood Road, S.W.6. Hackney 6 Lower Clapton Road, E.5 †Hammersmith 141 Uxbridge Road, W.12. Hampstead 3 Pond Street, N.W.3. Kensington 14 Holland Park, W.11. ‡Kilburn & West Hampstead 20 Dennington Park Road, N.W.6. (b) Ranyard Nurses and affiliated association Ranyard Nurses *St. Mark's Church Kennington Park Road, S.E.I 1. *Norwood 40 Hitherfield Road, Streatham, S.W.16. Metropolitan 18-20 Montague Street, W.C.I. North London 6-7 Canonbury Place, N.l. Paddington & St. Marylebone 117 Sutherland Avenue, W.9. *Putney 15 Earldom Road, S.W.I5. St. Olave's (Bermondsey & Rotherhithe) 13 Cherry Garden Street, S.E.16. Shoreditch & Bethnal Green 210 Kingsland Road, E.2. *South London 109 North Side, Clapham Common, S.W.4. Southwark, Newington & Walworth 65 Sancroft Street, S.E.11. Westminster & Chelsea 73 Cadogan Gardens, S.W.3. Woolwich & Plumstead 22 Nightingale Place, S.E.I8. (c) Independent associations Catholic Nursing Institute 60 Lambeth Road, S.E.1. Nursing Sisters of St. John the Divine St. John's Home, Watson Street, Deptford, S.E.8. *Stoke Newington Barton House Annexe, 235 Albion Road, N.l6. *Non-residential. †Superintendent only in residence. ‡Superintendent and Assistant Superintendent only in residence. 144 APPENDIX C SPEECH THERAPY IN L.C.C. SCHOOLS Introduction—Speech is not an automatic development, it is something learned by the child; to attain such a power the child must have a pattern to follow and the ability both to recognise this pattern and to follow it. A child who for various reasons (for example deafness or no speech in the environment) never hears speech used is unable to make speech sounds. Given hearing and the presence of speech, there must be some power of concentration and some intelligence before profitable progress can be made in developing speech. This development can be retarded by emotional problems and even if hearing is normal there may be difficulty in interpreting sounds and reproducing them as useful speech. The ability to communicate is a necessity to the human race if not indeed to all animals; speech, amongst those using the same language, is the simplest method. Education without speech and an understanding of speech becomes very difficult and life in the community is full of frustrations. It can be accepted then that, where speech is inadequate, there is a place for speech therapy in the work of the school health service. The reason for the inadequacy of speech is usually to be found amongst the conditions noted above, but in many cases it is not clear how they operate. More children are recommended for speech therapy now than formerly and there is a general impression that there is more poor speech amongst children in the younger, pre-school and infant school age groups. There is no obvious cause for this, but it may have relation to the amount of time that radio and television is left on in the home. Instead of talking, telling stories and reading at close range in quietness, there is an overlay of noise from the radio and fewer stories are told by parents; there is less accent on the value of the story read by the fireside and indeed on the relating of the day's doings amongst the family. The pattern of speech seen, heard and felt by the small child sitting close to the speaker is lost in these circumstances and lost with it is the stimulation of speech necessary to small children. There can be no objection to radio, but its indiscriminate use may well be harmful. Harmful too is the need for keeping children quiet in flats lest the people below or above object. There is need to experiment in speech just as in walking. Shouting and crying are useful as are whistling and laughing. The child needs to have someone to listen to and to talk to and nothing so far has replaced home companionship as the best way to achieve this. The speech clinic is able to help children to attain normal speech and language by correcting incorrect sounds and exercising the child in the development of new sounds necessary for language but not yet within the competence of the child; work done at home by the parents guided by the speech therapist is a useful supplement, and in the case of a school where there is good contact between the school and clinic and parents the situation is still better. The start—The need for some special provision to be made for children with some disorder of speech was becoming apparent in London by 1912. Before this year a few children 'suffering from stammering, idioglossia and cleft palate' were 'recommended for a course of instruction in articulation ' in a deaf school. Mr. Yearsley, the Council's otologist at that time, reported that this was not satisfactory and drew attention to the needs of children with disorders of speech requiring treatment, for whom no arrangements had been made. The annual report of the School Medical Officer for 1912 recommended the provision of centres for their treatment and emphasised that instruction must be by an expert. 145 The following year's annual report gave some details of the size of the problem and a first classification of the disorders: Total Boys Girls Stammering 625 473 152 Other defect of speech 1,939 1,135 804 The children were grouped by ages (infants, intermediates and leavers) and it was noticed that in both sexes stammering was most frequently found in the oldest age group, leavers (0.88 per cent. boys and 0.24 per cent. girls). The number of children recommended for treatment for stammering was 14 boys and five girls and for treatment for other defects 25 boys and 14 girls. A note in the 1913 annual report states that seven children seen by the otologist were physically defective, 'mostly cases of cleft palate requiring lessons in articulation'. The need for some special provision for these children was being made clear and by 1914 plans began to take shape. Much thought was being given to the question at this time and the following extract from the 1914 annual report is a summary of the state of affairs then: 'From time to time attention has been drawn to the need for special educational treatment for children suffering from stammering and schemes have been drawn up for the opening of experimental classes, but up to the present none of the schemes has reached maturity.' The first advance came in this year when the Council arranged for students in training colleges to have some teaching in the theory and practice of speech. It was St. Thomas' hospital which made the first practical advance in the field of speech therapy for schoolchildren, for at this time the hospital' established a speech clinic for the treatment of schoolchildren suffering from defective speech, including stammering, post adenoid conditions, respiratory defects and general nervous conditions'. This clinic was conducted by Miss Fogerty. The number of children reported as stammering was 559 and the proportion of boys to girls was about three to one (419 boys and 140 girls). Cautious experiment—In the latter part of 1915 the Council decided to add articulation for stammerers to the list of subjects which might be taught in evening classes and two classes were opened in the autumn term. These two classes for adult stammerers, taken by teachers of the deaf using oral methods, proved to be successful and it was decided that they should be kept going, but as a result of the experience gained it was thought that more effective work would be done if treatment were started at an earlier age. A suggestion was made that one or two visiting teachers should be appointed to attend in each district once or twice a week and give instruction to children who would attend at an elementary school in the district; this would be in addition to the clinic at St. Thomas' hospital which continued to treat schoolchildren. A survey of leavers from the ordinary schools was made in 1916. This showed that 0.5 per cent. of boy leavers stammered and 0.5 per cent. had other defects of speech; in girls 0.2 per cent. stammered and 0.4 per cent. had other defects of speech. Speech defects were noted as being more common amongst the children in the special schools for the 'mentally defective', 4.5 per cent. of whom had some defect of articulation. First development—Arrangements were made in 1917 for an experimental class in remedial exercises for stammering children from elementary schools. This class was conducted under the auspices of the Westminster Health Society. The class was very successful and was continued, with growing success, in 1918. As a result of this class the Council decided in 1919 to start a number of classes itself. It was estimated that about 1,000 children would need treatment in the proportion of three boys to one girl. Teachers were asked to report on the nature of the speech disorder and to classify each case as acute, moderate, or slight; 914 children were notified, 682 boys and 232 girls. The age distribution is of interest: 146 Age Number Boys Girls 7 15 12 3 8 73 54 19 9 123 89 34 10 146 105 41 11 154 121 33 12 187 150 37 13 197 137 60 14+ 19 14 5 The number of children actually having treatment in 1919 was 105. A revised estimate the following year showed that 1,200 children needed treatment, the proportion of boys to girls remaining the same. The proposed system for treatment was that five classes were to be established, with 20 children in each class, the whole to be under the general supervision of a medical officer. The effect of this scheme was good and 34 children were discharged at the end of the first term. As a result of this experience stammering children were classified in the following groups: (i) Children who started to stammer as they developed speech. (ii) Those in whom stammering came on at a later date and after the development of normal speech. It was noted that successful treatment of the first group was difficult. This work done in 1920 suggested some reasons for the onset of stammer of the second group and noted that air raids during 1914-1918 were associated, causing frights, nightmares and night terrors. Poor physique and spasmodic breathing were often found in these children, many of whom looked strained and anxious. Treatment was directed towards improving the general condition and relaxation. The first speech clinic organised and conducted entirely by the Council was opened this year in Brixton; experience with this class showed that 20 children was too large a number and 12 more satisfactory. At this time, 1920, it was thought that a total accommodation of 144 places would meet the need and a scheme was drawn up for the treatment of about 300 children each year. It seemed likely that the arrears of work would be overtaken and younger children admitted to the class. It was realised that there would be difficulties in getting the younger children to the centres—this problem is still with us. The plan provided for a gradual movement of centres from the central area towards the periphery of the county, so that vacancies occurring then could be offered to children from neighbouring authorities which might not have centres of their own. First expansion—Centres were opened in six schools in 1921. Two groups of 12 children attended twice weekly 'for treatment and advice from special instructresses in speech training'. A total of 330 children passed into the centres and 'a number of the more chronic patients were sent to Margate and Bushey Park Camp schools with beneficial results Until this time the classes had been for boys and girls separately, but in 1921 the number of girls requiring treatment fell and the experiment of putting the younger boys with the girls was made. This proved a happy experiment and since then mixed groups have been quite usual. The term 'treatment centre' came into use in 1922 and has been in current use since. Of 350 children treated for stammering in 1922 the greater part was made up of older boys; 95 out of the total of 350 were noted as provisionally cured. This term was used for children whose speech was quite clear or so nearly so that the standard of speech was readily acceptable. The six centres were continued throughout 1923 and as experience was gained more information about stammering children became available. It was noted in a report that after a period of treatment there was sometimes a period of standstill and in some cases this was an indication for a rest from treatment; after such a rest more progress was made on return to the centre. An attempt was made to define criteria on which to make a prognosis and it was thought that the main factors were the teacher, the time between onset and treatment, the intelligence of the child and the physical condition of the child. 147 K A development in 1924 was the opening of a clinic in the Jews' Free School in Shoreditch, which replaced one in Lombard Wall and was for the treatment of Jewish children in the school. In the following year 'very beneficial results ' were noted in three children who had cleft palates. No new centres were opened in 1926. The Headmaster reported that the centre in the Jews' Free School was producing good results. In 1927 an attempt was made to discover, a year after discharge, how permanent was the cure or improvement of children who had been treated for stammering— Remaining cured after a year 24 Much improved 19 Relapsed 5 Worse 1 49 (boys 43, girls 6) Experience in the centres and in the Jews' Free School centre was showing the great value of a close connection between the speech therapist and the school. It had proved very helpful in the Jews' Free School, so in 1928 one session a week was devoted to school visiting. The need for this has not diminished through the years and much useful work has grown out of school visits by therapists to heads and class teachers. A new centre was opened in Lewisham in 1929. The number of children reported in need of treatment had been growing slowly as facilities increased and in this year over 300 passed through the centres. In the following year another centre was opened, in Paddington, making eight in all and again there was an increase in the number needing treatment. The plan of treatment had been that each child attended twice a week for one-and-a-half hours, but in 1931 it was decided that instead of 12 children there would be nine in each group and that the period of treatment would be 50 minutes twice a week. Pressure on the centres was increasing and in 1933 the experiment of using studentassistants was begun. These were persons who, after they had observed the work of the clinic for some time, were given experience in the clinical work and could then obtain posts with other local authorities. By the end of the year there had been so many applications from students for places in the centres that it became necessary to regulate the attendances and to charge a small fee. This fee was charged until 1953. Students who attended for a year were given a certificate of attendance which, while not in any way a diploma, was evidence of practical experience. The requests from students for places in the centres increased and it became obvious that systematic training was required as well as clinical experience. Such a course was started for six students in 1934 by Dr. Boome and Miss Richardson. After a short time this venture was absorbed by one of the training schools. The annual report of the School Medical Officer for 1933 records that of 455 children who stammered, 273 were found to have another stammerer in their immediate family circle and 174 more had a near relative who stammered. Pressure was building up on the centres as more children were recommended for treatment and in 1935 the number of centres was increased by five: two for children attending primary and secondary schools were opened in June in Kennington and Hackney; two more, intended to serve children in secondary (now grammar) schools, were opened in November, at the North Western Polytechnic and at Henry Thornton School, Clapham and worked on Saturday mornings; another new centre was opened at Salter's Hill School to serve children in the Council's residential homes and schools. There were now 13 centres to serve school children; they continued through the following year and over 500 children were treated in 1936. An attempt to follow up some children who had left school five years or more ago after treatment gave the following result: Regular employment 29 No speech defect 13 Not employed 1 Slight speech defect 15 Still studying 1 Severe speech defect 3 31 31 148 The term 'speech therapists' was first used in the School Medical Officer's reports in 1937. The therapists employed by the Council had started monthly meetings in 1934 and had continued them regularly. In 1937, therapists living and working out of London were invited to attend these meetings which were held on Saturday afternoons. They were well attended and therapists were in this way helped to keep in touch with their colleagues. The 13 centres continued to operate through 1938; over 500 children attended, 403 from elementary schools, 51 from secondary schools and 48 from residential homes. One therapist noted the following in 100 consecutive cases of stammering: Onset of stammering related to age. Only child 6 At start of speech .. 16 First „ 31 2 years 2 Second „ 25 3 12 Third „ 16 4 14 Fourth „ 8 5 19 Fifth 7 6 7 Sixth „ 6 7 3 Seventh „ 1 8 5 9 1 10 7 11 6 12 2 Uncertain 6 In five cases the child was one of twins. War and contraction of field of work—The mass evacuation in September, 1939 so scattered the school population that school medical work in clinics in London was brought to an end. All the speech clinics were closed and later the therapists visited the reception areas. Where it was possible they continued treatment. Despite the number moved from London many children remained or returned and by December some clinical services were restarted and part-time school commenced. The story in 1940 was of more evacuation, the estimated number of children in London was then 85,000; this increased in 1941 as people began to drift back and by December reached 150,000. It was not until the autumn of 1942 that five centres for speech therapy, which could accommodate 144 children, were reopened. The drift back to London continued and by the end of 1943 there were 250,000 in the schools and two more centres had been opened, giving places for 180 children. Progress continued in 1944: two more centres, now nine in all, were operating, despite the number of school children beginning to fall as evacuation became more intense. Records show that 439 children attended speech therapy in 1944. The Education Act, 1944 recognised children suffering from speech disorders as being in need of special educational treatment and it became necessary for a legal process of ascertainment by the Chairman of the Education Committee to be completed before treatment could be commenced. The nine centres continued in 1945 and had places for 260 children. All that year the number of children in schools in London continued to increase, so that in December it reached 277,359 and a total of 361 children were treated in the year. The number of school children continued to increase in 1946 to 334,784 by December and the speech clinics were increased to twelve. All the centres were staffed by part-time therapists who worked under the general supervision of a principal assistant medical officer. Second period of development—The second period of growth commenced in 1947 when the school population had grown to 352,570. The 12 centres had 536 attendances. It had become plain that expansion of the speech therapy services was necessary and in 1948 the number of clinics was increased to 16, with 645 attendances. Two more centres were opened in 1949 and 670 children attended. It was in 1950 that two advances were made; 149 K* one more centre for ordinary schools was opened, one was started at the Children's department residential establishment at Banstead and one experimental clinic was started in a day school for educationally subnormal children. At this time the speech therapy staff consisted of one senior therapist (whole-time), one whole-time assistant therapist and four part-time therapists; a senior medical officer was charged with general supervision. Expansion of the service was rapid from then on, 23 centres in 1951 and three more whole-time therapists, with 536 children under treatment at the end of the year and a waiting list of 296. The experiment of conducting clinics in the schools for educationally subnormal children proved to be useful, time was saved, escorts were not needed and closer contact between school and therapists was possible. In general, progress was found to be slower than in normal clinics, but progress was made and these clinics in special schools have continued. These centres in special schools treated 205 children. In this year the service was extended to some severely handicapped children confined to their homes and having home tuition. There has never been a large number of such cases, but each year has produced two or three. The day schools for physically handicapped children had always had a number of children in need of speech therapy and in 1952 arrangements were made for a therapist to visit regularly 16 such schools. A start was made in some of the boarding special schools, too. Throughout the years difficulty has been experienced in keeping the boarding schools supplied and some schools have had long gaps when there has been no therapist. In particular those at a distance from London have been unfortunate. A therapist living nearby is wanted but this ideal state usually does not exist and some schools are supplied by a therapist travelling from London. There were 28 remedial clinics for day schools and 22 educationally subnormal day school clinics in 1952. There had been 778 new admissions and the total of children under treatment reached 1,059. During the next two years there was further expansion. In December, 1954 there were 1,135 children having tuition in 38 normal centres and 1,483 under treatment in 26 day educationally subnormal, 17 day physically handicapped and five residential schools. The staff had grown to one senior speech therapist, 12 full-time, three part-time and seven sessional therapists. It was about this time that the issue of free-paid bus tickets for children attending various types of clinics came under consideration and it was decided to stop the use of these tickets. This apparently simple decision caused much despondency amongst stammering children, who could not always bring themselves to ask the school teacher for the fare, much less ask for their ticket on the bus. It was clear too that difficulty would be caused in cases of severe dyslalia and dysphasia, because of the difficulty in being understood. It was decided that tickets for special clinics would continue to be available and the easing of tension could almost be felt. Speech therapy was extended in 1957 to two occupation centres, now junior training centres, for an experimental period of one year. In 1957 the number of children under treatment exceeded 2,000, with 270 on the waiting list in December; 124 sessions had been worked each week in 41 centres for children from ordinary schools and 78 sessions each week in 41 day special schools. Authority to start speech therapy in all junior occupation centres was given in 1958. In December, 72 children in the occupation centres were having treatment. In the same year a number of portable tape recorders were supplied for use in the clinics, following a period of experiment with one recorder kept in one clinic. Therapists can take these light machines from centre to centre themselves and keep a supply of tapes in each centre as may be required. The waiting list increased and stood at 322 at the end of 1958. An increase in staff the following year enabled more sessions to be worked and the waiting list to be reduced to 272. 150 Stewart Headlam special classes—Over the years several children had been admitted to speech clinics who suffered from various degrees of dysphasia. Some of these children were found to be unsuitable for Moor House, a boarding school which takes children with this defect. The usual weekly or twice weekly attendance in a speech clinic was found to give insufficient treatment and progress in school was very slow. Dysphasic children may have difficulty in the comprehension of spoken language or in the production of language or both; they need, therefore, much more help than can be given in an ordinary speech clinic. There is need of stimulus to speech, encouragement to practice and understanding guidance in both school and clinic. The support given by the family circle and regular contact with much normal speech are also of valuable assistance. A regime in which the child spends part time in normal school, part time in the speech clinic, part time in a special class and in the meantime lives at home and maintains normal contacts with family and friends would seem to be as good as possible. This is the scheme worked at the Stewart Headlam special class, where speech therapy and special educational arrangements are available four days each week. Children attend as frequently as can be arranged and spend the rest of the time in their ordinary school. This venture was started in November, 1959 in conjunction with the Education Officer and has been found to be of real value in helping these rather awkward children. Here they can be helped as individuals and also work as a community, they gain strength by discovering that they are not alone in their disability. The children in this group take part in very varied activities, some of which are handicrafts such as painting, modelling and woodwork, some more academic such as reading and writing and mathematics; they make visits, go swimming and have visitors—one memorable visitor was a mounted policeman, an inspector. All sorts of ways are used to enable normal contacts to be made and all sorts of people have been of great help; the teacher and speech therapist, of course, but also the schoolkeeper and the cook. Progress is apparently good at first, then seems to slow down and it is as yet uncertain how long children should attend; about two years is the expected minimum and some will need longer. The degree of difficulty experienced by the children varies greatly, some have a severe defect of expression, some have little language and in some there is an associated problem of the understanding of written symbols. The greatest difficulty in keeping the group in being has been that of attendance; escorts are necessary for most children and they have not been easy to find. The area from which the children attend is large, anywhere within the county and rarely can one escort bring two children. One boy from out-county was sent and fetched by car each day the group operated. This boy, at one time unable to speak with anyone, distinguished himself by ringing up a headmaster to enquire the whereabouts of his friend due in the group and who had not turned up. His message was understood and gave all concerned much satisfaction. Not so another occasion on which a message to be given to the teacher was taken by a boy and distorted from 'your visitors will not be able to come today' into ' you have two new children coming tomorrow Most of the schools from which these children come find some degree of improvement in a short time, at first in the reaction of the child to the staff and children and later in academic achievement. In one school a boy made such advances as to win an award for having made more progress than any other pupil. For the presentation of the award by the Lord Mayor he went with the school to the Guildhall. Alas, a mistake was made and this boy's name was not called. He took the disappointment bravely but was still very upset next day. The teacher in the special class made sure that the Lord Mayor heard of the error with the result that the boy was asked to meet the Lord Mayor and had a very special presentation on his own. He was more thrilled because the Lord Mayor of London was robed. 151 Present state—That speech therapy is filling a useful place is clear from statements by teachers and parents, but there is still a waiting list and still fields of work only touched. More needs to be done in the boarding schools, but there are still insufficient therapists. It is interesting to see that in several day schools enough work exists to make it necessary to allot sessions to these schools; in the day special schools the demand fluctuates but remains relatively constant in the infant and junior schools; the senior children, it may be, are showing the result of work done when they were in the junior school. The staff at present consists of one head therapist, 22 full-time, eight part-time and 11 sessional therapists. The number of sessions held each week is as follows: In school treatment and M. & C. W. centres 175 Ordinary schools 10 Special schools: E.S.N.— Day 54 Boarding 12 Physically handicapped— Day 26 Boarding 6 Partially sighted 6 Blind 1 Children's department establishments 7 Training centres 18 The 1961 survey—The original intention of this survey was to obtain information on every child who attended a centre between 1 June, 1960 and 31 May, 1961. Eventually, completed forms in respect of 3,290 children were received and it is estimated that reports on some 500 children were not completed. Staffing problems, particularly in the boarding schools, made a complete census impracticable. The numbers of children in the survey admitted, attending and discharged during the period are set out in table (i). Boys outnumbered girls by three to one. Table (i)—Children included in the survey Total Boys Girls Admitted before 1.6.60 2,140 1,519 621 Admitted after 1.6.60 1,142 812 330 Date of admission not recorded 8 6 2 Total children in survey 3,290 2,337 953 Dis.harged by 31.5.61 586 400 186 Transferred before 31.5.61 45 29 16 Left school before 31.5.61 35 30 5 Lapsed before 31.5.61 148 114 34 Refused treatment 54 35 19 Died 3 2 1 - 871 - 610 - 261 Remaining in attendance 2,419 1,727 692 Table (ii) shows the total number of defects for which these children required treatment. As 454 children suffered from more than one defect, the total number of defects is greater than the total number of children. Proportionately within the sexes, the incidence of stammer in boys is twice that of girls but the incidence of dysarthria and dyslalia is greater in girls. Details of children suffering from more than one defect are shown in table (ii) a. 152 Table (ii)—Number and type of speech defects reported Nature of defect All children Boys Girls No. % No. % No. % Stammer 880 23.3 721 26.8 159 14.6 Dysphasia 68 1.8 42 1.6 26 2.4 Sub-mucous cleft 7 0.2 4 0.1 3 0.3 Cleft palate 71 1.9 39 1.4 32 2.9 Alalia 74 1.9 50 1.9 24 2.2 Dysarthria 174 4.6 105 3.9 69 6.3 Dyslalia—simple 868 23.0 570 21.2 298 27.5 —multiple 986 26.1 720 26.7 266 24.4 —general 444 11.7 302 11.2 142 13.0 Dysphonia 209 5.5 139 5.2 70 6.4 Total defects 3,781 100.0 2,692 100.0 1,089 100.0 Total children 3,290 2,337 953 Table (ii) a—Multiple defects (main defect and associated defects) Main defect Sex Total cases Number with one other speech defect Number with two other speech defects Associated speech defects Dysphasia Cleft palate Alalia Dysarth ria Dyslalia simple Dyslalia multiple Dyslalia general Dysphonia Stammer B 721 178 15 6 3 1 10 70 78 21 19 G 159 43 4 1 1 1 3 23 15 5 2 Dysphasia B 36 21 4 — — 2 7 4 10 4 2 G 25 8 3 — — - 4 - 2 7 1 Sub-mucous cleft B 4 1 - - - - - - - 1 — G 3 2 - - - - - - 2 - - Cleft palate B 36 9 2 - - - 1 2 4 2 4 G 31 6 - - - - - 3 — 2 1 Alalia B 47 2 1 - - - 2 — — — 2 G 23 - - - - - - - - - - Dysarthria B 85 27 1 - - - — 1 12 5 11 G 62 20 7 - - - - - 12 5 17 Dyslalia simple B 493 27 - - - - - - - - 27 G 272 6 - - - - - - - - 6 Dyslalia multiple B 616 32 - - - - - - - - 32 G 235 16 - - - - - - - - 16 Dyslalia general B 269 12 - - - - - - - - 12 G 123 7 - - - - - - - - 7 Dysphonia B 30 - - - - - - - - - - G 20 - - - - - - - - - - All B 2,337 309 23 6 3 3 20 77 104 33 109 G 953 108 14 1 1 1 7 26 31 19 50 153 Therapists were asked to classify each case according to severity and defect with the following criteria: 1. Severe—complete breakdown in the process of communication. 2. Moderate—difficulty in communicating in some or all special situations. 3. Slight—variable or constant, not interfering with fluency. Their assessments are summarised in table (iii). Table (iii)—Severity of defect All children Boys Girls No. % No. % No. % Severe 290 8.8 200 8.6 90 9.4 Moderate 1,564 47.5 1,158 49.6 406 42.6 Slight 1,436 43.6 979 41.9 457 48.0 3,290 100.0 2,337 100.0 953 100.0 154 The type of school the children attended is shown in table (iv). Table (iv)—Type of school, etc. attended All children Boys Girls No. % No. % Open air 45 1.4 30 15 Maladjusted 18 0.5 15 3 Partially sighted 30 0.9 24 6 Physically handicapped 210 6.4 127 83 Educationally sub-normal 560 17.0 407 153 Secondary 461 14.0 339 122 Junior 993 30.2 717 276 Infants 753 22.9 546 207 Pre-school 67 2.0 38 29 Home tuition 2 0.06 1 1 Training centre 151 4.6 93 58 3,290 100.0 2,337 953 It is interesting to note that nearly a third of these children are receiving education in one or other type of special school. This is an under-estimate as the sample is known to be deficient in this type of child. Table (v) shows the age of admission by main type of defect, each child counted once only. Table (v)—Age* at admission according to type of defect and sex Defect Sex Total cases Approximate age* in years at admission Under 5 5 6 7 8 9 10 11 12 13 14 15 16 17 N.R. Stammer B 717 25 41 87 97 97 74 77 71 60 35 27 20 4 2 4 G 158 7 11 18 18 21 15 18 11 16 11 4 5 2 1 1 Dysphasia B 36 - 2 9 3 4 8 1 2 3 - 2 2 - - - g 25 3 7 5 1 1 2 1 - 2 1 2 - - - - Sub-mucous cleft b 4 - 1 1 - - 1 1 - - - - - - - - g 3 — 1 2 - - - - - - - - - - - - Cleft palate b 36 3 5 8 6 4 3 1 2 3 - - 1 - - - g 31 6 7 4 5 4 - 1 1 - 2 1 - - - - Alalia b 47 9 11 8 4 6 1 4 2 - 1 1 - - - - g 23 6 6 2 3 2 2 1 - - 1 - - - - - Dysarthria b 85 2 15 7 13 10 5 5 9 3 6 5 5 - - - g 60 3 5 9 10 8 3 5 4 2 6 2 2 1 - 2 Dyslalia simple b 492 12 40 79 86 88 42 39 42 29 14 9 8 2 2 1 g 271 8 21 42 35 48 32 27 15 18 13 9 2 1 - 1 Dyslalia multiple b 614 32 103 164 134 82 35 18 22 11 8 4 1 - - 2 g 235 13 29 72 46 30 13 12 6 10 1 3 - - - - Dyslalia general b 269 29 53 91 41 21 12 1 8 3 3 1 - - - - g 123 24 22 26 21 14 7 3 4 1 1 - - - - - Dysphonia b 30 - 3 2 2 4 6 3 2 3 1 2 2 - - - g 20 - 1 1 3 2 5 1 2 1 3 - - 1 - - All b 2,330 112 274 456 386 316 187 156 160 115 68 51 39 6 4 7 g 949 70 110 181 142 130 79 69 43 50 39 21 9 5 1 4 Both 3,279 182 384 637 528 446 266 225 203 165 107 72 48 11 5 11 *Age was calculated by deducting year of birth from year of admission. Those children suffering from alalia in the older age group were attending training centres. No marked modal age is demonstrated for stammering but there is a peak at 7-8 years old. The modal ages show for dyslalia at 6-8 years and a lesser peak at 11. This probably reflects the result of routine school medical inspections. 155 Tables (vi) B and G show, for boys and girls separately by type of defect, the position in the family of these children. Table (vi) B—Position in family according to type of defect—BOYS (a) Position in family of children with defect. (b) Percentage of (a) to total children in family positions. Defect No. of children with defect Only children Position in family 1 2 3 4 5 6 7 8 9 or more Not recorded Stammer(a) 721 102 192 199 118 52 20 18 4 4 5 7 (b) - - 31 33 29 22 17 24 7 7 28 - Dysphasia (a) 36 8 5 10 6 4 2 - - - 1 - (b) - - 18 36 33 33 25 - - - 100 - Sub-mucous (a) 4 - 1 1 1 - - 1 - - - - cleft (b) - - 25 25 25 - - 100 - - - - Cleft palate (a) 36 7 9 10 3 6 - - - - 1 - (b) - - 31 34 17 50 - - - - 100 - Alalia (a) 47 7 11 15 5 4 1 1 - - 2 1 (b) - - 28 38 22 31 11 33 - - 100 — Dysarthria (a) 85 20 22 19 14 2 2 3 - 1 1 1 (b) - - 34 30 42 10 14 43 - 50 50 - Dyslalia (a) 493 52 84 159 97 40 21 11 6 7 3 13 simple (b) - - 20 37 32 21 18 15 14 30 27 - Dyslalia (a) 616 51 94 218 109 64 33 17 9 6 8 7 multiple (b) - - 17 39 28 26 20 19 16 19 42 - Dyslalia (a) 269 25 37 78 56 39 15 1 4 3 2 3 general (b) - - 15 32 31 36 20 21 18 33 40 - Dysphonia (a) 30 5 7 14 2 1 - - - - - 1 (b) - - 29 58 17 12 - - - - - - Total (a) 2,337 277 462 723 411 212 94 58 23 21 23 33 (b) - - 23 36 30 25 18 20 12 20 39 - 156 Table (vi) G—Position in family according to type of defect—GIRLS (a) Position in family. (b) Percentage of (a) to the children in family positions. Defect No. of childdren with defect Only children Position in family 1 2 3 4 5 6 7 8 9 Not recorded Stammer (a) 159 26 48 50 23 1 5 2 - - 1 3 (b) - - 37 39 33 3 22 13 - - 100 - Dysphasia (a) 25 3 8 8 3 3 - - - - - - (b) - - 36 36 33 60 - - - - - - Sub-mucous (a) 3 - 1 - - - - 1 1 - - - cleft (b) - - 33 - - - - 50 50 - - - Cleft palate (a) 31 4 7 11 4 1 2 - - 2 - - (b) - - 26 41 25 20 50 - - 100 - - Alalia (a) 23 4 3 5 7 2 1 - - - 1 - (b) - - 16 26 50 25 25 - - - 100 - Dysarthria (a) 62 13 14 14 11 4 1 2 - 2 - 1 (b) - - 29 29 37 22 10 33 - 100 - - Dyslalia (a) 272 26 51 79 50 30 9 8 8 1 4 6 simple (b) - - 21 33 29 27 12 17 26 5 31 - Dyslalia (a) 235 12 37 77 55 27 11 4 3 3 3 3 multiple (b) - - 17 35 36 28 19 12 13 21 30 - Dyslalia (a) 123 10 20 41 25 13 4 3 3 1 2 1 general (b) - - 18 37 31 30 17 27 38 17 33 - Dysphonia (a) 20 1 4 6 2 3 2 2 - - - - (b) - - 21 32 18 38 29 67 - - - - Total .. (a) 953 99 193 291 180 84 35 22 15 9 11 14 (b) - - 23 35 32 25 17 17 18 17 33 - Only children are shown separately because order of position in family does not arise in their case. The proportion of only children in the survey was 12 per cent. for boys and 10 per cent. for girls; for both sexes these percentages were higher for the defects of stammer (14 per cent. boys, 16 per cent. girls) and dysarthria (23 per cent. boys, 20 per cent. girls). In a self-selected sample of families having children with a specific defect, there will invariably be an over-representation of the larger families. If, for example, the incidence of the defect was ten per cent., every ten-child family would be statistically likely to be represented but only half the five-child ones and one-fifth of the two-child families. Hence, if it is desired to see whether the position in the family has any bearing on the presence or absence of a particular defect, it is difficult to arrive at a population against which to test such a hypothesis. Practical alternatives are to assume that in, say, five-child families the theoretical distribution of defective children would be 20 per cent. for each position; or to relate the incidence to the numbers of children in each position to the numbers of children contained in all the families in the sample. There are complications with either course—for example, bearing in mind that this was a survey of schoolchildren, there is the risk that, in the larger families in particular, some of the children would be under or over the school age range and might not have been included. Fortunately, whichever method is used the results are of the same order and line (b) shows the children with defects (line (a)) as a percentage of the total children in the families occupying the respective positions. 157 Overall, for children with more than one child in the family, second and third children have a higher incidence of defective speech than do first and later children; this applies to both boys and girls. With boys this tendency towards second and third children is particularly noticeable with dyslalia, extending to the fourth child for general dyslalia; for stammer the higher incidence extends to first, second or third children. A similar pattern obtains for girls, though the numbers are smaller and do not have the same significance. Table (vii) shows age at admission by severity of selected defect. The sexes are shown separately. Table (vii)—Age* at admission according to severity of selected defects and sex Defect Degree of severity Sex Approximate age* at admission Total children Under 5 5 6 7 8 9 10 11 12 13 14 15 16 17 Stammer Severe b 3 4 7 7 5 5 2 5 4 3 2 8 - - 48 g - 1 1 1 3 1 1 2 2 - - 1 - - 13 Moderate b 11 23 56 64 66 48 42 41 34 19 16 14 4 1 439 g 5 4 13 11 12 9 8 5 9 9 2 3 1 - 91 Slight b 47 26 26 21 28 25 29 13 9 5 - - - - 230 g 2 6 4 6 6 5 9 4 5 2 2 1 1 1 54 Dyslalia simple Moderate b - 1 5 4 4 7 3 1 2 1 1 - - - 29 g 1 3 1 4 2 1 - - 2 - - - - - 14 Slight b 12 39 74 82 62 57 36 41 27 13 8 8 2 2 463 g 6 18 41 31 46 31 26 15 16 13 9 2 1 - 255 Dyslalia multiple Severe b 1 7 5 5 2 1 - 1 - - - - - - 22 g - 3 5 - — — — — 1 — — — — — 9 Moderate b 19 72 119 94 45 25 10 13 6 4 1 - - - 408 g 8 16 48 27 20 6 4 2 5 — 1 — — — 137 Slight b 12 24 40 35 35 9 8 8 5 4 3 1 - 184 g 5 11 18 19 10 7 8 4 4 1 2 — — — 89 Dyslalia general Severe b 10 16 13 5 3 1 2 1 1 1 - - - - 53 g 6 4 3 3 1 1 - - - - - - - - 18 Moderate b 17 34 66 29 11 7 5 6 1 2 1 - - - 179 g 14 15 16 13 11 5 3 3 1 1 - - - - 82 Slight b 2 3 12 7 7 4 _- 1 1 - - - - - 37 g 4 3 7 5 2 1 - 1 - - - - - - 23 Total Severe b 14 27 25 17 10 7 4 1 5 4 2 1 - - 123 Moderate b 47 130 246 191 126 87 60 61 13 26 19 14 4 1 1,055 Slight b 73 92 152 145 132 95 73 63 42 22 11 9 2 2 914 Severe g 6 8 9 4 4 2 1 2 3 - - 1 - - 40 Moderate g 28 38 78 55 45 21 15 10 17 10 3 3 1 - 324 Slight g 17 38 70 61 64 44 43 24 25 16 13 3 2 1 421 Severe Both 20 35 34 21 14 9 5 9 8 4 2 1 - - 163 Moderate Both 75 168 324 246 171 108 75 71 30 36 22 17 5 1 1,379 Slight Both 90 130 222 206 196 139 116 87 67 38 24 12 4 3 1,335 *Age was calculated by deducting year of birth from year of admission. 158 Table (viii) shows other members of the family reported to have defective speech. It will be seen that children who stammer have the highest incidence of defective speech in the family. Table (viii) B—Speech defect in other members of the child's family according to child's defect—BOYS Child's defect Number of children Members offamily with defective speech None Father Mother Brother Sister Twin Father's near relation Mother's near relation More remote Stammer 721 409 94 68 75 31 11 42 71 13 Dysphasia 36 28 - 1 4 2 — 1 1 1 Sub-mucous cleft 4 3 - 1 1 - - - - - Cleft palate 36 30 2 1 2 1 — — 3 1 Alalia 47 40 — 2 6 2 — — 1 — Dysarthria 85 77 1 — 3 3 2 1 — — Dyslalia— simple 493 372 19 16 51 32 4 7 17 4 multiple 616 406 33 26 76 43 5 22 32 13 general 269 176 13 19 42 20 6 3 19 1 Dysphonia 30 26 — 1 — 1 1 — 1 — All 2,337 1,567 162 135 260 135 29 76 145 33 Table (viii) G—Speech defect in other members of the child's family according to child's defect—GIRLS Child's defect Number of children Members of family with defective speech None Father Mother Brother Sister Twin Father's near relation Mother's near relation More remote Stammer 159 83 25 16 9 14 1 8 15 2 Dysphasia 25 21 3 1 - 1 - 1 - - Sub-mucous cleft 3 3 - - - - - - - - Cleft palate 31 24 — 1 1 2 — - 3 1 Alalia 23 20 — 1 — 1 — - 2 1 Dysarthria 62 59 1 — 2 — — - 1 — Dyslalia— simple 272 190 5 11 33 23 5 6 12 1 multiple 235 146 10 6 35 26 3 10 19 5 general 123 89 7 2 12 13 4 2 5 1 Dysphonia 20 18 — 1 — 1 — — 1 - All 953 653 51 39 92 81 13 27 58 11 Conclusions—As a result of this survey little that is new has come to light but some impressions have been confirmed, such as the excess of boys over girls particularly in stammering and that on the whole boys are more severely affected than girls. 159 Left-handedness was included in the survey but has not been shown to be associated with stammer. A small number of children was reported as having been changed from left-hand to right-hand and analysis suggests that such a change of laterality increases the child's chances of stammering. An odd sidelight would seem to indicate that in the E.S.N, schools a greater percentage of girls having speech therapy are left-handed than in ordinary schools. No evidence was found to suggest that children with parents, or one parent, of foreign origin, i.e. non-English speaking, were more likely to suffer from speech defect. Language difficulties exist, of course, in those children who normally speak some language other than English at home; in some special schools the speech therapist is able to assist these children to attain adequacy of English speech more rapidly than would otherwise have been possible. An attempt to gather information about the home background was not successful, mainly it would seem because only a limited number of questions was asked, each covering too wide a field. It is still thought that there is valuable information to be obtained about the relationships between a child's home background and speech, but it would need to be the subject of a specially planned enquiry. 160 APPENDIX D SOUTH EAST LONDON GENERAL PRACTITIONERS' CENTRE St. Mary's Road, S.E.I5 (Medical Director, Brigadier H. L. Glyn Hughes, c.b.e., d.s.o., m.c., m.r.c.s., l.r.c.p.) The following abbreviated account of the activities of the South East London General Practitioners' Centre during the first twelve months of its existence is based on the Director's report to the House Committee. Introduction The South East London General Practitioners' Centre, which was officially opened on 16 February, 1961 by Lord Cohen of Birkenhead, provides general practitioners with facilities for diagnosis, treatment and minor operations which they do not possess in their own surgeries and with a range of subsidiary services, including organised discussion groups, lectures and a well-equipped common room. The Centre was established by the London County Council, who provided, adapted and maintains the premises, supplied the furniture and non-specialist equipment, the nursing, health visiting and secretarial staff and appointed the Director. Generous financial assistance was given by the Nuffield Foundation towards the cost of adaptations and equipment and by the Sir Halley Stewart Trust in respect of the Director's salary and expenses. The South East Metropolitan Regional Hospital Board and the Camberwell Hospital Management Committee provided the specialist equipment, staff and consultants for the radiological and pathological departments. (See table (v) for financial statement.) The College of General Practitioners has supported the project throughout and invaluable advice and assistance has been given by local general practitioners, both in the planning stage and since the Centre has been open. The general management of the Centre is the responsibility of a House Committee consisting of members of the London County Council, representatives of general practitioners and of all the organisations associated with the establishment of the Centre. A Medical Staff Committee of general practitioners and the Centre consultants acts in an advisory capacity to the Director on existing and projected activities of the Centre. Background The Centre is in part of the former Pioneer Health Centre, where the 'Peckham Experiment' was carried out. This was pioneer research work into human health and the biological observation of the family as a unit, and the building was equipped for both medical and recreational activities, including a swimming bath. When the Pioneer Health Centre closed and the premises were purchased by the London County Council in 1951, various health and education activities were accommodated there and a committee was set up by the Council to consider the possibility of continuing some form of medico-sociological work in the building. In discussions with interested organisations the need emerged for a diagnostic centre for general practitioners and for a centre where senior medical students could obtain instruction in general practice, and support for such a project was promised. This need was confirmed at meetings of local general practitioners, whose support was immediately demonstrated by the election of representatives to form an advisory committee. In 1958, the approval of the Ministry of Health having been obtained to the Centre being set up under section 21 of the National Health Service Act, detailed planning began. 161 Planning and construction The building which houses the Centre was one of the first in this country to be built entirely in reinforced concrete. Part of the second floor, which it was proposed to adapt, had not been used for some time and required considerable alterations, the scope for which was severely limited because it was impracticable to pull down, alter or adapt any structural walls. The planning of the various rooms had to take into account the reinforced columns and beams and it was necessary to fit around these the operational parts of the Centre in a relationship which could not easily be changed. To simplify the layout, it was decided to build a separate entrance vestibule, staircase and lift block, connected by a bridge to the building at second floor level. The entrance to the lift and staircase was designed both for pedestrians and for patients arriving by ambulance; stretcher patients may be lifted direct from the ambulance into the lift under cover. A car park with turning space for ambulances was an essential part of the scheme and it has been surrounded by gardens. Within the Centre is a pathological laboratory, an X-ray suite with dark- and viewing-rooms, two consulting rooms, a nursing treatment and minor operations suite, a common room and office accommodation. There was already on the same floor a child guidance unit and it was necessary to reorganise this accommodation as part of the whole scheme. Special finishes were required to meet the high standards necessary in a centre of this sort; it was also thought that to some degree the Centre would provide an opportunity to demonstrate to general practitioners types of wall and floor finishes and other amenities which require little maintenance and which might be suitable for their surgeries. Cement glaze was used on the walls and ceilings of the minor operations and nursing treatment rooms and those rooms have anti-static earthed vinyl plastic floors. The walls of the X-ray room were plastered with a barium based plaster and the doors reinforced with lead sheet to prevent the penetration of radiation. Vinyl plastic fabric of various designs and colours was used for other rooms with vinyl plastic floor tiles. The cost of adaptations is given in table (v) but it will be appreciated that this figure is no guide to the cost of setting up a similar centre in different circumstances. Services provided at the Centre The facilities of the Centre are available to any general practitioner who wishes to use them and 106 local doctors have done so during the first year, sending 3,450 patients to the Centre in respect of whom 6,081 investigations, etc., have been carried out (see table (1). No doctors practise from the Centre. Diagnostic facilities—The. diagnostic facilities which are provided enable general practitioners to investigate more fully those patients who do not necessarily require a specialist opinion, to follow-up patients who need repeated investigations to record their progress and to make a single check on patients after certain illnesses; all without having to make what may be thought at times to be an unnecessary use of busy hospital facilities. This should be an incentive to better practice and there are other advantages for the patients in the non-institutional atmosphere of the Centre and the fact that they do not have to repeat their history to a strange doctor. It is not part of the concept of the Centre to have consultant clinics but specialist opinion is available to general practitioners when required from the part-time consultants who supervise each department and the clinical reports which emanate therefrom. The pathological laboratory provides services within the following range: haematology, urine examinations, bacteriology and bone marrow aspirations—but certain investigations such as blood grouping, tests for tubercle and diphtheria bacilli, etc., are referred to other laboratories. During the year 1,886 investigations were carried out and a further 329 requests were referred elsewhere (table iii). 162 The radiological department has, up to now, been mainly restricted to investigations to bones and joints, chests and sinuses. A larger X-ray machine is about to be installed and the range of examinations will be extended; 1,800 were carried out during the year (table iv). An electrocardiography service has been started during the year and to date 277 requests have been dealt with. The investigations are carried out by the radiographer and the results interpreted by the consultant physician. The allergy service is also one which has been started during the year and 125 patients have so far been investigated. Skin sensitisation tests are very time consuming, taking anything up to one hour to carry out and this service should be of assistance to busy general practitioners. Other facilities—In addition to diagnostic facilities, the Centre provides specially designed and fully equipped rooms in which general practitioners can carry out minor operations or intensive investigations to their own patients with the assistance of trained nursing staff; 133 operations have been carried out during the year. Nursing treatments, dressings and injections ordered by the general practitioner are carried out for him by the nursing staff. 280 patients were dealt with during the year, many of them attending a number of times, the total number of treatments given being 1,208. An important feature of the Centre is the Common Room, where doctors can meet, study the wide range of medical periodicals and consult the reference library and information service which is being built up. Many large medical conferences have been held here and lunchtime meetings for general practitioners, which are held every six weeks or so, have proved to be very popular, with an average attendance of over 50 each time. A tape recording on a subject of medical interest to family doctors is played, followed by a discussion led by a specialist in the subject; these have included discussions on cardiac emergencies, the coroner and the general practitioner, and speech disorders in neurological disease. Liaison with local health authority services is maintained by the health visitor for the immediate area, who works from an office in the Centre; 28 requests for assistance have been made to her during the year. It is hoped that her work in the Centre will increase and will stimulate closer contact between family doctors and local health authority staff in the area. Other activities of the Centre Research—A few research projects have been started and others are in the planning stage, but the first year has mainly been used to gain experience on which to assess what might be the potential of the Centre in this field and all clinical and statistical records have been designed with the possibility of research in mind. Some subjects for research suggest themselves from the ordinary routine work of the Centre. There are, for example, a number of Africans and West Indians living in the area and special records are being kept of those who attend the Centre, which it is hoped may be of use in studying morbidity in those groups. The Centre is also able to collect information for other organisations undertaking research, such as the recording for the purposes of a survey being carried out by the College of General Practitioners of persons who have had measles. Undergraduate education—In the first year it was not practicable to start a formal scheme for undergraduate education but consideration has been given to the ways in which the Centre can participate in the instruction of senior medical students in the art and performance of general practice. It seems probable that this would consist of co-ordinating schemes involving students and local general practitioners and of organising lectures and case conferences at the Centre in which students, general practitioners, social workers and nursing officers could take part. 163 L Appraisal of first year Tables are given at the end of this report which show the extent to which the Centre has been used and they indicate the continuing support of the local doctors and a steady growth of work. In the appendix are shown the classification of patients attending the Centre with more detail about certain of the groups. The value of the Centre, however, cannot be demonstrated in statistical terms. Some of the services provided have not hitherto been available to general practitioners and the only measure of the need is the use made of them. Radiological and pathological services were already available at eight large hospitals in the area and the opening of the Centre will not be reflected to any significant extent in the outpatient figures of any one of them. Similarly, no conclusive evidence is available that the Centre contributes towards earlier detection of disease, although it has been observed that a number of patients were sent to the Centre whose symptoms were so slight that they might not normally have been referred to a chest clinic or hospital and that in some of these abnormal conditions were found. The Centre is still in the experimental stage and it may not be until the third or fourth year that it becomes stabilised. During the first year it was important not to be too ambitious and not to start any project in so big a way that there was a risk of it not being carried through to completion. For this is essentially the general practitioners' Centre and, notwithstanding the part played by the London County Council and the other organisations concerned, its pattern, growth and success depend to a very large extent on the needs and continued enthusiasm of the local doctors and on their ability to add to their busy lives. It will be interesting to see how it develops. Table (i)—Use of Centre 1.3.61 to 31.5.61 1.6.61 to 31.8.61 1.9.61 to 30.11.61 1.12.61 to 28.2.62 Total Doctors using Centre 62 83 97 106 106 New patients 825 843 821 961 3,450 Patients seen 1,043 1,193 1,281 1,413 4,930 No. of investigations, etc. 1,268 1,481 1,592 1,842 6,183 Table (ii)—Work in various departments 1.3.61 to 31.5.61 1.6.61 to 31.8.61 1.9.61 to 30.11.61 1.12.61 to 28.2.62 Total Pathology investigations 488 517 584 677 2,266 Radiology investigations 451 454 441 677 2,023 Electrocephalograms 68 91 72 91 322 Allergy tests 16 52 42 19 129 Nursing treatments 187 306 385 330 1,208 Minor operations 33 36 42 22 133 Research investigations 25 25 26 26 102 1,268 1,481 1,592 1,842 6,183 Table (iii)—Pathology No. of requests received 2,215 No. of resulting investigations 2,216 Requests dealt with Requests dealt with in conjunction with entirely at Centre other laboratories Bacteriology 382 Bacteriology 45 Chemical pathology 53 Chemical pathology 87 Haematology 1,451 Haematology 32 Histology 26 1,886 Miscellaneous 139 329 164 Table (iv)—Radiology No. of requests received 1,800 No. of resulting investigations: Chest 1,067 Spine 172 Skull 71 Bones and joints 468 Other 22 2,023 Table (v)—Cost of setting up the Centre £ Net expenditure by London County Council 19,700 Contribution by Nuffield Foundation 12,000 Expenditure by S.E. Metropolitan Regional Hospital Board 4,300 £36,000 Details of expenditure £ Building works 15,850 Lift and staircase 7,200 Heating, water, electrical works and telephone 4,950 Furniture and non-specialist equipment 2,050 Layout of garden 550 Contract particulars 1,100 X-ray equipment 3,350 Pathological equipment 950 £36,000 Table (vi)—Cost of running Centre for first year £ Net expenditure by London County Council 6,515 Expenditure by S.E. Metropolitan Regional Hospital Board 1,025 Expenditure by Camberwell Hospital Management Committee 3,060 Contribution from Sir Halley Stewart Trust 2,815 £13,415 Details of expenditure L.C.C.: £ Salaries and wages of— nursing staff (3) 1,890 secretarial staff (2) 1,475 cleaner (1) 255 Provision and repair of equipment 225 Medical requisites 125 Printing, stationery, postage and telephones 980 Maintenance of building and grounds 500 Alterations and improvements to building 215 Heating, lighting, rates, transfer rent, etc 540 Miscellaneous running expenses 310 L.C.C. reimbursed by Sir Halley Stewart Trust: Salary, etc., of Director 2,815 South East Metropolitan Regional Hospital Board: Salaries, etc., of two part-time consultants 1,025 Camberwell Hospital Management Committee: Salaries and wages of radiographers and laboratory technicians 1,580 Medical and surgical appliances and equipment 1,480 165 APPENDIX The pattern of morbidity The classification of all patients attending the Centre has made it possible to demonstrate the requirements of the doctors and to produce a pattern of the diseases and conditions which are thought to require investigation in making a diagnosis. The requests by the practitioners, classified according to results in order of frequency, were: Diagnostic Group % 1. Symptoms and ill-defined conditions 20.4 2. Diseases of respiratory system 14.3 3. Diseases of blood and blood forming organs 13.0 4. Diseases of bones and organs of movement 10.6 5. Accidents and violence 10.3 6. Diseases of genito-urinary system 6.5 7. Diseases of circulatory system 4.5 8. Allergic, endocrine system, metabolic and nutritional diseases 4.3 9. Communicable diseases 3.4 10. Complications of pregnancy, childbirth and the puerperium 3.3 11. Diseases of skin and cellular tissue 3.2 12. Prophylactic procedures 2.2 13. Diseases of the digestive system 1.2 14. Mental, psychoneurotic and personality disorders 0.8 15. Neoplasms 0.7 16. Congenital malformations 0.7 17. Diseases of the nervous system and sense organs 0.6 18. Certain diseases of early infancy — 100.0 A few of these are examined here in a little more detail. Further particulars can be supplied on request to the Director. Symptoms and ill-defined conditions—This was the largest group, containing a majority of results which were within normal limits. When related to the clinical details supplied the requests were all justified. In most cases either the tests were asked for as a precautionary measure or in checking the progress of a patient following an acute incident. Accidents, chest cases and possible anaemias figure largely in this number. Females greatly exceeded males in the group study. It is of some interest that an appreciable number of patients in this group had normal results apart from high sedimentation rates; this may be worthy of follow up. Age groups Patients Male Female 20/29 30/39 40/49 X-ray Pathology ECG 512 195 317 110 77 99 284 205 56 The age distribution was mainly in the mid-range, 286 patients between the ages of 20 and 49. X-ray investigations (284) were largely chests, bones and joints, pathology (205) chiefly haematology. The age groups of the patients referred for electric cardiograms with normal results are of some interest when compared with the table for diseases of the circulatory system which records abnormals. Age groups Male Female 16/19 20/29 30/39 40/49 50/59 60/69 70+ 40 16 1 4 5 16 18 11 1 166 Diseases of the respiratory system—In this case men slightly exceeded women and the commonest conditions investigated were acute and chronic bronchitis (246), pneumonia pneumonitis (128), upper respiratory tract invections (57), sinusitis (47), tonsillitis (26). There were seven spontaneous pneumothoraces, all between the ages of 16 and 30. Diseases of the blood and blood-forming organs—These were mainly anaemias. Including only those outside the lowest recognised normal limits gave men (86) and women (367) suffering from hypochronic anaemia. The males were either very young or elderly. The women were mainly of child-bearing age, 42 of them being pregnant. it is hoped to study anaemia in the age group 60 years and above in relation to malignant disease of the gastro-intestinal tract. Diseases of bone and organs of movement—There were largely osteoarthritic and disc lesions including 266 women and 148 men. The remainder were mainly forms of arthritis, muscular rheumatism and fibrositis. Accidents and violence—These were equally distributed between male and female, nearly all in the young, and many of them injuries connected with sport and recreation. Diseases of the genito-urinary system—The great preponderance were women and almost all investigations were connected with cystitis and pyelonephritis. Diseases of circulatory system—These were equally divided between men (90) and women (85). They were mainly cases of arteriosclerotic heart disease and coronary thrombosis. As would be expected, the cases of arteriosclerosis were mainly in the higher age range. There were a proportion of cases of hypertension and functional heart disease. Patients with Age groups evidence of: Ma!e female 5/15 16/19 20/29 30/39 40/49 50/59 60/69 70+ Arteriosclerosis and coronary disease 40 18 - 2 2 7 15 27 5 Other cardiac conditions 19 19 1 — 2 1 5 15 12 3 Of those with definite evidence of ischaemic heart disease, 11 were known to have had previous attacks. It is assumed that of the remainder the majority were first attacks. In all types 59 of the patients were working, 37 were not. Diseases of allergic origin, metabolic, nutritional and endocrine diseases—These were nearly all associated with the allergy service and skin sensitisation tests. The distribution related to the presenting symptoms was asthma (35), hay fever (53), dermatoses (23), other allergic disorders (26). thyroid disorders (8), myxoedema (3), gout (7). Allergic conditions tested Patients Age groups Male Female 0/4 5/15 16/19 20/29 30/39 40/49 50/59 60/69 70+ 61 69 3 25 14 28 25 24 10 1 — Of these patients, 15 had previously been tested and eight treated; five with substantial improvement and three were free for two years. It is not known how many of those tested at the Centre have been treated but it is intended to carry out a follow-up check. The lowest age group comprised two cases of asthma and one of eczema. 167 Communicable diseases—The figures of male (61), female (72) largely represent forms of tuberculosis. They are very much swollen as all cases shown by chest X-ray to have old lesions are included in this category. This was done purposely to enable a follow up to be done if necessary. There were also a number of cases of infective hepatitis and infectious mononucleosis. Tuberculosis Patients Not Age groups Work- work- 0/4 5/15 16/19 20/29 30/39 40/49 50/59 60/69 70+ Male Female ing ing 40 43 54 29 — 4 4 6 20 11 20 14 4 Of these, it is estimated that new cases discovered totalled 11 and 72 patients who came for other investigations revealed evidence of old disease. Delivery and complications of pregnancy, childbirth and the puerperium—The large proportion of these were patients (130) in the ante-natal stage who came for various prophylactic procedures. A few were anaemias following severe haemorrhage in labour. Diseases of skin and cellular diseases—A high proportion of cases which came for dressings and minor operative procedures came into this category, e.g., boils, carbuncles, various forms of cellulitis and infectious warts. Prophylactic procedures—Use was made of the Centre for carrying out examinations for administrative purposes (17) and for prophylaxis (68). Diseases of the digestive system—There were comparatively very few of these as no barium investigations are done. Fifteen of the cases were conditions of the mouth. Neoplasms—The majority (28) were benign, but several cases of malignant neoplasms were detected; others were old cases sent for check up. Congenital malformations—An appreciable number (28) of congenital malformations were found during X-ray investigations of other conditions. The majority were not of any significant importance. Diseases of nervous system and sense organs—These were mainly associated with diseases of the ears: acute and chronic otitis, and cerumen. 168 APPENDIX E Statistics of the administrative work carried out by the Metropolitan Borough Councils in 1961. Borough DWELLINGS CLEARANCE AREAS DWELLING HOUSES AIR POLLUTION CLEA NSING AND £ ISINFh CTION LICENSED OR REGISTERED PREMISES PUBLIC HEALTH INSPECTORS Inspections 1 Repaired as a result of informal action l Defects remedied after service of formal notice Houses closed in pursuance of owners' undertaking Demolition Orders made Persons displaced Closing Orders made in lieu of Demolition Orders Persons displaced Closing Orders determined Closing Orders revoked and Demolition Orders made Houses demolished as a result of formal or informal procedure Persons displaced Rooms closed Undertakings accepted Water supply provided to tenement houses Complaints Observations Intimation notices served Nuisance notices served Prosecutions Smoke Control Orders confirmed Adults cleansed Employed at end of year Assistants employed at end of year Unfit houses Other houses Underground rooms Other rooms Public Health (London) Act, 1936 Housing Act, 1957 Underground rooms Other rooms Erected by Borough Council Erected by other persons Total number in the Borough Demolished Persons displaced Demolished Persons displaced Initial visits on complaint With a view to action under Part II of the Housing Acty 1957 Other reasons Re-inspections At home At cleansing station Children cleansed Premises disinfected Premises disinfested Licensed slaughterhouses Other offensive trades Common and Seamen's Lodging Houses Dairies and milk shops Ice cream premises Establishment Male Female Total Male Female Total Number Persons displaced Number Persons displaced Number Persons displaced Number By owners By local authority By owners By local authority Made fit for occupation by number of families accommodated Overcrowding abated Division 1 Chelsea 68 36 16,517 — — — - 807 — 14,179 7,524 126 51 - - - - - - - - - - - - - - - - - - - - - 1 28 20 - — — 1 — 77 35 226 337 — — — 59 116 9 6 2 8 - - - Fulham 30 40 30,259 29 67 - - 1,275 37 2,217 4,747 867 867 11 - 2 2 2 - 1 3 - - 3 - 1 - 3 6 5 8 - - - 37 94 - - - 1 45 2 55 514 - - - 123 228 16 10 1 11 4 - 4 Hammersmith 10 — 28,191 30 109 9 † 2,324 185 2,621 7,898 310 323 - - - - - - - 3 7 4 - - - - - - - - - - 1 - - 4 - - 1 413 204 55 537 - — — 276 418 12 9 - 9 1 - 1 Kensington 178 424 40,437 — 401 — - 2,679 1,173 6,654 23.412 610 263 7 2 - - - 1 5 3 23 6 - 9 35 75 41 11 8 3 - 2 17 19 - - - 1 3 214 550 291 1,544 - — — 201 377§ 14 13 — 13 1 - 1 Division 2 Hampstead 8 171 24,078 — — — - 742 81 12,664 12,560 586 99 - 13 2 - - - 24 78 - - 3 - 24 78 8 14 - - - - - 10 46 233 — — — 1 — 14 8 135 327 — — — 69§ 266 13 12 1 13 2 1 3 Paddington 10 238 38,225 17 100 — 64 3,325 229 4,079 21,312 702 364 3 - - - - - - 1 2 100 - - - 113 6 3 2 1 - 19 20 117 3 — - 1 68 109 25 81 639 — — — 141 211 17 11 1 12 3 - 3 St. Marylebone 92 204 24,721 12 24 — — 629 270 167 3,067 210 70 — — — — — — - — - - 16 — - — 3 6 - - 1 3 - — 108 52 29 1 — 2 — 1,120 160 59 248 — 1 2 92 187 15 10 3 13 1 - 1 St. Pancras 297 161 29,533 103 584 — — 2,645 132 2,287 9,175 977 857 17 — — — — — - — 17 — 31 — — — 76 — 8 — — — - 19 60 61 27 — — 1 — 715 218 279 393 — — — 246 239 19 18 1 19 — - — Westminster, City of 271 224 27,486 6 51 1 6 853 189 3,272 6,912 270 6 - - - - - - 1 4 - - 11 - 2 - 12 21 3 9 - - - - 41 572 - — — 1 — 557 — 142 530 — — 2 129 246 20 18 — 18 2 - 2 Division 3 Finsbury — 80 9,864 184 651 — — 832 7 4,220 9,124 502 64 3 - - - - - - - 4 5 1 — 1 — 14 — — — — — - 3 32 310 5 — — 2 — 67 40 179 402 — — 1 131 162 10 10 — 10 2 - 2 Holbom — 5 6,105 — — — — 79 146 2,431 691 64 3 — — — — — — - — - - — — — — 2 — — — 1 — - 1 58 210 1 — — 1 — 80 — 65 160 — 5 2 74 141 5 4 — 4 — - — Islington 88 316 46,853 4 129 — — 4,282 215 2,467 16,628 1,429 842 24 - - - - - 1 - 21 538 76 - 29 - 28 122 3 17 1 - - 11 46 388 20 39 - - 146 148 250 628 1.260 1 11 - 351 557 34 23 2 25 2 - 2 Division 4 Hackney 282 37 42,326 — 17 — — 4,374 405 18,088 28,636 94 1,452 30 1 — — — — - - 3 9 23 — 5 — 103 62 19 † — — - — 150 378 — 2 7 1 — 75 26 450 553 — 5 1 209 445 20 18 — 18 5 - 5 Shoreditch 142 14 11,843 — — — — 1,407 170 1,695 6,762 702 76 - — - - 2 3 5 14 2 5 - - 18 - 5 5 - - 11 6 - 2 12 457 6 — — - — 7 — 60 552 — 1 — 84 111 9 5 — 5 2 - 2 Stoke Newington 18 191 12,215 - - — - 1.316 - 5,136 3,322 207 174 8 - - - - - - - 1 6 4 - - - 7 - - - 6 - - - 39 42 - - - 3 - 15 1 54 79 - - - 55 116 7 7 - 7 - - - Division 5 Bethnal Green 31 6 15,057 36 110 34 51 2,008 652 6,222 6,076 858 366 9 - - - - - 1 - - - - - - - 5 - 3 - - - - - 16 23 - - - 1 201 99 5 8 418 - 2 - 93 142 9 8 - 8 2 - 2 City of London — — 1,044 — - — — 4 - 20 24 5 - - - - - - - - - 1 7 - - - - - - - - - - - - 9 - - * - - - 945 - 2 18 - - 1 23 72 19 19 - 19 - - - Poplar 18 726 17,064 — — — — 1,446 338 921 7,803 990 327 — — — 1 7 — 2 7 — 3 4 15 — — — — — — - 2 92 147 - — — - — 44 2 119 2,080 — 1 3 100 197 9 8 — 8 4 - 4 Stepney 93 403 27,257 — 1ll — — 3,221 — 8,105 4,166 335 1,325 40 - - - - - 5 13 2 † 1 — 1 13 2 - - - - - - 2 100 125 - 2 — 1 87 241 25 37 1,774 — 18 § 5 230 324 18 15 — 15 2 - 2 Division 6 Deptford 130 225 17,920 — — — — 1,178 21 5,889 9,844 426 215 1 2 - - 2 - - - - - 1 - - - 18 - - - - - - - 120 866 1 — — 1 613 502 204 106 324 — — 1 93 198 8 7 — 7 3 - 3 Greenwich — 89 24,736 74 243 — — 1,910 25 6,660 9,546 380 183 4 - - - - - - - 1 9 1 - - - - - - - 1 - - - 15 68 4 4 1 1 1,502 580 100 74 1,872 - - — 194 232 10 9 1 10 - - - Woolwich 503 1,005 44,439 116 350 62 47 1,184 213 7,615 6,305 517 259 - - - - 7 - 3 13 7 35 4 - 2 - - - - - - - - - 20 23 - - - 5 103 23 124 148 362 1 1 — 134 329 19 17 1 18 1 - 1 Division 7 Camberwell 30 248 45,239 68 195 - - 4,830 978 25,503 13 695 447 1583 5 9 - 1 1 - - - 2 5 5 1 3 - - 1 1 22 - - 1 - 18 279 1 - 1 1 - 92 184 164 1,093 - 3 1 226 524 20 16 - 16 3 1 4 Lewisham 207 493 65,330 28 31 6 † 1,284 54 14,943 14,737 134 379 - 8 - - - - 7 21 4 16 10 - 14 21 - - 48 10 - - 3 - 7 - - - - - - 28 73 351 258 - - - 120 351 20 20 - 20 4 - 4 Division 8 Bermondsey 94 175 15,454 76 181 18 49 1,866 10 2,283 13,213 710 238 1 - - 2 - - - - 9 35 - - - - - - 4 2 - - - - 8 69 - - 1 1 - 28 3 3 297 - 8 1 138 211 11 10 - 10 1 - 1 Lambeth 264 157 56,854 - 61 - - 2,955 76 2,386 9,260 643 568 108 - - - - - - - - - - - 3 - 3 3 1 - - - - - 20 167 - - - - - 75 69 169 1,077 - 1 - 277 598 21 15 1 16 - - - Southwark - 326 25,004 67 228 - - 2,582 80 12,56 4,78 707 523 33 - - - - 2 1 4 - - 9 2 50 163 2 1 1 7 18 38 - - 15 210 12 - - 1 - 948 514 52 1,211 - 3 6 147 306 20 16 1 17 4 - 4 Division 9 Battersea 293 77 29,387 100 364 49 402 2,438 24 5,012 9,801 403 519 13 11 - - - - - - 4 33 2 - 1 6 6 9 2 4 - - - - 11 333 1 - - 1 - 86 305 1,064 269 - 2 135 273 16 11 1 12 1 - 1 Wandsworth 408 725 120,120 70 57 - 22 5,422 15 13,691 16,725 854 425 6 - — 2 2 1 — 1 - 11 8 — 1 0 6 10 3 † 1 — 2 — 121 282 4 — — 1 — 33 13 214 291 — — 304 754 22 15 - 15 3 — 3 LONDON 3,565 6,796 893,558 1,020 4,064 179 641 59,897 5,725 221,383 287,843 15,065 12,421 323 46 4 8 23 6 52 163 85 746 319 6 168 331 486 307 115 84 44 47 8 71 1,266 5,545 118 48 10 44 2,723 7,380 3,140 5,270 19,419 2 62 26 4,454 8,331 442 360 16 376 53 2 55 * The whole of the City of London is a Smokeless Zone under the City of London ( Various Powers) Act, 1954. † Included in the previous column. § One prosecution. APPENDIX F STAFF OF THE PUBLIC HEALTH DEPARTMENT AT 31 DECEMBER, 1961 Medical Officer of Health and Principal School Medical Officer J. A. Scott Deputy Medical Officer of Health and Deputy Principal School Medical Officer A. B. Stewart Senior Principal Medical Officer M. MacGregor Administrative Officer D. J. B. Cooper Principal Medical Officers Maternity and child welfare Dorothy F. Egan School health G. D. Pirrie Epidemiology Ian Taylor Tuberculosis W. Hartston Mental health C. W. J. Ingham Staff medical examinations R. Cove-Smith Chief Dental Officer and Principal School Dental Officer W. Ritchie Young Chief Nursing Officer Evelyn Robinson Scientific Adviser S. G. Burgess Establishment Officer R. H. J. Stronge Principal Clerks G. Berridge G. M. Howes W. H.Joyce Officer-in-Charge, London Ambulance Service F. A. Richardson Statistician C. W. Shaddick Chief Inspector J. C. Clancey Principal Organiser of Children's Care Work Frances C. K. Gregson Principal Mental Welfare Officer Olive K. Bowtell Senior Officers of the Divisions Divisional Medical Divisional Administrative Divisional Nursing Division Officer Officer Officer 1. Bertha E. A. Sharpe T. A. Stone Joan A. Surr 2. H. L. Oldershaw N. A. Woodruff Eveline Beattie 3. W. G. Harding N. B. Chapman Margery D. Butler 4. S. King J. C. Minter Lilian E. Arrow 5. G. O. Mitchell E. L. Hannant Elizabeth J. Early 6. F. R. Waldron L. M. Longhurst Lilian Berry 7 Ann Mower White F. L. Clark Kathleen L. Sewell 8. W. H. S. Wallace D. E. Armstrong Bessie Thom 9. J. T. R, Lewis R. E. Haymes Winifred M. Winch INDEX Page Accidents in the home 70 Acoustics 42 Adoption of children 50 Air pollution 13,41 Alcoholics, hostels for 121 Ambulance service 61 Analgesia 53 Ante-natal care 47 Audiometry 49, 84 Bathing centres 80 B.C.G. vaccination 23, 32 Births 4, 5 Blind persons 35 Boarding out of children 50 Bronchitis 8 Building programme 43 Cancer 8, 9 Care committees 23, 76 Care of mothers and young children 47 Child guidance 84 Child help 57 Child minders 48 Child protection 51 Child welfare 47 Chiropody 65 Civil defence 64 Cleansing scheme 80 Community care, of the mentally ill 125 of the mentally sub-normal 122 Creches, occasional 48 Dangerous structures 34 Day centres for the mentally ill 125 Day nurseries 48 Deafness, young children 49 schoolchildren 84 Deaths 4,8,19 Dental auxiliaries 90 services 86 Diagnostic clinics for mentally subnormal 117 Diarrhoea and enteritis 14 Diphtheria 14, 58 Diphtheria investigation (Div. 1) 96 (Div. 7) 106 (Div. 9) 109 District nursing associations 55,137 Divisonal medical officers' reports . 96-110 Divisional statistical summary 111 Domiciliary midwifery 52 Drinking water 41 Dysentery 14 Educationally sub-normal pupils 83 Emergency Bed Service, maternity admissions 48 Employment of schoolchildren 81 Enteric fever 14 Environmental radioactivity 42 Exhibitions, health education 70 Expectant and nursing mothers 47 Page Family planning 47 Family Service Units 48 Family Welfare Association 48 Fertility 5 Finance 94 First aid competition 64 Food handlers 92 Foot clinics 65 Guardianship of the mentally sub-normal 119 Handicapped pupils 83 Health education 66 Health surveys of pupils 80 Health visiting 54 Hearing defects, in young children 49 Home help 57 Home nursing 55,137 Home safety 70 Hospitals, admission of mentally ill 117 Hostel for alcoholics 121 Hostels, for mentally disordered persons 120 Housing 34 Illegitimacy 4,7, 51 Immunisation 58 Improvement grants 34 Industrial training centres 124 Infant mortality 4, 10, 11 Infectious diseases 14,21,22 Infectious diseases, in schools 81 Influenza 14 Inhalation analgesia 53 In-service training 93 Invalid meals 38 Leptospirosis 14 Live births 4, 5, 6 London Ambulance Service 61 Lung cancer 8, 9 Maladjusted pupils 84,130 Marriage guidance 51 Marriages 4 Maternal mortality 4, 13 Maternity and child welfare 47 Maternity and child welfare dental service 89 Maternity beds, use on social grounds 48 Meals (children) 78 Meals (invalid) 38 Measles 14 Medical inspection of pupils 73 Medical treatment of pupils 82 Mental health education 49 Mental health services 112 Mental health statistics 131 Metropolitan borough councils 169 Midwifery service 52 Midwives Act 53 171 INDEX—continued. Page Milk sampling 34 Milk, school 78 Moral welfare associations 7, 50 Morning and evening helps 57 Mortality 4,8,19 Mother and baby homes 51 Neo-natal mortality 4, 11 Night helps 57, 143 Noise measurements 42 Nurseries, day 48 Nurseries, residential 49 Nursing home registration 37 Occasional creches 48 Ophthalmia neonatorum 15 Orthodontics 89 Perinatal mortality 4, 12 Personal hygiene of pupils 79 Phenylketonuria 49,100 Physical condition of pupils 77 Pneumonia 8 Poliomyelitis 15,16,59 Population 4, 5 Premature babies 11,52,53 Premises 43 Problem families 48 Prophylaxis 58, 82 Psychiatric day hospitals 127 Public health laboratory 34 Radioactivity 42 Recuperative holidays 65, 122 Rehabilitation of the mentally ill 125 Rehousing 34 Remedial foot classes (Div. 3) 102 Residential accommodation for the mentally disordered 120 Residential establishments for young children 49 Resuscitation certificates, award 64 River Thames 40 Safe driving awards 64 Safety in sewers 41 Sanitary inspection 35 Scabies 81 Page School care committees 76 School dental service 86 School health service 73 School meals 78 School medical inspections 73 School treatment centres 82 Scientific branch 40 Sewage treatment 40 Slum clearance 34 Smallpox 16,59 Social work in mental health service 128 South East London General Practitioners' Centre 46, 161 Special home helps 57, 143 Speech therapy 84, 145 Staff 91, 170 Staff training 49,92,115 Stillbirths 4, 5, 12, 52 Student health scheme 84 Swimming baths 42 Tetanus 58 Trade waste discharges 41 Training centres 122 Training, staff 49,92,115 Training, student health visitors 92 Tuberculosis 23 Tuberculosis care committees 23 Tuberculosis contact scheme 23 Tuberculous milk 35 Unmarried mothers 7, 50 Vaccination 58 Venereal disease 66 Vision tests 78 Visitors 95 Vital statistics 4, 5, 17, 18 Water sampling 41 Weather 20 Welfare Committee establishments 38 Welfare foods 47 Whooping cough 16, 58 Woodberry Down health centre 102 Yellow fever 60 References to local activities in the sphere of chiropody, health education, mental health education, home making courses, problem families, vaccination against poliomyelitis, etc., will be found in the divisional medical officers' reports, pages 96-110. 172 Printed for London County Council Supplies Department by Watcrlow & Sons Limited, 850 (71158) 11/62 228295