LCC 70 LONDON COUNTY COUNCIL Library. Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1964 Published by the Greater London Council The County Hall, London, S.E.I 1966 No. 51 5s. Od. Postage extra LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1964 By A. B. STEWART, m.d., d.p.h. COUNTY MEDICAL OFFICER OF HEALTH AND PRINCIPAL SCHOOL MEDICAL OFFICER THE COUNTY HALL LONDON, S.E.I CONTENTS Introduction page 3 London Administrative County—Vital Statistics (Summary) 4 Vital Statistics 5 Infectious Diseases 14 Tuberculosis 23 General Public Health 31 Health Service Premises 37 Care of Mothers and Young Children 48 Domiciliary Midwifery 59 Health Visiting 63 Home Nursing 64 Home Help 66 Immunisation and Vaccination 68 London Ambulance Service 71 Prevention of Illness: Care and After-Care 86 Mental Health 93 School Health Service 114 Dental Services 126 Staff 132 Finance 137 Visitors to the Department 139 Reports by the Divisional Medical Officers 140 Appendices: (a) Staff of the Public Health Department 160 (b) Staff—Survey of long term sickness 161 (c) Statistics of work carried out by the Metropolitan Boroughs 170 Index 171 2 INTRODUCTION In 1892 Sir Shirley Murphy prefaced the first annual report of the Medical Officer of Health of the Administrative County of London with the following statement: "The passing of the Public Health (London) Act, 1891, having placed the London County Council in direct relation with sanitary administration in the administrative county of London, I propose to present to the Council each year a report on the health of London." Both he and his successor, Sir William Hamer, were much concerned with the control of infectious disease and with matters relating to housing. It was evident from the space devoted to certain of the infectious diseases that they were the cause of very grave concern, as the following short table will show: Deaths Deaths 1892 1964 1892 1964 Smallpox 29 — Enteric fever 424 — Measles 2,388 2 Erysipelas 292 — Scarlet fever 1,169 — Influenza 2,264 28 Diphtheria 1,859 — Pneumonia 6,164 2,256 Whooping cough 2,491 — Pulmonary tuberculosis 8,053 178 The population in 1892 was 4,284,678, in 1964 3,179,000. The infant mortality rate for children under one year of age per thousand births was 154 in London in 1892 compared with the present day rate of 21.3. Sir William Hamer's successor in 1926, Sir Frederick Menzies, included in the report for 1925, in collaboration with his predecessor, a report presenting a review of London's health record during the existence of the Council up to that date. He made comment on progress made in housing by the aid of the Housing of the Working Classes Act and the new Building Act of 1894. During this period the school medical work came under the direction of the County Council and had the benefit of the services of Dr. James Kerr who from 1902 played a leading part in the school health service. Sir Frederick Menzies' great contribution to public health was mainly in the field of the re-organisation of London's hospital services. This work was, of course, interrupted by the war in 1939 when Sir Frederick retired. His successors, Sir Allen Daley and Dr. J. A. Scott, devoted their energies to the re-organisation of the personal health services which were transferred to the Council as a result of the National Health Service Act of 1946. Their successor has recently had to devote a great deal of effort to the transfer of services to the new London Boroughs. In the course of this transfer papers on nearly every aspect of the subject were transmitted to a working party set up to facilitate the working of the London Government Act of 1963, whose reports were furnished to the new Inner London Boroughs together with memoranda on the procedure in use by the London County Council. These documents have been preserved in three volumes which constitute a veritable Doomsday Book of the personal health services as they were in 1964. Inevitably, with progress, they will become out of date but they probably represent the best documented evidence for future historians of how the personal health services had developed. The County Council's successor, the Greater London Council, is still responsible for the Ambulance Service and has certain duties in slum clearance. The Inner London Education Authority, the other heir to the London County Council, will continue to be responsible for the School Health Service. Although this is the last report as at present constituted it is hoped that the Greater London Council will in "London Statistics" publish a chapter of health statistics annually which will cover not only the old London County Council area but also that of the new Greater London Council. 3 LONDON ADMINISTRATIVE COUNTY VITAL STATISTICS, 1964 Figures in brackets are for 1963 Population: Males 1,504,000 Females 1,681,000 3,185,000 (3,179,000) Area comparability factors: Births 0.86 (0.86) Deaths 1.06(1.05) Number of marriages registered: 32,953 (34,107) Live births: Legitimate 54,420 (54,465) Illegitimate 9,080 (9,035) 63,500 (63,500) Illegitimate live births per cent. of total live births: 14.3 (14.2) Live birth rate per 1,000 population: 19.9 (20.0) (adjusted rate 17.1 (17.2)) Stillbirths: Legitimate 787 (837) Illegitimate 177(181) U&4 (1,018) Stillbirth rate per 1,000 live and stillbirths: 15.0 (15.8) Total live and stillbirths: 64,464 (64,518) Deaths: Males 17,827 (19,866) Females 17,229(19,724). 35,056 (39,590) Death rate per 1,000 population: 110 (12.5) (adjusted rate 11.7 (131)) Deaths of infants: Legitimate Illegitimate Total Under 1 month 758 (756) 187 (167) 945 (923) 1 month to 1 year 357 (404) 52 (58) 409 (462) Total under 1 year 1,115(1,160) 239 (225) 1,354(1,385) Infant mortality rate: (per 1,000 live births) 20.5 (21 .3) 26.3 (24.9) 21.3 (21.8) Neo.natal mortality rate: „ „ „ „ 13.9 (13.9) 20.6 (18.5) 14.9 (14.5) Early neo.natal mortality rate: „ „ „ „ 12.5 (12 0) 18.6 (16.7) 13.4 (12.6) Perinatal mortality rate: (per 1,000 total births) 26.6 (26.9) 37.4 (36 0) 28.1 (28.7) Maternal mortality: Postabortion Other pregnancy and childbirth Total Rate per 1,000 live and stillbirths Deaths from sepsis 8 (9) — (—) 8 (9) Deaths from other causes 1 (1) 14(18) 15(19) Total 9 (10) 14 (18) 23 (28) 0.36 (0.43) 4 VITAL STATISTICS* Population Table (i)—Home population †, 1955-64 (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+ 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 3,180 247 396 404 893 839 401 37.5 1962 3,186 248 378 422 894 838 406 37.7 1963 3,179 269 368 434 893 826 389 37.2 1964 m 1,504 129 184 212 455 386 138 35.7 F 1,681 122 177 235 447 444 256 39.2 3,185 251 361 447 902 830 394 37.5 †Resident civilian population, plus any British, Commonwealth or Foreign Armed Forces stationed in the area. The population figure for 1964 is the estimate based on the final adjustments to the 1961 census enumerated population and therefore the apparent increase of 6,000 on the 1963 estimate may not be a real one. These adjustments make it very difficult to ascertain the trend of population over the past two-three years; all that can be said with any reliability is that there has not been very much change in the total figure. Differences in the age group estimates are also attributable more to adjustments of the figures than to real changes in the age composition of the population. For example, the apparent fall of 18,000 in the 0-4 years age group between 1963 and 1964 is unlikely to be a real change in view of the rise in the annual number of births in the last few years. Fertility Table (ii)—Live births and stillbirths, 1955.64 Year Live births Stillbirths No. Rate per 1,000 population No. Rate per 1,000 total births (live and still) 1955 49,826 151 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 57,368 180 1,052 18.0 1961 60,052 18.9 1,103 18.0 1962 62,524 19.6 1,054 16.6 1963 63,500 20.0 1,018 15.8 1964 63,500 19.9 964 15.0 *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. 5 Live births—There were 73,962 live births registered in London in the year; after correction for residence the final figure of births allocated to London was 63,500 (32,529 boys-30,971 girls), the same total as in 1963, which on the increased population of 1964 gives a birth rate of 19-9 per 1,000 population compared with 20.0 in 1963 and 19.6 in 1962. 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; since then the crude London rate has continued to exceed the national rate but whereas in 1964 the London birth rate remained at virtually the same level as that of the previous year that for England and Wales has continued to rise. 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 (0.86 for 1964) the rate becomes 17.1. 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, 1955-64 6 Illegitimacy— Table (iii)—Illegitimate live births in London (A.C.) and percentages for London and England and Wales, 1955-64 Year Illegitimate live births Illegitimate live births as a percentage of total live births Ratio London/ England and Wales London (A.C.) England and Wales 1955 3,827 7.7 4.7 1.64 1956 4,434 8.5 4.8 1.77 1957 4,686 8.9 48 1.85 1958 5,343 9.9 4.9 2.02 1959 5,765 10.4 5.1 2.03 1960 6,530 11.4 5.4 2.11 1961 7,632 12.7 6.0 2.12 1962 8,835 14.1 6.6 2.13 1963 9,035 14.2 6.9 2.06 1964 9,080 14.3 7.2 1.99 The increase in the percentage of illegitimate live births in London noted in previous years shows signs of slowing down, but the London figure is currently twice the national percentage compared with about one and a half times as great ten years earlier. As in the previous year, one in every seven babies born of London 'residents' in 1964 was illegitimate; in Paddington it was as high as one in four born illegitimate. The age of the mothers of these illegitimate children is shown in table (iv) below. Table (iv)—Illegitimate live births by age of mother Age of mother (a) London (A.C.) England and Wales 1963 % 1961 1962 1963 1964 (years) No. % No. % No. % No. % 12 - - - - 2 0.02 1 0.01 0.0 13 4 0.1 1 0.01 4 0.04 1 0.01 0.0 14 11 0.1 19 0.2 19 0.2 9 0.1 0.3 15 61 0.8 104 1.2 93 1.0 70 0.8 1.6 16 147 1.9 168 1.9 196 2.2 202 2.2 3.8 17 239 3.1 297 3.4 329 3.6 361 4.0 5.6 18 388 5.1 440 50 436 4.8 477 5.2 7.0 19 508 6.7 603 6.8 690 7.6 606 6.7 8.0 20-24 2,780 36.4 3,254 36.8 3,265 36.2 3,301 36.4 32.2 25-29 1,714 22.5 2,017 22.8 2,018 22.4 2,091 23.0 19.4 30-34 998 131 1,112 12.6 1,141 12.6 1,127 12.4 11.9 35-39 581 7.6 610 6.9 622 6.9 601 6.6 7.1 40-44 186 2.4 196 2.2 206 2.3 219 2.4 2.9 45 and over 15 0.2 14 0.2 14 0.2 14 0.2 0.2 Total 7,632 100.0 8,835 100.0 9,035 100.0 9,080 100.0 100.0 (a) Cases in which the mother's age was not stated (40 in 1961, 42 in 1962, 39 in 1963, 33 in 1964) have been proportionally distributed. It will be noted that the national figures show proportionately more illegitimacies among mothers below the age of 20 years. 7 It has been remarked in previous years that a complex of factors probably accounts for the higher rate in London—proportionately more single women (37.0 per cent. of those aged 16-44 years in London, compared with 26.9 per cent. in England and Wales (Census 1961)), a high immigrant element in the population, 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. The following table gives details of women seen by the moral welfare organisations in 1964, from which it will be seen that 1,001 (28.5 per cent.) were pregnant on arrival in London and that, in all, 1,216 (34.6 per cent.) were not born in the United Kingdom. It should be remembered that these components of the illegitimate births are minima; the moral welfare organisations only dealt with 39 per cent. of unmarried mothers, though doubtless they will tend to deal with proportionately more of the non-Londoners. Table (v)—Unmarried mothers seen by moral welfare associations in London, 1964 (Figures in brackets are for 1963) British (U.K.) Eire European West Indian Other Total Non-Londoners pregnant on arrival in London 593 (509) 283 (141) 37 (43) 32 (28) 56 (35) 1,001 (756) *Non-Londoners not pregnant on arrival in London 53 (89) 29 (118) 12 (24) 4 ' (7) 5 (15) 103 (253) Resident in London one year or more 1,654 (1,506) 384 (425) 80 (92) 206 (306) 88 (97) 2,412 (2,426) 2,300 (2,104) 696 (684) 129 (159) 242 (341) 149 1 (147) 3,516 (3,435) * Had lived in London less than 12 months before making contact with moral welfare association. Mortality The total death rate at 11.0 per 1,000 population was the lowest figure since 1954 (the number of deaths was the lowest ever recorded in London A.C.). Leading causes of death—The leading causes of death in London in 1964 were as follows: Deaths Rate per 1,000 population Diseases of the heart 10,419 3.27 Cancer 7,946 2.50 Bronchitis, pneumonia* 4,360 1.37 Vascular lesions of the central nervous system 3,672 115 Other circulatory 1,978 0.62 Violent causes 1,669 0.52 Digestive diseases 1,078 0.34 Diseases of early infancy (international classification nos. 760-776) 713 0.28 Congenital malformations (0-4 weeks) 184 Diseases of genito-urinary system 682 0.21 Other respiratory including influenza 347 0.11 Tuberculosis (all forms) 198 0.06 All other causes 1,810 0.57 Total 35,056 11.01 *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 has remained unchanged since 1954. 8 Cancer—The cancer death-rate for all ages was 2.50 per 1,000 in 1964—the highest figure since 1960. 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 (vi)—Cancer mortality rates per 1,000 living, 1955.64 Age and sex 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 Males: 0-24 0.11 0.14 0.11 0.09 0.10 0.12 0.11 0.11 0.09 0.10 25-44 0.40 0.43 0.37 0.42 0.40 0.38 0.37 0.38 0.37 0.41 45-64 4.50 4.51 4.55 4.52 4.46 4.75 4.52 4.53 4.57 4.67 65+ 15.73 15.77 15.29 16.01 15.20 15.74 15.72 15.40 16.06 16.90 All Males 2.73 2.76 2.77 2.85 2.76 2.90 2.83 2.81 2.78 2.91 Females: 0-24 0.07 0.09 0.07 0.10 0.07 0.07 0.07 0.08 0.08 0.05 25-44 0.45 0.50 0.47 0.52 0.51 0.52 0.50 0.43 0.46 0.47 45-64 2.93 2.77 2.97 2.71 2.63 2.82 2.72 2.81 2.79 2.77 65+ 8.43 8.75 8.34 8.50 8.18 8.44 8.02 7.93 8.37 8.24 All Females 2.08 2.12 2.16 2.15 2.09 2.20 2.11 2.12 2.14 2.13 All Persons 2.39 2.42 2.44 2.47 2.40 2.53 2.45 2.44 2.44 2.50 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. Table (vii)—Deaths and death rates from cancer of the lung by age and sex, 1955.64 (Rates per 1,000 population) Year Age 25-44 45-64 65+ No. Rate No. Rate No. Rate Males: 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 1962 37 0.08 903 2.33 860 5.93 1963 44 0.10 907 2.37 865 6.31 1964 49 0.1l 924 2.39 935 6.78 Females: 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 1962 13 0.03 153 0.34 189 0.72 1963 14 0.03 160 0.36 218 0.87 1964 21 0.05 173 0.39 243 0.95 9 Infant mortality Table (viii)—Infant mortality, 1964 Age at death Rates per 1,000 live births Under 1 day 1 to 6 days 1 to 3 wks. 1 to 11 mnths Total under l yr. Early neonatal Neonatal Total infant mortality Legitimate Males 235 162 44 226 667 14.2 15.8 23.9 Females 175 108 34 131 448 10.7 11.9 16.9 1963 410 270 78 357 1,115 12.5 13.9 20.5 414 237 105 404 1,160 12.0 13.9 21.3 Illegitimate Males 55 32 7 24 118 18.7 20.2 25.4 Females 56 26 11 28 121 18.5 21.0 27.3 1963 111 58 18 52 239 18.6 20.6 26.3 103 48 16 58 225 16.7 18.5 24.9 Total legitimate and illegitimate Males 290 194 51 250 785 14.9 16.4 24.1 Females 231 134 45 159 569 11.8 13.2 18.4 Both sexes 521 328 96 409 1,354 13.4 14.9 21.3 1963 517 285 121 462 1,385 12.6 14.5 21.8 The pattern of infant mortality over the past decade is given in table (ix) below: Table (ix)—Infant mortality by cause, 1955.64 (Rates per 1,000 live births) Cause of death 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 Whooping cough 0.06 004 0.02 — 0.05 0.05 - 0.03 0.03 - Tuberculosis — — — — 0.02 0.03 0.03 — — — Measles 0.10 — — — — — 0.03 0.02 0.02 - Bronchitis and pneumonia 3.57 3.57 2.88 3.45 3.50 3.63 3.18 3.63 4.35 3.81 Gastro-enteritis 0.48 0.35 0.42 0.31 0.27 0.16 0.30 0.37 0.44 0.41 Congenital malformations 3.43 3.70 3.96 4.51 4.75 4 32 3.94 3.68 4.11 4.22 Injury at birth 2.59 2.64 2.98 2.27 2.46 2.55 2.81 2.45 2.44 2.71 Post.natal asphyxia and atelectasis 4.32 3.66 4.17 4.08 3.59 3.63 3.61 3.63 3.17 3.26 Haemolytic disease 0.58 0.61 0.51 0.44 0.51 0.54 0.37 0.34 0.47 0.39 Immaturity 4.67 4.10 4.27 4.69 3.86 3.71 3.85 3.47 2.94 2.79 Convulsions — 002 — — — — — — — — Accidental mechanical suffocation 0.06 0.21 0.23 0 13 0.16 009 0.13 0.16 0.06 0.13 Other causes 3.35 2.55 2.56 2.60 3.26 2.77 3.10 3.28 3.78 3.60 All causes 23 21 22 22 22 21 21 21 22 21 10 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) Infant mortality Neo-natal mortality London England and Wales London England and Wales 1955 16.7 17.3 23.2 24.9 1956 15.9 16.8 21.2 23.7 1957 16.3 16.5 22.0 231 1958 16.6 16.2 22.5 22.6 1959 15.7 15.8 22.4 22.2 1960 15.4 15.6 21.5 21.9 1961 15.9 15.5 21.4 21.6 1962 15.2 151 21.0 21.6 1963 14.5 14.2 21.8 21.1 1964 14.9 13.8 21.3 20.0 As regards neo-natal mortality there were 945 deaths in London; of this number 562 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 62. Table (x)—Prematurity and mortality by birth weight, 1964. 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. 4oz. or less 652 13.9 239 36.7 318 48.8 3 lb. 5oz. to 4 lb. 6oz. 744 15.8 56 7.5 650 87.4 4 lb. 7oz. to 4 lb. 15oz. 939 20.0 35 3.7 877 93.4 5 lb. 0oz. to 5 lb. 8oz. 2,366 50.3 38 1.6 2,294 97.0 All premature babies 4,701 100.0 368 7.8 4,139 88.0 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 1955 34.8 37.6 1960 31.2 32.9 1956 33.3 36.8 1961 320 32.2 1957 34.2 36.2 1962 29.8 30.8 1958 34.3 351 1963 28.7 29.3 1959 32.7 34.2 1964 28.1 28.2 The deaths in the first day of life are shown in table (viii) 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) Act, 1960 and the following table gives the causes for 1964. 11 Table (xi)—Causes of stillbirth, 1964 Code No* Cause Male Female Number Per cent. Number Per cent. Y.30 Chronic disease in mother 24 4.6 18 4.1 Y.3I Acute disease in mother 2 0.4 2 0.5 Y.32 Diseases and conditions of pregnancy and childbirth: (1) Ectopic gestation — — — — (2) Haemorrhage 26 5.0 19 4.3 (3 and 4) Toxaemia 69 13.1 39 8.9 (5) Infection — — 3 0.7 Y.34 Difficulties in labour 28 5.3 30 6.8 Y.35 Other causes in mother 3 0.6 1 0.2 Y.36 Placental and cord conditions 161 30.7 119 27.2 Y.37 Birth injury 17 3.2 14 3.2 Y.38 Congenital malformation of foetus 62 11.8 88 20.0 Y.39 Diseases of foetus and ill-defined causes: (0.3) Diseases of foetus 29 5.5 19 4.3 (4.6) Other ill-defined or unspecified cause 104 19.8 87 19.8 Total 525 100.0 439 100.0 *International classification of causes of stillbirth. Maternal mortality— Table (xii)—Maternal mortality, 1955.64 Year Live births and stillbirths Deaths in pregnancy or childbirth excluding abortion Postabortion deaths Total maternal deaths No. Rate per 1,000 total births 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 1962 63,578 21 12 33 0.52 1963 64,518 18 10 28 0.43 1964* 64,464 14 9 23 0.36 *For the ninth year running none of the deaths in pregnancy or childbirth was due to sepsis; 8 of the 9 postabortion 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. 12 Air pollution The table belows shows for the past seven winters the average levels of pollution based on the recording stations described in appendix B to my report for 1956. Winter averages of air pollution Average daily readings of volumetric recording stations Micrograms per cubic metre Winter ' Smoke' ' Sulphur dioxide' Ratio smoke/SO2[/##] 1958-1959 309 340 0.9 1959-1960 206 275 0.7 1960-1961 200 277 0.7 1961-1962 182 302 0.6 1962-1963 173 365 0.5 1963-1964 153 284 0.5 1964-1965 133 276 0.5 There has been a consistent downward trend in the smoke index (a trend which began in 1956-57); although exact comparison is not possible because of a change in the method of measurement in 1961, pollution by smoke is now about one-third of what it was nine years ago. Pollution from sulphur dioxide does not show any consistent trend. The weather The monthly averages of temperature, rainfall and sunshine are given in table V.4, page 20. This year was characterised by a warmer than average summer; sunshine was noticeably high in the months July to October but 'sunny June' did not justify its reputation. Rainfall over the year was below average—the fourth successive year in which this has occurred. B 13 INFECTIOUS DISEASES Notifications of infectious diseases for the years 1955-64 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 1964 are given in table V.6, page 22, and deaths from infectious diseases are included in table V.3, page 19. Diarrhoea and enteritis—There were 27 deaths under the age of two years from diarrhoea and enteritis, this being a lower figure than that reported in 1963. A high proportion of the deaths from this condition were associated with concurrent infections of the respiratory tract and took place in the first quarter of the year. Diphtheria—During the year there were four notifications of diphtheria, all in Southwark. Diphtheria has in recent years ceased to be an endemic infection in London. Whenever the disease is found an energetic search is made for other infected persons in the neighbourhood and this is continued until the infection has been eliminated from the district. Vigilance and general immunisation continue to be necessary. The circumstances of recent outbreaks suggest that they may have resulted from infection imported from abroad. Dysentery—There were 2,262 notifications of dysentery compared with 4,917 in 1963. The highest incidence of the disease was in the months of February and March and the lowest in the autumn, this being the usual seasonal pattern. Once again the highest attack rate was in pre-school children. The overwhelming majority of notified cases are of mild Sonne dysentery, which has a low fatality rate. One death from dysentery was registered. Enteric fever—No local outbreaks of typhoid or para-typhoid fever were reported, although a number of single sporadic cases occurred. A high proportion of cases reported had been infected on holiday abroad. Influenza—The number of deaths from influenza (28) was the lowest for many years. Leptospirosis—For the eighth successive year there was no case of leptospirosis reported among the Council's sewer workers. Measles—1964 was an inter-epidemic year, the low incidence encountered in the early months building up in the latter part of the year towards the epidemic peak experienced early in 1965. The disease continues to be mild in the majority of cases. During the autumn injections of measles vaccine were given to over 5,000 children in London as part of a controlled trial organised by the Medical Research Council. The results of this trial are awaited. Ophthalmia neonatorum—The number of notifications rose from 96 in 1963 to 112 in 1964 and the rate per 1,000 registered live births increased accordingly from 1.31 to 1.51. The number of cases among children born to London residents was 80; in 70 cases vision was unimpaired and there was no information about the remaining ten who had moved from the area. Poliomyelitis—Only two cases of poliomyelitis were notified during 1964. That only two cases occurred in London in spite of the fact that many thousands of children remain unvaccinated indicates the virtual absence of disease-producing virus from the community. This must be attributed largely to the widespread use since 1962 of the Sabin vaccine which, unlike the Salk-type vaccine, has the effect of reducing the number of symptomless carriers in the population. Thus poliomyelitis, like diphtheria, has now reached the stage when the low level of incidence depends as much on the absence of infection from the community as it does on the high level of immunisation. The continuance of this favourable condition will require vigorous preventive action in the contacts of any case that does occur. 14 Figure 2 WHOOPING COUGH, LONDON (A.C.) INCIDENCE AND VACCINATION, 1946-1964 15 Smallpox—No cases of smallpox were notified during the year. Whooping cough—There was a fall in the number of notifications in 1964 to 1,401 from the figure of 2,601 in 1963. The incidence of this disease fluctuates widely from year to year, so it is necessary to study changes over a period of years if a trend is to be found. In figure 2, showing the whooping cough notifications in London in the last 20 years, the decline in incidence is impressive, although it did not occur in a dramatic fashion. The number of children immunised against whooping cough each year is also shown. The critical level of immunisation in the community appears to have been reached about 1953-4, since when incidence of whooping cough has been declining. 16 17 Table V.l—Vital statistics—Metropolitan Boroughs and the Administrative County of London, 1964 (a) Metropolitan Boroughs Estimated home population mid 1964 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 46,200 13.3 9.7 15.2 13.6 26 3.42 1.77 4.16 1.04 1.19 0.95 0.84 0.19 — 1 .08 — — — 0.11 0.17 0.24 0.02 Fulham 109,410 18 9 16.8 11.1 11.3 19 2.80 1.16 3.19 0.53 0.71 0.82 0.40 0.23 0.03 1.77 005 0.009 — 0.16 0.37 0 41 0.05 Hammersmith 107,530 22.3 19.2 10.7 12.0 26 2.70 0.96 3 02 0.48 0 69 0.76 0.61 114 0.11 1 .94 0.18 0.009 0.19 0.55 0.70 0.07 Kensington 172,990 18.5 10.7 8.6 10.1 25 2.02 0.97 2.29 0.50 0.40 0.57 0.61 0.18 0.23 2.19 0.11 — 0.08 0.20 0.56 0.12 Division 2 Hampstead 101,060 17.9 11.5 9.1 10.1 16 2.26 0.94 2.74 0.50 0.52 0.37 0.50 0.24 0.16 3.24 0.07 0.21 0.34 0.44 0.07 Paddington 117,050 21.3 15.5 9.3 11.2 14 2.14 0.79 2.87 0.51 0.42 0.62 0.72 0.15 0.49 5.27 0.11 — 0.21 0.37 0.79 0.13 St. Marylebone 67,250 10.9 8.3 13.2 9.8 23 2.87 1.89 4.51 0.61 0.59 0.77 0.61 0.06 0.22 2.08 0.01 — 0.13 0.06 0.52 0.10 St. Pancras 121,870 18.5 15.0 10.2 11.2 26 2.53 1.01 2.80 0.61 0.76 0.74 0.44 0.59 0.24 5.28 0.08 — — 0.31 0.35 0.83 0.07 Westminster, City of 85,840 11.7 9.7 10.5 10.5 23 2.50 1.05 3.13 0.48 0.47 0.56 0.86 0.15 0.43 4.53 0.01 — - 0.06 0.16 0.51 0.05 Division 3 Finsbury 32,070 17.3 15.2 9.4 10.8 24 1.96 1 .06 2.56 0.25 0.97 0.72 0.65 2.34 1.31 7.64 1.37 — - 0.62 0.47 0.72 0.03 Holborn 20,430 8.1 5.3 10.5 11.6 54 2.94 0.69 2.94 0.34 0.44 0.78 0.54 0.20 — 1.62 0.10 — - 0.15 0.05 0.64 0.05 Islington 227,090 25.4 20.8 10.7 12.0 20 2.24 1.06 3.37 0.81 0.70 0.71 0.51 0.73 0.37 7.49 0.09 — - 0.66 0.60 0.79 0.12 Division 4 Hackney 164,350 24.5 22.1 11.1 12.5 17 2.80 1.07 3.18 1.20 0.46 0.69 0.46 2.11 0.15 6.02 0.07 — - 1.00 0.57 0.56 0.10 Shoreditch 37,040 15.2 14.9 12.5 13.0 23 2.83 1.40 3.19 0.54 1.21 1.24 0.40 0.70 0.35 5.08 0.16 — - 1.40 0.97 0.38 0.13 Stoke Newington 53,330 26.8 23.0 10.3 12.8 24 2.21 1.16 3.21 0.62 0.51 0.71 0.47 0.62 0.17 7.05 0.02 — - 0.41 0.41 0.71 0.13 Division 5 Bethnal Green 46,420 17.7 16.6 10.5 11.4 17 2.43 1.01 2.84 0.45 0.95 1 .03 0.50 1 .34 0.06 7.56 0.04 — - 0.99 0.73 0.47 0.04 City of London(fc) 4,580 7.0 5.7 8.3 8.3 — 1.97 0.66 1.97 0.22 0.66 0.87 1.09 — — 0.44 - - - - - 0.44 - Poplar 68,530 20.1 19.1 10.4 12.7 24 2.55 0.83 2.79 0.60 0.77 0.98 0.53 2.61 0.12 6.07 0.51 — - 1.62 0.38 0.47 0.07 Stepney 91,130 19.9 18.1 11.6 13.2 25 2.70 1.10 3.03 0.59 0.87 1.00 0.52 0.33 0.11 6.69 0.57 — - 0.65 0.55 0.88 0.11 Division 6 Deptford 68,500 24.4 22.7 11.0 11.9 29 2.29 1 .05 3.04 0.42 0.92 1.09 0.42 1 .68 0.04 5.45 0.29 — - 0.74 0.54 0.91 - Greenwich 83,630 17.3 16.6 10.8 11.6 19 2.80 1.05 3.41 0.41 0.60 0.80 0.39 0.98 0.18 2.87 — - - 0.62 0.39 0.36 0.13 Woolwich 149,810 16.5 17.8 10.6 11.4 17 2.44 1.03 3.39 0.52 0.88 0.65 0.41 0.12 — 3.04 0.23 — - 0.48 0.53 0.31 0.04 Division 7 Camberwell 175,740 20.8 19.1 10.3 11.1 20 2.22 1.03 2.86 0.61 0.94 0.82 0.38 0.22 0.16 4.52 0.18 - - 0.61 0.25 0.60 0.02 Lewisham 223,170 18.7 18.1 11.5 11.2 20 2.55 1.51 3.35 0.51 0.81 0.81 0.47 0.56 0.11 5.29 0.07 — - 0.65 0.69 0.56 0.07 Division 8 Bermondsey 50,340 18.4 18.0 11.0 12.2 23 2.94 1.11 2.62 0.66 0.70 0.74 0.44 0.70 0.30 3.56 0.24 — - 0.74 0.30 0.87 0.04 Lambeth 223,140 25.0 22.0 10.8 12.1 22 2.33 1.13 3.16 0.54 0.66 0.96 0.55 0.31 0.02 4.21 0.18 — - 0.41 0.27 0.35 0.05 Southwark 84,830 18.5 17.2 12.9 12.5 21 3.05 1.19 3.97 0.53 0.83 1.12 0.59 3.69 0.25 4.89 0.46 - - 1.10 0.38 0.71 0.05 Division 9 Battersea 102,820 21.9 19.9 11.2 11.4 23 2.41 1.33 3.21 0.74 0.52 0.95 0.59 0.40 0.03 5.37 0.11 — - 0.28 0.34 0.57 0.08 Wandsworth 348,450 19.0 18.2 13.0 10.3 23 2.58 1.43 4.45 0.75 0.81 0.75 0.53 0.54 0.08 2.96 0.23 — - 0.39 0.63 0.41 0.06 London, 1964 3,184,600 19.9 17.1 11.0 11.7 21 2.50 1.15 3.27 0.62 0.71 0.78 0.52 0.71 0.17 4.40 0.17 0.0006 — 0.50 0.44 0.56 0.07 London, 1963 3,178,870 20.0 17.2 12.5 13.1 22 2.44 1.27 3.80 0.69 0.97 1.16 0.57 1.55 0.17 9.19 0.30 0.0003 0.0006 0.32 0.82 0.63 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-Administration County of London, 1955-64 Year Annual rate 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 1955 15.1 13.3 11.5 114 0.16 0.01 2.39 1.25 3.37 0.61 0.05 0.63 0.88 0.11 0.14 0.10 0.22 23 0.5 0.77 1956 15.9 14.0 11.7 11.7 013 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 0.51 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 0.1l 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 1962 19.6 17.6 12.0 11.7 0.08 0.01 2.44 1.22 3.75 0.60 0.05 0.83 0.92 0.11 0.18 0.13 0.25 21 0.4 0.52 1963 20.0 17.2 12.5 13.1 0.07 0.01 2.44 1.27 3.80 0.69 0.05 0.97 1.00 0.11 0.20 0.12 0.26 22 0.5 0.43 1964 19.9 17.1 11.0 11.7 0.06 0.01 2.50 1.15 3.27 0.62 0.01 0.71 0.67 0.10 0.17 0 13 0.22 21 0.4 0.36 Table V.3-Deaths by cause-Administrative County of London, 1964 Cause Sex 0- 1- 5- 15- 25- 45- 65- 75+ Total 1964 1963 1. Tuberculosis-respiratory m - — - 2 10 54 42 27 135 174 F - - - - 12 12 8 11 43 59 2. Tuberculosis-other m - — - - 1 7 1 1 10 13 F — 1 - - - 4 1 4 10 19 3. Syphilitic disease m - - - - 3 13 17 11 44 54 F - - 1 - 1 4 9 11 26 44 4. Diphtheria m - - - - - - - - - — F - - - — - — - - - - 5. Whooping cough m - - - - - - - - - - F - - - - - - - - — 2 6. Meningococcal infection m 1 1 1 - 1 1 — - 5 9 F 2 1 - 1 - - - - 4 7 7. Acute poliomyelitis m - - 1 - - - - - 1 - F - - - - - - - - - - 8. Measles m - - - - - - - - - 2 F - 2 - - - - - - 2 - 9. Other infective, &c., diseases m 3 4 - 4 2 11 2 3 29 37 F 1 3 — - 4 8 4 5 25 33 10. Malignant neoplasm: Stomach m - - - 1 27 210 156 107 501 506 f - - - - 8 73 114 160 355 429 11. Malignant neoplasm: Lung, bronchus m - - - - 49 924 608 327 1,908 1,817 F - - - 1 21 173 137 106 438 393 12. Malignant neoplasm: Breast m - - - - - 3 1 - 4 4 F - - - 1 56 315 184 164 720 697 13. Malignant neoplasm: Uterus F - - - - 27 121 72 54 274 279 14. Other malignant and lymphatic neoplasms m 1 7 12 19 92 634 552 527 1,844 1,728 F 1 2 7 8 90 516 452 619 1,695 1,688 15. Leukemia, aleukemia m 1 4 4 3 17 30 34 20 113 110 F 1 3 2 2 8 30 19 29 94 105 16. Diabetes m - — — — 8 27 24 34 93 88 F - - — - 3 32 40 87 162 182 17. Vascular lesions of nervous system m - - 1 5 37 303 403 585 1,334 1,483 F 1 1 2 5 35 297 558 1,439 2,338 2,566 18. Coronary disease, angina m - - - - 141 1,608 1,244 1,058 4,051 4,404 F - - - - 24 390 799 1,535 2,748 3,108 19. Hypertension with heart disease m - - - - 1 42 40 67 150 258 F - - - — 2 20 51 179 252 388 20. Other heart disease m - — 1 9 61 213 241 599 1,124 1,412 F 2 1 - 3 39 191 303 1,555 2,094 2,503 21. Other circulatory disease m - - - 4 21 193 194 346 758 843 F - — - 4 18 124 236 838 1,220 1,358 22. Influenza m — - - 1 2 4 1 7 15 63 F 2 - - - 1 2 1 7 13 98 23. Pneumonia m 127 10 - 2 10 142 233 535 1,059 1,405 F 70 9 5 1 5 58 200 849 1,197 1,682 24. Bronchitis m 33 2 1 — 11 388 527 545 1,507 2,141 F 12 6 1 1 5 93 125 394 637 1,046 25. Other diseases of respiratory system m 3 1 1 2 10 67 50 67 201 214 F 3 - - 1 3 36 16 59 118 138 26. Ulcer of stomach and duodenum m - - - — 12 56 63 73 204 203 F - - - - 5 15 46 60 126 105 27, Gastritis, enteritis and diarrhoea m 16 2 - 1 3 20 19 15 76 78 F 10 - - - 2 15 25 54 106 121 28. Nephritis and nephrosis m 1 1 1 4 16 34 26 24 107 114 F - - 1 2 8 15 20 39 85 95 29. Hyperplasia, prostate m - - - - - 10 27 93 130 156 30. Pregnancy, childbirth, abortn. F - - - 7 16 - - - 23 28 31. Congenital malformations m 150 14 4 4 11 12 10 4 209 226 F 118 15 7 4 5 18 5 8 180 171 32. Other defined and ill-defined diseases m 433 15 13 14 73 242 194 256 1,240 1,283 F 324 18 12 12 90 248 266 582 1,552 1,598 19 Table V.3 (contd.)—Deaths by cause—Administrative County of London, 1964 Cause Sex 0- 1- 5— 15- 25 — 45- 65- 75 + Total 1964 1963 33. Motor vehicle accidents M 1 7 22 72 40 53 29 39 263 234 F 3 1 11 17 15 23 28 39 137 132 34. All other accidents M 13 28 21 25 89 104 33 58 371 422 F 15 10 4 18 26 56 44 129 302 377 35. Suicide M - - - 33 116 119 23 24 315 368 F - - 1 15 57 95 49 22 239 259 36. Homicide, operations of war M 2 - - 6 12 5 - 1 26 17 F 4 - 1 2 5 - 2 - 14 14 ALL CAUSES M 785 96 83 211 876 5,529 4,794 5,453 17,827 19,866 F 569 73 55 105 591 2,984 3,814 9.038 17,229 19,724 Table V.4—Weather during 1964 (as recorded at Kew Observatory) Month Temperature Rainfall Sunshine Mean (a) Difference from Average (b) Total Difference from Average (b) Total Difference from Average (c) °F F ins. ins. hrs. hrs. January 39.2 -0.5 0.53 -1.44 37.1 -6.6 February 41.5 +1.3 0.70 -0.89 64.5 +4.6 March 41 0 -1.9 3.27 + 1.74 70.5 -36.6 April 48.4 +0.9 318 + 1.54 129.4 -23.4 May 581 +4.4 1.67 -0.07 207.9 +7.5 June.. 59.7 +0.3 3.89 +1.91 172.0 -31.7 July 64.6 + 1.9 1.95 -0.44 224.5 +26.1 August 62.2 +0.3 1.83 -0.45 220.0 +34.0 September 59.4 +20 0.41 -1.61 219.4 +76.2 October 48.9 -1.6 1.21 -1.27 132.1 +36.8 November 47.7 +3.3 1.34 -1.03 55.0 +2.6 December 40.6 -0.4 1.34 -0.81 50.0 +11.8 Year 50.9 +0.8 21.32 -2.82 1,582.4 +101.3 (a) Average of the daily means of 24 hourly readings. (b) Average over the 90 years ended I960. (c) Average over the 80 years ended 1960. 20 Table V.5—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—Administrative County of London, 1955-1964 Year Anthrax Diphtheria Dysentery Acute encephalitis Enteric fever Erysipelas Malaria Measles Meningococcal infection Ophthalmia neonatorum Pneumonia Poliomyelitis Puerperal pyrexia Scabies Scarlet fever Smallpox 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 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 (b) 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 16,664 517 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 1962 1 0 0003 — — 2,814 0.883 23 0.007 48 0.015 141 0.044 56 0.018 9,538 2.99 67 0.021 188 2.62 823 0.258 17 0.005 6 0.002 1,374 18.81 369 0.12 863 0.27 1 0.0003 619 0.19 676 0.21 1963 1 0 0003 14 0.004 4,917 1.547 17 0.005 54 0.017 130 0.041 36 0.011 29,209 9.19 64 0.020 96 131 955 0.800 1 0.0003 2 0.0006 1,093 14.70 518 0.16 1,025 0.32 — — 2,601 0.82 528 0.17 1964 — — 4 0.001 2,262 0.710 14 0.004 42 0.013 147 0.046 13 0.004 14,021 4.40 34 0.011 112 1.53 533 0.167 2 0.0006 — — 1,149 15.45 528 0.17 1,598 0.50 — — 1,401 0.44 544 0.17 (a) Rate per 1,000 live births registered in London, (b) Rate per 1,000 total births registered in London. 21 Table V.6—Notification of certain infectious diseases—distribution by age and date of notification—Administrative County of London, 52 weeks commencing 30 December, 1963 Fourweekly periods 1964 Dysentery Measles Meningococcal infection Pneumonia Scarlet fever Whooping cough 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—14 15+ Total 1— 4 M 36 19 42 98 47 17 4 69 2 - - 2 3 3 31 37 18 38 1 57 44 29 2 75 F 28 12 36 76 43 35 6 84 - - - - 4 2 31 37 9 39 - 48 59 25 3 87 5— 8 M 52 49 32 133 99 48 3 150 4 - 1 5 2 3 31 36 18 60 1 79 52 15 - 68 F 50 58 53 161 79 38 3 120 1 - - 1 4 3 19 26 27 52 4 84 59 33 - 92 9—12 M 41 28 40 109 102 91 4 197 - - - - 3 1 27 31 26 42 2 72 48 29 1 78 F 52 28 56 136 102 96 12 211 - - 1 1 1 3 16 20 12 50 1 64 41 32 4 77 13—16 M 38 41 25 104 143 90 10 244 2 - 1 3 2 5 32 39 14 42 4 60 38 17 - 55 F 53 23 49 125 163 113 17 293 1 - - 1 1 3 25 29 19 35 1 55 32 21 2 55 17—20 M 35 17 21 73 162 99 6 268 - - - - 2 2 13 17 14 54 7 75 25 16 1 42 F 31 11 25 68 162 92 13 268 1 - - 1 2 3 13 18 15 41 3 59 34 25 2 61 21—24 M 24 26 18 69 286 164 6 456 - - - - 1 - 8 9 13 42 1 56 24 11 1 36 F 29 22 19 70 256 169 13 438 - - - - 2 - 6 8 17 29 2 49 22 15 3 38 25—28 M 45 40 24 109 343 272 4 620 - 2 - 2 - 1 9 10 14 51 5 70 35 11 1 47 F 40 56 24 121 348 294 6 649 - - - - - 2 6 8 15 51 5 71 32 15 3 57 29—32 M 29 19 17 65 546 303 9 863 - - - - 2 2 8 12 9 25 5 39 23 10 1 34 F 25 17 19 62 507 283 8 799 1 - - 1 1 2 2 5 12 28 7 41 29 25 2 56 33—36 m 38 8 18 65 363 118 3 486 - 1 - 1 - - 13 13 4 8 - 12 26 19 - 45 F 34 11 27 73 352 129 4 489 1 1 1 3 - 1 7 8 10 13 - 23 31 25 4 60 37—40 M 30 9 18 57 228 75 3 307 1 -_ 3 4 _- 1 10 12 11 15 1 28 40 20 - 60 F 19 5 29 54 199 67 3 271 - - - - 7 1 4 7 10 16 1 27 46 14 3 63 41—44 M 33 19 18 70 295 188 4 489 - - 1 1 - 1 14 16 23 54 - 77 20 15 - 35 F 37 23 28 88 273 211 5 489 - - - - 1 1 11 13 28 49 - 77 28 8 7 37 45—48 M 57 24 18 99 608 358 2 972 - - - - 1 4 21 26 37 51 2 90 36 10 - 47 F 45 27 34 106 552 348 10 914 1 1 1 3 1 1 22 24 22 66 2 90 26 9 7 36 49—52 m 33 21 15 69 947 509 13 1,471 1 - 2 3 6 3 13 22 29 60 2 91 27 8 - 35 F 19 13 22 54 835 533 20 1,390 - 1 1 2 5 2 26 33 29 44 3 76 20 77 - 31 Total M 491 320 306 1,120 4,169 2,332 71 6,592 10 3 8 21 22 26 230 280 230 542 31 806 438 210 7 657 F 462 306 421 1,194 3,871 2,408 120 6,415 6 3 4 13 23 24 188 236 225 513 23 764 459 256 28 744 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.5 which relate to the calendar year 1964. 22 TUBERCULOSIS In 1948 the diagnostic and treatment services in respect of tuberculosis became the responsibility of the newly-constituted regional hospital boards. In consequence, the tuberculosis dispensaries in London, most of which had been provided by the metropolitan borough councils, were transferred to the metropolitan regional hospital boards. The provision of preventive and 'care and after-care' services at these dispensaries (later renamed 'chest clinics'), previously included in the Council's comprehensive scheme for the diagnosis and treatment of tuberculosis, became the direct responsibility of the Council. An account of the principal developments in these services follows. Preventive services Tuberculosis contacts—The Council continued to operate a scheme, already in existence for over 20 years, whereby children are boarded-out to protect them from infection by tuberculosis in their own homes or to enable their parents to undergo treatment in hospital. In 1950 the scheme was widened to meet the occasional need to segregate children from infectious homes during B.C.G. vaccination. Placing the children with suitable foster parents or in private nurseries was undertaken by the Invalid Children's Aid Association, acting as the Council's agent, until 1961 when this work was undertaken directly by the Council. Before boarding away from home is resorted to, the possibility of some alternative form of care, e.g. day nursery, child minder or home help service, is considered. A number of children were thought to have suffered adversely by prolonged removal from home and it became a point of policy only to board a child away from home when no other course was practicable. The number of children placed under the scheme rose from 362 in 1948 to a peak of 600 in 1953, since when it has been steadily reduced to 77 in 1964. B.C.G. vaccination—An important development in the preventive field since 1950 has been the initiation of B.C.G. vaccination schemes: (a) in 1950, for susceptible (tuberculin negative) contacts of known tuberculosis patients; (b) in 1953, for diabetic children in the Council's special residential school for such children; (c) in 1954, for tuberculin negative 13-year-old children attending London schools; (d) in 1959, for students at establishments for further education within the county— private, Council and university. The tuberculin testing surveys, which are a first step in the vaccination programme each year, in addition to showing who will benefit by B.C.G. vaccination also provide an accurate reflection of the amount of infective tuberculosis in the adult groups in the school, district and community from which the tested children come. This gives an epidemiological pointer to where mass radiography should be particularly directed by indicating foci of infection. Children who show 'severe' (more than 20 mm.) local reactions to the moderate dose (10 tuberculin units = 0 0002 mgm.) tuberculin test have been found to manifest twice as many (1.6 per cent.) active lesions on chest radiography as was found among moderate (5-20 mm.) reactors. It was therefore made a routine practice to X-ray annually, while they remained at school, those severe reactors whose first chest X-ray was normal. The many cases of active disease discovered in this way over the years and put on to treatment early has formed a valuable by-product of the protective B.C.G. vaccination scheme. These cases discovered by routine X-ray after a positive tuberculin test form a substantial proportion of the notified cases in their age group and many might have pursued a benign course undiscovered. 23 The tuberculin survey results and the vaccinations given during the 10 years 1955-1964 are set out below: Number of tuberculin tests and positivity rate in 13-year-old scholars, 1955-1964 Year Tuberculin tested % reactors Vaccinated 1954-55 22,569 14.4 19,301 1955-56 25,360 14.5 21,655 1956-57 26,517 130 23,023 1957-58 27,742 10.9 24,651 1958-59 23,847 8.5 21,798 1959-60 33,172 8.2 30,425 1960-61 to 31.12.61 38,521 8.8 35,050 1962 26,927 8.8 24,498 1963 23,457 7.5 21,629 1964 25,471 8.6 23,117 Active or suspect tuberculous cases ascertained by X-ray of reactors Year No. X-rayed Active or suspected T.B. cases ascertained 1954-55 2,387 14 1955-56 2,768 8 1956-57 2,998 20 1957-58 2,782 10 1958-59 1,966 21 1959-60 2,434 10 1960-61 to 31.12.61 3,229 23 1962 2,198 3 1963 1,673 27 1964 1,745 5 Notified new cases in age groups and two-year periods with percentage rise and fall 1952-1963 10-11 years 12-13 years 14-15 years 16-17 years 18-19 years No. Rise fall No. Rise fall No. Rise fall No. Rise fall No. Rise fall 1952 65 - 91 - 115 - 271 - 473 - 1953 1954 60 - 7 80 -12 96 -16 234 - 13 377 -20 1955 1956 40 -33 58 -27 28 -70 163 -30 275 -27 1957 1958 32 -20 53 - 8 14 -50 97 -40 197 -28 1959 1960 23 -28 51 - 4 26 +86 66 -32 123 -37 1961 1962 26 +13 41 -19 12 -54 74 + 12 107 -13 1963 24 Preventive measures—In addition to the B.C.G. vaccination schemes, other preventive measures initiated since 1948 include the chest X-ray examination of all newly-appointed staff likely to come into close and frequent contact with children, staff at the Council's training centres for mentally handicapped persons, and of tuberculin reactors discovered among the children and students tested with a view to B.C.G. vaccination. The X-ray examinations involved have been carried out mainly at mass radiography units of the regional hospital boards. Epidemiological investigations have been made among the contacts of cases of tuberculosis notified in children, staff or residents in the Council's establishments when no other source of infection has been established. Similar investigations have been carried out among adults at those secondary schools where the reactor rates disclosed by tuberculin surveys were significantly higher than the average for secondary schools in the area or at that school in previous years. Care and after-care Voluntary care committees—Voluntary care committees have continued to operate in association with most of the chest clinics. These committees, which obtain their funds from voluntary contributions, sales of work, Christmas seals, etc., have given valuable assistance to patients by means of money grants, clothes, holidays and other benefits and care not available from official sources. Hostels—An important development has been the establishment of hostels for homeless infective tuberculous men who, if a hostel were not available, would live in common lodging houses, where they might constitute an infective risk and be less mindful of their nutritional and other needs than men living a normal family life. The first hostel was opened in 1951 and there are now three hostels with a total of 91 beds. At the end of the year 88 men were in residence, including nine in similar accommodation specially provided for the Council's use at a hostel in British Legion Village, Maidstone, Kent. These hostels have provided social care and close medical supervision for a group of men known to take inadequate care of themselves and to have scant regard for the treatment needs of their tuberculosis. Although primarily intended for homeless infective cases, they have also provided useful temporary havens for not so infectious cases leaving hospital but with no arranged home or other living accommodation to which to return. Industrial rehabilitation—Selected patients recommended by chest physicians are sent to village settlements, where they undergo courses of instruction in work suited to their capacity and temperament. By agreement with the regional hospital boards, a patient comes within the Council's after-care scheme for rehabilitation when he is fit to work at the settlement for five hours a day. Maintenance charges then become the Council's financial responsibility until the patient returns home or becomes a settler. The number of patients at these settlements for whom the Council was financially responsible rose from 31 at the end of 1948 to 80 in 1954 and fell to 18 at the end of 1964. Diversional therapy—Diversional therapy classes to provide interesting and profitable working hobbies were organised mainly by the voluntary tuberculosis care committees and have continued at some chest clinics for patients able to travel. The instructors are provided and paid by the education department as part of the Council's evening institute teaching arrangements. A service for home-bound patients, started experimentally in 1953 in north west London, was extended in 1955 to other parts of the county where the need for such a service became apparent. At the end of 1964 there were 99 patients receiving instruction in their own homes from the Council's occupational therapists. 25 26 The crafts in which patients have been instructed include basketry, book-binding, leather work and dressmaking. The finished articles are purchased by the patients or their relatives or friends, or sold, after disinfection, at market stalls or sales of work. Home care—The Council's tuberculosis visitors, in addition to assisting the chest physician with clinic work, see patients in their own homes to advise on diet, hygiene, etc., to ascertain home conditions and needs and to persuade contacts to attend the clinic for investigation. Extra nourishment (milk, butter, eggs) is provided for necessitous patients on the recommendation of chest physicians. Some patients are helped to obtain extra nourishment by the voluntary care committees. Nursing attention is arranged under the direction of the family doctor or the chest physician; nursing equipment, e.g., back rests, bedpans, etc., is made available on loan; and home helps are provided in the homes of bed-fast patients and to care for children of mothers undergoing treatment in hospital. Housing—The Council has set aside a limited number of dwellings for the rehousing of families on purely medical grounds. Among the nominations for such rehousing are those where special preference has been recommended because of urgent need to reduce the danger of infection arising from inadequate accommodation for persons suffering from active tuberculosis. The number of recommendations received and the nominations made in the past five years are shown in the General Public Health section of this report. Open-air schools—For convalescent tuberculous children of school age not yet fit to return to normal school life, the Council provides day and residential open-air schools where educational activities are continued at a gentle pace in good surroundings with special emphasis on rest periods, medical supervision and nutritious dietary. Recuperative holidays—Holidays for London tuberculous patients who have recently been ill or in whom breakdown threatens have been arranged through the Spero Holiday Scheme of the Chest and Heart Association (formerly National Association for the Prevention of Tuberculosis) or direct by the Council. Statistics Table T.l—Tuberculosis—Statutory notifications (a) and deaths, Administrative County of London, 1955-1964 Year Pulmonary tuberculosis Non-pulmonary tuberculosis Notifications Deaths 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 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 1962 2,092 0.66 252 0.08 245 0.08 27 0.01 1963 1,993 0.63 233 0.07 266 0.08 32 0.01 1964 1,793 0.56 178 0.06 232 0.07 20 0.01 (a) Excluding posthumous notifications. 27 Table T.2—Pulmonary tuberculosis—Notification and death rates per 1,000 living by age and sex, Administrative County of London, 1955-1964 Year 0-4 5-14 Age 15-44 45 and over All ages M F M F M F M F M F Notification rates 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 1962 0.34 0.38 0.16 0.27 1.04 0.60 1.26 0.24 0.95 0.40 1963 0.38 0.29 0.26 0.32 0.96 0.58 1.16 0.25 0.89 0.40 1964 0.29 0.30 0.27 0.24 0.85 0.50 1.07 0.23 0.81 0.34 Death rates 1955 0.02 - 0.005 - 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 1962 - - - - 0.02 0.01 0.32 0.08 0.13 0.04 1963 - 0.008 - - 0.03 0.01 0.30 0.07 0.12 0.04 1964 - - - - 0.02 0.02 0.23 0.04 0.09 0.03 Table T.3—Non-pulmonary tuberculosis—Notification and death rates per 1,000 living by age and sex, Administrative County of London, 1955-1964 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 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 1962 0.008 0.041 0.057 0.032 0.111 0.151 0.034 0.044 0.068 0.085 1963 0.029 0.053 0.048 0.039 0.141 0.149 0.052 0.029 0.088 0.080 1964 0.008 0.041 0.054 0.040 0.106 0.114 0.048 0.050 0.071 0.074 Death rates 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 1962 0.008 0.017 - - 0.005 0.007 0.015 0.011 0.008 0.009 1963 - - - 0.006 0.006 0.004 0.017 0.022 0.009 0.011 1964 - 0.008 - - 0.001 - 0.017 0.013 0.007 0.006 28 Table T.4—Tuberculosis—Statutory notifications by age groups, Administrative County of London, 1964 Form of tuberculosis notified Sex Number of notifications of new cases of tuberculosis Total (all ages) 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75+ Pulmonary tuberculosis m. 3 34 24 26 50 103 202 211 200 223 107 31 1,214 F 4 33 22 20 41 85 128 86 74 41 36 9 579 Other forms of tuberculosis m. - 1 7 3 10 17 23 21 10 7 4 4 107 F. - 5 5 2 5 20 33 20 12 8 7 8 125 All forms of tuberculosis M. 3 35 31 29 60 120 225 232 210 230 111 35 1,321 F. 4 38 27 22 46 105 161 106 86 49 43 17 704 Table T.5—Tuberculosis—Deaths in Administrative County of London, 1964 Form of tuberculosis Sex Age at death Total (all ages) 0- 1- 5- 15- 25- 45- 65- 75+ Pulmonary tuberculosis m. - - - 2 10 54 42 27 135 F. - - - - 12 12 8 11 43 Other forms of tuberculosis m. - - - - 1 7 1 1 10 F. - 1 - - - 4 1 4 10 All forms of tuberculosis M. - - - 2 11 61 43 28 145 F. - 1 - - 12 16 9 15 53 Table T.6—Statutory notification of non-pulmonary tuberculosis—Distribution according to site and age, Administrative County of London, 1964 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+ Meninges and C.N.S. 2 5 2 4 13 Abdomen - - 7 7 14 Bones and joints - 4 10 32 46 Skin and erythema nodosum - - 2 3 5 Peripheral glands 3 8 19 67 97 Genito-urinary - - 6 43 49 Other sites 1 - 3 4 8 All sites 6 17 49 160 232 Table T.7—Patients on the registers—1955-1964 At 31 Dec. 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 Pulmonary: Males 19,300 19,715 19,946 20,308 19,553 19,380 18,759 18,153 17,379 16,553 Females 15,846 15,928 15,836 15,597 14,858 14,497 13,833 13,171 12,456 11,586 Other forms: Males 1,371 1,339 1,274 1,293 1,158 1,163 1,143 1,123 1,098 1,111 Females 1,704 1,710 1,709 1,674 1,555 1,527 1,473 1,402 1,368 1,353 Total 38,221 38,692 38,765 38,872 37,124 36,567 35,208 33,849 32,301 30,603 No. per 1,000 of population 11.6 11.8 11.9 12.1 11.6 11.4 11.1 10.6 10.1 9.6 29 30 Table T.8 —Principal tuberculosis statistics—Metropolitan Boroughs and the Administrative County of London, 1964 Metropolitan Boroughs Estimated home population mid 1964 New notifications New notifications per 1,000 population 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 31.12.64 Cases on register per 1,000 population Pulmonary Tuberculosis of Meninges and C.N.S. Other nonpulmonary tuberculosis Total Pulmonary Nonpulmonary tuberculosis Total deaths Total Percentage of pulmonary cases positive* during 1964 Division 1 Chelsea 46,200 11 - 1 12 0.26 2 - 2 0.04 0.05 273 3.1 5.9 Fulham 109,410 45 1 5 51 0.47 6 - 6 0.05 0.07 1,197 3.8 10.9 Hammersmith 107,530 75 - 7 82 0.76 4 1 5 0.05 0.05 1,373 5.6 12.8 Kensington 172,990 97 1 20 118 0.68 6 1 7 0.04 0.04 975 3.1 5.6 Division 2 Hampstead 101,060 44 - 7 51 0 50 1 - 1 0.01 0.01 602 5.8 6.0 Paddington 117,050 92 1 14 107 0.91 8 1 9 0.08 0.08 1,018 3.6 8.7 St. Marylebone 67,250 35 1 6 42 0.62 4 - 4 0.06 0.07 483 2.8 7.2 St. Pancras 121.870 101 - 8 109 0.89 8 1 9 0.07 0.08 1,022 1.4 8.4 Westminster, City of 85,840 44 - 4 48 0.56 11 - 11 0.13 0.14 764 0.3 8.9 Division 3 Finsbury 32,070 23 - 1 24 0.75 6 - 6 0.19 0.23 258 4.1 8.0 Holborn 20.430 13 - 1 14 0.69 1 - 1 0.05 0.06 176 7.1 8.6 Islington 227,090 179 3 24 206 0.91 8 2 10 0.04 0.04 2,207 2.1 9.7 Division 4 Hackney 164,350 92 1 16 109 0.66 6 1 7 0.04 0.05 1,550 3.4 9.4 Shoreditch 37,040 14 - 5 19 0.51 5 - 5 0.13 0.18 266 5.2 7.2 Stoke Newington 53,330 38 - 7 45 0.84 2 - 2 0.04 0.05 658 4.8 12.3 Division 5 Bethnal Green 46,420 22 - 2 24 0.52 2 - 2 0.04 0.05 674 2.8 14.5 City of London 4,580 2 - - 2 0.44 - - - - 49 10.6 10.7 Poplar 68,530 32 - 5 37 0.54 1 1 2 0.03 0.02 564 4.1 8.2 Stepney 91,130 80 - 10 90 0.99 7 1 8 0.09 0.10 1,260 21 13.8 Division 6 Deptford 68,500 62 - - 62 0.91 2 - 2 0.03 004 1,104 2.4 16.1 Greenwich 83.630 30 - 11 41 0.49 3 1 4 0.05 0.04 821 3.5 9.8 Woolwich 149,810 47 - 6 53 0.35 3 - 3 0.02 0.03 1,390 3.5 9.3 Division 7 Camberwell 175.740 105 1 2 108 0.61 19 2 21 0.12 0.14 766 8.3 4.4 Lewisham 223,170 126 1 14 141 0.63 5 2 7 0.03 0.03 2,070 1.4 9.3 Division 8 Bermondsey 50,340 44 - 2 46 0.91 7 - 7 014 0.18 671 1.6 13.3 Lambeth 223.140 77 - 12 89 0.40 15 3 18 0.08 0.09 3,478 2.6 15.6 Southwark 84,830 60 1 3 64 0.75 6 2 8 0.09 0.09 1,379 3.4 16.3 Division 9 Battersea 102,820 59 - 8 67 0.65 6 - 6 0.06 0.07 806 4.7 7.8 Wandsworth 348,450 144 2 18 164 0.47 24 1 25 0.07 0.08 2,749 1.2 7.9 LONDON 3,184,600 1,793 13 219 2,025 0.64 178 20 198 0.06 0.07 30,603 3.0 9.6 * Cases whose broncho-pulmonary secretion was positive during the year. GENERAL PUBLIC HEALTH Rehousing on medical grounds Since the war housing has never been far from the headlines. The demand for municipal housing has been very great and consequently the London County Council and the metropolitan borough councils have devoted a large part of their resources firstly to the repair of war damage and then to slum clearance and increasing the total housing resources. In the immediate post-war years the Council had a points scheme, whereby points were awarded to the applicants for housing accommodation for various factors such as bedroom deficiency, time on the waiting list, etc., and one of these factors was ill health. As a consequence, medical officers of this department had to assess a vast number of medical certificates submitted by housing applicants (between 30,000 and 45,000 each year for the years 1949/1955). As the majority of these cases required further enquiry, for instance of the borough medical officer of health concerning alleged sanitary defects, this was no light task. A review by the Housing Committee of the housing position in 1955 showed that most of the larger areas for building in London had been used and that there was bound to be a slowing up in building additional accommodation owing to lack of sites within the county. Moreover, slum clearance and other redevelopment required about 7,000 houses a year. Slum clearance was given first priority but nevertheless the Council decided to put aside a quota of dwellings annually for rehousing persons on purely medical grounds. In November 1956 all applicants on the housing list were informed that, as the Council had rehoused 75,000 families between 1945 and 1955, priority in the future had to be given to slum clearance. A letter was sent to hospital staff's and general practitioners explaining the limited amount of housing which could be allocated on medical grounds and requesting them not to submit medical certificates but to send a personal letter to the Medical Officer of Health for his consideration in each case where they considered that an applicant or a member of his family was suffering from a very serious medical condition which would benefit from rehousing. Such letters have since continued to be received at a rate of 2,500 to 3,000 a year, together with some 1,500 requests annually for reassessment of or giving further details of a case previously turned down. On receipt of a doctor's recommendation a health visitor filled in the family background and where necessary a public health inspector's report on the premises was obtained. A medical officer in each division assessed each case and indicated whether further consideration was justified. This decision has to be a realistic one, having regard to the number of recommendations received from doctors far exceeding the number of dwellings allocated. From those cases marked for further consideration, the most needy cases were selected for nomination by the Medical Officer of Health or his deputy to the Housing Committee for rehousing when dwellings became available. From 1956 there was a separate allocation of dwellings for tuberculous cases but as the number of recommendations received from chest physicians fell from 421 in 1957 to 126 in 1963, this quota was combined with the general health allocation in 1964 when the Housing Committee set aside 500 dwellings (including 50 mobile homes) for rehousing on medical grounds. During the years 1956-1964 the Council rehoused 2,847 families solely for medical reasons, 838 being on grounds of infectious tuberculosis. The following table shows the cases dealt with in the past five years. 1960 1961 1962 1963 1964 Tuberculous persons Recommendations received 232 224 180 126 108 Nominated for rehousing 209 139 110 110 88 Recommendations not qualifying for rehousing 93 20 70 61 19 Under consideration at end of year 45 110 110 65 66 Persons with severe medical conditions Recommendations received 3,357 2,570 2,263 2,586 2,570 Nominated for rehousing 607 164 363 449 978 Recommendations not qualifying for rehousing 2,503 1,791 2,082 2,653 1,682 Under consideration at end of year 1,300 1,915 1,733 1.217 1,127 31 . Slum clearance Extensive surveys of housing conditions had been completed in the period prior to the outbreak of war in 1939, but as a result of the war further proceedings in a number of clearance areas which had been represented to the Council were abandoned and the staff engaged on this work dispersed. In 1945 housing conditions had vastly changed—many houses had been removed by bombing, while most of those that remained suffered from its effects or were in serious disrepair through neglect. Demobilised servicemen came home to an acute housing shortage and it was not unusual to find them, with wives and children, living in restricted and bad housing conditions with their parents' families. Slum clearance work was resumed in 1947 leading to the representation of four small areas in 1948, but it was clear that a major effort was required if the worst housing conditions were to be tackled as urgently as the situation demanded. The Council decided, first, that six known large areas in Bethnal Green, Camberwell, Fulham, Southwark and Stepney should be re-surveyed and reported upon, and, secondly, that the metropolitan borough councils should be asked to carry out surveys of their boroughs to determine the extent of the problem. As a result of this and the detailed discussions which followed with the borough councils a joint programme of slum clearance for the period 1951-1955 was agreed, with the Council undertaking to clear 6,842 houses and the borough councils 3,290 houses. The six priority areas (totalling 31 acres and 1,291 houses) were dealt with by 1952 and the joint programme proceeded without undue delay. The Housing Repairs and Rent Act, 1954, required all local authorities in England and Wales, including the Council and the metropolitan borough councils, to submit joint proposals for dealing with unfit houses. A further five-year programme (1956-1960) for the administrative county was drawn up in respect of 7,218 houses, of which the Council undertook to deal with 4,094. In 1960 sufficient progress had been made to enable a further programme for the years 1961-1965 to be drawn up and this year the first steps have been taken to draw up a programme for the years 1966-1970. During the fifteen years from 1948 to 1963 the Council has declared some 713 areas, containing 25,404 unfit houses, to be clearance areas. In two Areas of Comprehensive Development designated by the Council under the Town and Country Planning Act, 1947, one in Bermondsey of 121 acres, and one in Poplar/ Stepney of 1,312 acres, clearance of individual unfit houses by Declaration of Unfitness Orders under Town Planning powers was commenced in 1949 and continued up to the end of 1964; 738 unfit houses were dealt with in this way. While unfitness for habitation is determined by the standards of the Housing Acts for this purpose, the provisions require it to be shown that the unfit houses cannot be made fit for habitation at reasonable cost. Work in connection with unfit houses during the past five years is summarised below: 1960 1961 1962 1963 1964 Areas represented as unfit for human habitation 48 34 87 109 30 Houses in such areas 1,356 932 2,808 2,990 1,247 Areas surveyed but not represented by the end of the year 39 90 74 13 3 Houses in such areas 1,291 2,869 2,183 421 70 Public local inquiries 42 12 10 26 37 Informal hearings 1 4 - - 4 Orders confirmed (i) after inquiry or hearing 41 27 9 17 37 (ii) without inquiry or hearing (no objection received) 15 2 2 7 19 Orders not confirmed by Minister 1 - - - 1 Confirmed order quashed on appeal to High Court - 1 - - - 32 Improvement of houses by grant aid In an attempt to encourage owners to provide bathrooms, hot water services and other amenities in sub-standard houses not likely to be included in development schemes, the Government in 1949 introduced the improvement grant provisions. These gave the Council powers, concurrent with the borough councils, to make grants, which it has exercised only where borough councils have been unwilling to do so or the Council is offering mortgage facilities. In the whole period up to the end of this year, 3,211 properties have been surveyed and 277 discretionary grants and 90 standard grants to the value of £596,102 have been made by the Council. I960 1961 1962 1963 1964 Improvement grants Surveys following applications to the Council 1,178 309 342 447 367 Searches following applications to metropolitan borough councils 572 595 576 930 1,091 Hostels Surveys following application to the Council for loan Premises - - - 5 5 Units of accommodation - - - 311 278 Housing loans* Searches following application to the Council for loan - - - 2,459 2,790 Surveys following application to the Council for loan - - - 229 155 * This additional work commenced during 1963 when the Council introduced a more extensive scheme for making loans to intending house purchasers. Sanitary inspection The inspectors dealt with the following matters in Council establishments: 1960 1961 1962 1963 1964[ Reports of infestation by a variety of pests 274 221 269 250 259 Visits and re-inspections involved 506 409 526 404 372 Inspections of school meals centres 341 208 242 156 195 Investigations of illness following consumption of school meals 8 11 7 3 11 Occasions when the meal was found to be the cause 2 - - - 3 Milk sampling Since 1908 the Council has arranged for samples of milk arriving in London by road and rail to be tested for the presence of tubercle bacilli. In 1959 it was decided that, as milk was received principally from tuberculosis eradication areas, sampling should be concentrated mainly in unpasteurised tuberculin tested milk bottled on the farm. Some 50 to 70 samples a year were taken. Any positive samples were reported to the medical officer of health of the district in which the milk was produced for him to take follow-up action. The following table shows the results of tests during the year, with last year's figures in brackets: Designation Samples examined T.B. bacillus isolated T.B. bacillus NOT isolated Passed phosphatase test Tuberculin tested (Farm bottled) 31 (33) - (-) 31 (31†) N/A Tuberculin tested † 4 (4) - (-) 4 (4) N/A Pasteurised 17 (17) N/A N/A 17 (17) Total 52 (54) - (-) 35 (35†) 17 (17) * Samples from a residential school which has its own farm. † In addition the test was not completed on two samples. 33 c* Blind and partially-sighted persons During the year 1,561 examinations were made in connection with certification under the National Assistance Act, 1948 of blind or partially-sighted persons and 46 persons were found to be neither blind nor partially-sighted. In addition, 550 certificates were accepted from other local authorities, hospitals and private ophthalmologists—47 more than in the previous year. The percentage of new registrations recommended to obtain treatment was 58.7 per cent. compared with 58.3 per cent. in 1963. The number of examinations of persons newly referred during the year was appreciably higher than for 1963, with a corresponding fall in the number of re-examinations of persons previously examined. The results of examinations of persons newly registered during the year are given in tables (i) and (ii). 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 4 - 2 4 10 5-15 years 1 1 - 1 3 16-64 years 57 14 - 201 272 65-74 years 111 39 - 152 302 75 years and over 334 68 - 397 799 Age not known 7 6 - 18 31 (a) Total No. of persons 514 128 2 773 1,417 (b) No. recommended to obtain treatment 348 106 - 378 832 (b) as percentage of (a) 67.7 82.8 - 48.9 58.7 Table (ii) Treatment recommendations in respect of newly registered persons* No. of patients examined Treatment recommended None Medical Surgical Optical Hospital supervision Early Later if general condition permits Cataract 514 166 39 67 55 43 42 157 Glaucoma 128 22 30 - 5 1 8 81 Retrolental fibroplasia 2 2 - - - - - - Other conditions 773 395 96 7 20 6 46 249 Total 1,417 585 165 74 80 50 96 487 *Includes cases recommended more than one form of treatment. 34 Table (iii) Re-examination of persons recommended to obtain treatment Principal cause of defective vision Total Cataract Glaucoma Other conditions No. of persons re-examined 177 64 246 487 No. found to have had treatment 125 59 170 354 Percentage treated 70.6 92.2 69.1 72.7 As a consequence of successful treatment eight persons previously registered as blind were found, on re-examination, to be partially-sighted and six persons previously certified as blind or partially-sighted were found to be improved to such an extent as no longer to justify registration. Notifications of ophthalmia neonatorum are given on page 21. Registration of nursing homes During the years since 1948 the number of private nursing homes in the county has shown a steady decline. In 1949 there were 58 registered nursing homes containing 1,023 beds and in addition there were 40 homes exempted from registration on the grounds that they were not run for profit. In 1963 there were 34 registered nursing homes containing 945 beds and 35 homes exempted from registration. The demand for maternity and surgical beds greatly decreased since the inception of the National Health Service but there has been an increase in the need for beds for medical patients, particularly the elderly, infirm and chronic sick. This change of user has led to a review of the staffing standards and state enrolled nurses may now be employed in suitable ratio to fully trained nurses on the staff of nursing homes. The Mental Health Act, 1959 came into operation in November 1960, and Part III of that Act and the powers for registration set out in the Public Health (London) Act, 1936 have now been applied to mental nursing homes. Four nursing homes have accordingly been registered for the reception of mentally ill patients. The Nursing Homes Act, 1963 repealed the power to grant exemption from the provisions of the Public Health (London) Act, 1936 to non profit-making homes and consequently all the homes previously exempted had to apply for registration. Regulations under this Act governing the conduct of nursing homes came into operation on 27 August 1963 and have strengthened the Council's powers to require and maintain good standards in nursing homes. Table (i)—Registration and inspection of nursing homes 1960 1961 1962 1963 1964 Registered at beginning of year 34 33 36 36 36 New homes registered - 5 1 - 1 Homes registered on change of keeper 3 1 - 1 1 Registrations cancelled—voluntary closure or change of keeper 4 3 1 3 2 Applications for registration from homes previously exempted - - - - 12 Homes previously exempt registered during the year - - - - 12 Registered at end of year 33 36 36 34 47 Inspections: Medical officers 35 46 45 39 70 Public health inspectors 84 122 116 125 199 Homes exempted from registration 40 37 35 35 - 35 Table (ii)- Accommodation in registered nursing homes at 31 December, 1964. No. of homes—47 Maternity beds 205* Others 917†‡ Mental 305 Total 1,427 * Alternative registration for maternity, medical or surgical case. † Numbers include beds for medical and surgical patients which cannot be used if maternity patients are accommodated in the same room. ‡ Number includes 45 beds registered for medical or mentally disordered cases. Invalid meals for London Under the National Health Services Act, 1946 the Council had power to arrange for the provision of meals at home for the sick, including the aged sick. Many parts of London were served by the Invalid Kitchens of London, a voluntary organisation which provided meals for invalids at several centres or delivered meals by car to the patient's home. The Council paid a grant to this organisation towards the cost of meals provided by them for persons in their own homes. Towards the end of 1959 the voluntary organisation asked the Council to take over this service as soon as possible but the legal formalities were not completed until December 1961. In the meantime, the metropolitan borough councils asked for powers to be obtained in a General Powers Act to enable them to provide this service and provision was included in the London County Council (General Powers) Act, 1961. Discussions then took place through the Metropolitan Boroughs' Standing Joint Committee concerning the transfer of this service to the boroughs but no decision was reached. Under the London Government Act, 1963 this service will be transferred to the new London boroughs. Since 1961 the service has been maintained and operated by the School Meals and Catering department who have replaced and made improvements in vans and equipment. The number of meals served during recent years was as follows: 1960/1 1961/2 1962/3 1963/4 1964/5 Meals served 180,291 196,695 202,430 239,814 251,525 Welfare Committee establishments Medical supervision of all types of establishments under the control of the Welfare Committee continued. These include large and small homes for the aged and infirm, accommodation for mothers and babies, homeless families units, homes for the blind and lodging houses. The Public Health department has continued to advise on steps to be taken to limit the spread of infectious diseases in homeless families units. The features which are of special importance in the spread of these infections include the close and intimate nature of contact, both of the adults and children, for a large part of the time they are in the units, the common feeding accommodation and the shared sanitary accommodation. Much has been done to stimulate the women inhabitants to a sense of responsibility in the maintenance of sanitary accommodation in good order. Where the inhabitants have failed to respond to training extra domestic staff have been allocated to maintaining clean sanitary accommodation. In the welfare homes the health of the chronic sick and other illnesses of an ageing population receive the constant attention of the medical and other staff. The treatment of minor conditions within the homes increases the elderly persons' sense of security but when a doctor has a large number of the elderly on his list it can be very time-consuming. Special investigations have been arranged and preventive measures carried out in order to maintain as high a standard of health as possible within the homes. 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. 36 HEALTH SERVICE PREMISES The maternity and child welfare centres transferred to the Council under the National Health Service Act, 1946 varied considerably both in standard and type, and were mainly accommodated in church halls, shops and converted dwelling-houses. They were generally sub-standard and in need of replacement. Only about 10 per cent. of the transferred premises had been purpose built and while a number of these provided excellent facilities others, built earlier, were too small to be regarded as adequate by modern standards. Furthermore, certain areas were not adequately served either by maternity and child welfare centres or day nurseries, partly as a result of alterations in the density of the population within the county which occurred during and since the war. It was recognised that shortages of materials and labour would preclude the erection of many centres and other health service buildings and that the rate at which progress could be made would be very largely dependent upon the economic position. Restrictions on capital expenditure prevented the Council from carrying out much of its health service building programme but a substantial number of high priority projects were completed or were nearing completion by the end of 1964. Particulars of these schemes and of other major building works completed since 1948 are set out in tables (i) and (ii) and summarised in table (iii). Comprehensive health centres Original proposals—The Council, recognising the importance of the role which the comprehensive health centre could play in securing the fullest co-operation between the personal health services and those provided by the hospital and specialist services and by general medical and dental practitioners, included in proposals for carrying out its duties under section 21 of the National Health Service Act, 1946 the following: (i) The building of the Woodberry Down comprehensive health centre, Stoke Newington; (ii) the establishment of a similar centre in each of the nine health divisions, if suitable buildings could be found for adaptation; and (iii) the acquisition and adaptation of suitable premises for use as group practices only in any area where the demand for such facilities existed. This constituted the initial stage of the ultimate provision of a comprehensive health centre service, which it was realised would take many years to achieve. The long-term plan was to provide a centre in each of 162 health service areas into which London was to be divided. Action to implement the proposals— (i) Woodberry Down health centre—Local authority and specialist services began when the centre opened in October 1952. All doctors practising within a mile of the centre were invited to apply for facilities. Although six were eventually selected, they were unwilling to work in partnership. In fact, they practised independently from their surgeries in the centre, although the Council recently agreed to arrangements whereby two of the practices include additional partners in the interests of making greater use of the facilities available. (ii) Other comprehensive centres—No suitable buildings were found for adaptation but some 40 sites were provisionally earmarked for the provision of health centres when circumstances became propitious. (iii) Group practices—All doctors practising in London were invited to say whether they would like to work in group practice buildings provided by the Council, if these could be found in suitable localities, and 29 groups expressed their willingness to do so. Of these, seven groups consisted of less than four doctors, the minimum number felt by the Council to be desirable to form a group. For some years a search was made to find premises for the other groups but without success. 37 South East London general practitioner centre—The South East London general practitioner centre established by the Council at Queen's Road, Camberwell, which was officially opened in 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 commonroom. The Council provides and maintains the premises, supplies the furniture and non-specialist equipment, nursing, health visiting and secretarial staff. 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. The South East Metropolitan Regional Board and the Camberwell Hospital Management Committee provide the specialist equipment, staff and consultants for the radiological and pathological departments. The College of General Practitioners supported the project and gave invaluable advice and assistance during the planning stages. Revision of the Council's policy—Long standing restrictions on capital expenditure and the unwillingness of general practitioners to engage in group practice from a health centre precluded the provision of further health centres. These problems were discussed on many occasions with the London Executive Council and with the Ministry of Health; the Minister finally advised the Council in 1955 that he would be unable to approve of the erection of health centres except in areas of new development where existing health services, including general medical services, were inadequate and provided that local doctors agreed to practise from them. In view of this and the practical difficulties in securing the vital co-operation of general practitioners in the provision of general medical services from health centres, the Council decided that it would be unrealistic and, because of the shortage of land in London, undesirable to continue the policy of long term reservation of health centre sites. The London Executive Council's suggestion was accepted that any housing development on these sites should be constructed so that ground floors could readily be converted to accommodation for general practitioners if required later. The Council has subsequently been willing to assist general practitioners wherever practicable to establish group practices in one of two ways: (i) to provide a building as the first instalment of the health centre and if a group were anxious to adopt this method in an area of new development the Council would give the proposal sympathetic consideration; and (ii) to provide accommodation in a housing block at an economic rent on the same basis as a practitioner who might be provided with a surgery by the Council if he were displaced by housing development. It has been open to any doctors to approach the Council on these matters through the London Executive Council and the London Local Medical Committee, with whom the Council has worked in the closest co-operation. Maternity and child welfare and school treatment centres It was apparent at the outset that many years would elapse before designed buildings could be erected in sufficient numbers to replace the improvised clinic accommodation to which reference has been made. To safeguard the future of the service, whenever opportunity arose the freehold or leasehold interest has been secured in the more satisfactory buildings and table (v) shows that the service relies much less now than in 1948 on rented premises. Improved alternative accommodation has been obtained to enable centres functioning in very unsuitable premises to be closed. Progress has also been made in providing new or improved accommodation for school health service purposes. In suitable cases the opportunity has been taken of incorporating some school health services in maternity and child welfare centres, so as to achieve fuller integration of the two services. 38 Financial restrictions obliged the Council to defer plans for the erection of replacement buildings and the building of new purpose-designed centres has been largely confined to those areas where expanding population or the development of new housing estates has created a new and urgent demand for services. The Council approved a number of schemes for the incorporation of purpose-designed clinics and day nurseries in ground floor accommodation in blocks of flats. Details of schemes in new housing developments are given in table (iii). Day nurseries Most day nurseries transferred in 1948 were established in haste during the war in requisitioned premises or in prefabricated buildings. Although the extent of day nursery provision in London has been appreciably reduced during the past decade, it will be noted from table (v) that effective steps have been taken during this period to place the service on a more secure basis. In addition to providing the new day nursery buildings named in tables (i) and (iii), the Council carried out much needed improvements to the standards of improvised day nursery accommodation in the interests of the care and well being of the children and to promote economy and efficiency in administration. Mental health services The 12 training centres for mentally subnormal persons administered by the Council since 1931 were closed during the war. Although war damage and other difficulties prevented the reopening of centres until 1948, by 1958 there were 21 centres established throughout the county. Six were accommodated in adapted buildings owned by the Council and the remainder in hired premises which in many cases were not entirely suitable. With the passing of the Mental Health Act, 1959, the provision of mental health service premises was given high priority in the formulation of building programmes incorporated in the ten-year plans (1962-1972 and 1964-1974) for the development of the health and welfare services. The programmes included provision for the replacement of all junior training centres in unsatisfactory premises by purpose-built centres, with sufficient additional places to permit a lowering of the age for admission and with special care units for subnormal children suffering from additional handicaps, physical or otherwise. All adult centres were to be housed in premises owned or leased exclusively by the Council with extra places to meet rising demand. The revised building programme for the ten years to 1974 included projects for 18 training centres for the mentally subnormal. The Council recognised that it was too early to determine the ultimate numbers of buildings required for the mental health service but included in the revised building programme initial provision for a further 22 hostels (envisaging a total of 26 by 1974), 15 day centres and six day rehabilitation centres. Table (i) gives details of the building projects for the mental health services during the years 1948-1964 and the projects at earlier stages of progress at the end of 1964. As the mental health services have been built up it has been found necessary to rent premises on short leases to meet the demand for new and additional services until such time as these can be accommodated in purpose-built or adapted premises. In addition to those listed in table (i) the following have been opened: Newlands adult training centre (women), Wandsworth, opened in 1962. Hindle House, Hackney; St. Giles, Camberwell and Rushey Green, Lewisham day centres were opened in 1964. Bishop Creighton House Psychiatric Social Club, Fulham opened in 1963 and a part-time social club at The Saville, Lewisham in 1964. Ambulance service Despite the limitations placed on capital works, substantial progress was made in restoring war damaged buildings and in providing the new ambulance stations (see table (i)) 39 0 needed to meet the gradually increasing demand for ambulance transport in London since the inauguration of the National Health Service. The ten-year building programme included a project for the replacement of the London Ambulance Service headquarters by a purposedesigned building and during 1964 the preliminary schedules of accommodation were approved by the Health Committee. The programme included also projects for eight new ambulance stations and 15 improvement schemes. Other Health Service premises The Council's first hostel for infective tuberculous men was provided in 1951 in an adapted house in Islington. A second opened in Fulham in 1953 and came into full use a year later, after adaptation and redecoration. The Islington hostel was replaced in 1954 by improved premises in Hornsey and a further hostel was opened in Lambeth during 1958. The Mayfield Recuperative Holiday Home, Mayfield, Sussex, transferred to the Council in 1948, proved to be uneconomical in maintenance and was replaced in 1950 by Roland House Holiday Home, Littlehampton, Sussex, which has been acquired and adapted to provide accommodation for 36 children. The Council made an agreement with the trustees of the Surrey Convalescent Home for Children, Cambridge House, Bognor Regis, Sussex, to take over and manage the premises as a holiday home for 44 older children. The building was brought into use in 1958 after works of improvement and redecoration. Table (i)—Health Service building works completed 1949-1964 Year of completion Health Division Scheme Works completed[ COMPREHENSIVE HEALTH CENTRE 1952 4 Woodberry Down, Stoke Newington. New building. MATERNITY AND CHILD WELFARE 1949 2 Sumatra Road, Hampstead New building*. 7 Consort Road, Camberwell Conversion of existing building. 1950 4 Upper Clapton, Hackney.. Conversion of existing building. 6 Rustall Lodge, Woolwich Conversion of existing building. 7 Downham, Kent† Rebuilding of premises demolished by enemy action. 1951 9 Earlsfield, Wandsworth Conversion of existing building. 1952 7 Amott, Camberwell Extension of existing building. 8 West Norwood, Lambeth Reinstatement of war damage and repairs. 1953 6-7 Blackheath Hill, Greenwich New building. 7 Queen's Road, Camberwell Conversion of existing building. 7 Lordship Lane, Camberwell† Adaptations on acquisition. 1954 1 St. Quintin, Kensington New building. 5 Mary Hughes, Stepney Extension of existing building. 1955 5 Greenwood, Bethnal Green New building. 1956 3 West Islington Major improvements. 5 Rochelle Street, Bethnal Green .. Conversion of existing building. 5 Wellington Way, Stepney Reinstatement of war damage to provide offices and residential accommodation for nursing staff. 7 Queen's Road, Camberwell Installation of new hot water and heating systems. 1957 2 Daleham Gardens, Hampstead New building. 2 Queen's Park, Paddington Conversion of existing building. 6 Lionel Road, Woolwich Adaptations and improvements. 9 Victoria Drive, Wandsworth Completion and adaptation of existing building. * Scheme initiated prior to 5 July, 1948. t Accommodation also provided for school treatment centre. 40 Table (i)—continued. Year of completion Health Division Scheme Works completed MATERNITY AND CHILD WELFARE—continued. 1958 2 Parkhill, Hampstead Conversion of existing building. 1959 6 Abbey Wood Estate, Woolwich Adaptation of flat to provide temporary clinic accommodation. 1960 4 West Hackney New church hall with special provision for maternity and child welfare sessions. 7 Bellingham, Lewisham Tenants' clubroom adapted for infant welfare sessions. 9 Welcome Hall, Battersea New hall built by Shaftesbury Society incorporating accommodation for health service purposes. 1963 8 Benson Home, Lambeth Adapted replacement for unsatisfactory centre. 1964 2 Sumatra Road, Hampstead Extension to existing building providing additional facilities. 5 The Island, Poplarf New free standing centre in borough council housing development, replacing unsatisfactory premises. 6 Avery Hill Estate, Woolwich Purpose-designed annexe to new tenants' clubroom to provide improved ties 6 Rusthall Lodge, Woolwich Adaptation to give improved facilities. SCHOOL HEALTH 1949 1 St. Dunstan's Road, Fulham Conversion of existing building. 7 Gordon Road, Camberwell Conversion of existing building. 9 Gatton, Wandsworth New building. 1950 5 Whitechapel, Stepney Conversion of existing building. 1951 5 East India Dock Road, Poplar Conversion of existing building. 5 Bethnal Green Conversion of existing building. 8 Brixton child guidance unit, Lambeth. Adaptations on acquisition. 1953 2 Westminster Conversion of existing building. 1955 9 Tooting, Wandsworth Conversion of existing building. 1956 8 West Norwood, Lambeth Adaptations to provide school treatment centre. 1959 7 Lewisham Extension to provide recovery room to dental suite. 1960 3 South Islington Conversion of basement to form school health suite. 1962 4 Additional child guidance unit in Shoreditch. Conversion of standing property. DAY NURSERY 1949 4 Wetherell Road, Hackney New building*. 5 Christian Street, Stepney New building*. 1950 1 Mulgrave, Fulham Conversion of existing building. 2 Ampthill Square, St. Pancras Conversion of existing building. 1951 2 Katherine Bruce, Paddington New building. 1952 3 Springdale, Stoke Newington New building. 4 St. John's, Hackney New building. 4 Woodberry Down, Stoke ton. New building. 1953 2 St. Stephen's, Paddington Completion of building. 5 University House, Bethnal Green Extension of existing building. 1954 6 Amersham Road, Deptford Conversion of existing building. * Scheme initiated prior to 5 July, 1948. † Accommodation also provided for school treatment centre. 41 Table (i)—continued. Year of completion Health Division Scheme Works completed DAY NURSERY—continued 1956 2 Carlton Hill, St. Marylebone Adaptations on acquisition. 4 Clifton Lodge, Hackney Major improvements. 1957 2 Camden Road, St. Pancras Major improvements. 9 Sisters Avenue, Battersea Major improvements. 1959 1 Uxbridge Road, Hammersmith Installation of sluices. 2 Portman, St. Marylebone New fencing and tarpaving of enlarged play space. 3 Canonbury, Islington Improvements to water services; additional toilet facilities. 8 Bishop House, Lambeth Improvements to grounds. 8 Coldharbour Lane, Lambeth Major repairs. 9 Putney, Wandsworth Resiting of boiler; improved toilet facilities. 1961 1 Ladbroke, Kensington Additional toilets; new heating and hot water schemes. 1 Eridge, Fulham Resurfacing of play space. 3 Scholefield Road, Islington Conversion to oil-fired boilers. 1964 1 St. Quintin, Kensington Extension to provide additional places. LONDON AMBULANCE SERVICE 1953 - Eastern ambulance station, Hackney. Adaptations and improvements. - Fulham ambulance station Major improvements. - South Western ambulance station, Lambeth. Extension of existing building. - West Smithfield ambulance station, City of London. New building. 1954 - Hampstead ambulance station New building. 1955 - Headquarters, Lambeth Conversion of existing building. Pear Place ambulance station, Lambeth. Major improvements. - Brook ambulance station, Woolwich. Reinstatement of war damage. - Mottingham ambulance station, Woolwich. New building. 1956 - South Western ambulance station, Lambeth. Reinstatement of war damage and repairs. - Upper Richmond Road ambulance station, Wandsworth. New building. 1959 - Eastern ambulance station, Hackney. Roofing at station yard. - Headquarters ambulance station, Lambeth. Additional storage space and office accommodation; installation of stores hoist. - North Western ambulance station, Hampstead. Reinstatement of war damage; alteration to office accommodation. - South Eastern ambulance station, Deptford. Extension of garage accommodation; improvements to entrance and offices. - Western ambulance station, Chelsea. Additional vehicle washing plant. 1960 - Brook general ambulance station, Woolwich. Improvement and re-arrangement of staff quarters. - Fulham accident ambulance station, Fulham. Adaptations for additional staff accommodation. - Western general ambulance station, Chelsea. Enlargement of office accommodation. 1961 Eastern general ambulance station, Hackney. Improvement and re-allocation of accommodation; improvements to entrance. 42 Table (i)—continued. Year of completion Health Division Scheme Works completed LONDON AMBULANCE SERVICE —contd. 1962 - Battersea accident ambulance station, Battersea. Replacement of building destroyed by enemy action. 1963 - South Eastern general ambulance station, Deptford. Improvements to access, service bay and lighting. 1964 = North Western general ambulance station, Hampstead. Adaptations to provide smallpox decontamination suite. MENTAL HEALTH (a) TRAINING CENTRES 1954 1 Fulham Conversion of existing building. 9 Wandsworth Conversion of existing building. 1955 5 Stepney industrial centre Conversion of existing building. 1956 5 Bethnal Green Conversion of existing building. 1957 9 Balham, Wandsworth Conversion of existing building. 1958 4 Shoreditch Conversion of existing building. 1959 1 Kensington (junior) Erection of new building. 7 Lewisham (junior) Erection of new building. 1960 3 Camden Road, Islington Church hall built to incorporate Council's requirements for use as a training centre for elder girls. 1961 1 College Park (elder girls), Hammersmith. Adaptation of former maternity and child welfare centre. 4 Hackney (junior) New junior training centre. 9 Clapham (industrial), Wandsworth Adaptation of premises to form an industrial training centre. 1962 6 Blackwall Lane (industrial), Greenwich. Adaptation of existing building as an additional industrial training centre. 1964 5 Mary Hughes (women), Stepney.. Adapted replacement for unsatisfactory centre. 5 Unity Hall (men), Poplar Adapted replacement for centre displaced by hospital redevelopment. 6 Park Vista (women), Greenwich.. (b) Hostels Adapted replacement for unsatisfactory premises. 1955 7 Dover Lodge, Lewisham Adaptation of premises to form hostel for subnormal girls in work. 1962 9 Chellow Dene, Wandsworth Adaptation of premises to form hostel for the mentally ill. 7 Honor Lea, Lewisham (c) DAY CENTRES Purpose-built hostel for the mentally ill. 1960 4 Clifton Lodge, Hackney Conversion of former day nursery into a centre for the mentally ill. 1964 5 Pritchards Road, Bethnal Green.. Conversion of former day nursery into a day centre for the mentally ill. TUBERCULOSIS—HOSTELS FOR MEN 1951 3 Highbury Quadrant Hostel, Islingtont. Conversion of existing building. 1954 1 Hurlingham Lodge, Fulham Conversion of existing building. 3 Cromwell Lodge, Hornsey Adaptations on acquisition. 1958 8 Knight's Hill House, Lambeth Conversion of existing building. 1961 3 Cromwell Lodge, Hornsey Provision of new boilers. 1962 1 Hurlingham Lodge, Fulham Improvements to kitchen; alterations to building due to road widening. 1963 3 Cromwell Lodge. Hornsey Annexe for occupational therapy. † Closed in 1954. 43 Table (i)—continued. Year of completion Health Division Scheme Works completed RECUPERATIVE HOLIDAY HOMES 1952 - Roland House, Littlehampton, Sussex. Conversion of existing building. 1958 - Cambridge House, Bognor Regis, Sussex. Adaptations on acquisition of lease. GENERAL PRACTITIONERS' CENTRE AND CHILD GUIDANCE UNIT 1961 7 South East London general practitioners' centre and Peckham child guidance unit, Camberwell. Major adaptations to third floor to provide general practitioners' centre and improved accommodation for existing child guidance unit. Table (ii)—Health Service building works in hand or planned at 31.12.64 Division Premises Work involved Works in hand MENTAL HEALTH 3 Junior training centre, Basire Street, Islington. New building. 6 Junior training centre, Maze Hill, Greenwich. New building. LONDON AMBULANCE SERVICE - Russell Square accident ambulance station, Holborn. Adaptation and reconstruction of out-of-date station to make best use of restricted site. - Oval accident ambulance station, Lambeth. Re-building to accommodate additional ambulances. South Western general ambulance station, Lambeth. Provision of additional garage space and workshop. Works approved but not commenced HEALTH CENTRE 4 Shoreditch Additional dental surgery accommodation. MATERNITY AND CHILD WELFARE 6 Garland Road, Woolwich New building. SCHOOL HEALTH 6 Garland Road child guidance unit, Woolwich. New building. 9 York Road child guidance unit, Wandsworth. New building. DAY NURSERY 4 Sun Babies, Shoreditch Reorganisation of accommodation; improvements to heating and sanitary facilities. LONDON AMBULANCE SERVICE - L.A.S. headquarters annexe Adaptation of premises to provide additional accommodation. 44 Table (ii)—continued. Division Premises Work involved MENTAL HEALTH 1 Junior training centre, Kensington Extension to existing building to provide special care unit and additional facilities. 4 Adult training centre (men), Morning Lane, Hackney. New centre to replace unsatisfactory centres with extra accommodation to meet demand. 7 Lewisham junior training centre Extension to provide special care unit. 2 Hostel for subnormal men in work, Lancefield Street, Paddington. New building. 6 Hostel for subnormal children, Ashburnham Grove, Greenwich. New building. 9 Chellow Dene, hostel for the mentally ill, Wandsworth. Extension to provide additional accommodation. 6 Day rehabilitation centre, Federation Hall, Woolwich. Adapted premises to meet new demand. Works approved in principle but still in planning stage HEALTH CENTRE 4 Woodberry Down, Stoke Newington.. Improvements to car park. MATERNITY AND CHILD WELFARE 6 Shooters Hill, Greenwich Adapted replacement for centre displaced by road scheme. 8 Lancaster Street, Southwark New building. LONDON AMBULANCE SERVICE - London Ambulance Service Headquarters. New building. MENTAL HEALTH 4 Hackney junior training centre, Hackney. Extension to provide special care unit. 7 Adult training centre (women), Harders Road, Camberwell. New building. 8 Three training centres for men, women and children, Grange Tannery site, Bermondsey. Adapted replacement for adult centres and purposebuilt junior training centre. 9 Adult training centre (women), Roehampton Lane, Wandsworth. New building. 6 Two hostels for subnormal men and youths, Brockley Congregational Church site, Deptford. New building. 8 Hostel for subnormal children, Grange Tannery site, Bermondsey. New building. 9 Hostel for subnormal women, Roehampton Lane, Wandsworth. New building. Table (iii)—Purpose-designed health service accommodation incorporated in housing schemes Year Health Division Scheme Authority responsible for housing development Works completed MATERNITY AND CHILD WELFARE 1955 8 Rose McAndrew, Lambeth London County Council. 1956 5 Will Crooks, Poplar London County Council. 1959 9 William Harvey, Wandsworth.* London County Council. 1960 2 St. Albans, St. Pancras St. Pancras Metropolitan Borough Council. 1961 2 Hallfield Estate, Paddington.* Paddington Metropolitan Borough Council. 1962 6 Burney Street, Greenwich Greenwich Metropolitan Borough Council. 8 John Dixon, Keaton's Road, Bermondsey.* London County Council. 9 St. Christopher's, Plough Road, Battersea. * Battersea Metropolitan Borough Council. 1963 8 Loughborough Estate, Lambeth.* London County Council. 1964 3 Barnsbury Estate, Islington* London County Council. DAY NURSERY 1956 8 China Walk, Lambeth London County Council. 1959 8 Coral, Lambeth London County Council. DAY CENTRE FOR THE MENTALLY ILL 1963 8 Draper Street, Southwark London County Council. Works in hand on 31.12.64 MATERNITY AND CHILD WELFARE - 1 Walmer Road, Kensington.* London County Council. - 6 Abbey Estate, Woolwich* London County Council. - 9 Stormont Road, Battersea* London County Council. DAY NURSERY - 9 Upper Tulse Hill, Wandsworth .. London County Council. Works approved but not commenced by 31.12.64 MATERNITY AND CHILD WELFARE - 5 Leopold Street, Stepney* London County Council. - 6 Royal Victoria Yard, Deptford London County Council. - 7 Dartmouth Road, Lewisham London County Council. SCHOOL HEALTH - 7 Peckham Park Road London County Council. DAY NURSERY - 1 Latymer, Hammersmith London County Council. - 7 Peckham Park Road, Camberwell London County Council. 7 Wyndham, Camberwell London County Council. * Includes school treatment centre. 46 Table (iv)—Summary of Health Service building works completed 1949-1964 Service New building Completion of existing building Conversion of existing building Extension of existing building Adaptation on acquisition Reinstatement of major war damage Major improvements Comprehensive health centre 1 - - - - - - Maternity and child welfare 22 1 8 3 4 3 4 School health 1 — 9 1 2 — — Day nursery 8 1 3 2 1 — 12 London Ambulance Service 4 - 3 2 - 4 10 Mental health— (a) Training centres 4 — 7 — 5 — — (b) Hostels 1 — — — 2 — — (c) Day centres 1 — 2 — — — — Tuberculosis — — 3 1 1 — 2 Recuperative holidays — — 1 — 1 — — General practitioners' centre - — 1 - - — - 42 2 37 9 16 7 28 Table (v)—Analysis of the tenure of maternity and child welfare centre and day nursery premises, 1948-1964 Tenure Welfare centres Day nurseries 5.7.48 31.12.64 5.7.48 31.12.64 Freehold 34 65* 8 43 Leasehold 15 33 13 23 Rented 103 59 36 5 Requisitioned 5 — 54 3 In joint use with other authorities 46 12 9 - * Includes 23 centres provided in housing accommodation owned by the Council. 41 d CARE OF MOTHERS AND YOUNG CHILDREN Since the beginning of the National Health Service the general policy of the Council has been to provide a uniform and properly co-ordinated service; although this still varies to meet local demands, the aim to provide the best possible service in all parts of the county has been continued. Maternity and child welfare The Council has made comprehensive provision for the care of mothers and young children. Maternity and child welfare centres provide ante- and post-natal clinics, child welfare clinics, mother-craft classes; the centres make available to mothers certain nutrients and simple medicaments and the full range of national welfare foods. By far the greater part of the maternity and child welfare work is carried out from the Council's own centres but the Council has agreements with and makes very substantial financial contributions (up to 100 per cent. of approved net expenditure) to 13 voluntary organisations and the medical schools of four teaching hospitals for the provision by them of certain maternity and child welfare services and with four voluntary organisations providing day nursery services. Particulars of sessions and attendances are given in the following table: Table (i)—Clinics for mothers and young children 1960 1961 1962 1963 1964 Ante-natal, post-natal and combined clinics: Number at end of year 109 109 108 110 105 Sessions per month 793 787 803 732 703 Total attendances 136,864 143,945 141,862 118,791 103,959 Ante-natal: Number of women attending during the year 29,387 32,440 32,809 31,874 27,272 Post-natal: Number of women attending during the year 3,369 2,859 2,335 3,822 3,283 Child welfare clinics: Number at end of year 179 178 174 173 176 Sessions per month 2,034 2,057 2,081 2,085 2,060 Number of children born in same year who attended 44,718 47,535 50,516 48,916 52,320 Total attendances (all ages) 742,095 768,953 766,837 713,845 814,608 Attendances at special toddlers clinics (not included in above) 37,533 38,203 37,790 40,196 43,965 There has been a gradual reorientation in the function and purpose of the child welfare service in recent years, which is of great significance for the future. Increasingly it has attempted to provide a comprehensive and purposeful diagnostic service for the early detection of mental or physical handicaps. Preventive mental health—The first steps in preventive mental health were taken when psychiatrists in the child guidance clinics set up to deal with maladjusted school children pointed out that some emotional disturbances might have been prevented or minimised had the child been seen earlier. In 1954 the Council set up case conference groups in maternity and child welfare centres, the groups consisting of medical officers and health visitors with a child psychiatrist and a psychiatric social worker. The groups provide a training for maternity and child welfare staff and at the same time give an indirect service to mothers and young children. 48 Children 'at risk' of or with handicapping conditions—The aim has been to detect handicaps as early as possible, so that training which will help the child to make the best use of his residual assets can be given at the most favourable time of development when skills would normally be acquired and to see that the child is not lost sight of for any reason; to assist parents to keep the child in the community as long as possible and also to advise in advance on the child's needs for special care for education. In order to do this, a register of handicapped or potentially handicapped children has been set up in each division. Babies are considered to be at risk of developing a handicap by reason of adverse factors occurring during pregnancy, labour or the puerperium. The register is compiled from information provided on the form of discharge report made available by the Council to domiciliary midwives and hospital maternity units and from information about children born with congenital handicaps provided since 1964 on the form of notification of birth. In each division the register is scrutinised at regular intervals by a senior medical officer so that the children's progress and development may be kept under continuous review and the offer of help made at the earliest possible time. Some 90 per cent. of infants born in the county are seen in child welfare clinics in their first year of life and clinic medical officers thus have the opportunity to screen babies for congenital handicaps. In 1957 training of medical officers in screening tests of the hearing of babies and young children began and all medical officers soon had the opportunity of studying these techniques. Every centre was equipped with the 'Stycar' hearing testing set devised by Dr. Mary Sheridan, Ministry of Health. Medical officers train health visitors not only to refer babies known to be at risk but also to carry out screening tests at the centre. All children suspected of deafness are referred to the divisional otologist. The youngest child for whom a hearing aid and auditory training have so far been prescribed was four months of age. Detection of children suffering from phenylketonuria—Since 1960 babies' urine has been tested as a routine to detect those with phenylketonuria—a rare inborn error of metabolism which can lead to mental defect—and from this screening test four cases have been found. One of these was a boy who, although tested with phenistix at the age of 32 days with an apparently negative result, was found over a year later to be suffering from phenylketonuria. The boy was admitted to hospital where several further phenistix tests were carried out in the ward with only faint results or none at all, but a more 'pronounced result was obtained after meals. Following this experience, wherever possible the test for urine is done an hour or so after a feed. Day accommodation for children Day nurseries are provided for children under five whose home circumstances are detrimental to health or whose mothers have to go out to work, priority being given on health and economic grounds. In recent years places have been set aside for children whose physical or mental development might be advanced in the care of the nursery and through mixing with children not suffering from a handicap. Since 1961 a number of special units for the admission of severely subnormal children have been provided in nine day nurseries. In addition, young deaf children may be admitted up to a maximum of 15 hours a week. In each case no charge is made except for meals or refreshment taken. Otherwise charges for admission have continued to be made but have remained abatable according to means. To an increasing extent nursery staff have become involved in co-operating with other workers on the social problems of some of the families using the nurseries. The number of children minded by voluntarily registered child-minders has doubled since the end of 1949. Comparable increases have occurred in the number of private day nurseries and in the number of children that can be minded by child-minders registered under the Nurseries and Child-Minders Regulation Act, 1948. 49 D* There are occasional creches in all divisions where children under five years are looked after without charge whilst their mothers are attending sessions at the centre or where they can be looked after for a small charge, abatable in case of necessity, whilst the mothers visit hospital, attend to domestic duties or shopping etc. Children who need relief from poor home conditions and the only child needing to mix with other children are also accepted at the creches. These sessions have increased over recent years; in 1964 there was an average of 128 sessions a week with average weekly attendance of 1,759. From the beginning of November 1964 mothers were allowed to leave their children in occasional creches free of charge upon production of documentary evidence that they had a hospital appointment on the occasion in question. This was an experiment with the object of assessing the financial burden that it would impose, so that consideration could be given to its introduction as a regular feature of the service. Table (ii)—Day nurseries and child-minders At 31 December 1949 1954 1959 1964 DAY NURSERIES: Maintained 114 100 75 72 Grant aided 6 5 4 4 Places 6,615 5,850 4,192 4,003 COUNCIL'S CHILD-MINDER SCHEME (Voluntary registration) Child-minders registered 584 925 875 720 Children minded 579 1,000 1,039 971 NURSERIES AND CHILD-MINDERS REGULATION ACT, 1948 (Statutory registration) Private day nurseries registered 28 61 60 109 Places 972 1,795 1,620 2,749 Child-minders registered 73 110 167 238 No. of children authorised to be minded 501 590 939 1,306 Family planning In July 1930 the Ministry of Health (Memorandum 153 MCW) authorised local health authorities to give advice on birth control to married women in attendance at maternity and child welfare centres where there were medical grounds for considering that further pregnancy would be detrimental to health. The medical grounds were widened in 1932 to include women suffering from organic diseases such as tuberculosis, heart disease, diabetes, chronic nephritis, etc., in which child bearing was likely seriously to endanger life and other forms of sickness, physical or mental, which were detrimental to them as mothers. What was or was not medically detrimental to health was to be decided by the professional judgment of the registered medical practitioner in charge of the clinic. (Circular 1408, 31 May 1934.) These limitations remain operative and the giving of contraceptive advice in circumstances other than those referred to above is at present outside the Council's powers as a local health authority and also appears to be beyond the scope of the National Health Service in general. To discharge its responsibilities the Council itself provides a few family planning clinics but over the county as a whole uses the services of the Family Planning Association. A payment of 17s. 6d. (two guineas for women receiving oral contraceptives, plus the cost of 50 a year's supply of the pills) is paid by the Council to the Association for each patient advised at the Association's clinics on referral on medical grounds by the Council's medical officers. Recommendations by general practitioners and hospitals made through the Council's divisional medical officer are included in this arrangement. The only charge made by the Association to patients referred in this way is for articles provided. In 1949 the Health Committee decided that the Family Planning Association should be allowed to hold clinics rent free in health service premises. The Association is not permitted to make any charge to the patients except for articles supplied. Women who are not recommended under the Council's scheme may attend the Association's clinics held on Council premises, where they may be advised and/or treated under conditions (including payment) determined by the Association. At the Council's own family planning clinics, appliances and medicaments on approved lists are stocked and sold or issued free of charge as appropriate. Since 1963 oral contraceptives have been issued free of charge to selected women for whom this is the only practicable means of birth control. A letter is sent to the patient's general practitioner asking for his approval or for information about contra-indication to oral contraception. Oral contraceptives are free of charge because they are regarded as a medicament rather than an appliance. In May 1963 the Marie Stopes Memorial Foundation, Ltd. started a limited experimental scheme with the Council's agreement, in the first instance in division 2 to which it is still limited, in which the mothers of problem families are visited in their own homes and given advice on family planning and the necessary appliances, etc., free of charge and without cost to the Council. Only families approved and notified by the Council's divisional medical officer may be included and the Foundation has undertaken to communicate with the family doctor before visiting. (Similar experiments by the Foundation are being conducted in Newcastle-upon-Tyne, Southampton and Birmingham.) The indications are that the experiment is proving most satisfactory. On 1 December 1964 the Council decided that it wished to extend its support to organisations giving family planning advice so as to include all their undertakings, including the giving of family planning advice on other than medical grounds, of advice on marital relationships and of advice to unmarried people. The Minister of Health was asked to receive representatives of the Council to discuss any necessary ministerial authority to enable this decision to be implemented. The meeting took place early in 1965 and the Minister assured the deputation that the Council's views and suggestions were under active consideration. Attendances at family planning sessions 1960 1961 1962 1963 1964 Attendances at sessions provided by the Council: First 945 899 1,034 1,849* 1,982* Total 4,337 4,226 4,423 4,434 5,288 Women referred by the Council to Family Planning Association 741 641 595 641 685 * First attendances do not exclude women who attended also in earlier years. Cervical cancer screening The value of exfoliative cytology in the early diagnosis of cancer of the cervix is now fully accepted. The Minister of Health has accepted that routine screening should be available to all women at risk as laboratory facilities become available and has said the intention is to rely on general practitioners to carry out the routine screening of their patients but local authorities might wish to assist in some areas. The Health Committee agreed (8.12.64) 51 that when the time came it should be possible for the Council to offer facilities for screening women attending the Council's ante and post-natal clinics and family planning clinics. In addition, the Council could start ad hoc screening clinics if the numbers justified it. The screening could be carried out by the Council's full-time and sessional medical officers but this would be done only at the request or with the agreement of the patient's general practitioner. General practitioners could also be offered facilities for holding ad hoc clinics in the Council's premises. At certain centres patients attending the ante-natal clinic are seen by their booked general practitioner obstetrician and he, too, with the agreement of the patient's own doctor, could carry out screening tests at the centre. Whatever arrangements were made for the taking of smears in the Council's centres, the Council would need to provide supporting nursing and clerical staff to assist the doctor, keep the appropriate records, send specimens to the laboratory and distribute reports from the laboratory on the test results. The Council's staff (health visitors and others) would have an important part to play in educating women to accept screening (particularly women in Social Classes IV and V). The actual arrangements would be agreed locally in the light of local needs and circumstances, but subject always to observance of the principle that smears should be taken only with the agreement of the patient's general practitioner, who would be given every opportunity, if he so wished, to convey the results of the test to the patient and who would always do this if the result were positive or showed the need for further investigation. The Local Medical Committee approved of these proposals, suggesting that when facilities for cytological examinations became available there should be local discussion between the local health authority, the hospital laboratory and the general practitioners in the area. So far in London four small pilot schemes are in operation (one started early in 1963 and three during 1964). In division 1 smears are taken from women attending a family planning clinic aged 35 and over, selected women aged 30 and over and some women who are taking oral contraceptives. In division 4 smears are taken from women attending a family planning clinic and who have been recommended to use oral contraceptives; in division 6 from all post-natal cases attending three clinics regardless of age and in division 9 from women referred to one clinic by general practitioners who have been advised that this facility is available. Maternity beds Although in London over 80 per cent. of births take place in hospital, the maternity bed situation has been a source of continual anxiety for many years. Maternity liaison committees have tried to improve local arrangements to ensure a planned selection of mothers for hospital confinement, but in the north-west parts of the county in particular for some years it has not been possible to book a hospital maternity bed for all the women who need hospital delivery on grounds of age, parity or social conditions, if such women attend for ante-natal care for the first time during the second half of pregnancy. Many such women are older multipare or immigrants, temporary residents or unmarried mothers with accommodation more often than not in lodgings or boarding houses. To help them, a general practitioner is asked to undertake the ante-natal care and, if no bed can be found during the pregnancy, to visit, when labour starts, to arrange for hospital admission through the Emergency Bed Service. In June 1963, a deputation from the Council informed the Minister of Health that three per cent. of women in London who need maternity beds had to be admitted in labour through the Emergency Bed Service. Most of these women were not emergency cases, for it was known during pregnancy that a hospital bed would be needed but one could not be booked. Nor was it a case of shortage of beds, because when the women went into labour a bed was found for them. The Minister said the problem in London appeared to be one of maldistribution of beds and he undertook to try to improve the situation. The result was the issue of a circular (780) by the Chief Medical Officer proposing: 52 (a) that groups of beds should be assigned to the service of areas defined by the Metropolitan Regional Hospital Boards in consultation with Boards of Governors of Teaching Hospitals, Local Health Authorities, Executive Councils and Local Medical Committees concerned; (b) that in each area so defined the Hospital Board should take the initiative in setting up a body representative of those authorities to agree and keep under review the procedures needed to secure that maternity beds serving the area meet its needs; (c) that it should be the responsibility of the hospital to which any expectant mother from the area served by its group applies, or is referred, to make a firm booking (if a hospital delivery is indicated on medical or social grounds) either in its own hospital or another hospital in the group or in another group. In response to the Ministry's circular, the four metropolitan regional hospital boards set up area committees (on which serve the Council's divisional medical officers and nonmedical supervisors of midwives) to agree and keep under review the prodecures and to secure that maternity beds serving the area meet its needs. These committees made recommendations to the Boards on proposed schemes for maternity catchment areas and the Council's officers were active in seeking improvements to the draft schemes where necessary. The four Boards subsequently provided details of the catchment area schemes which the individual hospitals had been asked to introduce from 1 May 1964, with the object that as bookings proceeded in the natural course of events the schemes would become fully operative by 1 October 1964. For its part and as a means of making greater use of hospital maternity beds, the Council has taken the initiative and offered to every hospital early discharge schemes for maternity patients discharged 48 hours after confinement. At present (December 1964) there are 22 schemes in operation. The number in each metropolitan regional hospital board area and the maximum number of patients agreed for maternity nursing at home per month are: No. of schemes Maximum discharges per month M.R.H.B. North West 6 68 North East 1 12 South West 5 52 South East 10 119 The early-discharged patients are nursed at home either by a part-time midwife specially employed for the purpose, or by the whole-time midwife for the area, as may be arranged. In addition to the schemes arranged by the Council, some hospitals having their own district practice discharge patients delivered in their hospital to the care of their district midwives. A considerable number of mothers return home early, other than under the agreed early discharge schemes. Some are mothers whose babies were stillborn or died shortly after birth; some, mothers who take their own discharge (often for domestic reasons) and other mothers who return home under an arrangement made by their general practitioner with the hospital. Until 1964 all these were nursed at home by a general nurse from the local district nursing association. However, the view is now taken that every mother requiring post-natal nursing should in her interests, and particularly in the interests of the neo-nate, be attended by a practising midwife within the definition of Rule E.3 of the Central Midwives Board. Accordingly, arrangements were made during the year to encourage sufficient general nurses who were state certified midwives to notify their intention to practise as midwives under Rule E.4 of the Board and to arrange for them to nurse any woman returning home early other than under an agreed early discharge scheme. These nurses receive an allowance of £10 a year. 53 The Council has introduced a change in procedure to meet the requests from hospital obstetricians and general practitioners for social reports on women who seek a hospital bed but have no medical priority for admission. The visit to assess the suitability or otherwise of the home for domiciliary confinement is now carried out by domiciliary midwives and not health visiting staff, where this was not already the practice, although of course there is close consultation between the midwife and the health visitor who knows the home. The midwives thus have the opportunity to encourage suitable women to accept home confinement and this makes a further contribution to relieving the pressure on hospital maternity units. A very much simplified form of request has been introduced for a home assessment visit for early discharge schemes and where a maternity bed is sought on social grounds, incorporating the domiciliary midwife's report. This new form, by the use of carbon copies, reduces to a minimum the clerical work involved in requesting and providing these reports. It is as yet too early to make any assessment of the likely success of the steps that are being taken to implement the Ministry's proposals. They are being watched very closely and adjustments made as necessary in the light of experience. However the number of maternity cases referred to the Emergency Bed Service has been very considerably reduced: Emergency Bed Service monthly totals Month 1963 1964 January 156 189 February 186 137 March 318 186 April 230 156 May 234 189 June 294 164 July 200 190 August 225 116 September 179 130 October 138 98 November 153 63 December 133 74 Total 2,446 1,662 Co-operation with hospital and general practitioner services The Council has placed particular emphasis on co-operation with the other branches of the health service; a strong link has been forged between the maternity and child welfare service and the hospital maternity and paediatric departments, with interchange of staff in some areas, and with the general practitioner service. One unique partnership is with the Institute of Child Health of the University of London at the Province of Natal centre. This centre, opened in 1955, provides a wide range of maternity and child welfare and school health services for the neighbourhood and also provides facilities under the direction of the Institute for post-graduate medical teaching and research. The cost of the centre site, the building and its initial equipment was met out of moneys given during the war by the people of Natal, South Africa to the Gift to Britain scheme, supplemented (for the purposes of the Institute's reference library and laboratory) by the University Grants Committee. Co-operation with general practitioners—Representatives of the Local Medical Committee and of the London Executive Council serve on the Council's central Health Committee and the Local Medical Committee is represented also on each of the nine divisional Health Committees. The Council nominates eight members of the London Executive Council and the County Medical Officer of Health is a member of the London Medical Committee. At field level, co-operation is seen as a matter of mutual understanding and 54 the development of close working relationships. The Local Medical Committee is always consulted before new arrangements are made with general practitioners and, in particular, all proposals for use of Council premises by general practitioners (and general practitioners' surgeries by the Council) or of allocation of local authority staff (health visitors, midwives, district nurses, social workers) to general practitioners. General practitioners are employed in the Council's health services on a sessional basis for many types of work, e.g., ante and post-natal, child welfare, vaccination, immunisation and in the school health service. At the request of the Local Medical Committee, they are not employed within their area of practice. Free facilities are provided in the Council's ante-natal clinics for general practitioner obstetricians to see their own booked maternity patients and others with the consent of the booked doctor concerned. The Local Medical Committee preferred this arrangement to the allocation of domiciliary midwives to surgeries of general practitioner obstetricians. The health visitor and general practitioners—Meetings with general practitioners have been arranged locally at which the part of the health visitor was given prominence and the wide range of her duties stressed. The fact that there are only some 400 health visitors in London and over 2,200 general practitioners on the Local Medical Committee's list limits the amount of effective help which the health visitor can give. Co-operation is very fruitful in dealing with the medico-social problems of families where difficulties do not come singly: the family doctor plays his part by giving treatment and influencing the family to accept specialised local authority services and to follow the skilled guidance of the health visitor. In some instances, especially where a group practice is concerned, it has been possible to set aside a regular time each week when a health visitor would call at the surgery to talk over such cases with the practitioner. Where attendances justify it, a health visitor is allotted to attend child welfare sessions provided by practitioners in their own surgeries. A condition is that the practitioners are willing to complete all appropriate maternity and child-welfare records and make them available as required. In addition, general practitioners doing child-welfare work should be willing to co-operate in the application of new trends in child-welfare introduced into the Council's own clinics, e.g., developmental diagnosis and routine screening tests of children 'at risk' of congenital handicaps; preventive mental health in the child welfare service. It is thought possible in these circumstances that the health visitor may gradually come to be based on the list of families registered with the practice, such families being withdrawn from the care of the district health visitors. The attendance of a minimum of ten children per session is thought to justify the allocation of a health visitor to an infant welfare session at a general practitioner's surgery. Social work with families Special mention must be made of the tremendous changes that have taken place in social work with families. Up to the end of the War the social services had been deployed mainly to serve the needs of the individual, with an emphasis on physical needs and the improvement of environmental conditions. The measures of social legislation passed after the War—the Family Allowances. Act, 1945, the National Health Service Act, 1946, the National Insurance and the National Insurance (Industrial Injuries) Acts, 1946, the Children Act, 1948 and the National Assistance Act, 1948—changed the pattern of social and welfare services and made available to all without distinction the benefits of these new services. The new services, coupled with general advances in living standards and education, brought into sharp relief the problems of a minority of families who appeared not to be benefiting from the new legislation and showed that now the need was for family casework and not casework with the individual in isolation from his family. Increasingly it became clear that such families' problems needed to be considered as a whole and services deployed in an integrated way if proper use was to be made of them. 55 Divisional co-ordinating committees were set up, under the chairmanship of divisional medical officers, with the object of bringing together all interests and activities available to help in the prevention of ill-treatment or neglect of children, the prevention of juvenile delinquency and the prevention of family break up. The committees have gained most valuable experience in the years since their formation in 1952. They have had to give particular attention to the problems of families facing eviction as unsatisfactory tenants. In each division the divisional social worker, the successor to the divisional treatment organiser of the school health service, acts as secretary, strengthening the links between the social agencies in the area, both voluntary and statutory. Increasingly the Children's, Education, Housing and Welfare departments, as well as other statutory and voluntary agencies and individuals, have referred families for the consideration of these committees. Family and hospital doctors seek help with their cases and often give active support to the co-ordinating committee. As much as possible is done to ensure that all those who come into contact with families and children know and understand the Council's policies and procedures and the interest of and the part played by each department. To help in this, a directory of social services has been issued to field workers and others, describing the arrangements made by the several departments of the Council and by other agencies (both national and local, and statutory and voluntary) for carrying out their aims and duties. In 1955 an approximate estimate of the number and distribution of problem families was made. The survey also revealed that there was good co-operation between the health visiting service and other statutory and voluntary bodies, but that the distribution of problem families, who tended to be found in or drift to areas of poorer housing, had resulted in some health visitors bearing a disproportionate case-load. The health visitor is well placed to recognise the early stages of family breakdown and her continued support of the family is essential when her special skills are needed to cope with health problems. On the other hand, she has not the time to spend from her normal duties to carry out intensive time-consuming casework with these families. In 1957 four full-time and two part-time social workers were appointed experimentally to do family casework in some of the divisions, the divisional social workers acting as their consultants and supervisors. Families are selected for this intensive casework by the divisional co-ordinating committees. Broadly the families fall into two main groups: (a) those in which there is some inherent or permanent disability such as severe subnormality, mental illness or low mentality which limits the extent to which the family is able to carry on without support; (b) those where it can be assumed that, given intensive support, the family will in time be enabled to become independent of the social caseworker, although still needing support from the ordinary social services. Early in 1959 an attempt was made to assess the work of the social caseworkers using the points system introduced for the 1955 survey. It appeared that more than half the families referred to social caseworkers had shown some definite improvement and there was no doubt that intensive casework could be successfully carried out within the framework of a statutory authority. It was decided, therefore, to appoint further caseworkers to bring the total staff up to fifteen. In addition, a number of health service social workers was selected, each to do similar work with two or three families and continuing their former duties in the school health service for the rest of the time. A casework consultant was appointed in 1962—the first appointment of its kind by a local health authority. Family Service Units, voluntary organisations employing trained caseworkers, carry out with substantial grants from the Council similar intensive work in several parts of the 56 county, namely, Kensington and Paddington; Islington, Finsbury and Holborn; Stepney, Poplar and Bethnal Green; Southwark and the northern parts of Lambeth and Bermondsey. From 1961 a grant has been made to the Family Welfare Association towards their work with families with problems. In 1964 a small grant was made to the Elfrida Rathbone Committee (Islington Branch) to enable that Committee to continue its work with problem families having educationally sub-normal children. The Council also provided training courses for selected home helps who were willing to work with problem families, helping them under the direction of the health visitor or social worker to be self-supporting. Since 1954 the Council has been associated with special home-making courses for selected mothers. Some of these have been organised by voluntary committees under the auspices of the London Council of Social Service, with financial support from the Council; others are run by the Council's own staff. The courses provide for regular weekly meetings of small groups of mothers known to have problems, including some mothers from ' problem families Residential establishments for young children in care 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, child health and problems of any children whose development is causing concern. Also the progress of handicapped children is discussed with the nursery staff and, if necessary, the question of additional investigation, treatment and training discussed with the visiting medical officer. A register is maintained of physically and mentally handicapped children and individual case histories are regularly reviewed by a senior medical officer, so that constructive plans can be made for special education or long-term care. Adoption and boarding out The number of children in care referred for advice by the Children's Officer and the decisions reached are shown below: 1960 1961 1962 1963 1964 1. Adoption cases: Suitable for adoption 270 259 291 270 283 Suitable for adoption subject to certain conditions . 2 34 45 48 73 Unsuitable for adoption but suitable for boarding out 23 13 6 9 - Withdrawn by Children's Officer 1 9 4 3 296 315 346 327 359 2. Boarding out cases: Suitable for boarding out 454 445 486 465 440 Suitable for boarding out subject to certain conditions — — — — 5 Withdrawn by Children's Officer 6 5 1 1 1 460 450 487 466 446 3. Unsuitable for either adoption or boarding out — 1 1 5 — TOTAL 756 766 834 798 805 57 Care of the unmarried mother and her child Moral welfare associations—Financial assistance totalling £18,760 was given during the year 1964/65 to the five large moral welfare associations of the major religious denominations: £ London Diocesan Council for Moral Welfare 10,450 Southwark Diocesan Association for Moral Welfare 7,000 Westminster Catholic Social Welfare Committee 660 Southwark Catholic Rescue Society 500 Jewish Board of Guardians 150 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. A total of £13,214 was paid during the year to the 17 homes receiving grant and the number of expectant and nursing mothers admitted to these homes was 1,558. One mother and baby home is maintained by the Welfare department together with two other units within their larger homes.The following table shows grants and number of girls admitted to the voluntary homes during the last five years. 1960 1961 1962 1963 1964 Total grants £8,865 £9,998 £11,743 £15,647 £13,214 Number of expectant and nursing mothers admitted 1,136 1,171 1,599 1,545 1,558 Child protection Child protection work under Part 1 of the Children Act, 1958 and Part IV of the Adoption Act, 1958 continued to be undertaken on behalf of the Children's Officer in six of the health divisions, visits being made mainly by health visitors. During 1964, however, the Children's Officer took over direct control in three areas and made arrangements to take over the direct control of the three remaining areas early in 1965. Marriage guidance The Council has made financial grants to the London Marriage Guidance Council, the Catholic Marriage Advisory Council and the Family Discussion Bureau. The latter was formerly a branch of the Family Welfare Association; since 1950 the Bureau has been associated with the Tavistock Institute of Human Relations and through it functions as an independent body. The London Marriage Guidance Council holds many of its weekly counselling sessions free of charge in the Council's maternity and child welfare centres. Monthly talks are given to groups of engaged or newly married couples and a rapidly expanding side of the work is visits to secondary schools, colleges and youth centres for talks and informal discussions with young people. The Catholic Marriage Advisory Council holds weekly sessions in its own headquarters but in some cases sessions are held free of charge in the Council's maternity and child welfare centres. Grants totalling £10,500 were made to the three marriage guidance bodies in 1964. 58 DOMICILIARY MIDWIFERY The coming into force of the National Health Service Act, 1946 meant that this service became free to the patient. The Council's domiciliary scheme has been basically unchanged since its inception in 1938. Over the years the number of midwives employed by hospital districts has fallen, their work being taken over almost entirely by midwives employed directly. The main result of the Act was to allow closer integration of the domiciliary midwifery service with the maternity and child welfare services and other services for which the Council became responsible under the Act and also with the maternity medical services provided under Part IV of the Act. It thus became Council's policy for all domiciliary midwives to use its ante-natal clinics for the booking and examination of their patients. (The clinics are also used by an even greater number of women booked for hospital confinement to obtain their intermediate ante-natal care.) A doctor, who is either a full-time assistant medical officer, a general practitioner with special experience or, to an increasing extent, a general practitioner obstetrician, attends all or alternate sessions with the domiciliary midwife, depending on the numbers in attendance at each session. Blood specimens are taken from all mothers attending the Council's ante-natal clinics for haemoglobin estimations, Wasserman and Kahn tests, determination of Rhesus factor and tests for Rhesus antibodies in appropriate cases. General practitioners are invited to use these facilities for their own patients. Midwives also take cord blood in those Rhesus negative cases which are fit for home confinement. Special emphasis is laid on the early recognition of toxaemia and weight records are kept as a routine. During 1960 the preventive measures against toxaemia were further reinforced by making home helps available free of charge where hospital consultants or general practitioners certify that rest at home is essential for this reason and that admission to hospital is thought unnecessary or impracticable. The administration of analgesia by midwives has shown a marked and rapid rise— expressed as a percentage of domiciliary confinement, from about three per cent. in 1946 to 34 per cent. in 1948, to over 70 per cent. in 1951 and to over 80 per cent. from 1955 onwards. There has also been a marked change in the number of domiciliary confinements booked by general practitioners for maternity medical services. In the early years of the National Health Service the number of domiciliary confinement in London booked by general practitioners for maternity medical services was low and by 1956 it was only 26.6 per cent. of all home deliveries. However, the Council's policy was that a general practitioner obstetrician and a domiciliary midwife should be booked for every domiciliary confinement and since 1961 the percentage has been well over 80 per cent. Plans to promote the fullest co-operation with general practitioner obstetricians were agreed with the London Local Medical Committee and in 1960 they were offered free facilities at the Council's ante-natal clinics. Further consideration was given during 1964 to the introduction of revised off-duty and night-duty schemes for the Council's directly-employed midwives and experimental schemes were tried out in several areas. By the end of the year a new off-duty and nightduty scheme had been adopted for the county, the principal feature of which was that in normal circumstances, with a full complement of staff, it is only necessary to require a midwife to be on duty at night on two nights a week. Naturally the midwife is on call for a much larger area than was previously the case and if she has not her own transport she may now call on Radio Taxis to take her to and from the patient's home. The midwives much appreciate the new arrangements and undisturbed nights. 59 Table (i)—Staff District midwives employed at 31 December by 1960 1961 1962 1963 1964 The Council 94 94 100 (+ 7 pt.) 107 (+ 12 pt.) 112(+ 17 pt.) District Nursing Associations* 46 43 46 30(4- 18 pt.) 22 (+ 8 pt.) Hospitals* 43 40 37 30 (+ lpt.) 32 (-) 183 177 190 (+ 7 pt.) 167 (+ 31 pt.) 166 (+ 25 pt.) *Including supervisory staff. In addition there were midwives employed in nursing homes or voluntary hospitals, or working through nursing co-operations or independently. Table (ii)—Domiciliary confinements attended and institutional deliveries nursed at home. 1960 1961 1962 1963 1964 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. 178 2,197 83 1,069 61 708 44 209 15 101 D.N.A. 47 1,193 39 716 9 359 11 111 5 47 Hospital district — — — — — — — — - - 225 3,390 122 1,785 70 1,067 55 320 20 148 3,615 1,907 1,137 375 168 (b) Doctor booked L.C.C. 1,563 2,848 2,237 3,759 2,608 4,238 2,696 4,501 2,421 4,447 D.N.A. 280 692 339 1,010 501 1,561 408 1,590 363 1,506 Hospital district 202 1,745 302 1,666 344 1,607 427 1,372 419 1,250 2,045 5,285 2,878 6,435 3,453 7,406 3,531 7,463 3,203 7,203 7,330 9,313 10,859 10,994 10,406 Total 10,945 11,220 11,996 11,369 10,574 (c) No. of institutional deliveries attended by midwives on discharge before the tenth day .. 1,463 1,954 2,187 2,810 4,051 Domiciliary confinements decreased by 795 from 1963 but institutional deliveries discharged home before the tenth day showed an increase of 1,241. The figures of early discharges include (i) cases sent into hospital during labour from the domiciliary midwifery service on account of some abnormality and returned for nursing by a domiciliary midwife (this has long been a normal practice); (ii) cases accepted after 48 hours in accordance with pre-arranged schemes with certain maternity hospitals (see page 53). The number of home confinements booked by general practitioners for the provision of maternity medical services continues to increase steadily; in only 168 cases, which included emergencies delivered by domiciliary midwives, had a doctor not been booked. 60 Table (iii)—Confinements by age and parity Age Total confinements Parity 0 I 2 3 4 5 and over Not known Under 20 .. No. 519 171 271 69 8 - - - % 1.6 2.6 0.7 0.1 — — — 20-29 No. 7,180 495 3,149 2,214 962 251 107 2 % 4.7 29.7 20.9 9.1 2.4 1.0 0.0 30-39 No. 2,754 29 567 910 704 293 250 1 % 0.3 5.4 8.6 6.7 2.8 2.4 0.0 40 and over.. No. 109 - 4 27 23 22 33 - % — 0.0 0.3 0.2 0.2 0.3 - Not known.. No. 12 1 1 4 5 - - 1 % 0.0 0.0 0.0 0.0 — — 0.0 Total No.% 10,574 696 3,992 3,224 1,702 566 390 4 % 66 37.7 30.5 16.1 5.4 3.7 0.0 Percentages are of the total confinements. On grounds of parity, 1,652 (15.6 per cent.) of mothers delivered by domiciliary midwifery services should have been delivered in hospital, but this was not possible either because beds were not available at the time the mother came for her ante-natal care or because the patient herself refused hospital booking. The peri-natal mortality rate for the domiciliary midwifery service was 8.3 per thousand total births and the stillbirth rate was 4.4 per thousand total births. 61 Table (iv)—Premature domiciliary live births I960 1961 1962 1963 1964 Number 517 525 474 438 385 Per cent, of live births 4.7 4.7 4.0 3.9 3.7 Particulars of domiciliary live births follow. The difference between the total (513) shown in this table and the number (385) quoted above represents the number of deliveries attended by doctors and midwives independently of the Council's domiciliary midwifery service and those which took place in nursing homes. Table (v)—Domiciliary or nursing home births—prematurity and mortality by birth weight 1964 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 2 lb. 3 oz. or less 28 5.5 12 42.9 15 53.6 3 lb. 4 oz. or less 36 7.0 10 27.8 20 55.6 3 lb. 5 oz. to 4 lb. 6 oz. 58 11.3 5 8.6 48 82.8 4 lb. 7 oz. to 4 lb. 15 oz... 93 18.1 4 4.3 87 93.5 5 lb. to 5 lb. 8 oz. 298 58.1 6 2.0 291 97.7 All cases 513 100.0 37* 7.2 461 89.9 * Fifteen babies died after the first day. Midwives Act, 1951 Notifications received of intention to practise as a midwife: 1960 1961 1962 1963 1964 1,404 1,447 1,502 1,560 1,697 In accordance with section G of Rules of the Central Midwives Board, 176 midwives in the county attended a refresher course during the year. Fees to medical practitioners called in by midwives in emergency: 1960 1961 1962 1963 1964 Number of claims 2,350 1,291 711 357 200 The decline in medical aid claims by general practitioners is a direct result of the encouragement given to every woman having home confinement to book a doctor as well as a midwife. When a doctor is booked he claims a fee from the local Executive Council under Maternity Medical Services Regulations. 62 HEALTH VISITING Even before 1948 there was a shortage of health visitors and the National Health Service Act, 1946, which laid new responsibilities on local health authorities, considerably broadened the scope of the health visitor's work. Her functions now covered the care and welfare of the family as a whole, not solely the expectant and nursing mother and the child under five, as had been the case in London before 5 July, 1948. The new spirit of social service added depth to her work and gave her the opportunity to enlarge her outlook and widen her experience and her value to the community. Even without a shortage of health visitors, redeployment would have been necessary in the new situation, so that the health visitor could use her special skills to the greatest advantage. Selective visiting has also enabled her to allocate more time to the families most in need of the help and support which she can give. Group working has enabled problems to be shared, language and religious difficulties to be met more easily and has provided continuity of staff during sickness and leave. For over fifty years most of the home visiting and medical follow-up of children attending the Council's schools has been undertaken by voluntary children's care committee workers, trained and organised by social workers employed in the education and public health departments. A continuing aim is the association of the health visitor with the voluntary worker in the care of the schoolchild. Home visits 1960 1961 1962 1963 1964 First visits this year to: Children under 1 55,226 60,995 67,829 68,661 (a) 68,065 Children 1-5 369,122 379,793 375,543 222,643 (b) 196,914 Persons aged 65 or over 14,350 14,772 15,526 7,945 (b) 6,571 Mentally disordered persons - - - 1,893 (c) 1,385 Persons discharged from hospital (other than mental hospital) - - - 2,894 (c) 2,049 Infectious households (other than T.B.) - - - 2,804 (c) 1,007 Unsuccessful visits 104,014 111,958 117,113 139,871 146,201 Total visits 838,990 878,767 891,079 822,517 851,646 (a) Since 1963 figures relate to children born in the same year. (b) Since 1963 first visits are shown, i.e. number of persons visited; for earlier years the figures relate to total visits. (c) Not available for previous years. e 63 HOME NURSING Throughout the county the home nursing service has been provided on the Council's behalf entirely by the voluntary district nursing associations, with the Central Council for District Nursing in London acting as the liaison and advisory body. Although from time to time individual associations have ceased work, others have always taken over their areas. Since 1948 the Council has paid an increasing proportion of the approved expenditure of the associations; from 1954 this has amounted to 93 per cent. and for some associations there has been an additional deficiency grant. With the coming of the National Health Service Act, 1946 the home nurse, who previously had provided nursing only for those who could not afford the services of a private nurse, began to serve all sections of the community. More and more, however, her concern was with older people. Ever since 1938 the proportion of elderly patients dealt with by the home nursing service has increased steadily; 52 per cent. of the patients were over 60 by 1949 and 58 per cent. over 65 by 1962. At the other end of the scale the improvement in child health has led to a decline in paediatric cases. New medical knowledge has meant an increase in injection therapy for complaints which used to need prolonged treatment, but many new patients, including children, now learn to give their own injections. In addition, there has been an increasing use of oral therapy, especially for diabetic and cardiac cases. The result has seen a steady fall, year by year, in the number of visits paid ' for injection only The shift of emphasis from hospital to the community care of the mentally disordered, with the operation of the Mental Health Act, 1959, had some repercussions on the home nursing service. Senility is commonly a reason for repeated visits by the nurse. Home nurses, too, have been called in to supervise the administration of drugs to the mentally ill discharged to their own homes. Other changes since the passing of the National Health Service Act, 1946 have been the integration of the home nurse with other members of the local authority team (the health visitor, the midwife and the home help); also the entry into the domiciliary nursing field, although only on a small scale so far, of the male nurse and the enrolled nurse. In the past few years there has been a steady decline in the number of patients nursed and in the total number of visits paid. From 1957-1962 the number of patients fell by 37 per cent. and visits by 21 per cent. The main reason these figures have kept in step is that the higher number of old people nursed has necessitated frequent visits in a growing proportion of cases. Details of the work done by the 24 voluntary grant-aided district nursing associations who act as agents for the Council are given below: Table (i)—Staff (numbers employed at 31 December)* 1960 1961 1962 1963 1964 State registered nurses 517 495 510 490 494 State enrolled nurses 34 35 36 43 44 Total number of nurses employed 551 530 546 533 538 Male nurses (included above) 39 38 40 39 38 Full-time equivalent of nurses employed 508 492 509 481 449 Students 27 64 32 20 33 * Exclusive of supervisory staff. Table (ii)—Numbers < of patients and visits 1960 1961 1962 1963 1964 Total no. of patients 51,325 49,137 46,263 47,226 45,709 Total no. of visits 1,690,084 1,601,860 1,569,004 1,559,246 1,576,008 Average no. of visits to each patient. 33 33 34 33 35 64 Table (iii)—Types of case nursed Type of case Number of new cases undertaken % Medical 28,665 79.2 Surgical 4,914 13.5 Tuberculous 540 1.5 Early maternal discharge 1,342 3.7 Maternal complications . 722 2.0 Mental ill-health 52 0.1 36,535 100.0 Table (iv)—Types of treatment and location Visits for At patients' home Elsewhere (e.g., Nurses' Homes) Total visits % Injections only 482,144 18,248 500,392 32 Injections plus other treatment 93,218 1,132 94,350 6 Other treatment only 979,291 1,975 981,266 62 1,554,653 21,355 1,576,008 100 Table (v)—Long-term cases (i.e., those nursed for three months or more) Number Percentage of total patients nursed 8,569 23-5 Long-term cases were formerly defined as those visited more than 24 times during the year. Table (vi)—Age distribution of patients Age No. of patients % 0-4 years 1,983 4.4 5-64 years 17,283 38.3 65 years and over 25,813 57.3 45,079 100.0 Table (vii)—Nursing treatments and case load 1960 1961 1962 1963 1964 Number of completed treatments 43,118 41,010 37,489 38,647 36,464 Number of patients being nursed at end of year 11,118 10,898 11,233 11,341 11,414 Average case load per equivalent whole-time effective* nurse at end of year 24 22 24 26 25 * Allowing for holidays and sickness. 65 E* HOME HELP Immediately before 5 July 1948 all the metropolitan boroughs (but not the City of London) operated home help schemes for maternity cases and all but one of the boroughs and the City had schemes for assisting sick and infirm persons. The extent of the provision varied widely from borough to borough—in all 7,389 cases were attended in 1947 and at the end of that year 826 home helps were employed. Section 29 of the National Health Service Act 1948 brought together these two kinds of help (previously provided under separate powers) and widened the circumstances in which help could be given, making it turn on the presence in the household ' of any person who is ill, lying-in, an expectant mother, mentally defective, aged, or a child not over compulsory school age . . . ' After 5 July 1948, under the Council's arrangements, there was a rapid increase in the number of home helps and cases assisted and the demand for the service continued to increase thereafter: 1947 1949 1959 1962 1964 No. of home helps (equivalent full- time units) 826 1,265 2,150 2,192 2,469 Households assisted 7,389 25,933 36,056 38,461 40,217 The growth in the service, since the first expansion in the late 1940s, is accounted for almost entirely by the increasing demand from old people and the chronic sick. The number of maternity cases has remained fairly steady; the number of tuberculous and miscellaneous cases has declined. The Council has introduced five extensions of the service: Night helps—introduced in 1953 (after an amendment to the scheme)—provided for the chronic sick in their own homes to enable relatives to get one or two nights' undisturbed sleep a week. Demand was always small and, perhaps because of known difficulty in finding staff, has latterly declined even further. Child helps—also introduced in 1953—for children in their own homes who are temporarily deprived of both parents and with no other adult to care for them. Again demand has been small, partly because home conditions are often unsuitable for sleeping an additional adult. Alternative arrangements under section 1 of the Children and Young Persons Act 1963, are now possible. Morning and evening helps—introduced in 1954—provided for children who owing to their parents' hours of work cannot be cared for in the day time at a day nursery or school. This service has continued to play a part in avoiding the reception into care of the children of between 150 and 250 families every year. Specially trained home helps—introduced in 1956—for families in danger of breaking up. They teach the rudiments of housekeeping to the mothers of such families in an attempt to keep the home together and prevent the children coming into care. These home helps, there are now 118 trained, do not spend their whole time on these more demanding calls but have helped about a hundred or more every year. Provision—introduced in 1960—of free home help for expectant mothers suffering from toxaemia of pregnancy to ensure complete rest for the patient. In addition, experiments have been in hand in limited areas to provide a more flexible allocation of help to old people. Something on these lines, possibly leading to an arrangement where one help is made responsible for a group of old people, is the most likely next development in the service. 66 Statistics of the service provided during the past five years are shown in the following tables. 1960 1961 1962 1963 1964 Number of households assisted 38,031 38,546 38,461 39,389 40,217 Number of new applications received 18,168 18,096 17,085 17,976 18,295 Applications deferred or refused because home helps were not available 23 18 17 7 9 Details of households assisted 1960 1961 1962 1963 1964 Maternity 1,913 1,785 1,642 1,670 1,625 Tuberculosis 692 647 547 509 473 Old people 31,602 32,215 32,744 31,190 3,253 31,834 3,448 Chronic sick Early morning and evening help 244 257 238 244 254 Child help (resident) 8 24 12 2 20 Night help for chronic sick 28 17 17 15 12 Special help (problem families) 116 112 109 101 99 Miscellaneous 3,428 3,489 3,152 2,405 2,452 38,031 38,546 38,461 39,389 40,217 In the scheme for free home help service to women suffering from toxaemia of pregnancy whose applications were supported by request from a hospital consultant or general practitioner obstetrician, assistance was given to 79 cases (included above), amounting to 6,552 hours of service. Staff details 1960 1961 1962 1963 1964 Home helps employed at end of year 3,830 3,896 4,040 4,210 4,200 Equivalent of whole-time staff* 2,242 2,164 2,192 2,595 2,469 Hours worked during the year 5,129,000 5,059,064 5,064,696 5,372,640 5,473,104 * Excluding staff on annual and sick leave. 67 IMMUNISATION AND VACCINATION Vaccination against smallpox had been a function of the metropolitan borough councils before 5 July 1948 but on that day the Public Vaccinator and the Vaccination Officer, who had for many years been responsible for carrying out the provisions of the Vaccination Acts, disappeared from the scene. Thereafter compulsion was replaced by persuasion and in London this resulted in a steady increase in the acceptance rate of infant vaccination. In twelve years the acceptance rate rose to about double its previous level. From 1963 onwards, largely as a result of altering the age for vaccination to 18 months of age, the acceptance rate fell considerably and it is still uncertain whether it will be possible to restore it to its previous level. The rate of diphtheria immunisation fell for a few years from 1949 onwards, following reports of provocation poliomyelitis following inoculations and the uncertainty resulting therefrom. This fall was not as great as that occurring in some areas because, although alum-containing prophylactics were discontinued at that time, it was decided to continue using combined and triple prophylactics not containing alum. A considerable improvement in the rate of primary immunisation against diphtheria occurred following the introduction of a standard schedule of immunisation in 1959. The virtual abolition of diphtheria since the beginning of the immunisation campaign is now a matter of history. The result of many years of infant vaccination against whooping cough is now becoming apparent in the very marked reduction in incidence of this disease in recent years. Since 1959 the routine infant course of vaccinations has included three injections of tetanus toxoid. The object of this course is to try to reduce the necessity to give an injection of horse serum to injured persons. The fact that by now most of the children in London under the age of five years have had a course of active immunisation against tetanus must in time affect the routine of treatment in the hospital accident departments. Inoculation against poliomyelitis began on a small scale in 1956, being restricted at first to children born from 1947 to 1954. It was extended in 1957 to young people aged under 16 years, expectant mothers and other priority groups and was further extended in 1958 to everyone under the age of 40 years. British Salk-type vaccine was used from the early years but Sabin (oral) vaccine was available from early in 1962. Salk vaccine reduced the incidence of the disease but had no effect on the carrier rate in the population. The introduction of Sabin vaccine, by inducing intestinal immunity, produced the virtual elimination of carriers of pathogenic poliomyelitis virus from the community, with consequent benefit to immunised and unimmunised alike. In 1964 there was only one notification of poliomyelitis in London. At the invitation of the Ministry of Health, a yellow fever vaccination service has been provided by the Council since 1960. This is operated by arrangement with the authorities of the centres shown in table (v) who give vaccination and issue the appropriate international certificates. No charge is made to the public for this service. Diphtheria, tetanus, whooping cough— Table (i) 1960 1961 1962 1963 1964 Diphtheria immunisation: Primary course— Born in same year 20,203 20,990 20,852 22,710 23,826 Born in previous four years 28,980 32,276 22,054 24,068 27,375 Total under 5 49,183 53,266 42,906 46,778 51,201 Age 5-14 7,648 14,490 12,902 3,972 5,361 Reinforcing doses 40,511 87,758 42,472 57,625 66,495 Immunity index 1-4 years 74.1 82.2 87.3 82.7 94.7 Tetanus immunisation 48,605 60,298 46,963 51,168 57,194 Whooping cough vaccination 48,539 54,064 42,637 46,122 50,374 68 The number of children referred to in table (i) who received multiple antigens is as follows: Table (ii) 1960 1961 1962 1963 1964 Diphtheria/whooping cough 1,536 722 215 106 148 Diphtheria/whooping cough/tetanus 46,650 52,927 42,108 45,548 49,667 Diphtheria/tetanus 1,734 5,860 2,435 3,415 5,290 Smallpox— Table (iii) 1960 1961 1962 1963 1964 Primary vaccinations: Under 1 year 23,057 30,482 36,406 2,974 1,844 One year 2,135 3,568 12,036 3,177 15,913 2-4 years 1,259 1,937 20,876 1,032 4,249 5-14 years 15 years or over 808 1,072 1,186 1,372 74,080 115,662 831 1,453 402 836 Total 28,331 38,545 259,060 9,467 23,244 Given by— L.C.C 20,583 29,913 150,157 4,740 18,043 General practitioners 7,748 8,632 108,903 4,727 5,201 Re-vaccinations: Under 1 year 44 63 8 2 — One year 22 31 200 50 63 2-4 years 113 185 11,405 319 324 5-14 years 455 556 73,000 1,019 532 15 years or over 2,940 3,024 267,464 5,902 4,041 Total 3,574 3,859 352,077 7,292 4,960 Given by— L.C.C 1,598 1,715 171,538 1,854 1,998 General practitioners 1,976 2,144 180,539 5,438 2,962 Population 3,194,000 3,180,000 3,186,000 3,179,000 3,184,600 Percentage vaccinated during the year 0.9 1.2 8.1 0.3 0.7 Percentage re-vaccinated during the year 0.1 0.1 11.1 0.2 0.1 During the year one vaccinated child aged 23 months developed post vaccinial encephalitis, and one other child aged 13 months developed eczema vaccinatum; both children recovered. Four other cases of eczema vaccinatum were reported in unvaccinated children, one of whom died. 69 Poliomyelitis—The number of persons who have received protection against poliomyelitis is as follows: Table (iv) Salk Sabin 1964 Since commencement of scheme 1964 Since commencement of scheme Primary vaccination:* Born in 1960-64 11,872 495,158 48,6301 165,765 1943-59 387 115,312 1933-42 Londoners 238 184,311 2,939 15,043 Others — 48,541 96 495 1932 or earlier (under 40) Londoners 130 85,337 1,562 15,004 Others — 17,711 215 975 Other (over 40) 5 15,427 145 1,184 Total 1,947 846,485 68,899 198,466 Given by— L.C.C 420 601,769 57,444 165,103 General practitioners and hospital doctors 1,527 244,716 11,455 33,363 Booster doses† 570 103,729 32,632 65,504 Given by— L.C.C 117 84,387 29,327 58,600 General practitioners and hospital doctors 453 19,342 3,305 6,904 * Those who have received a third injection of Salk or three doses of Sabin. t Those who have received a fourth injection or a fourth dose of vaccine orally. Yellow fever vaccination—The numbers of persons vaccinated were: Table (v) 1960 1961 1962 1963 1964 Hospital for Tropical Diseases 10,571 9,297 9,550 8,978 9,181 Shipping Federation Clinic, King George V Dock . 809 2,762 2,937 2,529 2,478 Unilever House 1,249 1,173 1,263 1,277 1,311 West London Centre 4,031 3,682 4,055 4,254 4,392 16,660 16,914 17,805 17,038 17,362 70 LONDON AMBULANCE SERVICE London had a comprehensive ambulance service even before the coming into effect of the National Health Service Act on 5 July 1948. The London County Council had itself instituted an accident ambulance service in 1915 under powers secured by a private Act of Parliament introduced by Sir William Collins. At first this Service operated from one station only but by the end of 1915 five additional stations had been opened and by 1930 there were 14 stations with 20 vehicles and a staff of 165. In 1930, under the Local Government Act of 1929, the Council took over the ambulance services previously provided by the Metropolitan Asylums Board and Boards of Guardians. The former operated from six large stations attached to infectious diseases hospitals and the Boards of Guardians operated ambulances from certain general hospitals and infirmaries. These services for general sick removals and the accident section were placed under the direction of the Medical Officer of Health. For reasons of operational and administrative convenience, the London Ambulance Service has continued to operate an emergency section and a general service section although vehicles and men are interchangeable. At the outbreak of war in 1939, the Council had a fleet of some 200 vehicles and a staff of 422 operating from 22 stations. When the National Health Service Act became effective in 1948 the ambulance service had still not fully recovered from the effects of the war; enemy air attack had destroyed the Western ambulance station and the Battersea accident station and much damage had been sustained to other ambulance buildings; in addition the vehicle fleet was obsolescent. Plans had been prepared during 1947 for the expansion of the service to meet the expected needs arising from the new Act as well as to repair the war damage. Provision for an additional 25 ambulances was planned by extending the South Eastern and South Western ambulance stations and building a new accident station in Hampstead. A second stage provided for the extension of the Brook and the Eastern ambulance stations, the provision of accident services from a station in the City of London (where the service had previously been provided by the City itself) and the building of accident ambulance stations in Mottingham and Putney—providing in all for a further 36 ambulances. The impact of the National Health Service Act on the ambulance service of London was immediate. During the first year in which the Act was in operation the number of patients conveyed to and from hospital rose by 35 per cent. The number of patients continued to rise year by year until 1960 and has since remained about constant. It may be argued, however, that the statistics represent the maximum number of patients who can be carried without intolerable delays occurring rather than the maximum potential demand on the service. An increasing number of old people are now able to live in their own homes or with relatives because ambulance transport is made available to take them for regular visits to the physiotherapist or to geriatric day hospitals. A particular and an increasing problem for the service is the transport of patients for deep-ray therapy and to some of the highly specialised clinics where patients are treated with isotopes and premedication is necessary. Such journeys assume a high degree of priority, because in the one case the treatment is so debilitating for the patient that any delay is a serious matter and in the other because of the narrow time limits within which certain procedures must be carried out. Reference must also be made to the intention of the Minister of Health* to provide for out-patient surgery and day wards on an increasing scale, which will undoubtedly lead to increased demands on the ambulance service. * A Hospital Plan for England and Wales (Cmd. 1604). 71 LONDON AMBULANCE SERVICE, 1947-64 GENERAL SECTION, INCLUDING AGENCY AND SUPPLEMENTARY SERVICES From 1955 onwards the figures of patients conveyed are based on the Ministry of Health definition of a ' patientwhich differs somewhat from that formerly used by the Council. 72 Table (i)—Work performed by the directly provided service and by the agency and supplementary services, including both general and accident section work 1960 1961 1962 1963 1964 Patients: Accident Section 103,497 108,235 110,225 117,567 121,553 General Section 1,033,909 1,008,539 969,215 956,546 980,125 Total—directly provided service 1,137,406 1,116,774 1,079,440 1,074,113 1,101,678 Joint Committee 32,593 31,701 31,349 33,515 40,523 Hospital Car Service 189,337 183,231 188,365 189,559 187,666 West Ham C.B.C. 338 331 326 330 402 Total—agency and supplementary services 222,268 215,263 220,040 223,404 228,591 Total patients 1,359,674 1,332,037 1,299,480 1,297,517 1,330,269 Journeys: Accident Section 109,551 114,953 117,020 125,183 129,452 General Section 488,422 480,978 476,081 479,751 491,571 Total—directly provided service 597,973 595,931 593,101 604,934 621,023 Joint Committee 10,877 10,858 10,456 10,829 11,165 Hospital Car Service 58,441 61,294 66,704 66,111 74,938 West Ham C.B.C. 335 329 324 328 393 Total—agency and supplementary services 69,653 72,481 77,484 77,268 86,496 Total journeys 667,626 668,412 670,585 682,202 707,519 Mileage: Accident Section 556,390 605,904 618,075 661,082 674,830 General Section 3,960,964 3,928,746 3,908,580 3,898,270 3,995,283 Total—directly provided service 4,517,354 4,534,650 4,526,655 4,559,352 4,670,113 Joint Committee 441,468 435,851 427,119 436,759 430,497 Hospital Car Service 1,207,439 1,191,201 1,271,863 1,265,272 1,276,856 West Ham C.B.C. 4,061 3,850 3,543 3,622 4,017 Total—agency and supplementary services 1,652,968 1,630,902 1,702,525 1,705,653 1,711,370 Total mileage 6,170.322 6,165,552 6.229,180 6,265,005 6,381,483 Another problem in London arises from the concentration within the county of so many teaching and specialist hospitals. Patients come to the capital from all parts of the country for specialised treatment; many others, travelling for convalescence from their homes and from hospitals outside the county, frequently have to cross London in the course of their journeys. For these reasons a technique of sending patients who have long distances to travel by ambulance/train/ambulance arrangements was rapidly developed; the Service now meets over 100 trains a day to pick up patients arriving in London or to send them to their homes after treatment. 73 Table (ii)—General section 1960 1961 1962 1963 1964 Average mileage per patient 3 83 3-89 40 41 407 Average mileage per journe 811 817 8-2 81 812 Patients carried per 100 journeys 212 210 208 199 199 Table (iii)—Accident section Year Number of calls received Ambulance not required Average time to incident (in minutes) A verage time from incident to hospital (in minutes) 1960 109,551 9,644 6.8 6.4 1961 114,935 10,350 7.0 6.2 1962 117,020 10,420 7.0 6.5 1963 125,183 11,584 7.0 6.5 1964 129,452 12,718 7.0 6.3 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 1960 1961 1962 1963 1964 Public and L.C.C. staff 76,705 81,755 84,261 88,947 93,506 Police 16,505 16,753 16,396 16,937 17,599 Midwives* 326 339 307 234 162 Doctors 7,522 7,964 8,549 11,225 10,243 Hospitals 2,186 2,045 1,933 2,000 1,798 Railway officials 2,896 2,868 2,654 2,690 2,808 Local callsf 893 788 827 779 162 London Fire Brigade 1,055 789 596 687 761 Out county 1,463 1,634 1,497 1,684 1,813 Total calls 109,551 114,935 117,020 125,183 129,452 * Fewer calls for gas-aad-air analgesia apparatus because of the introduction of trilene apparatus which is portable by midwives. † Made personally at ambulance stations. Operational control and communication—The volume of work undertaken by the Service increased much more rapidly than it was possible to increase the staff and vehicles and while the volume of work undertaken in 1964 was two and a half times greater than in 1947 the staff had increased by less than 50 per cent. To enable the Service to cope with these dramatic increases every effort had to be made to improve the efficiency of the Service, much of which depends on efficient communication. To this end radio control was introduced in 1956, at first on an experimental basis. It was soon clear that it had a valuable part to play in ambulance control; it was extended to the whole accident section and subsequently by progressive stages to the general service, the last stage in the development being made in 1964/65. Telex was introduced in 1963, 74 primarily as a time-saving method of passing information between general ambulance stations and headquarters control, but it was hoped that with the general spread of this system it would provide a valuable means of communication with major hospitals and with other ambulance services. Major incidents are fortunately very few in number—the outstanding one of the past decade being the Lewisham disaster in 1957, when two trains collided in dense fog and 85 people died as a result. In all 223 casualties were removed by ambulance, the last vehicle leaving the scene of the disaster 60 hours after its occurrence. Arising from this disaster existing plans of the hospitals and other authorities for dealing with these emergencies were reviewed and these have been amended from time to time to suit changing circumstances. The plans provide for close co-operation between the Ambulance Service and hospital authorities, the London Fire Brigade and the Police. Since 1951 a mobile control vehicle has been maintained at headquarters. This is designed to serve as a mobile control room with radio communications with Headquarters Control, as well as 'walkie/talkies' enabling officers to maintain control while moving about the scene of an incident. It carries, in addition, a considerable supply of reserve equipment (see Annex). Agency services—In addition to the services directly provided by the Council, services under agency arrangements have continued to be given by the Hospital Car Service and the Joint Committee of St. John and the British Red Cross. The latter having indicated their wish to hand over to the Council, negotiations to this end were opened during the year. Vehicles As previously stated, the ambulance fleet at the end of the war was in a run down condition and the Council's officers gave much thought to the design of a suitable replacement vehicle. A prototype vehicle was built under the direction of the Council's transport officer in the Mechanical Works division of the Supplies department. Trade enquiries drew from the Daimler Motor Company an offer to produce an ambulance which would embody practically every feature of the Council's prototype, including the requirements regarded as essential by a Working Party appointed to advise the Minister of Health on the subject. The Daimler, which became the standard vehicle in the London Ambulance Service and for years was used also by many other services, set a new trend in ambulance design. Its salient features were low loading; a spacious, well equipped and easily cleaned interior; a high powered engine; fluid transmission; pre-selective gear box, off-set transmission shaft; excellent suspension and independently sprung front wheels. These vehicles gave excellent service, their only defects being lack of manoeuvrability and heavy petrol consumption. It became apparent, however, that the Daimler Motor Company would discontinue the manufacture of these vehicles and the need to provide an alternative became a matter of urgency. During 1956 a fresh prototype ambulance was designed in the Mechanical Works division of the Supplies department, which took advantage of developing techniques in the use of resin bonded fibre glass for the manufacture of vehicle bodies. While preserving the same low-loading level and providing accommodation for patients comparable with that of the Daimler ambulances, the new vehicle was smaller in over-all dimensions, lighter in weight and more economical in operation. The Council authorised the production of these vehicles by direct labour in the Supplies department and nine were in operation by the end of 1958. In due course they replaced the Daimler ambulances entirely, the last Daimler being taken out of commission in 1964. The vehicle strength at 31 December, 1964, was: Large ambulances 264 Single stretcher, sitting case ambulances 104 Sitting case cars 18* Ambulance coaches 6 Mobile control unit for major accidents 1 Tenders 2 395 * Including four cars for the use of visiting officers. 75 The new ambulances have been modified from time to time and of special note is the sprung stretcher bed developed jointly by the Council's staff and Messrs. Delaney-Gallay during the course of 1963. This bed is independently sprung on vibrashock pads which were originally developed for the insulation of delicate instruments in rockets. It was decided to instal oil burning heaters independent of the engine in all the stretcher-carrying vehicles; this was found to be the only effective means of maintaining a high temperature in the patients' compartment during winter in vehicles operating in circumstances in which the large rear doors are opened at frequent intervals. The changing needs of the Service, which now carries many more patients able to sit while in transit, led to the purchase of vehicles designed to the Council's specifications for the carriage of such patients. All ambulances in the emergency section carry a most comprehensive range of equipment, including portable apparatus for the administration of pure oxygen or a mixture of oxygen and carbon dioxide either on demand or under manual control. In 1964 plastic inflatable splints were taken into service. These provide an entirely new system of splinting fractured limbs and eliminate the need for wooden splints and padding. The double skin of plastic is placed round the injured limb, the ends are joined together by a rapid fastener and the splint is inflated by mouth. A list of the equipment carried on emergency and on general service vehicles is given at the end of the article. An exhibition of ambulance vehicles and of ambulance equipment was held at the Mechanical Works division depot at Wandsworth in March 1964 at which recent developments, many pioneered by the Council, were displayed. A large number of the public and of representatives of other ambulance services visited the exhibition. Premises During the period 1948-1964 major improvements and adaptations were carried out at the following stations: Year Station Details 1948 Western .. .. Moved from temporary accommodation in Allen Street to present location. 1950 Oval .. .. .. Moved from South Western Ambulance Station to former fire station, Foxley Road, S.W.9. 1953 West Smithfield .. Station rebuilt. 1954 Hampstead .. ,. New station opened. Brook .. .. .. Reinstatement after war damage. 1955 Mottingham .. .. New station opened. 1956 Upper Richmond Road New station opened. 1958 Streatham .. .. Yard roofed to provide accommodation for a third ambulance. Fulham .. .. Former superintendent's house reinstated after war damage for use by staff engaged on day work ambulances. 1959 Northwestern .. Extra accommodation for vehicles provided. 1962 Battersea .. .. New station opened—rebuilt on old site. 1963 Oval Moved to temporary premises at South Western Hospital during rebuilding of station. 1964 Russell Square .. Improvements to station officer's office and staff accommodation. South Eastern .. Extra accommodation provided for fitters and vehicles. At the end of 1964 work was in progress on the provision of extra accommodation for vehicles and the provision of a workshop at the South Western station. 76 Staff At 5 July 1948 the total fixed establishment of staff was 642 made up as follows: Administrative staff Uniformed staff Officer-in-Charge 1 Chief Superintendent 1 Assistant Officer-in-Charge 1 Superintendents 6 Administrative and clerical 21 Assistant Superintendents 6 Supervisor, Control Room 1 Station Officers 21 Assistant Supervisor, Control Room 1 Driver/attendants 514 Senior Ambulance Clerks 16 Ambulance Clerks 53 The subsequent great increase in the volume of work undertaken and various developments of the Service have led to the enhancement of staff numbers in most grades and by the end of 1964 the establishment was as follows: Administrative staff Uniformed staff Officer-in-Charge 1 Chief Superintendent 1 Assistant Officer-in-Charge 1 Assistant Chief Superintendent 2 Administrative and clerical 31 Superintendents 8 Supervisor, Control Room 1 Senior Assistant Superintendents 20 Assistant Supervisor, Control Room 1 Assistant Superintendents 5 Ambulance Control Officers 78 Station Officers 25 Station Sub-Officers 28 Driver/attendants 749 In addition the establishment provides for 11 staff in domestic grades at Headquarters and general stations. In practice, owing to sickness and holiday reliefs it has been necessary to employ a larger number of driver/attendants than indicated in the establishment. In addition to an increase of about 45 per cent in the establishment of driver/attendants, the greater number of supervisory staff now provided for has come about in consequence of the introduction of a full training scheme (see below) and because of closer supervision which it is now possible to undertake to the benefit of the Service as a whole. Certain redesignations have taken place since 1948 and in some instances new positions introduced. Thus in 1954 the grade of 'leading driver' was first created to help superintendents, particularly on yard supervision; this grade was re-titled 'station sub-officer' in 1963. There are now 28 such officers, three at each general station and Fulham, the remainder at Headquarters. Other additions in supervisory grades have been in respect of instructional staff at the training school and training stations and in consequence of a system of visiting officers. Four of these, in the rank of senior assistant superintendent, are known as hospital visiting officers and undertake much useful liaison work with the many hospitals in the county. This system is regarded as having been notably successful. Seven positions of senior assistant superintendent are filled by duty officers who provide a 24-hour rota at Headquarters, as well as a rota of visiting officers throughout the day and night whose duties include visiting stations and hospital casualty departments. Training—One of the great changes over the years has concerned the arrangements for new entrants to the London Ambulance Service. In 1948, in common with other ambulance services, new entrants acted as a ' third man ' with an experienced crew and picked up what knowledge they could until their station officer felt they were proficient. They had to obtain a first aid certificate in their own time within six months of entry. In February, 1951 basic civil defence training for men already in the Service commenced and the 42 one-week courses held in that year were attended by 386 men. This training continued throughout 77 1952 and was concluded in 1953. From then on, all members of the regular service began to receive advanced civil defence training and new entrants were given basic training on entry. In 1956 the Civil Defence Training School was expanded to take in peace-time training and a three-week course was given—one week being devoted to Civil Defence and the other two to first aid and ambulance duties. From April to December 1956 there were seven such courses, attended by 79 men. In October 1962 the procedure was again revised to provide a more comprehensive scheme. The syllabus in the Training School was expanded to four weeks and in addition new entrants are now sent to a Training Station for a minimum of four weeks, where they are paired up and allocated to an Instructor who accompanies them on all calls. Initially the instructor does most of the work at a call but gradually, as trainees become more competent, he remains in the background ready to advise if necessary. The Training Station has three accident ambulances manned by 16 driver/attendants. The most recent development in the training field was the agreement by the Health Committee that the Oval station, when rebuilt, would become the new Training Station and with 10 general ambulances in addition to three accident ambulances. The number of trainees at any one time will thus be greater and wider training and experience will be possible. At the time of writing the new station has not become operational. Staff awards—It is gratifying to record various awards which have been made to members of the Service. Details of the more important ones are given below: B.E.M.—Driver F. W. Summerfield. Council's Silver Medal Driver H. Legon (first time ever awarded). 1956 M.B.E.—Superintendent Ridgwell. 1958 Council's Silver Medal—Driver P. Poole. 1961 Council's Silver Medal—Driver E. Shoults. 1962 Council's Silver Medal—Driver A. W. Drury. 1964 Queens Commendation for Bravery—Drivers A. C. Jewby and B. T. Eagle. In addition, the Resuscitation Certificate of the Royal Humane Society has been awarded to one station officer and thirty-three drivers. Competitions—The National Association of Ambulance Officers has for many years organised Regional Ambulance Efficiency Competitions. London is situated in No. 5 Region covering the Home Counties. In this competition the London Ambulance Service won the Wadham Trophy in 1954 and the Lomas Shield (for the runners up) in 1963. Until 1964, staff were invited to form teams to compete in an eliminating round to decide on the representative team for the Service; in 1964 a fully fledged inter-station competition was introduced for this purpose—the Brook Ambulance Station being awarded the Richardson Cup (presented by the then Officer-in-Charge, Mr. F. A. Richardson). An international competition organised by the Casualties Union was started in 1961 and teams from various N.A.T.O. countries were invited to take part. The competition was in two parts, a first aid test and a diagnosis test and two cups were awarded, the Buxton International Trophy and the Dawson Cup. The Council received a request to enter a team to represent the United Kingdom and despite short notice the team was successful in winning both cups. The team retained the Buxton Trophy in 1962 but was placed third in 1963. The Casualties Union also stages a National Competition for first aid and diagnosis and in 1964 it was decided that only the winning team in the National Competition should be eligible to enter the International one. 78 Incident in Leadenhal Street, 4th April 1964 London Ambulance Service Training School National Safe Driving Competition—In common with drivers in other departments of the Council, most ambulance driver/attendants enter for the annual National Safe Driving Competition held by the Royal Society for the Prevention of Accidents. The following table shows the number of drivers entered annually and the success achieved: Awards Year Entrants Total 1-9 years 10-14 years 15-19 years 20 years or more{/###] 1948 N/A 347 263 35 25 24 1949 N/A 397 321 32 22 22 1950 N/A 432 339 51 20 22 1951 N/A 462 357 60 21 24 1952 N/A 474 369 60 23 22 1953 628 500 395 62 23 20 1954 676 546 434 63 24 25 1955 671 570 441 70 33 26 1956 716 615 473 77 37 28 1957 750 610 464 77 39 30 1958 763 531 394 82 31 24 1959 765 519 371 88 40 20 1960 779 520 362 101 41 16 1961 692 481 324 104 38 15 1962 769 539 384 99 39 17 1963 753 536 383 92 37 24 1964 769 547 403 82 42 20 To this statistical data about the staff of the London Ambulance Service there should be added a word of recognition of the spirit which imbues the Service. Throughout the years reviewed in this report a remarkably high level of morale has been maintained. The men and women of the London Ambulance Service, with very few exceptions, have shown a notable devotion to their calling. For them 'Service' is no casual expression lightly thrown off: it has real significance. Civil Defence A review of Civil Defencc training over the period 1948-1964 falls naturally into two parts: training given to members of the regular peacetime service and training given to volunteers in the Civil Defence Corps. Training given to members of the peacetime service—Local authorities are required by Regulation 2(b) of the Civil Defence (Ambulance) Regulations 1949 (S.1.2146) to train in Civil Defence members of the staff of their ambulance services. As mentioned above such training in London commenced in February 1951 when 10 men at a time were given a week's course; lectures were given by two station officers and 42 courses were held that year. This basic Civil Defence training was completed in 1953 and from then on it was given to all new entrants to the Service, whilst drivers already in the Service were given more advanced training. In 1956 the one week's Civil Defence course was incorporated in a three-weeks course for new entrants, the other two weeks being related to peacetime duties and to first aid. As more and more Civil Defence exercises have been held, designed particularly for participation of volunteers, so members of the peacetime service have increasingly taken part. Plans made to introduce refresher training for the peacetime service early in 1965 include a strong element of Civil Defence revision to bring drivers' knowledge up-to-date in the light of many changes in Civil Defence organisation which have taken place since reorganisation in 1962. 79 F The training of Civil Defence volunteers must be given by persons who hold a Civil Defence instructor's certificate either obtained centrally (i.e. at one of the Home Office Civil Defence Schools at Falfield, Gloucestershire, or at Easingwold, Yorkshire) or obtained locally and it has been the aim of the London Ambulance Service to allow as many as possible uniformed supervisory staff to attend instructors' courses at the Home Office Schools. Over the years 25 officers have attended; because the instructors' certificates are only valid for a period of six years, eight have attended instructors' requalifying courses. In addition, 42 senior officers, both uniformed and administrative staff (including three volunteer officers) have attended ambulance officer courses at the Home Office Schools and 11 have attended a senior officers' course at the Civil Defence Staff College, Sunningdalc, where the aim has been to provide a wide background knowledge to Civil Defence in a way which is not possible within the framework of the usual training syllabuses. Training for volunteers in the Civil Defence Corps—The Civil Defence Act, 1948 brought various sections of the Civil Defence Corps into being, among them the Ambulance Section. When a volunteer enrolled in the Corps he did so through a metropolitan borough council and his general basic training was arranged by that borough. It was only after he elected to join a particular section, where specialist training was required, that he was passed on to the appropriate authority. This meant that ambulance service instructors confined their attentions to first aid and ambulance duties. Home Office Circular 32/1953 discontinued this arrangement; from 1954 onwards a volunteer enrolled directly into the section of his choice and all his training was arranged by that section. The Ambulance Section was renamed the Ambulance and Casualty Collecting Section. Also in 1954, plans were completed for volunteers to receive driving instruction and practice accompanied by members of the regular service. For volunteers who were non-drivers, instruction at the Council's expense was arranged through a driving school, whilst volunteers holding a full driving licence proceeded to driving practice on various types of ambulance under the eye of a peacetime driver. In addition, courses began in elementary vehicle maintenance. In 1956 courses in casualty simulation (a valuable adjunct to first aid training) and for the selection of officers were added to the curriculum. In 1960, following an extensive review of the organisation and functions of the Section by the Home Office, it was renamed the Ambulance and First Aid Section, with functions altered to match new concepts in Civil Defence. There followed in 1962 a full-scale reorganisation of the whole Corps, aimed at bringing into being a more efficient nucleus of volunteers around which to expand in case of emergency. The Home Office introduced tests of standard and advanced training; classes in which volunteers could elect to serve following the recruit stage and after passing the standard test; and the payment of an annual bounty, varying with the rank held and depending upon fulfilling certain conditions of training. Furthermore, recruits were given a limited period in which to complete their standard training. The full effects of the reorganisation are only now being experienced and have been entirely beneficial. Although the new scheme resulted in a substantial fall in 1962 and 1963 in the number of volunteers on roll, it could be felt that the lower numbers were at least realistic. The following table shows the strength of the Section over the years: Year No. of volunteers Year No. of volunteers at 31 December at 31 December 1950 940 1958 1,623 1951 1,244 1959 1,600 1952 1,452 1960 1,678 1953 1,662 1961 1,895 1954 2,060 1962 1,310 1955 2,215 1963 1,129 1956 2,052 1964 1,031 1957 1,747 80 An indication of the various training courses held since 1954 is given below: Type of courses Year Ambulance duties First aid Vehicle maintenance Officer selection Other Total{?###] 1954 15 14 — — 31 60 1955 37 16 12 — — 65 1956 29 14 9 1 2 55 1957 20 21 12 6 3 62 1958 26 15 5 3 16 65 1959 19 12 11 4 2 48 1960 24 13 9 6 7 59 1961 17 7 12 6 6 48 1962 28 8 11 4 3 54 1963 24 12 7 2 30 75 1964 16 9 6 — 23 54 The 1,129 volunteers registered at the end of 1963 comprised 596 recruits (i.e. had not completed their standard training, or having completed it had not taken a standard test revision course and passed the test), 353 in Class A (the most active class and taking advanced training), 32 in Class B and 148 in the Reserve. At 31 December 1964 the corresponding figures were: 337 recruits; 440 in Class A ; 36 in Class B; and 218 in the Reserve, a total of 1,031. Civil Defence exercises—To supplement the theoretical and practical training given in the lecture room, numerous Civil Defence exercises have been organised either by the Council or by the metropolitan borough councils. Some have been confined to activities of a particular section of the Corps but a number of large scale exercises have been held in which all sections have taken part. It is gratifying that the Ambulance and First Aid Section has figured largely in nearly all these exercises and has indeed promoted many of them. Week-end schools and camps for the more highly trained volunteers have been held and ceremonial occasions have also been well attended. The following notes on a few of the many exercises held over the years give some impression of their scope and of the planning and administration involved. In October 1962 exercise 'Leader 4' involved, for the first time in London, the deployment of a full ambulance column—some 100 vehicles and 330 personnel. Exercise 'Leader 7' in March 1963 involved some 700 personnel from all sections of the Corps, all of whom were fed by the Welfare (Emergency Feeding) Section. Some 250 ' casualties ' (all ambulance section volunteers) were made up and taken to the Training Ground at Bully Fen where they were rescued, treated and taken to ambulance loading points; from there they were taken by ambulance to a Forward Medical Aid Unit and were finally evacuated by launch across the Thames, loaded into ambulances again and returned to a simulated hospital area. Exercise 'Leader 10' in September 1963 involved over 1,000 personnel and over 100 vehicles—once again a full ambulance column worked to a Forward Medical Aid Unit in dealing with large numbers of casualties. Exercise 'Cabot/Whittington' in November 1963 involved Ambulance and Rescue Section volunteers from both London and Bristol. A convoy and map reading drive to Bristol on Saturday afternoon was followed by a social evening organised by the Bristol authorities and by an exercise in the grounds of the Home Office Civil Defence School, Falfield, Gloucestershire, on Sunday morning. Units returned to London on the Sunday afternoon. In May 1964 exercise 'Olympic' broke new ground in that the preliminary planning for the exercise and the direction of the exercise (movement at night in the early hours of Sunday morning) was all carried out by volunteer officers as opposed to regular service training and administrative staff. 81 F* Exercise 'Scottish Border' in September 1964 was one of the most ambitious exercises ever attempted and involved some 120 personnel and 60 vehicles from all sections of the Corps, who were away from London for four days on a convoy publicity and recruiting drive which took them the length of the country. Various small exercises were carried out en route in collaboration with other County Divisions of the Corps. The exercise obtained considerable publicity, both locally and nationally, and had an undoubted effect on recruitment as well as a stimulating effect on those taking part. The Section has also provided detachments or representatives at a number of national and civic occasions. 82 ANNEX A LONDON AMBULANCE SERVICE EQUIPMENT CARRIED BY ACCIDENT AMBULANCES Beds, rubber (2) Hot-water bottle, rubber (1) Bed-pan, plastic (1) Hot-water bottle cover (1) Bed-pan cover (1) Manifold harness (1) Blanket, cot, in canvas envelope (I) Mask, Schimmelbusch (1) Blankets, red (6) Oxygen apparatus (1) Bowls, kidney, small (2) Pillows, rubber (2) Bowl, kidney, large (1) Resuscitator, bellows (1) Bowl, round (1) Rope, 40 foot length (1) Bowl, vomit (1) Rubber sheet, 8 ft. (1) Burns sheet (1) Satchel, first aid (1) Carrying chair (1) Splints, inflatable (2) Carrying sheet (1) Splints, set of 16 (1) Deodorant spray (1) Splint, back leg, 18 in. (1) Dressings case (1) Stretcher canvases (6) Drinking-water bottle (1) Stretcher poles, duralumin, pairs (2) Drugs case (1) Stretchers, rigid (2) Feeding cup (1) Stretcher, Neil Robertson (1) Fracture board (1) Surgical instruments, set (1) Gloves, rubber, electrician's, pair (1) Tissues, paper, in box (1) Guide lines, 12 yd. lengths (2) Towelling square for use with cot blanket (1) Hacksaw (1) Traverse irons, pairs (2) Hacksaw blades (6) Additional equipment Clip-board, phonetic alphabet (1) Lamp, electric, Hunter pattern (1) Coats, crew's protective (2) Lamp, electric, Pifco, red (1) Jemmy (1) Pliers, pair (1) Key, housing-estate barrier (1) Screwdriver (1) Key, station (1) Spanner, adjustable (1) Key-ring and plastic ball (1) Wheel chock (1) Contents of Drugs case Cetrimide, 4 oz. bottle (1) Olive oil, 4 oz. bottle (1) Epsom salts, saturated solution, 4 oz. bottle (1) Sal volatile, 4 oz. bottle (1) Labels, casualty (6) Skin pencils (2) Magnesium oxide, 2 oz. bottle fl) Teaspoon (1) Measure, 4 oz. (1) Vaseline, tube (.1) Measure, 2 oz. (1) Vinegar, 4 oz. bottle (1) Mustard, 2 oz. bottle (1) and the following items TO BE USED ONLY BY A MEDICAL PRACTITIONER *Adrenalin tartrate ampoules (6) Surgical needles and sutures, sterile, in tubes (3) Amyl nitrite ampoules (12) Syphon, stomach (1) Chloroform, 2 oz. bottle (1) Syringe, hypodermic, sterile, with three needles, tMorphine (Omnopon) in ampoule-syringes (6) including one 3i in. (1) *Nikethamide (coromine) ampoules (6) * For hypodermic injection. † Carried in special locked cupboard containing also six casualty labels and one skin pencil. 83 Contents of Dressings case Dressings, No. 0 (6) Gauze, white, roll (1) Dressings, No. 1 (6) Gloves, surgical, pair (1) Dressings, No. 2 (6) Lint, white, 4 oz. packets (2) Dressings, No. 3 (6) Lint, boric, 4 oz. packet (1) Dressings, No. 4 (6) Mouth cloths (3) Bandages, roller, 1 inch (6) Pins, safety (12) Bandages, roller, 2 inch (6) Plaster, adhesive, 1 inch roll (1) Bandages, roller, 3 inch (6) Plaster, adhesive, 2 inch roll (1) Bandages, triangular (12) Scissors, dressing, pair (I) Cotton wool, 4 oz. packet (1) Splinter forceps, pair (1) Surgical instruments contained in sterile cellophane wrappings Forceps, artery (4) Saw (1) Forceps, dissecting (1) Scalpels (2) Forceps, Treves (1) Scissors, surgical, pair (1) Knife, amputation (1) Tracheotomy tube, adult (1) Probe (1) Tracheotomy tube, child (1) Contents of First Aid satchel Dressings, No. 0 (1) Cotton wool, 1 oz. packet (1) Dressings, No. 1 (6) Gag (1) Dressings, No. 2 (6) Glucose, in 2 oz. polythene bottle (I) Dressings, No. 3 (4) Lint, white, 1 oz. packet (1) Dressings, No. 4 (2) Mouth cloth (1) Bandages, roller, 1 inch (6) Rubber bandage (1) Bandages, roller 2 inch (6) Sal volatile, 4 oz. bottle (1) Bandages, triangular (6) Tongue depressors, wooden (6) EQUIPMENT CARRIED BY GENERAL SECTION AMBULANCES Beds, Dunlopillo (2) Pillows (2) Bed-pan (1) Satchel, first aid (1) Blankets (as required) Stretcher canvases (2) Carrying chair (1) Stretcher poles, duralumin, pairs (2) Deodorant spray (1) Tissues, paper (as required) Drinking water bottle (1) Traverse irons (2) Feeding cup (1) Urine bottle (1) Hot water bottle ") available from station Vomit bowl (1) Hot water bottle cover J when necessary 84 EMERGENCY VEHICLE EQUIPMENT First Aid equipment Dressings, No. 1 (48 doz.) Cotton wool, 4 oz. packets (66) Dressings, No. 2 (64 doz.) Mouth cloths (24) Dressings, No. 3 (80 doz.) Splints, wooden (3 sets) Dressings, No. 4 (84 doz.) Splints, plastic (3 sets) Roller bandages, 1 inch (24 doz.) Burns sheets (6) Roller bandages, 2 inch (24 doz.) First Aid satchels (6) Roller bandages, 3 inch (24 doz.) Skin pencils (12) Triangular bandages (40 doz.) Casualty labels (200) Lint, 4 oz. packets (66) Ambulance equipment Stretchers, rigid (20) Blankets (52) Stretcher canvases (6) Rubber beds (4) Stretcher poles (24) Rubber pillows (4) Traverse irons (6 pairs) Bed pan (1) Neil Robertson stretcher (1) Stretcher carrying slings (24) Carrying chair (1) Resuscitation equipment Oxygen set (Oxyvator) (1) Spare cylinders, mixture (Oa and C02) (4) Spare cylinders, oxygen (4) Bellows resuscitator (1) Medical equipment Omnopon (6 ampoules) Schimmelbusch masks (2) Surgical instruments (2 sets) White coats (medical officer) (3) Hypodermic syringe (1) Armbands (doctors) (12) Chloroform (2 bottles) Radio equipment Pye radio set, complete (1) Walkie-talkie sets, with aerials (4) Walkie-talkie master set (1) Miscellaneous equipment Rubber boots (6 pairs) Batteries, 6 v. (6) Boiler suits (1) Batteries, 12 v. (1) Fog flares (48) 40 ft. rope (1) Lamp (Hunter) (1) Guide ropes (2) Batteries, Ever Ready 45 v. (8) Saws (set of three) (1 set) Batteries, Ever Ready 1^ v. (12) Stand-by equipment Calor gas cylinders (2) Emergency rations (2 tins) Calor gas fire (1) Administrative equipment Map of London (1) Occurrence book (1) Sectional maps (24) Armbands (L.C.C. Ambulance) (70) Atlas of Greater London (Geographia) (1) 85 PREVENTION OF ILLNESS: CARE AND AFTER-CARE Chiropody In 1948 the London County Council took over 26 foot clinics established by the metropolitan borough councils; the service was, however, unevenly distributed over the county area. The Minister of Health agreed to the service being continued by the Council at that level pending a decision as to whether chiropody was an appropriate form of treatment for provision by local health authorities. Despite repeated representations from the Council, the Minister was unable to agree to any extension of the service. The Cope Committee recommended in 1951 that local health authorities should be empowered to provide chiropody under the National Health Service Act, but the Minister stated that an extension of this service was not possible in the then existing financial circumstances. In 1956, however, the Minister agreed to a more even geographical allocation of existing sessions and this was carried out. In 1959 the Minister sanctioned the extension of chiropody services and the Council immediately approved an increase of 100 sessions a week, pending a full review of the needs in the county. Unfortunately it was not possible fully to implement the increase owing to lack of chiropodists. Only recently, following the setting up of the Register of Chiropodists, has it appeared that sufficient staff might be available. Services provided by the Council have been augmented since 1959 by services provided by various voluntary organisations, usually Old People's Welfare Associations, who provide chiropody services for the elderly. The Council pays these organisations 100 per cent, deficiency grants for the services provided. In 1964 grants were made to 32 such organisations. The following tables show the attendances at the Council's clinics in recent years New cases and attendances Year New cases Attendances Staff at the end of the year (in terms of whole units) 1960 9,405 186,735 57.7 1961 10,379 196,788 55.6 1962 8,575 192,500 57.7 1963 7,510 193,498 60.7 1964 8,305 218,076 66.7 Analysis in age groups of treatment given at clinics Group 1960 1961 1962 1963 1964 Children under 5 years 129 117 78 91 110 5-14 years 7,062 6,599 6,549 5,940 5,502 Males 15-64 years 14,766 14,076 12,237 11,181 11,829 65 years and over 17,613 19,675 20,106 21,188 25,478 Females 15-59 years 57,980 55,237 49,957 45,546 47,376 60 years and over 89,185 101,084 103,573 109,552 127,781 Total 186,735 196,788 192,500 193,498 218,076 86 Recuperative holidays Recuperative holidays, where the emphasis is on rest, fresh air and good food but regular medical and nursing attention are not required, totalled 8,467 in 1949, the first full year in which the service was provided. There was a considerable increase in the following year but since then, apart from 1959, there has been a steady reduction in the demand for the service. One reason is that doctors in child welfare centres and general practitioners no longer refer very young children, especially those under two years, for recuperative holidays unless the circumstances are quite exceptional. The risk of infection among babies has always been a problem in placing mothers with very young children. This has been minimised by the use of private accommodation, where only one or two mothers with such children are received for recuperative holidays at any one time. This accommodation is kept under close surveillance by a medical officer. Private accommodation is also largely used for holidays for adults. It has been the Council's policy for social as well as medical reasons not to send patients with a history of tuberculosis to the same homes as non-tuberculous patients. Although these patients may be non-infective and the tuberculosis quiescent, experience has shown that their presence in ordinary homes may upset other patients. The homes approved to take tuberculous patients are grouped as follows: Group I—Approved to take adult patients with active or quiescent tuberculosis Group II—Approved to take a tuberculous person accompanied by his/her family. A few homes are placed in both groups, on the clear understanding that at any one time the patients in residence must be in only one of these groups. For the purposes of the Council's recuperative holiday scheme for tuberculous patients, it is not thought safe to differentiate between a case of known active pulmonary tuberculosis and what may be thought to be a quiescent case in a patient who has recently been ill enough to need a recuperative holiday on medical grounds. The proprietors of some homes will not accept patients with known active pulmonary tuberculosis and their wishes are observed. 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 cannot be accommodated in these homes and all adults are placed at the Council's expense in homes under private ownership or maintained by voluntary organisations. For the first fourteen weeks of 1962 Roland House, Littlehampton, was used exclusively for children from homeless families in Welfare department establishments. This proved beneficial both to the children and to their families, who were relieved from the need of caring for them in difficult circumstances for a short period during which they would find it easier to search for a new home for the family. Similar arrangements were made in subsequent years and some 200 children benefited each year. Admissions to recuperative holiday homes 1949 1954 1959 1964 Expectant and nursing mothers 379 197 123 81 Other adults 2,779 2,954 2,457 2,040 Children under 5 not at school (a) 1,517 486 571 410 School and nursery school children (6) 3,121 3,404 2,597 2,032 Children in age groups (a) and (b) above accompanying parents but not cluded in these totals 671 424 * • 8,467 7,465 5,748 4,563 * Included in (a) and (b). 87 Health education The department's health education activities in 1964 were directed mainly in four fields, three regarded as of growing importance with dental health of continuing importance. Smoking and health—The health education mobile unit continued its work of visiting schools, youth clubs and other groups. Visits by health education unit—1964 No. of establishments visited Primary schools 13 Secondary schools 88 Youth clubs 19 Further education establishments 9 Teacher training colleges 4 Welfare centres 7 Other groups 8 Many of the establishments were visited a number of times and a total of 262 lectures was given by the health educator, aided by films, film strips and other material to some 32,300 persons. Because of the demand for the services of the unit and the need for follow-up visits, the provision of a second unit was authorised. At various times during the school holidays film shows on health education topics have been held for staff at County Hall. In all, there were 91 showings to a total audience of 2,874. In the summer school holidays a van was adapted for the rear projection of films on the smoking theme and appeared in 18 of the Council's parks. This was very successful and attracted a total of 9,450 children and young adults. No doubt the exceptionally sunny weather contributed to the success. Two leaflets were produced within the department with the assistance of the Chief Officer of Supplies. One stresses the need for adults who have constant contact with children to set a good example by not smoking; this has been made available to head teachers of all the Council's schools and to youth club leaders in London. The other emphasises the statistical evidence for an association between smoking and chest disease and this has been distributed to older school children, to members of youth clubs and other young persons. While the smoking advisory sessions held in three of the divisions continued to operate, attendances were not maintained at the initial levels. Venereal disease—Leaflets and posters were produced by the department with the aim of persuading young people who had taken risks to seek proper advice and, as necessary, treatment. This material was offered to every London youth club leader, to London general practitioners, to principals of colleges of further education and to medical officers of health of the metropolitan borough councils for distribution by them; the response has been encouraging. A special direct telephone line was made available at County Hall to permit those worried about their possible condition to seek advice as to where to obtain treatment this facility was publicised in the leaflet. In addition, descriptive leaflets of the venereal diseases issued by the Central Council for Health Education were distributed to head teachers and to youth club leaders to assist them and their staffs in answering questions on the subject. Dangers from oil heaters—An intensive campaign was launched in the autumn to encourage awareness of the dangers from: (i) Unguarded oil and other heaters, particularly when young children or the elderly are present; (ii) Improperly maintained oil heaters, and (iii) Oil heaters which do not conform to British Standard 3300. 88 A leaflet was specially designed and distributed to 650,000 homes, including all of the Council's houses and flats (both in and out-county), many of the metropolitan borough councils' housing estates and to houses in areas regarded as risk areas by reason of gross multiple occupation or large immigrant populations. For the latter purpose the leaflets were translated into Turkish and Greek Cypriot, Urdu, Bengali and Hindi. In addition, a poster was produced illustrating the desirability of providing a separate guard for all types of heater when children are present; this was displayed on most London railway and underground stations. Monthly advertisements based on this poster were inserted in local newspapers during the autumn and early winter. Dental health—In response to a suggestion to local authorities by the Ministry of Health, dental health weeks have been held in each division with the co-operation of the divisional education offices. These 4 weeks' were preceded by periods of build-up and followed by periods of lower level dental health activity in an endeavour to consolidate the message. The degree of activity has varied between the divisions but many schools have participated and much publicity material produced by the Council and by outside agencies has been used. The campaigns have been supplemented by film showings, exhibitions and competitions. Other material—While care has been taken not to produce any publicity material which is exactly covered by that produced by outside agencies, the year has seen the production of a wide variety of health education material produced by the department in co-operation with the Chief Officer of Supplies. In addition to that referred to above, a leaflet was produced on mouth-to-mouth resuscitation; this has been made available to professional staff in the department who may be called upon to meet an emergency situation and it has also been supplied to schools. A poster with an associated leaflet was prepared for display in child welfare centres, warning mothers of the desirability of first ascertaining that any child minder to whom they wish to give the charge of their child is either not in a registerable category or if so, is properly registered. The leaflet was so designed that it could be distributed by health visitors on its own. A separate leaflet was prepared for distribution by health visitors and other field workers warning likely child minders, or potential child minders, of the legal requirements of registering. A leaflet was also produced for distribution to parents on the need for care in choosing children's shoes. General—The nine health divisions have continued to provide health education on a personal level through the day-to-day contact of the field staff with the public and make their own arrangements for the ordering of material direct from those supplying it. The departmental advisory panel on health education has met at approximately quarterly intervals, as has the health education working party of senior nursing officers in the divisions. The department has continued to be represented on the Education Officers' standing advisory committee on health education in schools which has met quarterly. Health education talks—The following tables show the variety and volume of talks and discussions arranged and given by the field staff. Films and film strips supplied from the central office continued to be widely used in these activities. Talks given by health visitors in schools at the invitation of head teachers ranged over a variety of subjects and numbered over 4,000. 89 VO O Table (i)—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 978 6,968 772 6,119 279 3,071 325 3,417 366 4,532 637 6,218 634 6,286 35 356 203 1,785 4,229 38,752 Care of older children 3 16 25 253 — — 7 75 13 230 — — 9 113 — — 9 46 66 733 General family health topics 11 104 5 53 12 142 27 200 15 232 — — 23 318 6 156 4 20 103 1,225 Environmental hygiene 6 49 2 20 — — — — 2 26 - - - - - - - - 10 95 Infectious diseases and prophylaxis 26 171 5 39 12 126 — — 5 78 16 260 32 279 3 10 5 24 104 987 Prevention of accidents 29 243 12 141 4 31 4 59 13 144 6 65 17 186 3 57 5 34 93 960 Smoking and lung cancer 1 2 — — 1 11 1 40 5 64 — — 3 40 1 16 — — 12 173 Cancer education (other than above) - - - - - - 1 50 - - - - - - - - - - 1 50 Mental health — — — — 4 41 — — 3 26 — — 6 66 3 49 — — 16 182 First aid 3 25 1 15 — — — — 9 88 3 41 2 27 1 40 1 16 20 252 Other 35 319 155 1,063 7 83 55 723 58 622 9 129 147 2,148 9 114 30 194 505 5,395 Total 1,092 7,897 977 7,703 319 3,505 420 4,564 489 6,042 671 6,713 873 9,463 61 798 257 2,119 5,159 48,804 Health education talks—1964 Table (ii)—Speakers Divisions 1 2 3 4 5 6 7 8 9 Total Medical officers - 52 5 1 - - 1 2 - 61 - - - - - - - - - - Health visitors and school nursing sisters 1,044 691 294 304 348 661 694 41 252 4,329 Domiciliary midwives 9 17 4 — 1 1 28 — — 60 Teachers/instructors 19 192 9 109 77 — 14 — — 420 Other Council officers 1 2 2 — 3 — 23 2 - 33 Lecturers from outside the Council's service—Nursing 1 4 2 3 - - 2 2 1 15 Other 18 19 3 3 60 9 111 14 4 241 Total 1,092 977 319 420 489 671 873 61 257 5,159 Table (iii)—Audience groups Divisions 1 2 3 4 5 6 7 8 9 Total Expectant mothers 890 593 245 250 247 628 441 30 191 3,515 Mothers, mothers' clubs, etc. 174 384 74 102 232 43 429 28 66 1,532 Parent/teacher associations 1 - - - - - 3 1 — 5 Day continuation classes 3 — — 68 - - - - - 71 Voluntary organisations 24 — — — 10 — — 2 — 36 Total 1,092 977 319 420 489 671 873 61 257 5,159 Venereal diseases The responsibility for the diagnosis and treatment of venereal diseases passed to the hospital authorities with the coming into operation of the National Health Services Act, 1946. The Council's interest was, therefore, restricted to prevention. Under Defence Regulation 33B the Council had power to bring to treatment certain persons believed to be suffering from venereal disease and employed staff for this purpose. This power expired on 31 December 1947, but the Council continued to employ staff under section 28 of the National Health Service Act to persuade contacts and defaulters from treatment to attend clinics. In 1950, at the request of the Prison Commissioners, the part-time services of a welfare officer were made available for attendance at clinics at Holloway Prison and for following up contacts and persons on discharge who needed to continue under treatment. The initial trial period showed great scope for this work and a whole-time welfare officer has been allocated to these duties since 1951. Another welfare officer employed on tracing the contacts notified to the department at County Hall continued this work, in addition to attending the Endell Street clinic of St. Peter's, St. Paul's and St. Philip's hospital. The services of a male inspector have always been available where necessary. 91 The incidence of venereal disease, as indicated by the number of new cases attending clinics in London, fell gradually until the mid-1950's; then there was a rise until 1961, thereafter the figures appeared to have levelled off at about double the 1955 level. This increase led to a request for the services of a welfare officer at St. Mary's hospital, Paddington, which is one of the busiest clinics in London and later a welfare officer was employed at St. Thomas's and the London hospitals. In 1964, after discussions with the consultant venereologist concerned and with officers of the Ministry of Health, it was decided to try out a scheme of concentrated contact tracing at two clinics. In this scheme the welfare officer would see each patient, as far as possible, on his first attendance. The old method of issuing ' contact slips ' will continue in suitable cases with closer follow-up of results. The Council agreed to the employment of two additional welfare officer's for a period of six months at the London and St. Thomas's hospitals, so that the needs and effectiveness of such a scheme could be assessed. This scheme started at the end of November 1964 and results are awaited with interest. The tracing of contacts and the help that the local health authority can give is now appreciated by the staffs of most clinics and at the end of the year requests from four more hospitals for help from welfare officers were under consideration by the Council. These requests were subsequently approved and the number of staff employed full-time on this work was increased to nine. Treatment of venereal disease at London out-patient clinics New cases Year Syphilis S. Chancre Gonorrhoea Total venereal cases Total non-venereal cases Total attendances M. F. M. F. M. F M. F. M. F. M. F. 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 1962 1,060 533 52 2 12,225 2,533 13,337 3,068 27,360 11,939 243,078 87,860 1963 909 426 49 2 11,895 2,906 12,853 3,334 29,005 13,189 229,506 89,050 1964 1,073 389 47 2 12,000 3,131 13,120 3,522 29,512 13,855 206,666 85,174 Number of patients completing treatment and of defaulters I960 1961 1962 1963 1964 Syphilis—patients completing treatment— Males 526 572 507 430 420 Females 434 362 359 229 218 patients not completing treatment— Males 677 776 682 528 737 Females 431 390 389 199 210 Gonorrhoea—patients completing treatment— Males 5,700 7,800 5,398 4,429 6,157 Females 1,334 1,269 1,129 1,163 1,461 patients not completing treatment— Males 6,536 8,085 4,929 7,466 6,078 Females 1,485 1,550 1,237 1,743 1,705 92 MENTAL HEALTH Historical developments Social workers have been employed on mental deficiency work ever since the Mental Deficiency Act, 1913 came into operation. From the beginning the social enquiries necessary for the ascertainment of new cases were carried out by social workers, designated Mental Deficiency Act inspectors, employed by the Council and based at County Hall, but the supervision of mentally subnormal persons (then known as mental defectives) living in the community was originally undertaken on the Council's behalf by social workers employed by the London Association for Mental Welfare. The work of that body 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 early that the provision of centres for the trainingand occupation of mentally subnormal 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, the best available but many of them 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 1,270 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. 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 being carried out by the National Association for Mental Health and the Mental After Care Association 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 consultant in mental health. 93 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 newly-constituted 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 hospital care and treatment for persons suffering from mental illness. The Council welcomed the findings published in May, 1957 of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency 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 underlined the concepts now accepted by many of the general public, as well as by those 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. 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 1964, to put them into effect. 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 all the services were administered centrally from the County Hall. 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 under a divisional mental welfare officer (now divisional mental health social worker) responsible to the divisional medical officer. A principal mental welfare officer (now principal mental health social worker) was appointed 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 background, training and experience of the members of the divisional teams varied widely and the bringing together 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 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 together 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 divisional basis 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 94 medical evidence to courts in respect of mentally disordered persons, 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. The devolution of responsibilities for the mental health services to Divisional Health Committees included 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. Planning and the formulation of policy, the supervision of training and general control over admissions, the engagement and allocation of supervisory staff and the arranging of transport were retained as central responsibilities under the guidance of a principal medical officer assisted by an organiser of training centres. In 1961 the divisional staffing structure was reviewed. It was evident that staff had been working under extreme pressure and the Health Committee agreed to an increase of 18 additional social worker positions to a total of 95 and to a further review in the light of 18 months' experience. It was soon evident that the increased establishment was inadequate to deal with the very considerable increase in the volume of work falling to the social worker staff and this was confimed by an O. and M. review of the service carried out in 1963. An increase of 25 per cent. in the volume of work since the Act came into operation (85 per cent. of which related to mentally ill persons) was revealed and to enable the staff to continue adequately to perform the Council's statutory functions and to allow for a further anticipated expansion of service a 35 per cent. increase in social worker positions was approved. A case load of 40 mentally ill persons or 160 mentally subnormal persons receiving community care for each social worker was suggested as a general yardstick. To improve recruitment and give greater stability to the service a revised grading structure was also agreed. At the end of 1964 a total of 136 mental health social workers were employed. The staffing of training centres has followed a formula fixed some years ago, namely, a supervisor with one assistant supervisor for each group of 15 or part of a group, with attendants as necessary, subject to the overall ratio of staff (supervisory and attendants) not exceeding 1:10. A slight strengthening of the supervisory staffing at the larger centres was subsequently found to be desirable. The number of staff employed in the training centre service at the end of 1964 was 147, comprising one organiser of training centres, one industrial manager, 24 supervisors, 84 assistant supervisors, 34 attendants and three home teachers. 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. 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. During 1964, the Council paid the fees of selected officers attending evening courses on such subjects as abnormal psychology, human relations, marriage guidance, case work principles and problems of old age. The policy of seconding suitable officers to full-time courses continued; four officers so seconded completed the Mental Health course during the year and five commenced the course. Two officers were also seconded to take the two-year 'Younghusband' course and two the National Institute of Social Work oneyear course; another six returned from these courses. Arrangements also continued for officers to attend conferences and residential weekend schools. While 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 95 g to their work and to give them every opportunity of keeping abreast with new and changing ideas, it has been possible during the year to start in-service training on these lines. A case discussion group has met weekly, made up of a mental health social worker from each division and led by the assistant principal mental health social worker. The response in growing understanding and awareness has been most encouraging. Springfield hospital arranged for the second time a useful intensive course lasting a week and two social workers attended it. Staff have also started to attend seminars in mental subnormality at Queen Mary's hospital, Carshalton. Five training centre staff were seconded on one-year full-time courses arranged by the National Association for Mental Health and six returned to duty. Five assistant supervisers successfully completed the diploma course for teachers of the mentally handicapped, one of whom gained the highest examination marks and was named the student of the year. One assistant supervisor completed the diploma course held in Birmingham for staff of adult centres. Medical and diagnostic services Since the passing of the Mental Health Act, 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 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 specialising in mental subnormality. These officers, based centrally at the County Hall, are responsible for the more difficult and complicated clinical work arising from the local health authority's duties under the Act and are also available for carrying out diagnostic examinations in the divisions at the request of the divisional medical officers. They 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. Special advisory clinics The Royal Commission on the Law relating to Mental Illness and Mental Deficiency had 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. Special clinics have been set up in all the Council's health divisions, 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 an 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 care and training indicated and necessary arrangements made. These clinics are staffed by medical officers with considerable experience in mental subnormality, most 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. 96 Admission to hospital and guardianship The Council's mental welfare officers, known in the Council's service as mental health social workers, provide a continuous service, available through the 24 hours of each day, to receive and act upon calls received from general practitioners, hospitals, police and the public. During office hours such calls are received and dealt with divisionally but outside these times a nucleus of staff is maintained on duty at the County Hall to deal with any emergency arising in the London area. During 1964, 4,689 persons who were alleged to be mentally ill and in urgent need of care and control were referred to the Council's mental health social workers for investigation, of whom 3,706 were removed to hospital. 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 and Tooting Bee hospitals. The remaining seven hospitals are Bexley; Banstead; Cane Hill, Coulsdon; Horton, Epsom; Long Grove, Epsom; West Park, Epsom and Friern, 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. Rather more than 200 beds are provided at the general hospitals for these cases. There are 21 hospitals which admit subnormal and severely subnormal persons from the county area; two in London and 19 out-county. The Council acts as the normal channel for admissions of London patients to these hospitals, assists with the assessment of priorities and in the provision of medical and social reports. These patients are normally received in hospital on an informal basis. Difficulties persist in obtaining beds, particularly for children; at the end of the year 148 children under 16 and 27 patients over this age were awaiting admission, of whom 61 were regarded as being in urgent need. Informal admission to hospital—Hospital care under the Mental Health Act, 1959 is 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 health social workers are not, of course, concerned with the large majority of informal admissions of mentally ill persons to psychiatric hospitals but in 1964, of all removals of such patients dealt with by mental health social workers, 26.6 per cent. were arranged informally. Compulsory admissions to hospital—The Mental Health Act embodied a new code for compulsory admission to hospital of mentally disordered patients, whereby compulsion is applied only in the case of 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 health social worker or the nearest relative supported by two medical recommendations. In the case of an emergency admission under section 29, a mental health social worker 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 1964, 977 persons were admitted to hospital for observation under section 25, 367 for treatment under section 26 and 1,583 were the subject of emergency admissions for observation under section 29. The police have 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 97 o* 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 health social worker and for making any necessary arrangements for treatment or care. During 1964 mental health social workers were concerned in the compulsory removal to hospital of nine 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 the nature or degree of 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 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 staff. During 1964 the Council's staff were concerned in the compulsory removal to hospital of 199 persons as the result of Court Orders. Guardianship—Under the Mental Health Act, 1959 a local health authority can itself act as guardian and guardianship may 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 1964, however, this form of control had not been used by the Council for mentally ill or psychopathic persons. 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 in 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 of 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, which must be accompanied by a medical recommendation, are made by the nearest relative or by a mental health social worker and in these applications reasons must be given why the person cannot properly 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 mentally disordered person's father and the person 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 on severe subnormality or mental illness or in relation to patients who are the subject of Court Orders. Under the new Act a 'responsible medical officer' had 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. Of 92 London cases then under guardianship 51 were discharged and continued in community care on an informal basis, three were admitted to hospital and 38 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. These 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 are appointed to exercise the power to order the discharge of a patient from guardianship, a power which 98 is also given to the nearest relative. At the end of 1964 there were 26 persons under statutory guardianship, of whom 13 were placed at addresses in the care of the Guardianship Society, Brighton. 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 the 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 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 21 members who, up to the end of 1964, had considered 345 applications and approved 317. Residential accommodation The Council has long been alive to the need to provide residential accommodation for mentally disordered persons. The scheme submitted to the Minister of Health in 1948 under section 28 of the National Health Service Act, 1946 stated that the Council would: (i) Make use of homes founded by voluntary organisations for persons not needing treatment in a hospital and would itself consider making direct provision in suitable cases ; and (ii) would consider the provision of hostels for mental defectives under guardianship. In 1955 the Council established Dover Lodge hostel, Camberwell, the first of its kind in the country, where accommodation is provided for up to 13 mentally sub-normal 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 very useful purpose in training them to become self-supporting members of the community. Fifteen girls were accommodated in the hostel during 1964 and nine were resident at the end of the year. Since the passing of the Mental Health Act, the problem of providing residential accommodation for various classes of mentally disordered persons has been one of the most onerous that the Council has had to face in developing its mental health service. Whilst recognising its ultimate obligations under the Act to provide such accommodation for a very large number of persons, the Council decided to proceed with the provision of hostels on a broad basis of priority for certain classes. Initially, the categories of persons for whom hostel provision was proposed, were : (i) Persons discharged from psychiatric hospitals and considered likely to benefit from rehabilitation, and such other persons needing a period of hostel care to avoid hospital admission. (ii) Young persons of both sexes leaving residential schools for the maladjusted and needing extra care and guidance. (iii) Subnormal or severely subnormal children requiring short-term care to avoid hospital admission at times of particular domestic difficulty. (iv) Subnormal persons discharged from hospital and urgently requiring temporary accommodation or living accommodation on a somewhat longer term basis where necessary in the person's interests. 99 (v) Persons needing long-term care who are (a) in outside employment; (b) not working (including the aged mentally infirm). 'Chellow Dene', the Council's first hostel for mentally ill persons, opened in specially converted premises in Putney in 1962 with accommodation for 23 men and women between the ages of approximately 18 and 60 years, who require a period of sheltered accommodation to help establish themselves in employment and in the community when recovering from mental illness. Admissions are on a trial basis, normally of one month. During this period, and indeed during the whole period of stay, very active rehabilitation is often necessary by the warden and psychiatric social worker to help the residence in the process of re-adjustment. During 1964 a total of 75 persons were resident in the hostel, the average stay being ten weeks ; the length of stay varied between one day and twelve months. At the end of the year 18 persons were resident. When the Council was required by the Minister of Health in Circular 2/62 to submit its ten-year plan for the Development of Health and Welfare Services, further consideration was given to the hostel development programme and the categories of mentally disordered persons for whom such accommodation should be provided. A total of 19 hostels was proposed for the ten years up to 1972 ; of these, 11 hostels were programmed for the first five-year period to 1967. The general principle was adopted that in the first instance there should be one hostel for each of the approved categories, so that the need for further hostels of each type could be re-examined in the light of experience. It was found in practice, however, that consideration of possible sites in relation, for example, to existing and projected health service premises and to the location of nearby light industry and neighbouring properties, determined to a large extent the categories of persons for which hostel accommodation could be suggested, with the result that a second or even third hostel of a particular type might be possible before the provision of an initial hostel in another category. This was recognised when the first revision of the ten-year plan was carried out in 1963; at the same time the development programme was expanded to provide for a total of 26 hostels in the period up to 1973. The following additional priority categories were approved: (i) Chronic unemployable mentally ill persons needing long-term care. (ii) Employable mentally ill persons requiring long-term care. (iii) Employable subnormal women requiring short or long-term care. (iv) Subnormal or severely subnormal persons of both sexes not able to be employed in the community and needing long-term care. 'Honor Lea', the Council's first purpose-built hostel for mentally ill persons, opened at Brockley Rise, Lewisham in September 1964 with accommodation for a maximum of 59 persons requiring a sheltered hostel environment after hospital care or a period of support away from home surroundings to prevent a more serious breakdown. Admission is normally restricted to persons who are sufficiently recovered as to be capable of undertaking outside employment within a reasonable period following admission or are suitable to attend a day centre for the mentally ill in South London. By the end of the year 44 persons had been accommodated in the hostel and 33 persons were resident at 31 December. Further progress made towards the implementation of the hostel development programme is shown in the section of the report dealing with health services premises. Voluntary organisations—In addition to direct provision of hostels, the Council places and maintains a number of mentally disordered persons in hostels and homes under the control of voluntary organisations and with private persons. In particular, use has been made of homes provided by the Mental After-Care Association for the long-term care of persons suffering from mental illness. Persons are maintained at homes owned or sponsored 100 by the Association; at Parnham House (National Association for Mental Health); at Winston House, Cambridge, and Hill House, Elstree (S.O.S. Society); at Cheshire Foundation, Richmond Fellowship and Jewish Welfare Board hostels. Persons who are maintained by the Council contribute towards the cost according to their means. As regards mentally subnormal persons, private homes and hostels run by voluntary organisations are used when this form of care is considered appropriate. Placings are made in convents and other training establishments run by religious communities and through the Guardianship Society, Brighton. At the end of 1964 the Council was maintaining 186 subnormal persons under these arrangements. Grant-aided hostels—The Council contributes 90 per cent of the net cost of maintenance of a hostel for the after-care of alcoholics run by the West London Mission, at the Alcoholic Rehabilitation Centre in Lambeth. This hostel opened in 1961 to provide after-care for up to 40 persons who have received psychiatric treatment and who are under the continuous supervision of psychiatrists. Subsequently, in 1963, a female wing for up to 12 patients was opened. During 1964 a total of 174 men and 27 women were resident in the hostel. A similar maintenance grant is paid by the Council to the Easton House Trust in respect of a hostel opened in 1963 in Stoke Newington for leavers from the Council's boarding special schools for maladjusted boys. The hostel provides accommodation for 12 boys and was fully occupied throughout 1964. Short-term care and holidays for mentally disordered persons—The provision of short term residential 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 1964, 529 persons were placed under these arrangements for periods normally not exceeding eight weeks. 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. Recuperative holidays are provided for persons recovering from mental illness in the same way as for those who have suffered from physical illness. During the year 159 persons were given holidays for two or three weeks in approved recuperative holiday homes. Each year since 1951, the Council has organised a two-week seaside holiday for about 200 mentally subnormal children and adults who attend training centres, at a holiday camp at St. Mary's Bay, Dymchurch, Kent. A grant to a local branch of the National Society for Mentally Handicapped Children, towards the cost of purchasing two caravans to be used to provide seaside holidays for families with mentally subnormal children, was approved by the Council in 1964. Training for mentally subnormal and severely subnormal persons 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 : (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 101 of additional centres to cater for the increasing demand from both children and adults ; (ii) provision of special care units for children who require attention because of physical handicap or other difficulty ; (iii) reduction in the general age of admission 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 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 and Greenwich of two additional industrial centres with places for 126 youths and men, the opening of additional centres for older girls and women in Islington and Wandsworth with a total of 80 extra places, and the opening of centres for older girls and women in Bethnal Green, Stepney and Hammersmith in specially adapted premises to replace centres in unsatisfactory church hall premises. By the end of 1964 the number of centres had increased to 24 and the total number of available places to 767 for juniors, 365 for older girls and women and 381 for youths and men, a total of 1,513 places. The provision of new centres has been hampered by difficulties in acquiring suitable sites but at the end of 1964 the following projects were in hand : (i) Erection of two new junior centres each with 112 places in Greenwich and Islington, which had reached an advanced stage of construction. (ii) Replacement of older girls' centre in unsatisfactory premises in Greenwich by a centre in specially adapted premises ready for occupation in January 1965. (iii) Provision of a new industrial centre in Hackney to provide training for 120 youths and men—detailed plans approved and building work about to commence. (iv) Provision, on a site in Bermondsey, of a new junior centre with 112 places, a female adult centre and one for youths and men, including an industrial workshop— scheme approved and detailed plans under consideration. Special care units— The Council's first special care unit was brought into use in a specially adapted part of the Bethnal Green centre in 1962. The unit provides accommodation for 12 severely subnormal children aged 5 to 16 who are also severely physically handicapped or of such a restless or aggressive behaviour that they could not be accepted for admission to an ordinary junior training centre. A more generous staffing ratio is provided, which enables the children to be given a greater amount of individual attention than is possible in a training centre. Attendances are very good and the results achieved are most encouraging. A few children improve sufficiently to enable them to be transferred to junior training centres. It is the intention that special care units should form part of all new purpose built junior centres and plans have been approved for the addition of these units to the three existing purpose-built centres. 102 The Council makes a grant to the Friends of the Centre for Spastic Children of 90 per cent of the net annual cost of maintaining a special care unit for subnormal, multi-handicapped spastic children at the centre in Cheyne Walk, Chelsea. The unit, which was opened at the end of 1962 and considerably enlarged in 1963, provides accommodation for up to 30 of these severely handicapped children between the ages of two and seven years. Training of children—Training for mentally subnormal children between the ages of five and sixteen is provided in the nine junior training centres. These are open during ordinary school hours and are run as closely as possible on the lines of schools, the aim being to make the children socially acceptable and to enable them to make the fullest use of their limited potentialities. Pending the opening of new and larger centres, lack of places has precluded any general lowering of the age of admission to junior centres below five years, although it has been possible to accommodate a number of four-year-olds in the centres serving west and south west London and children of this age are admitted to other centres in special circumstances. Following the publication of the report of the Ministry of Health Sub-Committee on the training of staff of training centres for the mentally subnormal (of which Dr. J. A. Scott, the Council's former Medical Officer of Health, was Chairman), which drew attention to the need for further educational psychological research into mental subnormality, arrangements were made for educational psychologists employed in the Council's Education department to visit all the junior training centres to investigate the training potentialities of the children and to advise on training methods generally and, at the request of supervisors, on individual children. As an experiment, Montessori training has been introduced with most encouraging results at two junior centres, whose supervisors have taken a special course of training in this method of teaching. It is planned to extend the experiment to other centres as soon as the supervisory staff have completed the appropriate training. Speech therapy is provided for those children who need it and the whole range of school medical services is available to them. Midday meals are provided by the school meals service at a charge of sixpence and coach transport is provided for all juniors as well as trainees attending centres for older girls and women. Special units in day nurseries—In furtherance of the Council's intention to provide training for subnormal children from an early age, it has been possible to open special units for these children in nine of the Council's day nurseries. A total of 63 places is provided, the children being admitted on the recommendation of the medical officers conducting the special advisory clinics. In addition, the Council approved grants representing 90 per cent of approved maintenance costs of nursery units run by three local branches of the National Society for Mentally Handicapped Children. A grant to a fourth local society for a similar purpose is under consideration. The Council is represented on the management committee of these units. Play centres—Following the Council's proposal to afford additional relief to the parents of children attending junior training centres, a small number of centres have been kept open as play centres each year for four weeks of the centres' summer holiday period. Attendances at the play centres have been rather disappointing, but this additional service has been appreciated by the parents of those children who attended the centres. Training of adults—Adult centres provide accommodation for persons normally from the age of 16, the social training given in the junior centres being continued with more 103 emphasis placed on craft work and the production of useful articles. Carpentry and other crafts are taught to the boys and the older girls receive instruction in domestic crafts, such as cookery, laundry work and needlework. Industrial outwork has been introduced at most of the adult centres ; to stimulate this form of activity, an industrial manager was appointed in 1961 to negotiate orders for and generally supervise the work. There is no doubt that this new activity has been welcomed by the trainees, who have shown keenness capable of quite a wide range of work. Income received by the Council for the work done is shared between the trainees who take part in it. At the three industrial training centres, to which the most promising boys are transferred on the recommendation of the industrial manager, the trainees concentrate on industrial work. Two of the centres carry out work for the Council's Supplies department, orders to the value of about £4,000 having been completed in 1964 and the third undertakes work for outside firms. Each trainee at an industrial centre receives a daily payment of 3s., a figure calculated on the annual profits of the three centres. Some trainees from industrial centres have been able to secure and keep outside employment, but for the majority the centres must serve as a form of sheltered workshop. Part-time centres for older mentally subnormal persons—The need for centres of this kind was not regarded as a first priority when the Council's development plans were formulated, but it is now evident. A plan for an experimental centre in Camberwell in 1964 unfortunately had to be abandoned, as the premises it was hoped to use were no longer available. Training and occupation at home—When the Council made proposals under the Mental Health Act two 'home teachers' were employed to give instruction and occupation to mentally handicapped persons who were prevented by an additional handicap from attending training centres; about 40 persons were visited in 1959. A third home teacher was appointed in 1960 and since the number of persons receiving teaching remains roughly the same, it has been possible to increase the amount of attention devoted to each one. The opening of the special care unit at the Bethnal Green training centre resulted in less demand for 'home teachers' for children living in north east London and the opening of further special care units should have a similar effect. 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 necessary and practicable, both directly and through 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. It also intended to participate in the provision of such psychiatric day hospitals as were considered appropriate within the limits of its statutory functions, generally by making available the services of occupational therapists and social workers. Day rehabilitation centres—The Council's first day rehabilitation centre, Clifton Lodge, Hackney, opened in 1960 to provide for the rehabilitation of 40 persons who had been suffering from some form of mental illness with a view to their ultimate return to full community life. At first only traditional occupational therapy was available, but in 1961 a start was made on industrial work obtained through local firms and this work now forms a major part of the activity of the centre. Originally, all the persons attending were referred from the main psychiatric hospital serving the area but increasing numbers of referrals are now received from other sources. During 1964 there were 26 persons admitted to the centre and at the end of the year 34 persons were on the register. 104 The Castle day rehabilitation centre, the first specially built centre, opened in Southwark early in 1964 with accommodation for 30 persons. Activities are similar to those at Clifton Lodge and 81 persons have been admitted to the centre during the year. There were 27 on the register at 31 December. Admission to the centres are made on the recommendation of the Council's consultants in mental health and after interview by the supervisor and a mental health social worker. Persons attending the centres who carry out productive work receive, after an initial probationary period, a daily payment of three shillings. Travelling expenses are refunded and meals provided at a charge of two shillings, which is abated in cases of need. When the Council's ten-year development plan was formulated in 1962, it was proposed to open two additional day rehabilitation centres during the period 1967 to 1972. Five further such centres by 1973 were proposed when the first annual revision of the plan was carried out, so that there would be a centre of this kind within easy reach of persons living in all parts of London. Day centres for chronic mentally ill persons—A day centre for 20 chronic mentally ill persons opened in Shoreditch in 1962, its purpose being to prevent further deterioration by providing a meeting place for patients for a few hours daily and some occupational and educational interests to relieve relatives from the care of patients and to provide an opportunity for them to discuss and receive advice on personal problems and difficulties from the Council's mental health workers. Some industrial work was carried out and after an initial probationary period persons taking part received a daily payment of two shillings. Further centres of this type have since been opened in Camberwell (40 places), Hackney (30 places), Bethnal Green (40 places), Lewisham (14 places part-time) and Deptford (12 places part-time); a number of additional centres in other parts of London are in the planning stage. Voluntary centres—Since 1949 the Institute of Social Psychiatry has provided a centre, the Blackfriars rehabilitation centre, for the rehabilitation of mentally ill persons and the Council has contributed 90 per cent of the approved cost of attendance of London residents. As there was only one centre, it was necessary for persons needing to attend on a long term basis to be treated in association with those who were recoverable, but in 1961 the Institute opened a second centre, Crossway rehabilitation centre, which was also grant aided on the same basis by the Council. This centre was adapted to cater for recoverable mentally ill persons capable of some industrial work and there is special emphasis on work routine and work tolerance with a view to their eventual rehabilitation in the community. At the Blackfriars centre, which caters for those who are more withdrawn and require long term attendance, the emphasis is on group activities and resocialisation in the group, thus encouraging them to live a fuller life outside the centre. During 1964, 70 persons resident in London were admitted to the two centres and at the end of the year there were 76 London persons on the registers. In 1962 the Psychiatric Rehabilitation Association opened a day centre for 40 mentally ill persons in Hackney and a similar centre for 40 persons in Stepney in 1963. The Council makes a grant of 90 per cent of the approved maintenance costs of the centres. Grants are also made to the Blackfriars Settlement in respect of the attendance of mentally ill persons at the Settlement's occupational work centre and to Trinity Church, Poplar, in respect of a centre in East India Dock Road for older persons who have been discharged from the day hospital at St. Clements hospital. 105 Occupation and instruction in the home—In 1961 an experiment was carried out in two health divisions, where the part-time services of occupational therapists previously employed on work with tuberculous patients were given to the home teaching and occupation of mentally ill persons. The experiment was welcomed by hospital doctors and general practitioners and has since been extended to other health divisions. By the end of 1964 the employment of occupational therapists for a total of 78 sessions a week had been authorised for this work. Simple industrial work is carried out by some home-bound persons and payments on the same basis as at day centres for chronic mentally ill persons are made to them. Social clubs—Since 1948 the Council has contributed 90 per cent of the approved cost of attendance of London residents at the psycho-therapeutic social clubs run by the Institute of Social Psychiatry, which include a drama group and a youth club. The clubs meet on one evening a week under the guidance of a psychiatrist and a social therapist. In addition, the Council gives financial assistance towards the cost of clubs run by psychiatric hospitals for persons living in their catchment areas and psychiatric departments of general hospitals, to a club run by the psychiatric department of one of the London teaching hospitals (which has an average attendance of 50) and to other voluntary organisations. St. Olave's psychiatric day hospital, which is run in association with the Council's mental health staff, has its own associated social club. The Council runs its own social clubs in Hackney (Clifton Lodge and Hindle House day centres), Shoreditch (Shoreditch day centre), Putney (Putney health centre), Stoke Newington (Woodberry Down health centre), Islington, Fulham, Lewisham, Poplar and Wandsworth. These clubs are well attended and consideration was being given at the end of the year to the establishment of further clubs of this kind in other parts of London. The present clubs cater for a maximum of 400 persons weekly. In 1964 the Council agreed to make a grant to the Central After-Care Association towards the cost of establishing the Circle Trust Club, a club for discharged prisoners who suffer from some form of mental disorder and to the Blackfriars Settlement in respect of a social club for mentally disordered persons. Psychiatric day hospitals—The Council co-operated with the South East Metropolitan Regional Hospital Board and the Bermondsey and Southwark and Cane Hill Hospital Management Committees in the establishment in 1960 of a psychiatric day hospital at St. Olave's hospital, Bermondsey. The Council assumed responsibility for the provision of occupational therapy for those patients attending the day hospital who would benefit from it; this entailed the appointment of an occupational therapist and the provision of equipment and materials. In addition, the Council meets the cost of providing recreational activities for the patients, such as tennis and ballroom dancing, which are considered to be of a therapeutic nature. In view of a marked increase in the number of persons attending the day hospital a second occupational therapist was authorised in 1964. A social worker who attends the day hospital is also a member of the Council's staff. Experience of the working of the day hospital has been very encouraging; it has been possible to treat a wide range of physical illness and patients who have been able to travel daily from home and a number of persons who would otherwise have needed in-patient treatment have been catered for satisfactorily as day patients. Since 1962 the Council has co-operated with the hospital services in the provision of occupational therapy and social worker services at further day hospitals set up by Bexley Hospital Management Committee, at Castlewood hospital, Woolwich; by the Paddington Group Hospital Management Committee in Torquay House, Harrow Road, W.9, and by Westminster hospital, Vincent Square, S.W.I. Co-operation on a similar basis in respect of a fifth day hospital at the West Park and St. George's day hospital 106 centre, Tooting, began in 1963 and the provision of a second occupational therapist was authorised in 1964. The Council also agreed to cooperate with Tooting Bec hospital by allocating a psychiatric social worker for half time at Tooting Bec day hospital. Social work with alcoholics—Since 1963 the Council has made a grant to the Royal London Discharged Prisoners' Aid Society, representing 90 per cent of the salary of a social worker employed on work with alcoholics, both prior to and after discharge from Wandsworth Prison. Samaritan service—Since 1964 the Council made a grant to the St. Giles Centre (formerly Camberwell Samaritans), towards the cost of employing a psychiatric social worker to organise the social work of the centre and the training of a corps of 'Befrienders' for persons faced with social problems. A grant to the Samaritans towards the cost of services provided for persons on the verge of suicide was authorised in 1964. Crude spirit drinking—Following a noticeable increase in crude spirit drinking in certain parts of London, particularly Stepney, Southwark and the City of London, the Council in 1963 set up a special sub-committee to consider this problem. During 1964 a large number of interested statutory and voluntary bodies were contacted and invited to give their views as to the best way of dealing with the problem and a comprehensive report by the sub-committee was submitted to the Council early in 1965. Social work in the mental health service The Principal Mental Health Social Worker reports: The mentally 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. 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 come from many quarters and the number known to the service increases steadily. The community has, of course, always carried a heavy burden of mental illness but until comparatively recently the load was lightened by long term hospital care, 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, 107 h many still 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. The needs of parents of patients and relatives are various. For some a friendly visit and re-assurance that help is available is enough, others may require constant care over a long period. Visits may need to be frequent and of a length that enables social worker and patient or relative to develop a knowledgeable and friendly relationship that will be supportive whilst also, where possible, enabling a progressive independence to be established. For cases requiring special skills, psychiatric social workers in the mental health teams are available. They are also able to offer advice and consultation to mental health social workers who seek help with their more difficult problems. Steps taken to prevent further breakdown or assist rehabilitation 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 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 health social worker. 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 health social workers remain in close touch with all severely subnormal children and also with 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 108 number of officers attend centre open days; these afford a valuable opportunity for fostering good relationships with the family and liaison with centre staff. Closeness of contact is usually maintained by mental health social workers 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. 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. Hostels for the mentally disordered—Social work for the residents of the three hostels so far established by the Council is undertaken by a mental health social worker or psychiatric social worker from the division in which the hostel is situated, although contact may be maintained by a social worker from another division with certain residents needing this kind of continuing relationship. The role of the social worker includes close co-operation with the youth employment service and child care officers in the case of subnormal girls and with employment officers, employers, psychiatric out-patient clinics and the hospitals in that of the mentally ill. The social worker must also work closely with the staff of the hostel on all that concerns the well-being of the residents, such as employment conditions, recreational activities, relationships within the group and personality difficulties. They must also play their part in helping to establish in the community those subnormal girls and mentally ill adults who are ready to go into lodgings, residential work or their own homes and arrange where necessary for their follow-up and care by the local mental health social worker or other social worker. 109 H* Day centres and social clubs—The essential, individual help that is given by social workers will release potentials that can find healthy and constructive outlets in the activities of a centre. The social worker may need to persuade the over-protective parent of the adult subnormal that there is reward for both if the subnormal is allowed to attend a centre. The parent will gain regular daily relief from the arduous task of care ; the subnormal gains from social exchange and learns to develop self-reliance and new skills. But in the case of the mentally ill, the relatives are often glad for the patient to attend a day centre, though the patient may need encouragement and persuasion to try it. Once the initial difficulties are overcome these centres are found to benefit the whole family situation. Social clubs are also necessary and important functions in the rehabilitation of the mentally ill as they enable social workers to introduce patients into groups which help to reduce the sense of social isolation and increase the channels of communication with others. 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 health social workers have actively participated in the meetings held at divisional level to which general practitioners and others were invited. During the year they 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. In the wider field talks have been given to students attending various social work training courses, welfare officers in other fields, nurses in hospital and there has been a growing demand from training colleges and universities for student placements in the divisional teams. It can be said that the educational role of the mental health social 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. 110 Statistics Details of the work of the mental health service during 1964 are given in the following tables, with comparative figures for 1963 in italics. Table (i)—Source of referral of all cases Mentally ill Subnormal and severely subnormal Total 1964 Total 1963 With a view to hospital admission Community care No. % No. % No. % No. % No. % Psychiatric hospital or ward 608 13.0 999 35.9 1ll 9.4 2,471 28.5 2,568 28.8 Psychiatrist at general ward 303 6.5 80 2.9 Non-psychiatric referrals from hospitals 340 7.3 30 1.1 Psychiatric out-patient clinic or day hospital 182 3.9 257 9.2 41 3.5 538 6.2 387 4.4 Non-psychiatric hospital outpatient – – 58 2.1 General practitioner 1,832 39.1 295 10.6 19 1.6 2,146 24.8 2,496 28.1 Police or court 452 9.6 25 0.9 28 2.4 505 5.8 622 7.0 Patient or relative 270 5.7 253 9.1 71 6.0 594 6.9 618 6.9 Landlord or neighbour 156 3.3 — — — — 156 1.8 173 1.9 Education officer 546 11.6 101 3.6 601 50.7 2,246 26.0 2,028 22.9 Health visitor 49 1.8 75 6.3 National Assistance Board — — — .– Miscellaneous* 636 22.8 238 20.1 Total 1964 4,689 100.0 2,783 100.0 1,184 100.0 8,656 100.0 Total 1963 5,543 2,155 1,194 8,892 8,892 100.0 * Includes other departments of L.C.C., other local authorities, government departments and welfare associations. Table (ii)—Initial action and final disposal of mentally ill persons referred to mental health social workers with a view to removal to hospital Initial action Final disposal No. % No. % Informal admission 838 (1,017) 17.9 (18.3) 2,263 (2,596) 48.3 (46.8) Compulsory admission: For observation (sec. 25) 977 (973) 20.8 (17.5) – – – – Emergency admission for observation (sec. 29) 1,583 (1,874) 33.8 (33.8) – – – – For treatment (sec. 26) 100 (79) 2.1 (1.4) 367 (402) 7.8 (7.3) Court order 199 (300) 4.2 (5.4) 199 (202) 4.2 (3.6) Absent from hospital without leave (sec. 40) 9 (2) 0.2 (0.0) 9 (9) 0.2 (0.2) Psychiatric out-patient clinic or day hospital 111 (148) 2.4 (2.8) 111 (149) 2.4 (2.7) General ward for physical care 42 (59) 0.9 (1.1) 42 (80) 0.9 (1.4) Community care from general practitioner, Welfare dept., etc 133 (194) 2.8 (3.5) 133 (194) 2.8 (3.5) Other cases, including no further action 694 (897) 14.8 (16.2) 1,562 (1,191) 33.3 (34.5) Not known 3 — 0.1 — 3 — 0.1 — 4,689 (5,543) 100.0 (100.0) 4,689 (5,543) 100.0 (100.0) 111 Table (iii)—Hospital admissions dealt with by mental health social workers 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 65 years and over Total Under 65 years 65 years and over Total No. % No. % No. % No. % No. % No. % Informal admission 632 21.8 206 34.1 838 240 1,764 83.6 499 95.8 2,263 86.0 (770) (23.8) (247) (35.0) (1,017) (25.8) (2,033) (84.6) (563) (94.8) (2,596) (86.6) Compulsory admission: For observation (sec. 25) 770 26.6 207 34.3 977 27.9 – – – – – – (743) (23.0) (230) (32.6) (973) (24.7) — — — — — — Emergency admission (sec. 29) 1,399 48.4 184 30.4 1,583 45.2 – – – – – – (1,649) (50.9) (225) (32.0) (1,874) (47.5) — — — — — — For treatment (sec. 26) 93 3.2 7 1.2 100 2.9 345 16.4 22 4.2 367 14.0 (76) (2.3) (3) (0.4) (79) (2.0) (371) (15.4) (31) (5.2) (402) (13.4) Total 2,894 100.0 604 100.0 3,498 100.0 2,109 100.0 521 100.0 2,630 100.0 (3,238) (100.0) (705) (100.0) (3,943) (100.0) (2,404) (100.0) (594) (100.0) (2,998) (100.0) Table (iv)—Disposal of cases referred specifically for community care (a) Suffering or suspected to be suffering from mental illness 1964 1963 No. % No. % Hospital care: Informal admission 84 3.0 73 3.4 Compulsory admission 40 1.4 33 1.5 Psychiatric out-patient clinic or day hospital 23 0.8 55 2.6 Community care of mental health service 2,025 72.9 1,634 75.8 Other community care, e.g., Welfare or Children's depts., general practitioner, probation officer, etc. 57 2.0 70 3.2 No further action 554 19.9 290 135 No. of persons involved 2,783 100.0 2,155 1000 (b) Mentally subnormal and severely subnormal 1964 1963 No. % No. % Hospital care 55 4.6 67 5.7 Community care of mental health service: Residential home, hostel, convent, etc. 42 902* 76.3 49 924* 77.3 Attendance at training centre 61 78 Receiving visits from m.h.s.w 885 895 Other types of community care 24 24 Other community care, e.g., Welfare or Children's depts., general practitioner, probation officer, etc. 68 5.7 45 3.8 No further action 159 13.4 158 13.2 Miscellaneous — — — — No. of persons involved 1,184 100.0 1,194 100.0 *Number of persons; some cases are being visited as well as receiving some other form of care. 112 Table (v)—Persons receiving community care at 31.12.64 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. 279 52 4.1 102 2.8 154 3.1 433 (230) (42) (3.3) (92) (2.4) (134) (2.6) (364) Boarded out 2 4 0.3 56 1.5 60 1.2 62 (5) (0.4) (60) (1.6) (65) (1.3) (68) Home training 27 17 1.3 36 1.0 53 1.0 80 (17) (1.3) (28) (0.7) (45) (0.9) (45) Attendance at day centres. 350 – – – – – – 350 (218) — — — — — — (218) Attendance at social clubs for mentally ill* 475 — — — — — — 475 (526) — — — — — — (526) Training centres for subnormal and severely subnormal – 623 48.9 784 21.2 1,407 28.4 1,407 (668) (52.1) (740) (19.5) (1,408) (27.7) (1,408) Receiving visits from m.h.s.w. or p.s.w. 3,055 1,214 95.2 3,579 96.6 4,793 96.0 7,848 (2,427) (1,226) (95.7) (3,671) (96.5) (4,897) (96.5) (7,324) Other types of community care 165 61 4.8 101 2.7 162 3.2 327 (146) (37) (2.9) (117) (3.1) (154) (3.0) (300) †No. of persons involved. 3,322 1,275 – 3,706 – 4,981 – 8,303 (2,664) (1,281) (3,795) (5,076) (7,740) *Some patients who are not included were attending clubs which receive financial or other help from the Council. † Some persons were receiving more than one type of service. 113 SCHOOL HEALTH SERVICE Pupils on day school rolls— Type of School January 1965 January 1964 Primary 234,982 232,242 Secondary 169,648 171,463 Nursery 2,422 2,188 Special 8,422 8,319 Hospital 271 386 Total 415,745 414,598 Medical inspection Details of medical inspections during 1964 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 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. 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 1964 was 37.3 per cent of the school roll, compared with 37.0 per cent. in 1963 and 39-3 per cent. in 1962. It is of interest that of the 11,285 special inspections, over half were requested by head teachers, a quarter by school health visitors and one-tenth by parents. In an experiment started during 1962, the routine examination of the seven to eight years age group was suspended in selected schools to allow more time for the examination of children considered to be in need of particular attention. This experiment has been extended to further schools throughout the county but the number of inspections is not yet sufficient to allow a full assessment of its value. Preliminary findings indicate a much greater yield of defects noted, proportionally about a third more eye defects, twice as many defects for tonsils and adenoids, speech, lungs, nervous, psychological, rheumatism and enuresis and about three times as many cervical gland defects. During the year 3,791 pupils were interviewed or discussed at case conferences and found not to warrant a medical examination. The total number of medical inspections (periodic and other) carried out in 1964 was 277,464. Periodic general medical inspections Age groups 1962 1963 1964 No. % No. % No. % /o 4 and less 7,995 4.9 7,874 5.1 8,166 5.3 5 28,647 17.4 27,811 17.9 28,667 18.5 6 8,972 5.5 9,670 6.2 10,778 6.9 7 9,039 5.5 9,345 6.0 9,300 6.0 8 20,783 12.7 19,585 12.6 20,501 13.2 9 5,843 3.6 5,199 3.3 5,655 3.6 10 2,109 1.3 2,051 1.3 2,525 1.6 11 10,416 6.3 11,636 7.5 11,502 7.4 12 18,992 11.6 18,578 11.9 16,954 10.9 13 6,280 3.8 6,366 4.1 5,496 3.5 14 8,152 5.0 5,316 3.4 4,508 2.9 15 and over 36,828 22.4 32,072 20.7 31,221 20.2 Total 164,056 100.0 155,503 100.0 155,273 100.0 114 Non-routine medical inspections 1962 1963 1964 Reinspections 73,794 71,675 72,911 Secondary school reviewals 1,994 1,637 1,497 Other non-routine inspections (see next table) 46,682 47,685 47,783 Total 122,470 120,997 122,191 Analysis of non-routine medical inspections Nature of inspection Number inspected 1962 1963 1964 Bathing centre inspections—scabies 23 25 24 Bathing centre inspections—other 31 31 93 Employment certificates 4,226 3,910 4,421 Licences for theatrical employment 399 419 381 School journeys 20,556 20,847 20,520 Recuperative holidays—before holiday 952 1,216 1,200 —on return 69 31 80 Candidates for higher awards 50 41 79 Nautical School entrants 159 107 104 Outward Bound and Adventure courses 183 229 167 T.B. contacts 7 25 9 Boarding schools for the delicate— Before departure 133 171 182 On return 38 28 35 Other handicapped pupils— Statutory examination 1,175 1,631 1,675 Periodic special defect examination 5,795 5,897 5,924 Research investigations and enquiries 339 384 199 34,135 34,992 35,093 Specials, at request of: Head teacher—special book 1,572 1,321 1,554 —other 4,496 4,209 4,605 School nurse—after health survey 1,076 932 1,005 —other 1,819 1,899 1,867 Divisional officer (Education) 716 805 722 Divisional school care organiser or care committee 485 582 441 Parent 1,175 1,158 1,091 11,339 10,906 11,285 All other non-routine inspections 1,208 1,787 1,405 Total 46,682 47,685 47,783 Pupils found at periodic general medical inspections to require treatment (excluding dental treatment and disinfestation) Age groups inspected For defective vision (excluding squint) For other conditions Total individual pupils 4 or less 26 686 709 5 294 2,433 2,679 6 223 1,048 1,228 7 690 819 1,442 8 1,617 1,606 3,075 9 526 555 1,023 10 221 239 438 11 1,376 670 1,963 12 1,932 985 2,794 13 656 304 919 14 583 200 757 15 or over 4,219 986 5,054 12,363 10,531 22,081 115 Defects noted at routine medical inspections—The percentage of children referred for treatment of a defect was 14.2 in 1964 compared with 13.4 in 1963. The comparative percentages for sex and age are shown in the following table. The percentage referred for vision defects has increased from 7.1 in 1962 to 8.0 in 1964; for other defects it has increased from 6.4 in 1963 to 6.8 in 1964. In nearly all age groups the percentages of boys and girls referred for treatment of vision defects have increased over those of last year. Vision defects are dealt with in more detail in a later paragraph. If the figures for the percentage of children found to have defects in those age groups where the largest numbers of children were examined are compared with those for 1963, marked increases are apparent in respect of boys and girls aged 15 or over, and less marked ones in respect of boys aged 5 and 12; for 8-year-old boys there is a decrease and no appreciable change in respect of the girls aged 5, 8 and 12. For boys and girls aged 15 and over and for boys aged 12 the increases are attributable to increases in vision defects but for boys aged 5 the increase was greater in other defects. In the case of boys aged 8 the decrease was attributable solely to a decrease in vision defects. Percentage of children noted for treatment Age and sex All defects Vision defects Defects other than vision 1962 1963 1964 1962 1963 1964 1962 1963 1964 4 Boys 8.6 9.8 9.3 0.3 0.2 0.2 8.3 9.6 9.1 Girls 7.9 7.6 8.0 0.3 0.3 0.4 7.6 7.3 7.7 5 Boys 8.6 9.8 10.4 0.8 1.0 1.2 8.0 8.9 9.3 Girls 7.9 8.0 8.2 0.9 1.0 0.8 7.1 7.2 7.6 6 Boys 11.3 12.4 12.6 1.6 2.2 2.3 9.8 10.6 10.8 Girls 9.5 10.1 10.1 1.5 2.0 1.9 8.3 8.3 8.6 7 Boys 15.0 15.6 16.6 6.4 7.1 7.4 9.4 9.3 10.1 Girls 14.1 13.4 14.4 7.4 6.7 7.4 7.5 7.4 7.5 8 Boys 13.7 16.1 15.5 7.0 8.3 7.7 7.3 8.6 8.6 Girls 12.4 14.4 14.5 7.0 8.3 8.1 6.0 6.8 7.0 9 Boys 14.3 16.2 18.6 6.4 7.8 9.3 8.4 9.2 10.3 Girls 14.1 15.5 17.5 7.9 8.8 9.3 7.0 7.5 9.3 10 Boys 15.4 17.4 19.0 7.0 8.6 9.0 9.3 9.4 11.2 Girls 14.9 15.4 15.6 8.7 8.4 8.5 6.7 8.0 7.7 11 Boys 12.4 13.3 15.6 8.1 8.9 10.5 4.9 4.9 5.7 Girls 17.2 17.9 18.5 12.1 13.0 13.4 6.0 5.5 6.0 12 Boys 14.3 14.4 15.1 9.8 9.6 10 1 5.1 5.5 5.6 Girls 17.2 17.8 18.0 11.4 12.5 12.9 6.6 6.2 6.0 13 Boys 13.0 14.9 15.8 8.8 10.7 10.7 4.7 4.8 5.8 Girls 17.5 18.6 17.7 11.9 13.2 13.3 6.6 6.2 5.2 14 Boys 11.7 13.7 15.9 9.0 10.8 11.7 2.9 3.5 4.6 Girls 15.5 16.4 17.8 12.2 12.6 14.3 4.0 4.5 4.2 15 and over Boys 11.8 12.5 13.8 9.5 10.2 11.5 2.6 2.7 2.7 Girls 14.9 16.9 18.6 12.1 13.5 15.5 3.3 4.1 3.6 Total Boys 12.0 13.1 13.9 6.4 6.9 7.2 6.0 6.7 7.2 Girls 13.2 14.1 14.6 7.8 8.4 8.7 5.9 6.2 6.4 Total Both sexes 12.6 13.6 14.2 7.1 7.6 8.0 6.0 6.5 6.8 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 total percentage referred for treatment. The following table shows the percentage of children of all ages noted for treatment or observation of the defects listed for the years 1961 to 1964. These percentages remain fairly stable over the period but some variations of detail will be noted. 116  1961 1962 1963* 1964 Numbers examined 163,598 164,056 155,503 155,273 Percentages Skin diseases 1.19 114 1.17 1.18 External eye diseases 0.54 0.48 0.51 0.41 Defective hearing 0.90 0.99 1.05 1.15 Otitis media 0.51 0.49 0.49 0.54 Enlarged tonsils and adenoids 3.59 3.72 3.65 3.57 Defective speech 0.87 0.89 0.95 1.00 Enlarged cervical glands 0.63 0.66 0.65 0.60 Heart and circulation 0.87 0.86 0.94 1.00 Lung disease (not T.B.) 1.21 1.25 1.40 1.46 Orthopaedic defects 3.52 3.31 3.39 3.00 Defects of nervous system 0.43 0.43 0.46 0.56 Psychological defects 1.08 1.06 1.44 1.42 Anaemia 0.12 0.11 0.12 0.13 Enuresis 1.77 1.96 2.28 2. 41 * Details of children examined at age seven under the experimental selective arrangements have now been included in this column although omitted from the corresponding table in the Report for 1963. Attendance of parents and care committee representatives at periodic inspections—The percentage of medical inspections at which a parent is present decreases as children get older. The overall percentage was 50.9, slightly higher than in 1963 when it was 49.6 per cent. Care committee representatives attended 85.0 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 76 per cent. in the secondary school age groups. This was probably the result of a shortage of care committee workers in some large secondary schools. Attendance of parents and care committee representatives Age group Number of pupils inspected Parent present Care committee representative present at inspection % % 4 or less 8,166 93.3 80.5 5 28,667 86.7 92.7 6 10,778 78.4 94.4 7 9,300 70.9 91.8 8 20,501 69.4 94.6 9 5,655 61.7 94.0 10 2,525 52.0 92.4 11 11,502 36.2 74.9 12 16,954 29.6 79.6 13 5,496 24.0 82.7 14 4,508 9.8 81.6 15 31,221 5.0 73.1 117 Physical condition of pupils The classification of pupils' physical condition at medical inspections during 1964 and the four preceding years is set out below. Physical condition Nutrition defect noted for Satisfactory Unsatisfactory Treatment Observation % % % % 1960 99.0 10 0.2 0.5 1961 99.2 0.8 0.2 0.4 1962 99.4 0.6 0.2 0.4 1963 99.4 0.6 0.2 0.4 1964 99.4 0.6 0.2 0.5 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 five years' figures are: Percentage unsatisfactory physical condition Year of birth Year of examination 1960 1961 1962 1963 1964 1945 0.4 — — — — 1946 0.6 | 0.4 — — — 1947 0.8 0.4 0.3 — — 1948 0.9 0.6 0.3 0.4 — 1949 0.9 0.6 0.5 0.5 0.3 1950 2.2 0.6 0.5 0.6 0.6 1951 1.6 1.7 0.4 0.5 0.7 1952 11 1.5 0.9 0.5 0.6 1953 1.8 1.0 0.9 1.2 0.7 1954 1.8 1.2 0.8 0.8 1.1 1955 1.2 1.8 0.9 0.8 10 1956 10 0.7 0.8 0.8 0.5 1957 — 0.8 0.6 11 0.9 1958 — — 0.8 0.7 10 1959 — — — 0.6 | 0.5 1960 and later — — — — 0.3 School meals and milk The Department of Education and Science 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 22 September or the nearest normal school day thereto. The figures are set out below with those for 1963 in brackets. Number of Number who took Type of school children school dinners present On payment Free Total % Secondary 152,895 91,877 8,076 99,953 65.37 (158,824) (95,347) (8,010) (103,357) (65 08) Primary 207,319 121,281 15,014 136,295 67 19* (205,055) (115,640) (14,098) (129,738) (64.22) Special 5,553 4,235 1,239 5,474 98.58 (5,652) (4,275) (1,233) (5,508) (97.45) Nursery 1,961 755 69 824 98.211 (1,870) (885) (95) (980) (96.55) 367,728 218,148 24,398 242,546 66.98* (371,401) (216,147) (23,436) (239,583) (65.19) * Percentage of 202,846 children, as 4,473 children attended half time and did not have dinners. †Percentage of 839 children, as 1,122 children attended half time and did not have dinners. ‡Percentage of 367,505 children. 118 On the selected day 303,527 children in Council-maintained schools took milk compared with 300,383 in September, 1963. Of 28,974 children present in independent schools, 21,278 had milk under the scheme. The percentages for the several types of school for the corresponding days were: 1960 1961 1962 1963 1964 Secondary 66.05 63.12 61.08 59.64 61.72 Primary 96.32 96.51 96.01 95.42 96.05 Day special 98.47 99.18 97.32 97.26 97.59 Nursery 98.51 98.67 97.86 96.84 9704 Boarding 98.51 97.52 98.41 97.42 98.64 Independent 74.60 77.66 74.62 71.90 73.44 Vision Visual acuity standards expressed as percentages of the numbers of children whose eyes were tested are set out in the following table. The proportion of children not already wearing spectacles who are referred for treatment does not vary much from one age group to another, 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, 0.7 per cent, were noted for treatment of squint, compared with 0.6 per cent, in 1961, 1962 and 1963. The percentage ranged from 1.4 in the entrant group to 0.1 in the leaver group. Boys Age group Not wearing spectacles Wearing spectacles 6/6 6/9 6112 or worse Referred for treatment 6/6 6/9 6/12 or worse Referred for treatment Under 7 87.5 6.6 4.4 4.9 0.7 0.3 0.5 0.5 7 80.1 9.7 6.5 6.5 1.3 10 1.4 1.6 8 81.4 8.6 5.3 5.6 1.5 1.2 2.0 2.2 9 80.0 7.9 6.7 7.0 1.8 1.6 2.0 2.5 10 82.5 5.9 6.8 7.0 1.7 1.4 1.7 2.2 11 79.3 5.7 6.5 6.7 3.7 2.4 2.4 3.8 12 79.7 5.7 6.0 6.0 3.6 2.3 2.7 4.1 13 80.3 4.7 6.4 6.1 4.0 2.5 2.1 4.6 14 78.5 4.6 6.9 6.5 4.3 2.7 3.0 5.3 15 and over 76.7 4.1 6.0 5.7 7.0 2.9 3.3 5.9 Total 80.0 6.2 5.9 5.9 3.6 2.0 2.3 3.6 119 Girls Age group Not wearing spectacles Wearing spectacles 616 6/9 6/12 or worse Referred for treatment 6/6 6/9 6112 or worse Referred reatment Under 7 88.8 6.3 3.4 3.8 0.7 0.3 0.5 0.4 7 79.2 10.6 6.3 6.7 1.6 1.0 1.3 1.4 8 79.8 9.5 5.6 5.8 1.9 1.4 1.8 2.4 9 78.8 8.9 2.1 7.0 1.7 1.6 1.9 2.4 10 80.6 8.1 5.4 6.3 2.1 1.4 2.4 2.4 11 75.2 7.0 6.9 7.8 4.4 3.3 3.2 5.7 12 76.2 6.0 6.8 7.5 4.6 3.1 3.3 5.4 13 76.6 6.2 7.0 8.1 4.8 2.4 3.0 5.4 14 76.4 5.5 6.0 7.6 5.4 2.6 4.1 6.7 15 and over 72.3 4.8 6.3 6.6 9.0 3.9 3.7 8.9 Total 77.3 6.9 6.0 6.6 4.6 2.5 2.7 4.9 note : The percentages of children referred for treatment differ slightly from those quoted in the defects for treatment table on page 116 in which the percentages were based on the number of children medically inspected. Personal hygiene Health surveys—The number of comprehensive health surveys conducted in 1964 was six per cent, less than that conducted in 1963. There was an increase of 11 per cent, in the number of selective health surveys. No. found Pupils found to be verminous No. examined verminous % of No. examined Comprehensive health surveys* 274,128 2,659 0.97 1293,770) (2,401) (0.82) Selective health surveys* 157,390 3,150 2.00 (141,130) (2,557) (1.81) * 1963figures in brackets. The number of individual children found to be verminous at both types of survey in 1964 was 3,135, an increase of 279 over the number in 1963 and a reversal of the downward trend of recent years. Percentage found to be verminous at health surveys 1960 1961 1962 1963 1964 Comprehensive surveys 0.93 0.90 0.83 0.82 0.97 Selective surveys 1.24 1.77 1.83 1.81 2.00 The introduction in 1960 of Lorexane No. 3 shampoo throughout the county swiftly brought about a decline in the percentage of children found at comprehensive surveys to be verminous, but 1964's figure shows a sharp increase and a return to just above the 1960 level. Most of this increase was accounted for by abnormal figures in division 3; but even excluding this division the percentage for the rest of the county was 0.86, again a reversal of the trend of recent years. Selective surveys have also indicated an increase in the percentage of infestation. These of course are concentrated on schools whose ' infestation ' record indicates a need. If the frequency and number of the selective surveys is increased (16,260 more were carried out in 1964 than in 1963) and the examinations restricted to known likely cases, it is to be expected that this percentage would increase without necessarily indicating that the incidence of infestation is greater. Excluding division 3, the percentage for the rest of the county was 1.94 for selective surveys. It should be noted that the overall trend has been for the proportion found verminous to increase at selective surveys since their introduction in 1959/60. 120 Nevertheless, the rise in the percentage figure for infestation found at comprehensive surveys and the increase in the number of individual children found verminous at comprehensive surveys, coupled with an increase in the number of cases treated at bathing centres, reinforce the suggestion of an increase in the number of verminous cases. The problem is how much of the increase is due to improved case finding and how much of it is a real increase, which poses the question of the cause of any such increase. This is a matter worthy of further investigation, which it will receive. Details of the work done under the cleansing scheme are shown below. The emphasis of the cleansing scheme as now carried out is on the children being cleansed by the parents at home, where any other verminous members of the family may, in the privacy that the home affords, also use the Lorexane No. 3 shampoo, eradicating a possible source of recurring infestation. In about nine per cent, of the instances where children were found verminous at comprehensive and selective surveys the issue of advice alone was necessary; in about 74 per cent, a tube of Lorexane No. 3 shampoo was given. For the remaining 17 per cent, voluntary attendance at bathing centres was sought and on six occasions statutory notices were issued to enforce attendance. (93 such notices were issued in 1962.) Cleansing scheme 1960 1961 1962 1963 1964 Advice notice only issued 2,381 575 405 483 530 Advice notice with Lorexane No. 3 6,552 4,488 4,087 3,709 4,305 Number of pupils referred for further action N/A 1,204 996 766 993 Pupils attending bathing centre voluntarily 1,628 735 758 617 804 Statutory cleansing notices issued 320 62 93 8 6 Pupils cleansed after service of statutory notice: Voluntarily 84 18 12 3 2 Compulsorily 197 37 81 5 4 Total 281 55 93 8 6 Bathing centres—The number of cases of infestation with vermin treated at bathing centres showed an increase of 29 per cent, compared with 1963 and the number of attendances for treatment a similar increase. 1960 1961 1962 1963 1964 Scabies Pupils treated 637 514 458 451 534 Vermin Pupils treated 3,441 2,265 1,983 1,813 2,349 Treatments needed 4,345 2,764 2,422 2,242 2,905 Impetigo Pupils treated 1,020 1,033 903 699 675 Ringworm New cases 10 7 6 5 6 Employment of schoolchildren Medical examinations were carried out divisionally of 4,421 children with a view to the issue of employment certificates and 381 medical examinations were carried out at the County Hall in respect of employment under licence in public entertainments. 121 Choice of employment The percentage of school leavers advised against particular forms of employment was 13.0 per cent, of those inspected, only 0.2 per cent, less than that for 1963. For boys the figure fell slightly from 15.2 per cent, in 1963 to 15.1 per cent, and for girls it fell from 11.3 per cent, to 10.7 per cent. As in recent years, work involving 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 248 128 Sedentary work 12 6 Indoor work 3 — Exposure to bad weather 108 102 Wide changes of temperature 61 144 Work in damp atmosphere 77 73 Work in dusty atmosphere 151 103 Much stooping 46 36 Work near moving machinery or moving vehicles 116 80 Prolonged standing, much walking or quick movement from place to place, work at heights 248 175 Normally acute vision 1,246 960 Normal colour vision 334 2 Normal use of hands 32 12 Work requiring freedom from damp hands and skin defects 22 27 Handling or preparation of food 51 24 Normal hearing 71 39 Any other work which would be unsuitable 28 10 Unfit for any employment — 1 note: An individual may be noted for two or more contra-indications. Infectious diseases in schools When a pupil was absent from school and the cause either known or suspected to be due to infectious disease, the head of the school notified 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 nurse/health visitor and, if necessary, by a school doctor, in order to investigate the situation and take whatever control action is necessarv. The numbers of cases of infectious diseases reported during 1964 and the preceding years are given below: I960 1961 1962 1963 1964 Chicken-pox 8,357 5,895 8,332 7,176 6,868 Dysentery, diarrhoea or enteritis 1,557 669 988 3,180 1,355 German measles 631 3,891 12,332 1,314 2,006 Impetigo 194 187 193 167 191 Influenza 229 127 183 140 97 Jaundice 253 493 274 106 217 Measles 2,544 14,343 2,875 6,141 4,091 Mumps 8,783 2,338 1,677 8,250 5,821 Ophthalmia and conjunctivitis 299 536 645 277 289 Ringworm (scalp) 8 10 10 18 12 Ringworm (body) 51 26 19 18 22 Scabies 76 78 59 65 66 Scarlet fever 721 634 526 548 940 Sore throat and tonsillitis 905 1,416 911 1,302 1,643 Whooping cough 1,454 395 245 879 514 122 Prophylaxis—The 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 68, 69 and 70. Age group Number of pupils inspected 0/ /o vaccinated against smallpox o/ /o immunised against diphtheria 0/ /o immunised against whooping cough % vaccinated against poliomyelitis 4 or less 8,166 80.0 90.8 89.2 84.7 5 28,667 77.6 86.7 83.8 82.2 6 10,778 741 81.0 76.7 77.1 7 9,300 770 86.0 78.6 83.5 8 20,501 75.8 89.2 80.1 85.2 9 5,655 71.5 83.0 73.2 78.3 10 2,525 69.3 71.2 59.8 69.2 11 11,502 72.6 88.7 71.9 85.0 12 16,954 69.9 88.2 64.8 82.3 13 5,496 69.0 83.6 60.2 77.9 14 4,508 69.9 81.9 53.9 75.9 15 and over 31,221 70.1 84.9 57.9 81.5 Medical treatment of schoolchildren Treatment statistics—The number of sessions, new cases and total attendances at school. children's clinics during 1964 (including sessions held in hospital premises) were as follows: Type of clinic Sessions New cases Attendances Minor ailments (nurse) 13,784 39,689 275,902 Minor ailments (doctor) 1,688 15,256 Special investigation 2,015 2,274 14,643 Dental 26,389 75,545 217,923 Vision 4,452 22,458 63,738 Orthoptic 1,660 859 5,237 Ear, nose and throat 473 1,832 4,347 Audiology 520 1,873 4,442 Rheumatism (supervisory) 79 34 567 Enuresis 125 109 695 Handicapped pupils New assessments—During 1964 the numbers of new assessments of pupils for special educational treatment were as follows: Day Boarding Blind 1 3 Partially sighted 40 — Deaf 28 1 Partially hearing 51 1 Delicate 456 237 (a) E.S.N 912 86(b) Epileptic — 5 Maladjusted 414 225 Physically handicapped 146 10 Speech defect 1,280 (c) 28(d) Dual/multiple defect — 108 (a) Including seven diabetic/delicate, 22 already E.S.N., one already partially sighted and one already maladjusted. (b) Including seven already delicate. (c) All these children received speech therapy at clinics or in schools they already attended. (dj Includes only one child recommended specifically for admission to boarding school for children suffering from speech defects. The other 27 children received speech therapy at clinics or in the boarding schools they already attended. 123 I (a)Partially hearing with additional handicap. (b)A number of epileptic children (apart from those in ordinary schools) are placed in schools for the delicate, physically handicapped or educationally subnormal. (c)These day school children (nearly all L.C.C. pupils) attend only part-time at the special classes. (d)Includes 914 pupils in day and boarding special schools. 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 considered unsuitable for education at school, the review of cases previously so reported and the cancellation of the report where the child on reexamination 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: 1960 1961 1962 1963 1964 Children not in any school 84 100 133 97 141 Children in ordinary schools — 3 3 5 4 Children in special schools 57 68 72 60 49 Children receiving home tuition under section 56 of the Education Act, 1944 — 1 — — — 141 172 208 162 194 Section 51A—Review of cases: 1961 1962 1963 1964 Number reviewed 20 27 20 28 Still considered unsuitable for education at school 16 19 13 21 Cancellation of report 4 8 7 7 124 Special educational provision—At the end of 1964 special educational treatment was being provided for almost 13,000 pupils (London and out-county). The following table shows the main categories of handicap and numbers of pupils receiving full-time special education: Day special schools Council boarding special schools L.C.C. pupils in nonCouncil boarding schools, hostels and foster homes Council's hospital schools and groups London County Council pupils Outcounty pupils Total London County Council pupils Outcounty pupils Total London County Council pupils Outcounty pupils Total Special classes, etc. Blind 60 48 108 30 Partially sighted 235 158 393 — — 9 — — — — Deaf 172 35 207 68 — — — — Partially hearing 146 16 162 31(a) 41(a) 72(a) 28 — — — — Physically handicapped 806 67 873 80 34 114 77 207 163 370 Delicate 1,343 55 1,398 154 12 166 108 — — — — Educationally Subnormal 3,640 60 3,700 616 13 629 152 Epileptic (b) — — — — — — 26 — — — — Diabetic 12 29 41 5 — — — — Maladjusted 269 8 277 379 10 389 373 46 44 90 467(c) Speech defect — — — — — — 4 — — — 2,623(d) Dual/multiple defect — — — 19 10 29 — — — — — 6,611 399 7,010 1,351 197 1,548 880 253 207 460 3,090 Routine audiometer testing—The numbers of children given ' rapid-sweep ' audiometer tests during 1964 are as follows: Pupils given screening tests 59,052 Pupils failing screening tests and given pure tone tests 4,481 Pupils failing pure tone tests and referred to otologists 1,720 Speech therapv—By the end of the year 310 sessions a week were being held, 148 in 54 clinics and 162 in special schools. During the year 1,314 pupils were assessed as requiring speech therapy (including two recommendations for boarding schools), 618 were discharged from treatment and 289 ceased to attend. The number of pupils under treatment at the end of the year was 2,592 and 327 were on the waiting list. Child guidance units— Details of the work done during the year at the seven child guidance units maintained by the Council follow: No. of patients 1963 1964 At 31 December On waiting list: 222 (a) awaiting first interview 207 (b) interviewed and awaiting treatment 85 94 In attendance: (a) active 415 422 (b) under review* 376 429 During year Applications received 988 1,156 Applications withdrawn 266 335 Cases closed 819 737 * 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 '. Student health service The student health service continued to function during 1964 at the London College of Fashion (formerly Barrett Street Technical College), Westminster Technical College and Brixton Day College where the service was extended to include students from the Brixton School of Building. At the City of Westminster College the demand for the service was not sufficient to justify its continuance and a medical advisory service was introduced instead. It was decided to bring the London College of Printing into the scheme as soon as practicable. 125 DENTAL SERVICES The Chief Dental Officer and Principal School Dental Officer reports as follows: To give dental treatment to young patients, to overcome their dislike and fear and to gain the respect and confidence of parents, requires professional skill of a high order as well as great personal patience and integrity. In this, my final annual report, I would like to place on record my personal thanks to and appreciation of those members of my profession who have helped to sustain—particularly through the past few difficult years and health service changes—the Council's dental services at a high standard of personal service. School dental service During 1964 increasing numbers of parents declared their intention to make private arrangements for the care of their children's health; intending in most cases, no doubt, to make demands on National Health Service dentists as well as on National Health Service doctors. A slight increase in dental sessions was necessitated by an expansion and intensification throughout the year of the revisional treatment introduced in 1962 for patients who had completed a course of treatment. This of itself is an improvement in the quality of dental care now given to children who attend the Council's dental surgeries with regularity, but must, of course, result in smaller numbers of children being treated per dentist. Table (i)—Staff and sessions 1960 1961 1962 1963  Dental officers Number employed (i) full-time 36½* 36½* 33½* 32½* 33½* (ii) part-time 84 72 68 65 64 Total 120½ 108½ 101½ 97½ 97½ Full-time equivalent (i) School service 64.6 609 58.9 56.4 57.5 (ii) M & cw service 4.9 4.8 4.8 4.6 4.6 Total 69.5 65.7 63.7 61 62 Establishment (temporary) 95 95 95 95 95 Weekly sessions School service (i) by full-time dental officers 373 361 338 326 342 (ii) by part-time dental officers 337½ 308½ 300½ 292½ 289½ Total 710½ 669½ 638½ 618½ 631½ M & CW service (i) by full-time dental officers 31 32 34 30 32 (ii) by part-time dental officers 22½ 20½ 18½ 19½ 19½ Total 53½ 52½ 52½ 49½ 51½ Grand Total 764 722 691 668 683 * '½ ' full-time officer accounted for by appointment of half-time Assistant Chief Dental Officer. 126 Table (ii)—School dental service: Attendances and treatments 1960 1961 1962 1963 1964 Number of inspection sessions held at schools 2,473 2,514 2,092 1,773 1,758 Number of children inspected at schools by dental officers 244,630 246,803 212,597 194,886 202,814 Number found to require treatment 165,439 161,277 137,853 127,308 129,599 Percentage requiring treatment 67.6% 65.3% 64.8% 65.3% 63.9% Additional number inspected at centres 23,229 19,778 17,580 16,063 14,987 Total number found to require treatment 188,668 181,055 155,433 143,371 144,586 Total cases treated 77,781 69,470 66,558 75,027 75,834 Attendances 256,983 237,411 220,639 226,651 224,826 Ordinary treatment sessions 29,006 28,060 26,638 25,747 *25,838 General anaesthetic sessions 1,049 922 699 628 551 Temporary teeth extracted 42,343 35,286 29,147 27,866 26,432 Permanent teeth extracted 14,467 11,072 8,947 7,525 6,757 Temporary teeth restored by fillings 38,164 37,533 40,091 42,705 47,125 Permanent teeth restored by fillings 109,586 100,755 89,130 85,718 84,999 Fillings in temporary teeth 40,996 40,350 43,935 46,143 51,453 Fillings in permanent teeth 124,821 115,294 101,534 96,676 96,211 Other operations: temporary teeth 43,889 38,682 40,493 42,325 43,889 permanent teeth 63,835 57,641 51,009 53,513 53,977 General anaesthetics 21,753 18,101 14,125 12,293 10,814 Cases for whom immediate treatment was completed 8,407 5,317 4,364 4,099 4,336 Cases discharged as dentally fit 50,584 45,003 40,011 45,758 48,478 *For 1,274 of these sessions certain dental officers were also supervising the work of dental auxiliaries. From inspections in the schools and observations in the surgeries, there is no doubt that a very considerable amount of treatment is now being obtained for schoolchildren from sources other than the school dental service. A study of ' acceptance ' and ' dentally fit' figures would indicate that approximately 50 per cent, of schoolchildren obtain dental treatment within any 12 months. Only half the school population attending for such treatment in a year does not necessarily imply neglect of/by the absentee half; many of them will have attended in preceding months or will attend later, while of those co.operating in a current year not all will continue to do so in a succeeding year. The one-time familiar figure of total dental neglect is now very seldom seen. Parents are no longer ignorant of the advisability of ensuring that their children have a regular dental' check-up '; nevertheless procrastination and deliberate avoidance are still too commonplace. Tables (i) and (ii) show fluctuations and afford comparison with previous years and also show that there is little difference in results from the preceding year. Reflections of the better standard of dentistry in the Council's treatment centres can be seen in table (iii) where the ratio of fillings in permanent teeth to extractions has reached the highest point recorded (12-5:1) and table (ii) shows a continuing decline in the number of sessions devoted to ' gas extractions'—from approximately 1,000 in 1960 to half that number in 1964. Attendances on average at the sessions held were also reduced, indicating that need for destructive treatment is declining. Table (iii)—School dental service: Average number of permanent teeth restored for each permanent tooth extracted 1955 7.39 1956 6.50 1957 6.41 1958 6.34 1959 7.41 1960 7.57 1961 9.10 1962 9.96 1963 11.39 1964 12.58 127 EXPERIMENTAL PROCEDURES IN DIVISIONS 1 & 9 These experiments, aimed at estimating, inter alia, parental co-operation and commented upon in my reports of the past two years, were finalised and results analysed towards the end of 1964. As these experiments aimed at a revolution in methods of screening the school population to meet dental facilities which have changed through out the land, I feel justified in reporting procedures and results rather extensively. In May, 1961, approval was given to institute, in divisions 1 and 9, a trial scheme whereby routine dental inspections in schools would be suspended; parents of schoolchildren were to be advised by letter to obtain a dental' check-up ' for their children at least annually and invited to make use of the school dental service OR to make their own arrangements (in most cases possibly through the National Health Service). Reports were to be furnished after an experimental period indicating, inter alia, the degree of apathy among parents. The scheme was introduced at the beginning of the summer term 1962, following discussion with the London Executive Council and the London Local Dental Committee. The main object of the experiment was to make a positive contribution to the preservation of healthy mouths by encouraging regular visits to dentists and, where necessary, early conservative treatment, bearing in mind the shortage of dental manpower. It was hoped that the Council's dental resources could, under these arrangements, be utilised to the best advantage, since the dental time saved from school inspections would be available for treatment. Abortive work in making dental appointments for children whose parents did not desire the Council's facilities would be avoided and there would be less interruption of school activities. At dental inspections in schools a large number of children are repeatedly inspected who are patients of National Health Service, or other practitioners, and normally attend those dentists—-they do not intend, generally speaking, to make use of the school dental service. Routine dental inspections in the schools in the two divisions were suspended and a letter was distributed, through the school organisation, at annual intervals to the parents of every pupil. The letter reminded parents, in the interests of their child's well-being, that at least an annual check of a developing mouth by a dentist was highly desirable; that regular and systematic checks could detect at an early stage defects that might arise and that any treatment subsequently found necessary would have a better chance of proving successful. Parents were asked to return a slip to the school stating whether they (a) wished the child to have a dental check at a Council surgery or (b) intended to make private arrangements; school teachers were asked to see that forms were returned by the parents. A basic feature of the new scheme was the fact that it brought many children within the orbit of dental care before dental defects developed and some children before the defects had become extensive or severe; whereas under the old scheme of routine inspections in schools children were not classified and called for treatment unless and until they had defects. We have long had preventive medicine but still need to advance in preventive dentistry. This scheme is a real step in that direction. When a dental check at one of the Council's centres was requested an appointment was made at which full inspection could be carried out and any necessary treatment commenced. Where the name and address of a general dental practitioner was given, the dentist—with the agreement of the London Executive Council and the London Local Dental Committee—was informed. It was hoped that the general dental practitioner selected by the parent would take any initiative necessary to ensure that the child was offered dental care if not presented at an early date by the parent. In many cases the child was already a patient in the care of the practitioner. The statistical results from both divisions 1 and 9 show no significant variation and I consider that the lessons learned should be applied to the whole of London and give a reasonable basis on which the need for dental provision for London schoolchildren can be assessed. Of the parents asked to express a choice 95 per cent, did so. Of these, 35 per cent, indicated that they wished to use the school dental service, but in actual fact only 128 about one half of these parents actually responded to appointments to attend. It appears therefore, that some 20 per cent, of London schoolchildren will, at the present stage of developments, avail themselves of the school dental service; this would seem to indicate that on the basis of the present school population of 414,598 the school dental service may expect to be asked to provide attention for some 83,000 children. With regard to the remaining 65 per cent, of the parents—i.e. those who replied stating that they would be making their own arrangements for their children's dental care—it was not, of course, so easy to obtain so exact a picture of the proportion of these children who actually attended for treatment, as not all general dental service practitioners were prepared to co-operate and not all parents actually named a dentist. The picture does emerge however, from the cross-section samples obtained from the London Executive Council, of some 50 per cent, of attendances. It is interesting to note that the failure rate was similar to that for the school dental service. This common failure rate of around 50 per cent, both of those who nominated a National Health Service dentist and of those who chose the school dental service—is disturbing but can hardly be unexpected as dental treatment is seldom regarded with enthusiasm. It must be stressed that these figures reflect the position at one given time, that a follow-up service operates for non-attenders and that parents who do not send their children for treatment one year may do so the next. It must also be remembered that pain acts as a spur to attendance for treatment and that children so attending will receive not only treatment for the immediate emergency but also be offered such other treatment as may be found necessary. It can be accepted in fact that, one way or another, the great majority of schoolchildren in London do receive relatively frequent dental treatment during their school life, though not necessarily as often as is desirable. During 1964 officers of the Department of Education and Science and of the Ministry of Health were consulted informally about the scheme and expressed great interest (as did the Estimates Committee of the House of Commons on the Dental Services in 1962). They pointed out, however, that there remains a statutory duty to inspect the mouths of children at schools and suggested that this might be met in a manner acceptable to all by continuing at least one school dental inspection during school life. They thought that this could be carried out with greatest benefit on school entrants and this is particularly valid because this is the one dental inspection which parents are most likely to attend. This would therefore afford the best opportunity to impress on parents the importance of regular attendance for care by a dental practitioner and the various ways in which professional dental services can be obtained. In September 1964 a report on the above lines was submitted to the relevant Committees carrying the following recommendations; (a) All children should have a dental inspection at five years of age or as soon as possible thereafter, and all parents should then be informed of the Council's arrangements for dental care and their responsibilities for their children's dental health. (b) Each year parents to be reminded of the need for an annual dental check and asked whether they wish their children to have this at one of the Council's surgeries or by a National Health Service dentist. (c) A follow-up of any children found at routine medical or hygiene inspections to be in need of dental treatment. The recommendations were approved. Further support for the scheme was forthcoming when the developments were reported to the Central Consultative Committee of Headmasters and Headmistresses and to the Standing Joint Advisory Committee of Teachers and Officers. The London Executive Council and the London Local Dental Committee were also furnished with a copy of the official report on the scheme and were officially thanked for their co-operation in the experiment. 129 Under the London Government Act, 1963 responsibility for the school dental service will pass to the Inner London Education Authority on 1 April 1965. Full information on this new method of screening the school population for dental treatment purposes was passed to this new authority, in anticipation that the method will come into use generally throughout the Inner London area. The I.L.E.A. expressed the intention to implement the method as from 1 April 1965. Orthodontics Table (iv)—School dental service: Orthodontic work 1960 1961 1962 1963 1964 Number of special orthodontic sessions 237 254 422 422 411 Number accepted at special orthodontic sessions 152 171 275 257 282 Number accepted at routine sessions 401 470 227 251 232 Number referred to hospitals 154 154 237 186 202 Total number of patients accepted or referred 707 795 739 694 716 In the special field of orthodontics there was little change in results. The gross malocclusions which were relatively common in the earlier years of the school dental service are now seldom seen and, with a slower flow of patients through the surgeries, dental officers have now an opportunity to treat at least some of the more simple cases that still appear. I would like once again to acknowledge the excellent assistance given in the production of appliances by the staff of the Central Dental Laboratory. Maternity and child welfare dental service As in the case of schoolchildren, the drift towards the use of facilities available in the national dental services continued. Expectant and nursing mothers (like their children) are not charged for their treatment by general dental practitioners and, in the main, seem to prefer private arrangements for their treatment. Table (v) shows numerical fluctuations in the Council's dental service in 1964, when the principle agreed with the Ministry of Health some years ago continued to be applied, viz.: that approximately 10 per cent, of the Council's dental efforts should be specifically directed to the dental service for maternity and child welfare patients. Table (v)—Maternity and child welfare patients: Attendances and treatments 1960 1961 1962 1963 1964 Number of sessions 2,592 2,300 1,908 1,838 1,739 Number of appointments offered 27,368 23,864 19,158 17,728 15,411 Attendances—by appointment 19,651 16,500 12,958 11,893 10,437 —other 1,060 894 553 422 322 Silver nitrate treatment 5,858 5,718 4,141 4,206 2,588 Fillings 8,716 7,399 5,976 5,411 5,449 Extractions 4,513 3,624 2,619 1,588 1,301 Dentures supplied—new full 351 327 151 91 89 —new partial 468 485 240 231 134 Number made dentally fit 4,165 3,255 2,507 2,234 2,185 Table (vi)—Breakdown of table (v) separating nursing or expectant mothers from children under five—1964 Total Nursing or expectant mothers Children (under 5) Number of sessions 1,739 — — Number of appointments 15,411 7,814 7,597 Attendances—by appointment 10,437 5,069 5,368 —other 322 103 219 Silver nitrate treatment 2,588 337 2,251 Fillings 5,449 2,682 2,767 Extractions 1,301 863 438 Dentures supplied—new full 89 89 — —new partial 134 134 — Number made dentally fit 2,185 665 1,520 130 Residential homes and schools Treatment for children at residential establishments continued to be erratic and not altogether satisfactory at all establishments. Visiting dental officers were not easily recruited and the contracted services of local practitioners produced transport and other difficulties not always capable of satisfactory solution. At most schools local general dental practitioners undertook treatments and were paid N.H.S. standard fees by the Council. Dental auxiliary experiment Participation in the national experiment in the use of dental auxiliaries continued, but resignations and replacements of staff clouded results. Towards the end of the year two of the five girls employed in the Council's services were re-deployed to work in the two Council surgeries at New Cross School for Dental Auxiliaries, as their full employment in normal Council surgeries could not be maintained, and one girl resigned. STAFF Some account is given below of the problems and development of staff and establishment matters since 1948. During 1948 there were many staffing problems arising from the large changes in the health services. During the first six months, in addition to carrying on the normal administration of the hospital service, detailed arrangements were made for handing over nearly 100 hospitals to the new Hospital Boards and a considerable number of staff experienced in hospital administration were sent to the Boards to assist in the heavy task of preparation. Concurrently, arrangements were made for taking over the personal health services transferred from the metropolitan borough councils and for the general assumption by the Council on 5 July 1948 of powers and duties under the National Health Service Act, 1946. This creation of the nucleus of a new department within the framework of one that was to end was achieved without the employment of additional staff. It was realised at the outset that efforts should be directed towards co-ordination of the services which the Council had taken over and those for which the metropolitan borough councils continued to be responsible, viz. environmental health. A scheme was adopted in October 1948 for the use of the services of borough medical officers of health as administrative medical officers in the personal health services and as a corollary certain of the Council's medical staff were seconded for part of their time to act as borough medical officers of health and deputy medical officers of health. These arrangements were maintained and extended during the ensuing years as opportunity offered; in addition some borough medical officers undertook clinic duties in the Council's establishments. Nearly 5,000 staff in many different grades were taken over from the boroughs and the major task of assimilating most of these staff on to appropriate scales of pay and conditions of service was progressively achieved in the ensuing three years. In some services, notably health visiting and dental, there was significant under-manning and central recruitment for a number of grades was introduced to ensure allocation of new entrants to areas experiencing severe staff shortages. Reference is made later to the development of staff training. By the end of 1950 the general shortage of qualified nursing staff was acutely felt in welfare homes and residential nurseries and schools; despite earnest efforts to improve recruitment complete stability was unfortunately never achieved. Also by this time the appreciable yearly wastage of health visitors largely made good by the induction of newlytrained staff, under arrangements sponsored by the Council, emerged as the pattern for the years ahead. The introduction in 1951 of the new grade of clinic nurse relieved health visitors of certain clinic duties, enabling them to devote more time to district work. In the dental service the first pay recommendations of the Dental Whitley Council were not made until 1950. Although further pay awards were made subsequently, the shortage of dental officers persisted for some years; unlike the position in most nursing grades, however, and due in part to the decrease in demand for the service, the shortage became much less acute. Assimilation of the transferred services and staff was completed by 1952 and the steady development of services in the next three years produced no staff changes of any magnitude. The general upward trend of salary and wage levels was followed in varying degrees amongst the department's staff. Some new grades appeared, notably those of night help and child help, which were introduced as an extension of the home help service, in connection with schemes for the care in the home at night of the aged and chronic sick and the care of children temporarily deprived of their parents. A comprehensive review of the work, organisation and staffing of the department was completed in 1955. This review, started in 1953, of the third largest department of the Council with 7,500 staff and a salary and wages bill at that time of £3,500,000 a year was 132 a formidable undertaking. The Reviewing Committee found no need for radical changes in the staffing structure, although some changes in numbers and gradings as well as detailed improvements in methods and procedures were recommended. The original decision to permit the largest practical measures of decentralisation of services by dividing London into nine divisions—about 80 per cent, of the staff worked in services locally controlled— was found to be sound. During the next five years, Ministerial Working Parties published reports which, although full achievement of their aims has not as yet been realised, have profoundly affected the approach to staff training and deployment in several vital sections of the Council's Public Health department. In 1956 the report of the Jameson Committee on the existing and future functions of the health visiting service was published. The Committee's recommendations envisaged that the field work of the health visitor would include health teaching and social advice for the whole family and have an important place in mental hygiene and the care of the elderly. To fit the health visitor for her enlarged role, revised training arrangements were proposed which were eventually instituted by the Health Visiting and Social Work (Training) Act, 1962. In the light of the Committee's advice on remuneration, a national pay award in 1957 secured a significant salary increase for health visitors. The Jameson Report was followed by the publication in 1959 of the report of the Younghusband Committee on the field of work, recruitment and training of social workers. This Committee recognised the serious deficiency of social workers of all kinds and among their proposals for stimulating recruitment were measures for improved training facilities and better career prospects. Although no specific proposals were made, negotiation of new salaries was recommended. The Council already had a coherent staffing structure for its social workers based on grades reflecting various levels of responsibility and no fundamental change in its own structure was considered necessary. Even so, the Committee's general recommendations, notably those on training, had a marked effect on the work of the department's staff division. In 1960 new staffing arrangements were introduced to meet proposals for the reorganisation and development of the department's mental health work in the light of the Mental Health Act, 1959. This reorganisation involved the decentralisation of existing services to the nine health divisions, in each of which a mental health social worker team was set up under the leadership of a divisional mental welfare officer. Central co-ordination and supervision of mental health social work were provided for in the appointment of a principal mental welfare officer. Three years later a comprehensive review of the mental health services by the O. & M. branch of the Clerk of the Council's department resulted in revised salaries and a substantial increase in staffing for statutory and community care work. There was considerable difficulty, however, in recruiting experienced staff to fill the additional positions and in spite of intensive advertising there were still vacancies in 1965. The last and by far the most important event affecting the work of the central staff division and the divisional staff sections was the passing of the London Government Act, 1963 under which the department's services fell to be transferred to 15 new authorities, 12 Inner London boroughs and the City of London, the Inner London Education Authority and the Greater London Council. By 1965 the total staff had increased by more than 1,000 to well over 8,000 and the exacting task of arranging for their transfer to the new authorities in accordance with the Act and the regulations issued under it and bearing at the same time the normal load of staff work was accomplished without additional staff. It is not possible in this brief summary of the department's staff work to detail the processes of the staff transfer arrangements which were, of course, intimately related to the transfer of the various services. Over a period of 18 months, the transfer arrangements were planned, developed and kept under constant review by senior officers. In the final phase, as the momentum of transfer work gathered, staff at different levels were increasingly occupied with the work and despite their feelings of uncertainty about their own future this massive task was well done. 133 Finally, reference should be made to the department's relations with trade unions and staff organisations. It was the Council's policy to encourage all members of its staff to belong to their appropriate trade union or staff organisation; necessarily there were frequent consultations and negotiations with the various associations concerned on pay and conditions for the department's many grades of staff and on matters affecting the interests of individuals. Relations remained cordial throughout and in all the considerable activity in this field in the 16 years from 1948 official disputes were rare. Local problems affecting day nursery staff and dental surgery assistants were discussed by joint consultative committees and senior officers of the department represented the Council on the management sides of Medical and Dental Whitley Councils, the Nurses and Midwives Whitley Council and the Professional and Technical Councils ' A ' and ' B ' of the Health Service. The following statement shows the number of staff employed in the department at the end of 1964 (part-time staff are expressed as whole-time equivalents). The principal officers of the department at that date are shown in Appendix A. Location Types of staff Central office Divisional offices and establishments (a) Other establishments (b) Total Administrative and clerical (including ambulance control clerks) 262 671 78 1,011 Medical officers (c) .. 27 163 — 190 Dental officers 3 62 65 Scientific branch staff 59 — 23 82 Inspectors 16 — — 16 Medical auxiliaries (d) 36 186 15 237 Social worker grades (e) 33 413 26 472 Nursing and midwifery staff 11 1,783 265 2,059 Ambulance service operational staff — — 856 856 Manual workers, home helps, domestic grades, telephonists, etc 17 3,295 17 3,329 Totals 464 6,573 1,280 8,317 (a) Including divisional health offices, home help offices, welfare centres, school treatment centres, training centres for the mentally subnormal, etc. (b) Including residential schools and nurseries, welfare department homes, recuperative holiday homes, ambulance stations, outfall works laboratories, central dental laboratory. (c) There are 125 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 health social workers, welfare officers (chest clinics), social workers (health services), etc., and workers in allied fields (e.g. home help organisers). Appointments and retirements—Dr. J. A. Scott, Medical Officer of Health and Principal School Medical Officer retired on 8 August. He was succeeded by his deputy, Dr. A. B. Stewart, who was appointed Medical Officer of Health and Principal School Medical Officer on 11 November. Dr. B. E. A. Sharpe, Divisional Medical Officer, Division 1, retired on 17 August and Dr. E. M. Cran was appointed acting Divisional Medical Officer. Mr. F. A. Richardson, Officer-in-Charge, London Ambulance Service, retired on 31 July and was succeeded by Mr. N. A. Woodruff (formerly assistant Officer-in-Charge) in an acting capacity. Mr. L. J. J. Clark, Divisional Administrative Officer, Division 2, replaced Mr. Woodruff and was succeeded in Division 2 by Mr. D. A. Collins. 134 Staff training There was full recognition by the department of the importance of a comprehensive and adaptable programme of staff training which resulted in a steady expansion in the volume and variety of the facilities provided. With, as its main objective, improved recruitment in the grade of health visitor, the department from 1948 appointed each year a number of student health visitors and arranged for their attendance at courses of instruction leading to the health visitors' certificate. By 1964 the annual number of such students had risen to 75, the majority being trained on a special course provided by the London University Institute of Education, in association with the Council. Over 600 students have qualified in this way, of whom nearly one half were still serving with the Council as health visitors or in higher positions. Without this scheme the department would have been unable to maintain an adequate health visiting service in London. The training of nursery students in day nurseries, started by the metropolitan borough councils before 1948, was fostered; by the end of 1964 over 1,500 students had successfully completed the two-year course and obtained the certificate of the National Nursery Examination Board. There were then 46 day nurseries providing practical training for nursery students with the approval of the Ministry of Health. The department welcomed the lead given in 1959 by the Younghusband Committee towards improved facilities for the training of social workers. The annual number sent to full-time courses arranged by universities and professional bodies increased until in the autumn of 1964 ten social workers in the department, nine of them employed in the mental health service, were embarked on one- and two-year full-time courses besides those attending a part-time course. In addition, by that time the annual number of supervisory staff of training centres for the mentally subnormal who were taking one-year full-time diploma courses had risen to six. Regular refresher training, on the basis of courses of one to two weeks' duration every five years for medical, health visiting, school nursing and midwifery staff was provided through professional bodies to keep the staff abreast of current professional thought and practice. In other instances, specific training needs were effectively and economically met by ' in-service ' courses arranged by the department. In this way specialised training was provided for many categories of staff, notably medical and nursing. Food handlers Since 1953 it has been the practice to arrange for employees of the School Meals and Catering, Education, Children's and Welfare departments who handle food to have appropriate bacteriological examination before returning to work after suffering from illnesses which might give rise to food-borne infection. Staff who have been in contact with such illnesses in their own homes are similarly scrutinised. The numbers of staff referred for investigation during recent years are set out below. 1960 1961 1962 1963 1964 Contacts 205 118 114 212 147 111 419 307 375 553 395 Allowed to resume work after examination or fixed period of exclusion 578 406 444 728 508 Resigned, retired or died 23 16 28 28 25 Excluded from work and referred to own doctor for treatment 23 3 17 9 9 135 The nine cases referred to their doctor in 1964 had been found to have the following micro-organisms: Condition Organism isolated Discharging ears Staphylococcus aureus Enteritis Shigella sonnei Enteritis Salmonella typhi Vomiting Salmonella tenessee Scarlet fever contact (4) Haemolytic streptococcus Dysentery contact Shigella sonnei Staff medical examinations The number of staff medically examined on entry to the service or following prolonged sickness has increased considerably in the past 15 years, the greatest change being, of course, in the larger number of recruits to the service. Medical examinations reached a total of 13,832 in 1964 compared with 5,768 in 1953. Another significant change has been the casualties (i.e., staff requiring treatment whilst on duty), which have risen to over three times the 318 treated in 1953. Details for the past four years are set out below. Medical examination of staff— 1961 1962 1963 1964 Number of medical examinations 14,410 14,265 14,186 16,284 Number of recommendations without medical examination 1,384 1,111 1,138 1,200 Number of follow-ups (i.e. usually hospital or specialist reports) 5,292 5,541 5,120 4,749 Number of medical examinations carried out for other authorities 135 125 148 185 Total 21,221 21,042 20,592 22,418 Reason for medical examination (persons) Candidates for employment 11,388 11,536 11,853 13,832 Following prolonged sick leave 2,993 3,010 3,356 3,035 Following accident on duty 541 470 375 439 Fitness for duty (e.g. approaching confinement leave, special duties) 570 659 422 511 Eligibility for spouse pension 86 80 89 120 Total 15,578 15,755 16,095 17,937 Candidates examined for the Council by other authorities 72 104 157 94 Staff casualties dealt with in the medical inspection rooms at County Hall 863 1,058 1,017 967 136 FINANCE Making of charges and assessments—Some of the services provided by the local health authority under the National Health Service Act, 1946 must be free of charge (as are general medical services and hospital treatment) but the health authority may, with the approval of the Minister, make and recover reasonable charges for services and articles provided under sections 22, 28 and 29 having regard to the means of the persons availing themselves of the services. The Minister, in approving the making of charges under these sections, prescribed in Circular 100/48 that the charge should not exceed the actual cost to the authority of providing the service and that the charge should be reasonable having regard to the means of the persons concerned. Section 6 of the Mental Health Act, 1959 permits local health authorities to provide, inter alia, residential accommodation for persons suffering from a mental disorder and, with respect to charges, applies section 28 of the National Health Service Act, 1946. When the principal Act came into force in July 1948, the Council fixed charges for services and scales of assessment for abating the charge where the person responsible for payment was unable to meet it in full. These charges and scales followed closely the national recommendations of the County Council's Association and associated bodies. The scales have been reviewed from time to time to conform with changes in National Assistance scales of grants and amendments have also been made when experience has shown them to be appropriate, e.g. having regard to increased costs of the services and in incomes. At present, voluntary organisations providing similar services (such as day nurseries) for which they are grant-aided by the London County Council are required, as one of the conditions of assistance, to conform to the Council's scales and assessment procedures. Charges are made in accordance with the scales approved by the Council. There are in effect five assessment scales: Scale A—for services which are small in cost or needed at irregular intervals. Scale B—which is applied for services of a more continuous nature. Scale C—for ascertaining charges payable in respect of residential care provided for the mentally disordered (other than short-term care for the mentally subnormal). Day nursery service—special scale. Home help service—special scale. Expenditure: Capital—The total capital expenditure on the health services for the period from 5 July 1948 to 31 March 1964 was £1,917,761. That for the year ended 31 March 1964 was as follows: £ Ambulance stations—acquisitions, erection and adaptation 13,825 Day nurseries—extension of premises 4,949 Maternity and child welfare centres—acquisition and erection 53,369 Mental health hostels and training centres—acquisition, erection and equipment 145,019 £217,162 137 Maintenance—The gross cost of the various health services in 1949/50 was £4,167,204 and the contributions recovered from recipients of the services amounted to £206,136. Comparative figures for the year 1963/64 are given below: Service Cost £ Amount recovered in contributions £ Ambulance 1,549,199 — Day nurseries 1,219,099 146,274 Domiciliary midwifery 328,192 — Foot clinics .. 136,172 12,316 General health (including health education) 65,121 — Health centres 46,510 — Health visiting 498,093 — Home nursing 694,378 — Home help 1,596,587 76,099 Maternity and child welfare 1,085,350 118,004 Mental health 700,451 36,696 Prevention of illness, including care and after-care of tuberculosis 454,608 27,510 School health 1,195,320 — Vaccination and immunisation 180,429 — 9,749,509 416,899 Whilst to some extent the increase in expenditure over the years can be attributed to the general rise in the cost of staff and services there were many expansions of services, of which three prime examples are shown: Service Cost 1949/50 £ Cost 1963/64 £ Ambulance 506,946 1,549,199 Mental health 122,926 700,451 Home help 340,008 1.596,587 138 VISITORS TO THE DEPARTMENT During the year 419 visitors were received through the central office—of whom 182 came from overseas. As in past years many visits were arranged at the request of authoritative bodies, amongst which were the Ministry of Health, the British Council, the Central Office of Information, the Women's Council and several foreign embassies. Individual overseas visitors included H.R.H. Princess Himalaya Bir Bikram Shah Deva, sister of the King of Nepal; the Chairman of the Municipal Corporation of Karachi; the Director of the Maternity and Child Welfare Service and the Director of Commission of Public Health, Cairo; the Head of Pathological Services, California and the Head of Bureau of Sanitary Health, Kobe City. Parties included members of Bombay Municipal Corporation and members of the National Assembly of Malawi. Another party comprised some 40 participants in a World Health Organisation Mental Health Seminar. 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 635 people, 72 from overseas and 563 (506 students) from the United Kingdom; the Ambulance Service headquarters received 350 visitors and training centres 471 visitors, including 357 students. Facilities were again provided for medical, nursing and social science students to study the health services. Courses of visits of observation and talks were arranged for postgraduate students preparing for the Diploma in Child Health and the Diploma in Public Health. Members of the department's nursing staff gave talks to student nurses at hospitals and programmes were arranged to enable 3,900 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 University of London (Institute of Education) Speech therapy students Speech Therapy Training School of the West End Hospital for Neurology Other students (medical, nursing, teaching and social science) Bedford College Cheshire County Training College London School of Economics and Political Science National Association for Mental Health National Children's Home Staff Training College North Western Polytechnic Nottingham Training College Queen's Institute of District Nursing University College of Swansea University of Edinburgh University of Exeter University of London—Institute of Education University of London—Department of Social Studies University of Manchester 139 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. Eva M. Cran reports: During the year normal activities have been fully maintained, notwithstanding the additional responsibilities and duties arising in connection with the transfer of functions to the new London Boroughs on 1 April 1965. As part of the preparation for this transfer, responsibility for a number of services was decentralised to divisions, e.g. B.C.G. vaccination, inspection of nursing homes, registration of the blind and a variety of additional duties under the Mental Health Act 1959. These additional functions, together with the onerous task of dividing the work of the division in anticipation of the transfer to the London Borough of Hammersmith and the Royal Borough of Kensington and Chelsea have been loyally and conscientiously undertaken by the staff and I am deeply grateful to them for their devoted service. As regards the normal work of the division, it has again been a year of satisfactory progress consistent with the record of development and expansion which has been maintained since 1948. Day nurseries—Attendances were consistently high throughout the year and in many weeks reached 96 per cent. The extension to provide 37 additional places at St. Quintin day nursery was completed by the end of the year and is expected to be fully staffed and occupied early in 1965. Occasional creches—At these also there have been near capacity attendances at all sessions. An interesting experiment, authorised by the Health Committee, started in November to allow children to attend creches free of charge while their mothers are attending hospital. There has not, of course, been sufficient time as yet to assess the effect of this. Chiropody—The demand for this service continues to increase and an additional clinic was opened in April at Westbourne Grove welfare centre to provide two additional sessions weekly. These proved so popular that a third session was added in August. Maternity and child welfare—The divisional maternity bed bureau established in 1962 produced quite remarkable results. Of a net total of 1,513 cases referred to the bureau during the year (another 50 were withdrawn), a hospital booking was arranged for 1,508 and in only five cases had the mother to be referred for admission through the Emergency Bed Service. This probably represents the optimum achievement of the Bed Bureau, bearing in mind that the ' failures ' were all social cases who attended a clinic for the first time very late in pregnancy. For the third year running a bed was found for every case referred on medical grounds. Co-operation with general practitioners and general practitioner obstetricians was further strengthened and improved. The weekly evening paediatric session at Lancaster Road welfare centre was continued throughout the year and a high average attendance of working mothers was maintained. 140 Health education—The Smokers' Advisory clinic at the Fulham Chest clinic, which started in October 1963 with one session a week conducted by Dr. H. C. Price, Chest Physician, was extended in February by the addition of a second weekly session conducted by Dr. J. Vahrman. I reported in November that the Chest Physicians, although they were unable to make any firm assessment of results, were satisfied that the progress made by individual patients amply justified the extension of the experiment and the Health Committee authorised the continuance of the clinic until further order. A campaign was launched at the beginning of the Autumn school term and is to be continued until the end of the Spring term 1965, directed at the education of school children in the importance of dental hygiene. During November a ' Dental Health week ' was held in the division, when talks were given and films shown to children at schools and clinics, highlighting this important aspect of school health. Further efforts were made to increase public awareness of the fire risk from the use of oil heaters. Specially printed leaflets were distributed in the Autumn by bulk postage delivery and, in the case of houses in multiple occupation, personally by health visitors. Prophylaxis—The immunisation state of children in the division was further improved and in November a trial was started with an additional protection, namely, vaccination against measles. With the approval of the Health Committee arrangements were made, in co-operation with the Medical Research Council, to offer this vaccination to children in the age group ten months to two years and to follow-up all children vaccinated and also a suitable control group. Six thousand invitations were issued to parents and two thousand consents received. Forty-eight additional vaccination sessions were held between the end of September and the end of November and all children will be seen again after three, six and nine months. Prevention of break-up of families—Divisional co-ordinating committee meetings and an increased number of intermediate case conferences have been held throughout the year. Nearly 40 per cent of the cases referred have come from Housing departments (both L.C.C. and Borough Council) and rent arrears has been the biggest single problem. Referrals have also been made by the N.S.P.C.C., the Family Welfare Association, the Family Service Unit, probation officers, general practitioners, and the Council's own officers in Children's, Health, Education and Welfare departments, the Mayor of Hammersmith and a Building Development Corporation. During the year a second full-time family caseworker was appointed, making two full-time and three part-time caseworkers. School health service—The seven special investigation clinics continue to be well attended, the main problems presented being enuresis and obesity. An increasing number of fathers accompany children to these clinics, especially among the immigrant population. The number of children attending vision, ear, nose and throat, and minor ailment clinics continues to decline slightly. DIVISION 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and the City of Westminster Dr. H. L. Oldershaw reports: Population—Despite a large increase in immigrants to parts of the division, the total population has fallen by 76,000 (13-5 per cent) since 1948, due largely to the clearance of slum dwellings and redevelopment schemes providing less housing accommodation than hitherto. This, together with an expansion of service in some fields to older people, has produced interesting changes in the use of the health services and consequential effect upon the role of the health visitor, who traditionally had been associated almost solely with maternity and child welfare. 141 K* Maternity and child welfare—Nine new centres have been opened since 1948, some replacing obsolete buildings and others to provide amenities in areas previously inadequately served. Evening sessions for ante-natal, infant welfare, immunisation and family planning have been opened in various parts of the division for the convenience of mothers employed during the day and these are well attended. Many immigrants with no knowledge of English present a serious language difficulty. Apart from the occasional use of interpreters, printed instructions for the guidance of mothers on all aspects of maternity and child welfare have been made available in nine different languages. Owing to the high birth rate and the poor housing conditions in many parts of the area the demand for hospital confinement greatly exceeds the supply of maternity beds. In order to obtain as many beds as possible for priority cases, a divisional Bed Booking Bureau was set up in 1956. This has been successful in obtaining beds for about 50 per cent of the unbooked ' emergencies Day nurseries—Five day nurseries have been closed, reducing the number of places from 1,404 to 971, provided in 18 day nurseries. In recent years the daily attendance has been 90 per cent of the approved accommodation and the demand continues to be high. Private day nurseries and child-minders—In 1948 there were 28 voluntary child-minders in the division, minding 22 children; these figures have increased to 165 and 134 respectively in 1964. There are also 21 child-minders registered under the Nurseries and Child-Minders Regulation Act, 1948, minding 129 children for reward; while 37 registered day nurseries provide places for 940 children. One of the major problems today is to counteract the indiscriminate use of unguarded and inefficient oil heaters used by child-minders. The advice and help given by the Council's public health inspectorate, who have visited homes upon request, have been invaluable. Arrangements are being made for Fire Prevention Officers to inspect unsatisfactory conditions as they come to notice. Home help service—One of the most outstanding changes in the use of the personal health services is demonstrated by the work now undertaken by the home helps. Since 1948 the number of home helps employed has trebled and the households served increased five-fold. This massive extension of the service is mainly devoted to the care and attention of the elderly and infirm and the visit of the ' help' becomes a highlight in the recipient's life, not only for the assistance given but also for the social contact. Chiropody—In 1948 four sessions a week were provided by the Council, the bulk of the chiropody work for the elderly being undertaken by the Old People's Welfare Associations. Because of increasing demand, a large expansion of this service was authorised in 1960. Recruitment presented a problem but 29 sessions a week, with an average attendance of seven per session, are now being held at five different centres. Cleansing scheme—Following a report by the Council's Scientific Adviser on the efficiency of a shampoo, Lorexane No. 3 containing gannaxene, as a parasiticide, a six-months experimental use of the preparation was undertaken in the division in January 1959, with the object of ascertaining whether parents would use the shampoo on themselves and their children without the need for special home visits to urge them to do so. The experiment proved that the home use of Lorexane was successful and the reinfestation of school children was frequently avoided because other members of the family were willing to use the shampoo. This had the direct effect of markedly reducing the number of attendances of verminous children to cleansing stations, resulting later in the closure of unwanted sessions. The trial led in 1960 to the use of this shampoo throughout the county. 142 Disposable syringes—In 1959 attention was given to possible alternative methods for providing sterile syringes and needles for immunisation work in the division other than by boiling, which was the then accepted practice. The Health Committee approved the provision through the Paddington Group Hospital Management Committee's central syringe service of sterile syringes and needles to be distributed to the various clinics in sealed containers for a twelve-month trial period; this arrangement proved to be a distinct advance on the boiling method. Plastic disposable syringes were made available in March 1961. They were found to be more satisfactory and the cost less than that of the syringe service and their use was extended to all the centres in the division and subsequently to other divisions. Prevention of break-up of families—It is of particular interest to note that the experiment carried out in March 1956 in three divisions, of which this division was one, of appointing the divisional treatment organiser (later styled the divisional social worker) as secretary of the local co-ordinating committee was so successful that it was extended to the remaining divisions. As a result of the work undertaken by the committee, there has been a marked increase in the amount of consultation and co-operation with other statutory and voluntary organisations, whose representatives are constantly in touch with the divisional social worker about problem families. This is invaluable in the casework and is probably one of the most encouraging developments of social work. This division was also one of the first to introduce home advice groups for selected mothers, as part of the general arrangements for dealing with mothers of problem and potential problem families. There are two in the division and although the numbers attending are small they serve a most useful purpose. Mental health—Over the four years of decentralisation since 1960 the mental health work in the division has steadily increased and with the provision of additional staff, advances have been possible in the community care field. Mental health social workers attend weekly after-care conferences at two of the division's catchment area hospitals and also at the Westminster day hospital. Another valuable link has been forged by the arrangement whereby two medical students studying psychiatry spend a whole day once a month in training with the mental health social workers. The special unit for severely sub-normal children at Coram's Garden day nursery was opened in 1963; this year six children attended regularly. Health education—Health education plays a prominent part in the activities of this division and has developed considerably during the past sixteen years. In addition to individual teaching, health visitors have organised health education in the welfare centres through mother's clubs, courses in mothercraft and ante-natal exercises, cookery and sewing classes. A programme covering the year and projecting a different health education theme each month is compiled; literature, posters, leaflets and films are discussed and selected for distribution at each monthly meeting. The meetings also act as a forum for the exchange of information and ideas between health visitors. In addition, large-scale campaigns are held from time to time with the co-operation of the Education Officer and other organisations. The local press help with publicity and exhibitions, displays, films and talks are given at schools and welfare centres. An indication of the interest aroused is shown by the fact that at the campaign at the end of 1964, which was on dental health, over 1,200 school children from 26 schools attended an exhibition during one week in October and 142 film shows and talks were given at schools and welfare centres. 143 DIVISION 3, comprising the boroughs of Finsbury, Holborn and Islington Dr. W. G. Harding reports: Maternity services—During 1964 a series of meetings of liaison committees were held under the auspices of the North East and North West Metropolitan Regional Hospital Boards. Senior officers represented the Council and agreement was reached on comprehensive maternity catchment areas served by a number of hospitals. This resulted in part of South East Islington being transferred, for this purpose, from the North West to the North East Board's area, with a consequent re-arrangement of the system for referring maternity patients to hospital. Arrangements for planned early discharge from hospital for suitable maternity cases operated throughout the division by the end of the year. Handicapped and Risk Registers—The total number of children under five years old on the handicapped register at the end of 1964 was 274 and on the ' at risk' register 2,033. This scheme is now being extended to include school children over five years of age. Day nurseries—The increasing demands for day nursery places made it necessary to continue the exclusion of all the less urgent priority cases and to accommodate, where possible, children living near the boundaries in day nurseries in the two adjoining divisions. During the year approval was given to the provision of a second new 50-place day nursery. Health education—Approval was given to the continuation of the smoking advisory evening clinic sessions at East Islington welfare centre. A dental health campaign was carried out in the Autumn school term in co-operation with heads of local schools and officers of the Education department and the local Dental Committee. Two ' Dental Health Weeks ' in October and November served as foci of the campaign, when the preliminary build up was intensified by film shows and talks on dental health subjects in schools and a special exhibition at Barnsbury welfare centre. The assistance of local authorities and organisations, doctors and dentists was obtained in distributing publicity material during this phase of the campaign. Infectious disease—It was noted that a very low number of infectious disease notifications was being received from many schools; head teachers throughout the division were therefore reminded of the importance of notifying every case of infectious disease occurring in their pupils. This resulted in about double the number of notifications being received and enabled the divisional health services to take prompt action where necessary. Prophylaxis—Approval was given in January to participation, in association with the Institute of Child Health, in a field trial of a new measles vaccine to be given intra-muscularly in one dose, without gamma-globulin. The trial continued throughout the year. In September another measles vaccine trial was begun in association with the Medical Research Council with the two-fold purpose of: (a) confirming the findings of small scale trials about the absence of significant vaccination reactions; and (,b) assessing the degree and duration of protection against measles after vaccination. Under this scheme parents of all children born in 1963 living in Islington and Finsbury were invited to register their children for vaccination; 1,700 out of some 6,000 children at risk were registered and allocated at random to vaccine or control groups. Vaccinations were carried out during October and November; follow-up investigations will take place at intervals of three weeks, three, six and nine months. 144 The routine vaccination with B.C.G. of all tuberculin negative children between the ages of 13 and 14 years whose parents give their consent is now to be spread more evenly through the year. A divisonal team (doctor, nurse and clerk) instead of a team from central office will undertake the work. Tuberculosis incidents in schools are being particularly closely followed up. Family planning—A six-month survey of the family planning clinics in the division showed that only about one third of the women referred to the clinics on medical grounds actually attended. Accordingly, arrangements have been made for clinic doctors who have referred women to these clinics to be informed at monthly intervals of patients who have not followed their advice. Premises—The Islington training centre closed in April; the staff and 12 of the girls transferred to the Mary Hughes centre, Whitechapel, and the remaining nine girls went to the Camden training centre. West Islington welfare centre and South Area home help office vacated premises at Richmond Avenue, N.l, at the end of September. The services were transferred to the new purpose-build Barnsbury maternity and child welfare centre, Carnegie Street, N.l, which was opened ceremonially by the Chairman of the Health Committee, on 5 November, in the presence of the Mayor of Islington. Services previously conducted at Pentonville school treatment centre, Vittoria Street, N. 1 were also transferred to the new centre, where six weekly chiropody services are also held. Mental health—Casework has continued to develop steadily during the year, one notable feature being the increasing number of referrals for community care coming from general practitioners. At the request of the psychiatrist concerned, the mental health social workers now attend one of the weekly out-patient clinics connected with Friern hospital. It has still not been possible to open a much-needed day centre in the division, but it is hoped that the vacated premises referred to above may become available for this purpose. An interesting recent development has been a very successful occupational therapy class for former housebound patients, held twice a week at the divisional office; also the psychiatric social worker now runs a therapeutic group at the office once a week which is proving very useful. The psychiatric social club, which was at first slow to grow in numbers, is now a happy well-established group. School health service—The scheme for selective medical inspections, which in 1963 showed a proportionately greater incidence of defects in children examined than did the routine seven-year-old medical inspections, has continued successfully in the past year with encouraging results. DIVISION 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington Dr. S. King reports: On the eve of a major re-organisation of London's government it seems that I should comment on changed aspects of the personal health service since 1948. Maternity and child welfare—This service, basically the same, but re-shaped to fit changing circumstances, now includes close liaison with general practitioners and the provision of facilities at welfare centres for general practitioner obstetricians and domiciliary midwives. 145 The integration of the child welfare and school health services now provides continuous supervision and it is hoped that this will continue. Prophylaxis—The very much greater prominence of prophylaxis with the resultant decrease in the incidence of infectious disease and the introduction of B.C.G. vaccination of school children are worthy of mention. It is pleasing to record that in 1964 not one case of diphtheria or of poliomyelitis was notified. Health centre—In 1952 the first (and only) comprehensive health centre in the administrative county was opened in the division. This centre caters not only for the local health services but for general medical and dental services also and is attended by more than 2,000 persons each week, including the patients attending the general practitioner and dental surgeries. Each year since it opened there has been a constant flow of students and visitors from overseas to view the centre and the services provided. This year there were 89 parties comprising 635 visitors. Mental health—With the implementation of the Mental Health Act, 1959, with its emphasis on community care, considerable local development took place. One of the most important developments has been the provision of day centres where persons suffering from mental illness can perform simple tasks. Formerly this type of patient when not kept in hospital was left to his own devices in his own home: by encouraging him to attend a day centre where output is not the main feature he is able to gain sufficient confidence to take a more normal and active part in community life. In the last four years three day centres have been opened, providing places for 90 patients. As our knowledge increases it has been possible to develop the potentials of this service. A variety of simple industrial processes are carried out at these centres and I am pleased to report a satisfactory standard of success. Each of these day centres has a social club and there have been very successful evening ventures. Because of lack of accommodation and staff, admissions to training centres for the mentally sub-normal have had to be restricted to children over five years of age. Their handicap usually becomes apparent at a much earlier age and many parents suffer severe mental strain in looking after the mat home. To ease some of the burden, two special-care units for severely mentally sub-normal children have this year been opened at St. John's and Victorian Grove day nurseries. Up to four such children may now be admitted to each of these nurseries. Dental health—The Ministers of Health and Education drew attention to the poor condition of school children's teeth and to help imprint on the school children's minds the importance of looking after their teeth a Dental Health exhibition was held in October. The exhibition which lasted four days was held at Shoreditch Health Centre and was attended by over 2,000 children. Subsequently, the children were asked to produce projects illustrating some aspects of dental health and a further exhibition of their work was held at Hackney Town Hall in November. Prevention of break-up of families—The divisional co-ordinating committee met regularly during the year and 73 individual families were discussed at intermediate case conferences. As in previous years many cases were referred from the Housing department, not less than 27 being in arrears of rent sufficiently high to put them in danger of eviction. The difficulties involved in unravelling and straightening tangled financial situations gave the most trouble. Staff— During my 16 years in office I have been highly impressed by the consistently high standard of work of the entire divisional staff and I take this opportunity of expressing my appreciation. 146 DIVISION 5, comprising the boroughs of Bethnal Green, Poplar and Stepney and the City of London Dr. A. L. Thrower reports: In any review of the development of the Council's health services in this division since 1948, tribute must be paid to my predecessor, Dr. G. O. Mitchell and his deputy, Dr. Lily Butler who, because of their links with and knowledge of the East End for many years prior to 1948 and thereafter until the end of 1963, were responsible not only for the smooth re-organisation following the transfer of services from the boroughs to the Council in 1948, but also for the continuity in administration thereafter. These officers played no small part in the co-operation always forthcoming in this locality between the varied voluntary and statutory organisations and committees working for the health and welfare of all concerned. Drastic changes have occurred in the area and re-building in this part of London may well be greater than in any other area of the Metropolis. This is not surprising when one recalls the widespread destruction of property in the City and in the East End during the war-years 1939-1945 and the enormous programme of slum clearance initiated since the war. This has led to great population movements. VitaI statistics—A comparison between the census of 1951 and that of 1961 reveals that the population of the division dropped by over 25,000 (i.e. from 236,114 to 210,449). The live births occurring to residents, however, in the years under review (1948-1964) have remained fairly constant. In 1949, for instance, the total number of live births was 4,272; the number each year thereafter fluctuated between the lowest recorded, 3,742 in 1960, and this year's figure of 4,172. The number of still-births during this same period has decreased encouragingly from the highest of 99 (in 1952) to 78 this year. Quads—Whilst reviewing the number of births it is appropriate to recall that one of the few surviving sets of quads are two boys and two girls born to a Stepney mother in December 1957 in the East End maternity hospital. Nursing and home help services were provided to assist the parents in caring for the children at home and the family were moved to larger accommodation by the Stepney Borough Council. The children made excellent progress and are now at school. Maternity and child welfare premises—It was recognised in 1948 that much needed to be done to provide more suitable accommodation for this purpose. The movement of population due to rehousing schemes also necessitated the resiting of some welfare centres. Steady progress has been made and the use of most of the unsatisfactory premises discontinued. In all, eight new centres have been opened in the division. Day nurseries—In 1948 there were seven Council day nurseries in the division; in addition, 65 places were available at two voluntary nurseries. The total number of places available was 485. Four nurseries have been closed and the total number of places available at the end of 1964 in five day nurseries (four Council and one voluntary) was 235. In spite of the closures there was no undue pressure on places. One reason for this may be the relatively generous provision of nursery school places in the division and the provision of full-time nursery classes in many primary schools. In September 1963, a special unit was opened in Queen Mary day nursery for the admission of up to six severely sub-normal infants. This provides special care for these mentally handicapped children and some relief to the parents from the often overwhelming task of caring for them at home. 147 Occasional creches—These are provided at selected welfare centres for minding children aged 2-5 years for short periods to enable the mothers to visit hospitals, attend to shopping and other domestic duties, or to take part in activities at the centres in which the creche is held. A growing demand for the service has led to the opening of these creches at seven welfare centres in recent years. Child minders—The Nurseries and Child Minders Regulation Act, 1948 requires those women who wish to daily mind for reward more than two children to whom they are not related to apply to the local health authority for registration. By the end of 1964 there were only eight statutory minders. The Council also encourages the voluntary registration of women who wish to mind one or two children daily. In 1949 only eleven such minders were registered. This number increased steadily until in 1957 it reached a peak of 133 minders on the voluntary register; since then fewer women have come forward and at the end of 1964 only 60 names were on the register. Recuperative holiday scheme—The demand for recuperative holidays for all age groups has shown a continual decrease year by year from the peak in 1950 when a total of 2,381 applications for this service was received. During 1964, this number had dropped to just over 1,000. Loan of home nursing equipment—An increasing number of handicapped and aged persons are now able to remain in their own homes with the supporting health and welfare services now available. One of these facilities is the loan by the Council of home nursing equipment. This loan scheme has developed rapidly from very small beginnings in 1949 and items now loaned, without charge, include special beds, Dunlopillo mattresses, hoists of various kinds, wheel chairs, walking aids, commodes, etc. At the end of 1964 some 280 of these articles were on loan. Home help service—The picture of the rapid development of this service in the division over the sixteen years is akin to that which took place throughout the county. The service inherited in the division in July 1948 was very limited and in some parts of the area almost non-existent. The extent of the expansion over the years, despite the difficulties experienced in recruiting suitable home helps is illustrated by the following statistics: Year ending 31.12.48 31.12.64 Number of home helps employed Whole-time Part-time 3 78 21 274 While in the last six months of 1948 only 432 persons in all received home help, the number of households actually being attended on 31 December 1964 was 2,355. Much credit is due to the organising staff for the service now available. Foot clinics—No municipal foot clinics were in existence in the division in 1948. For a number of years thereafter Ministry of Health restrictions made it impossible to initiate such a service. In 1954, however, two foot sessions a week were authorised. Development since then has been very slow, mainly because of the difficulty in this part of London of recruiting chiropodists. Nevertheless, gradual improvements were made and further foot clinics opened. By the end of 1964 there were such clinics at six centres, with a total of 28 sessions weekly. In addition, some foot treatment service was provided by old peoples' welfare organisations, grant-aided by the Council. Menial health—The Mental Health Act, 1959 emphasised the urgent need for developing community care services for the mentally ill and considerable progress to this end is being made in this division though much remains to be done. An increasing number of mentally disturbed persons are being referred to the mental health team by doctors, hospitals, courts, 148 relatives, neighbours, etc., and more and more home visits are being made to patients by mental health social workers. Close co-operation has been built up with hopital and other social workers and voluntary bodies. Invaluable help is received from the consultants at Long Grove hospital, who are always willing to see patients at short notice. Also of immense value is the day hospital at St. Clements, Poplar, which caters mainly for the elderly mentally ill. Nurses from this hospital visit the homes of the patients with mental health social workers to the benefit of all concerned. The Pritchards Road day centre, Bethnal Green, for 40 mentally ill persons was opened by the Council in August 1964. This is not yet running to full capacity but is proving worthwhile. Already four patients have benefited sufficiently to return to open employment. There are three evening social clubs for the mentally ill, two of which are run in conjunction with the Psychiatric Rehabilitation Association. A special advisory clinic for mentally backward children under five—the first of its kind in London—started in this division in 1953. It is conducted by a doctor with special experience in this field and sessions continue to be held once monthly. The first experimental industrial training centre in London for mentally handicapped older boys and men opened in the division in Whitechapel in 1955. The unit was transferred in February 1964 to better accommodation at Unity Hall, Poplar and the number of places increased from 20 to 30. This is a most successful project. Two training centres in the division for older girls and women—one at Bethnal Green and one at Whitechapel— provide a total of 85 places. These opened in 1962 and 1963 respectively. The centre at Bethnal Green also has a special care unit for 12 children who are physically as well as severely mentally handicapped. The staffs of all these centres give devoted service and there is no doubt that more projects of this kind would be of immense benefit. There is a flourishing Peter Pan Society (a local branch of the National Society for Mentally Handicapped Children) and a club run by parents for all of the severely subnormal who are over 12 years of age. Health education—This has steadily expanded in the division and now includes thriving mothers' clubs at seven centres, and a schoolgirls' club for 15-17 year olds at Wapping, which is doing very well. Talks and demonstrations by representatives from various outside organisations are given regularly and are very much appreciated. The mothers choose the type of lecture to be given and the programmes cover a wide range of health education subjects. Creches are provided for the afternoon clubs. Evening film shows are given at Wellington Way centre, which parents attend regularly. Health visitors teaching in schools arrange for the girls to see at the welfare centres the practical part of mothercraft lectures, e.g. ' Bathing the baby', ' Making up feeds' etc. which is more interesting for them than ' just another lecture at school'. Posters and projects are planned for each month in all child welfare and school treatment centres, in day nurseries and in home help offices. Social work for schoolchildren—The great improvement since the war in the health of schoolchildren and also the facilities available under the National Health Service are reflected in the reduced social worker effort needed to ensure that individual pupils receive the medical and dental treatment which they have been found to require. Special observation clinics for rheumatism cases and sessions for treating ear conditions are not required, while social workers no longer have to play a regular part at minor ailment sessions, which have greatly declined, or in the dental service. The social work associated with special investigation clinics which absorbed the nutrition and enuresis clinics has, however, increased and liaison work with hospitals on behalf of schoolchildren continues unabated. 149 Mention must be made of the social work arising from the Council's development over the years of schemes for improving the standard of its service for children with defective hearing. A divisional audiology clinic has functioned for 12 years and for four years there has been there a teacher of such children. In addition, the divisional social worker has been given special responsibility for the maintenance of a divisional register of the deaf. Perhaps the most important change has been the appointment of the divisional social worker as secretary of the divisional co-ordination committee, which deals with the problems of families whose activities or social weaknesses, for one reason or another, often need the assistance of social workers in a number of departments of the Council or in the employ of other statutory bodies or voluntary organisations. From 1957, when the divisional social worker assumed this function, the extent of the work involved has mounted year by year and latterly much time has been devoted to trying to prevent families from breaking up because of eviction. Case conferences, at each of which a number of families are discussed, now have to be held at least weekly and, because the discussions have to be thorough, are very time-consuming. One aspect of this work in this part of London which calls for special mention is the amount of effort arising from the rehousing into the area of difficult families from Welfare department accommodation in other parts of London. In addition to their other troubles, many of these families are not familiar with the East End and settlement here is not always easy for them. The division now has two full-time family case workers for intensive effort with ' problem ' families and the divisional social worker and some of her staff also undertake a small amount of this work. The divisional social worker herself now supervises case work students. DIVISION 6, comprising the boroughs of Deptford, Greenwich and Woolwich Dr. F. R. Waldron reports: Premises—New purpose designed clinic accommodation was opened at the Tenants' Clubroom, Anstridge Road, Avery Hill, Eltham, in July and named the Anstridge Welfare Centre. These new premises replaced a temporary centre conducted in a church hall in the area served. Maternity services—Since catchment areas were delineated by the South East Regional Hospital Board, pressure on local units decreased as far as Greenwich and part of Deptford were concerned. The district of Deptford, which was transferred to the Lewisham hospital catchment area, continued to pose problems in connection with booking of ‘ social need' cases. Early discharge schemes from the St. Alfege's hospital and Lewisham hospital units worked well and contributed a large measure of easement to the general problem. Ante-natal care—The general practitioner obstetrician scheme, which started in 1957 at one centre and with one general practitioner and covered the whole area of the division by 1961, has since worked very smoothly to the general benefit of the ante-natal case. Prophylaxis—An assessment of the results of the quadruple vaccine trial is still awaited. During the Autumn months the division took part in a measles vaccine trial which was still proceeding at the end of the year. Chiropody—Due to staffing difficulties the maintenance of a full service continued to present difficulties. Credit is due to the staff who made every effort to meet the demand of the priority classes, but at times the waiting period was inevitably longer than desirable. 150 Prevention of break-up of families—The co-ordinating committee met regularly to consider policy and matters of common concern, as well as measures to help particular families who presented especially difficult problems, the allocation of social workers and of specially trained home helps. A number of departments of the Council and the majority of other local statutory and voluntary agencies continued to be associated with the work of intermediate case conferences. Staff— I would like to take this opportunity of acknowledging gratefully the support of all grades of staff during the years since the division was established. There were many testing occasions including polio and diphtheria outbreaks in the early years and more recently the small-pox scare of 1962 when, through the untiring efforts of the professional and administrative staff, 150,000 members of the public were vaccinated in two weeks. DIVISION 7, comprising the boroughs of Camberwell and Lewisham Dr. Ann Mower White reports: During the year the full range of activities has been maintained, with some additions in anticipation of the re-organisation under the London Government Act, 1963.1 should like to pay tribute to the way in which the staff of all grades and at all levels have carried on existing work, often under trying conditions, and have also looked ahead to the need for planning the new local health services. In this report I have summarised the principal changes that have occurred in the services provided by the division since its inception in 1948. • Maternity and child welfare—During the period 14 new welfare centres have been opened, in rented or adapted premises, to serve new areas or to replace unsatisfactory accommodation often in church halls and seven new school treatment centres have been started. Of the ten voluntary committees who ran centres in 1948, six still continue. Day nurseries—The number of day nurseries has fallen from eight (with 439 places) to six (with 279 places) and the average daily attendance from over 350 to under 250. More and more use has been made of them for children with the most urgent priority need, i.e. families in an adverse environment or with a lone or sick mother. Creches for the occasional care of young children have been introduced successfully. At two day nurseries special units have been established, each for nine severely sub-normal children under the age of five years, where they receive special care and training. The work is closely associated with the day nursery and is staffed by day nursery staff who work in close association with health visitors and mental health social workers and, wherever possible, in touch with the parents. Associated with the decline in the day nurseries is an increase in child-minding. Preschool play groups have been developed privately of recent years and receive advice on standards of child care and hygiene from the Council's officers, voluntarily if they are not statutorily registered under the Nurseries and Child-Minders' Regulation Act, 1948. General Practitioners’ Centre—In 1961 the South East London General Practitioners' Centre was set up in the division for use by local doctors, where they can see their patients for minor operative treatment and refer them for bacteriological and X-ray examination. Post graduate discussions and meetings are also held. 151 Home help—This service has responded to the national policy of using it as an ancillary to the other medical and hospital services for confinement cases and for chronic sick persons. The needs of old people and problem families have received special attention both in the training and allocation of home helps. The full-time equivalent number of helps employed has grown from 185 to 431 and the number of households served from 1,160 to 5,868. Chiropody—From 1959, in accordance with a Ministry of Health decision, the number of chiropody sessions at foot clinics for old people, expectant mothers and handicapped persons was increased; 86 weekly sessions are now held, including a few at welfare centres. Handicapped children—Intensive attention has been given to the care and treatment of handicapped children of all ages, beginning with congenital malformations notified at birth, incorporating the observations of clinic doctors and linking with the statutory examinations under the Education Act and the Mental Health Act. Divisional registers have been built up of children who are deaf, at risk for deafness and handicapped; the registers serve not only as an index but as a basis for the regular review of the progress of each child. Prophylaxis—Vaccination and immunisation have been maintained on a voluntary basis by invitations to parents and general emphasis as part of health education. From time to time public demand has been stimulated by incidents of infectious disease and resultant press publicity. The divisional staff have taken a leading part in investigating local outbreaks and in providing mass vaccination sessions in co-operation with general practitioners and borough officers. Recent incidents of tuberculosis in schools have called for investigations on a large scale and B.C.G. vaccinations in co-operation with the local chest physician and mass X-ray unit. School health service—The special investigation of pupils referred from school medical inspections has grown considerably, due perhaps in part to the withdrawal of the issue of cod liver oil and malt and halibut oil capsules in schools. The most noticeable fall has been in cases and attendances at rheumatism supervisory clinics; although this may be partly offset by a diversion of cases to special investigation clinics or to hospital departments, it undoubtedly reflects a decrease in the overall number of cases. There has been a greatly increased use of ear, nose and throat sessions over the same period. The co-ordination of the activities for the prevention of break-up of families and the rehabilitation of problem families has continued under the chairmanship of the divisional medical officer and family caseworkers have been employed on the ' hard-core ' cases. Co-operation—A well-defined pattern of co-operation has evolved with other branches of the National Health Services, with other local authority services and public bodies. These efforts have been directed towards special classes in the community, the care of expectant mothers, problem families, maladjusted children and old persons, the prevention and control of infectious disease, in health education and the avoidance of accidents. They have included surveys, investigations and experimental schemes. Following the recommendations of the Maternity Services (' Cranbrook ') Committee, free use of ante-natal clinics has been given to general practitioner obstetricians to see their own booked maternity patients and, by agreement, those of other doctors. At the end of 1964, ten ante-natal clinics were attended in this way for 15 sessions a week by 29 doctors. Mental health—Following the passing of the Mental Health Act, 1959, with its emphasis on community care, a team of mental health social workers was set up in the division in October 1960. Since that date the establishment has risen to 16, including two psychiatric social workers (one of whom is the divisional mental health social worker), two senior occupational therapists and a craft instructor. 152 A full-time day centre for 40 mentally ill pateints has been opened in Camberwell and a part-time centre in Lewisham for 12 patients. The centres provide sheltered occupation for those either unable or not yet ready to work in open industry; day to day activities are organised by a senior occupational therapist. A full time centre has been planned for Lewisham. Similar centres have been planned for subnormal persons who are too old or unsuitable for the existing training centres. Evening clubs have been commenced for the mentally ill meeting weekly. ' Honor Lea’ purpose built hostel for chronic mentally ill patients, able to work or attend a day centre, opened in Lewisham in September 1964. It is run by an experienced warden, an ex-mental nurse, and caters for 59 residents of both sexes. A full time trained social worker is attached to the hostel and it is hoped to develop various social activities for the residents, with the aid of a local church group who have shown great interest in the hostel. An important part of the community care service is that dealing with the educationally subnormal and maladjusted school-leavers. In addition to the normal social work, plans have been made with one of the local (Camberwell) University Settlements for two clubs to be opened, one for E.S.N. school children, the other for E.S.N. school-leavers. A number of maladjusted teenagers will be absorbed by the latter, which will be run by one of the trained workers at the Settlement together with voluntary helpers. Two clubs for lower grade teenage subnormal boys and girls in Lewisham have been organised by the Lewisham Branch of the National Association for Parents of Mentally Handicapped Children and by a local church minister. A recent venture has been the work in liaison with the Camberwell Centre in an experimental scheme on the lines of the Samaritans, whereby six voluntary workers who have had a certain amount of training in mental illness are asked to visit selected clients regularly in order to support and befriend them. During the four years liaison has been built up with the local catchment area mental hospitals. Weekly case conferences have been held at the Maudsley hospital and monthly conferences with Bexley and Cane Hill hospitals. Recently the divisional mental health social worker has been invited to attend the two-monthly conferences held at Goldie Leigh, the children's unit of Darenth Park hospital for the severely subnormal. Dover Lodge, the hostel for subnormal working girls, has built up a good average number of girls and the deputy divisional mental health social worker attends regularly as the social worker and helps them to find work in the district. An interesting development has been the practical work placing of students with the community care service. Students from the University of Manchester mental health course have spent two months in the division, a Nottingham University Social Science student six weeks and students from the National Institute for Social Work Training and the Northwestern Polytechnic ' Younghusband ' courses have been placed for five months. Overall the picture has been one of a community care service gradually expanding and taking a definite shape. 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 centres taken over from the boroughs in 1948 were of different types and quality. Most of the centres in Lambeth had been under voluntary control, many centres were in unsatisfactory premises and new 153 accommodation was difficult to find. The task of rationalising the services, with adequate premises conveniently placed for the mother and with the health visitors' case loads evenly spread, has been carried on over the 16 years. The policy of providing fairly large centres, where there can be a staff of several health visitors working together and complete maternity and child welfare and health education services provided, has proved successful. New firstclass centres have been provided—Tulse Hill, Rose McAndrew, Loughborough, Moffat and John Dixon. These centres have attracted large attendances of mothers and children and given opportunities for teaching and guidance to mothers that have played a great part in the improvement of health and welfare of the community. The development of the ante-natal services in co-operation with the hospitals and general practitioners has been carried on over the years. The continued shortage of maternity beds, coupled with a rising birth rate and immigrant population, has led to constant pressure on hospital admissions. Agreement has finally been reached with the hospitals for them to have definite catchment areas for which they are responsible for all maternity cases requiring a hospital bed. Co-operation has also been effected with the general practitioners, many of whom are using the Council's premises, where, together with the midwives, they see their own patients booked for home confinement at the ante-natal clinics. Day nurseries and creches—There has been a gradual decline in the use of day nurseries. This has followed the policy of providing nursery places only for children of mothers who are in the priority groups and not for mothers only working to supplement the family income. The number of day nurseries in 1948 was 16, of which 11 still remain. One new day nursery (Coral day nursery) has been built to replace one in hutted accommodation. This excellent building has attracted many visitors, who have appreciated its design and lay-out. The number of children in the day nurseries would have fallen much further if it had not been for the large immigrant population in parts of the division, among whom there is a large proportion of priority cases requiring admission to a day nursery. The nurseries also provide assistance for the children of problem families and children whose parents are in temporary or permanent difficulties. The nurseries have played a most valuable part in the prevention of children being taken into care. The development of the creche, where children can be left for a short time to allow the mother to be free at times for shopping, attendance at hospital or other urgent business, has proved a most popular and valuable service. These creches have been provided at four welfare centres in the division. Immunisation—Facilities have been provided at all welfare centres for the complete immunisation programme to be carried out on all children. A follow-up system has been arranged for the health visitors to persuade all mothers to have their children immunised. At most infant welfare clinic sessions material and facilities for immunisation are kept at hand during the sessions, so that mothers can have their children immunised without having to attend at a special session. A special evening session for immunisation has been opened at the Loughborough centre. This has proved a most successful and busy session, which is attended by many mothers who may be at work or who cannot attend during the day. During this last year measles vaccine has been introduced and given under controlled conditions under the direction of the Medical Research Council. Health education—The work of the doctors and health visitors advising the mothers individually at clinic sessions, in school and in the homes, is, of course, a major part of health education in its widest sense. Many other branches of health education, aimed at teaching all members of the community the rules of healthy living, have also been developed. Mother clubs have been organised at many clinics, where films, lectures and discussion on health topics have been held. Health visitors have attended schools to give talks to the children. Displays on health topics were exhibited in the Brixton shop window for several 154 years. The subjects have included immunisation, dental health, feeding and diet, care of the feet and footwear, sleep and exercise, prevention of accidents, and anti-smoking. Recently the most important subject of the danger of smoking has been brought before the public. Attention has been drawn to the relationship between lung cancer and heavy cigarette smoking and every effort has been made to draw the attention of the public to the grave danger of cigarette smoking. In particular, efforts have been concentrated on the school children. It is particularly tragic to see the practice of smoking among so many children at such an early age. A health education officer from County Hall has visited the schools, clinics and offices with a cinematograph projector, giving lectures and anti-smoking propaganda. This has been a most valuable asset to the campaign. School health service—The great achievement of the school health service, particularly since 1948, has been the outstanding improvement in the health of the school children. This has resulted in the main in a reduction of the services which have been provided and it has been possible to terminate several treatment facilities which were no longer needed. These included a tonsil and adenoid operative service, rheumatism supervisory sessions and some minor ailment sessions. All minor ailment times throughout the division have in fact now been drastically reduced, without ill effect, as is clearly shown from the satisfactory results of school medical inspections. Three sections of the school health service are still expanding, however—hospital work, audiology and special investigation clinics. During the period the teaching hospitals in the division have greatly developed both their social medicine services and their arrangements for the assessment and treatment of handicapped children, giving consideration not only to the child's medical condition, but also to the personal and family problems arising from the condition, and to the close integration of hospital and community services in meeting these problems. The public health social workers attached to the hospitals have been asked to play an active part in both these fields. There has also been a great extension of awareness at all levels of the problems of the children with impaired hearing and of the services for the early diagnosis, treatment and education of such children. Audiology sessions have increased in the division from one a month to two a week. Specially trained teachers from the deaf schools have been seconded as peripatetic teachers of the deaf and, in fact, play a considerable part in the assessment and treatment of infants, as well as of children over two. Partially hearing units have been opened in both primary and secondary schools, divisional deaf and ' at risk ' registers have been established and a medical officer designated for the general supervision of the registers, in addition to the specialised diagnostic work of the divisional otologists. These services are now linked through a public health social worker. The third expanding service, the special investigation centres, is popular with the parents largely because of the time available at the school treatment centres. Appointments can be spaced to give mothers plenty of time to talk to the doctor about minor difficulties of diet and behaviour and particularly about the social difficulties of enuresis, which some feel nervous of raising in the more formal setting of a hospital out-patient clinic. Moreover, many girls who have menstrual difficulties refuse to go to hospital and do not wish to consult a male general practitioner but are set at ease by women medical officers who deal with this matter at the school centres. Mental health services—The mental health services have been steadily developed and consolidated since the passing of the Mental Health Act, 1959. Referrals for mental health action now amount to over 1,000 each year and the department carries an active case-load of approximately 900 mentally disordered persons. At the same time, the mental health social workers have been taking in their stride the admission of over 600 patients each year to psychiatric hospitals. 155 L Castle day rehabilitation centre, which opened officially in July 1964, had already begun admitting mentally ill patients early in the year. An encouraging number of these have been rehabilitated and have returned to work, including some who had spent many years in hospital. St. Olave's hospital has been a focal point for much mental health community care in Bermondsey and part of Southwark. Social workers and occupational therapists are provided by the Council for the day hospital. Patients admitted to the psychiatric in-patient unit for short-term treatment may pass from there through the day hospital and into the community with the Council's social workers keeping in touch at every stage. A further link between this hospital and the community has been the appointment of an additional occupational therapist to share her time equally between working in the day hospital and visiting house-bound psychiatric patients in the community. Co-ordinating committee—The committee began as a result of the need that was felt for the prevention of child neglect and ill treatment and juvenile delinquency, and in the hope of reducing the necessity for reception of children into care. It has brought together members of the staffs of Council departments, statutory and voluntary organisations concerned and led to a great improvement in mutual understanding. The divisional co-ordinating committee has met at regular intervals for policy and reviewing, under the chairmanship of the divisional medical officer and with the divisional treatment organiser (later divisional social worker) as secretary. Intermediate case conferences on individual families, to which field workers from every agency concerned and the family doctor are invited, are held as frequently as required and there has been an increased number of field-level conferences, at school medical inspections, in M. and C.W. centres and care committee offices, etc. to avoid both duplication and confusion in immediate action. This remains the structure of the work in the division today but the outlook has changed from the original plan of collaboration in known cases of neglect or suspected neglect to close collaboration at much earlier stages, aiming at long-term educative work to remove or modify possible causes rather than to deal with effects. A number of services and routines have been evolved to further this end. A rent guarantee scheme, worked out by the divisional co-ordinating committee, was later accepted for the county. Specially selected home helps were given brief appropriate training to prevent breakdown in the home and used, with considerable success, in rehabilitating some inadequate and discouraged mothers or in helping fathers who have undertaken to look after their children without a mother. Residential rehabilitation has also been tried in a few cases, but with less success, local experience being that very disorganised families may manage in sheltered conditions but they tend to break down again on return to the normal community. There was, however, an obvious need for additional case work service in the community and the co-ordinating committee gave every support from the earliest discussions to the establishment of the South London Family Service Unit; indeed the first organiser of the unit was housed in a school treatment centre until the unit found its own premises. Collaboration with the Family Service Unit has remained very close, a high proportion of the families with whom the unit has worked throughout having been referred through intermediate case conferences called for the purpose, at which Family Service Unit workers are, of course, present. Following the appointment of public health caseworkers to the division in September 1963 the same procedure has been used in allocating their families. Rent arrears were recognised very quickly to be a symptom of social circumstances which might well lead to neglect or breakdown and a routine for their early notification to the co-ordinating committee, by both Council and borough housing departments, was established 156 and is now working well. Another matter of serious concern was the question of rehousing of problem families and of the rehabilitation of families rehoused. In 1963 a special drive was made to collaborate with the housing and welfare departments in clearing the bottleneck in short-stay accommodation. It is difficult to assess the ultimate effect of the great amount of social work being done for problem families and all families suffering as a result of neglect, ignorance and incompetence. These social problems are the problems of our times and we may consider ourselves fortunate that now that the effect of physical disease have been largely overcome we can turn our attention to the social problems that so often lead to more serious consequences. We can pay tribute to the patience and understanding given by the health visitors and social workers and all the staff concerned who are constantly dealing with these difficult problems. DIVISION 9, comprising the boroughs of Wandsworth and Battersea Dr. J. T. R. Lewis reports: Development since 1948—Apart from the normal developments to be expected in an expanding health service, the main special feature has been the attempt to integrate the environmental and personal health services by the ‘ tripartite’ agreement between the Council and the two Metropolitan Boroughs of Battersea and Wandsworth. This is now old history but it is worthwhile recording that this scheme was not only the largest of its kind in the country but over a period of more than 13 years secured the closest co-ordination of the environmental and personal health services that is possible outside a county borough organisation. It has been to me, and I also speak for my medical colleagues, a great privilege and pleasure to participate in this form of administration. Although very demanding from the personal point of view and time consuming, it has been an interesting and worthwhile experience. A noteworthy development has been the growth of the mental health service in the last four years. This has been put on a basis from which there is every hope of expansion and growth. I should like to place on record the help I have received from all grades of staff in this area since 1952. The co-ordination of the services to which I refer above would not have been possible without the wholehearted support of all my colleagues. Putney health centre—The history of this centre testifies to successful pioneer voluntary endeavour and partnership between local authority and voluntary bodies. The forerunner of the present centre was opened in a converted shop in 1914 by Miss Eileen Lecky, M.B.E., with voluntary support. The existing purpose-built establishment in Clarendon Road was opened in 1931 as the Children's Health Centre for South-West London; from 1948 to 1958 the Council co-operated with the Trustees in the provision of a full range of health clinics. Full responsibility for the operation of Putney health centre was taken by the Council in July 1958. Mental health—One of the early fruits of the Mental Health Act, 1959 was the opening in July 1962 of the mental health hostel ' Chellow Dene’. The hostel meets the needs of persons who require a period of sheltered accommodation to help them to establish themselves in employment and in the community as a whole after recovery from mental illness and includes the temporary care of patients from the community in circumstances where a period of support away from home surroundings might prevent a more serious breakdown. 157 The Clapham training centre for 100 mentally subnormal men and boys aged 16 and over is the largest of the Council's industrial centres for the subnormal and the first to be opened (1961) in South London. The centre includes power driven machinery. Training aims to help those attending to make the most of their capabilities and to enjoy lives as full and independent as possible. The emphasis is on the production of useful articles for which contracts are negotiated with local firms and the Council's own supplies organisation. Premises—The very extensive housing developments in the Roehampton area led first to the establishment of welfare centres in hired premises and next to their replacement by Victoria Drive centre (within the ‘ shell’ of a house partially erected before the war) and by the William Harvey centre. This purpose built centre was opened in July 1959 on the Council's Ashburton Estate at Roehampton. The two-storey centre is incorporated into a three-storey block of flats and has been planned to provide a full range of clinical services. There are clinics for expectant mothers, and young children; a child guidance clinic staffed by part-time psychiatrist, psychotherapist, psychologist and social worker; and for school children, minor ailment clinics, consultative ophthalmic and orthoptic clinics staffed by the hospital service. It is a curious fact that hitherto no hospital or clinic has borne the name of the eminent physician renowned as the discoverer of the circulation of the blood. William Harvey spent the declining years of his life in a house at Roehampton not far from where the centre now stands. Older areas of the division were not neglected although here the problem of development is clearly much more difficult. It was possible, however, with the co-operation of the Battersea Borough Council, to provide the St. Christopher's combined welfare and school treatment centre on the ground floor of a block of flats in 1961. 158 Statistical summary 1964—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 1964 436,130 493,070 279,590 254,720 210,660 301,940 398,910 358,310 451,270 3,184,600 Foot clinics Births and associated mortality Sessions 4,974 1,305 4,285 3,961 1,129 6,219 3,685 3,515 2,612 31,685 Live births 8,283 8,296 6,495 6,011 4,043 5,595 7,819 8,074 8,884 63,500 Total attendances 34,822 9,115 28,416 30,162 6,650 47,158 20,656 23,975 17,122 218,076 Rate per 1,000 population 190 16.8 23.2 23.6 19.2 18-5 19.6 22.5 19.7 19.9 Day nurseries Deaths under 1 month 139 117 97 81 57 82 112 109 151 945 Rate per 1,000 live births 16.8 14-1 14.9 13.5 14-1 14.7 14.3 13.5 17.0 14.9 Number of places at 31 Dec. 629 971 361 379 235 58 279 654 437 4,003 Deaths All ages 4,563 5,052 2,954 2,833 2,294 3,239 4,381 4,063 5,677 35,056 Total attendances 148,451 225,581 85,511 89,853 49,782 13,723 63,391 149,637 94,978 920,907 Child minders Rate per 1,000 population 10.5 10.2 10.6 111 10.9 10.7 110 11.3 12-6 110 Statutorily registered 31 Dec. 34 20 21 20 8 53 49 3 30 238 Health visiting Children minded (authorised no.) 166 129 120 84 33 287 258 26 203 1,306 Voluntarily registered 31 Dec. 111 119 72 49 38 103 106 109 13 720 Total visits 131,232 139,446 69,517 64,691 60,511 73,572 102,368 116,896 93,413 851,646 Children minded 190 136 120 58 61 121 130 132 23 971 Staff at 31 Dec. W/T equivalents 60 60 40 32 28 39 52 51 55 417 Home help Welfare centres Households attended 4,517 4,950 3,043 4,448 3,299 4,312 5,868 4,867 4,913 40,217 Children— Sessions 2,403 3,413 2,488 1,522 1,923 2,253 2,525 2,902 2,456 21,885 Households attended per 1,000 population 10.4 10.0 10.9 17.5 15.7 14.3 14.7 13.6 10.9 12.6 Total attendances 81,135 110,681 82,248 63,132 62,865 91,427 106,288 99,424 111,408 808,608 Expectant mothers—ante and post Home nursing natal clinics— Sessions 1,713 1,755 881 601 205 1,178 1,110 251 740 8,434 Total visits 222,738 226,390 115,727 124,873 102,496 211,865 198,867 185,876 187,176 1,576,008 Visits per 1,000 population 511 459 414 490 487 702 499 519 415 495 First attendances this year— Ante-natal 3,394 5,869 5,351 2,230 320 2,596 3,123 1,203 3,186 27,272 School health service Post-natal 70 259 539 852 140 668 352 108 295 3,283 Medical inspection, routine, special, Total attendances 12,358 21,084 19,880 8,475 2,064 11,196 13,260 4,378 11,264 103,959 reinspection 35,236 30,178 26,817 20,529 23,949 32,906 36,743 28,996 40,667 276,021 Health surveys 78,741 104,883 64,134 33,753 28,466 89,777 51,531 43,234 67,261 561,780 Prophylaxis Hospital/specialist clinics— New cases 3,854 3,276 3,525 2,222 1,898 3,141 2,039 1,967 3,227 25,149 Poliomyelitis (L.C.C. and general practitioners)— Salk vaccine Total attendances 7,176 9,150 12,642 5,637 5,563 7,413 6,683 *7,869 11,189 73,322 Primary course (3 injections)— born 1960-64 155 147 81 10 40 83 410 116 145 1,187 Dental services Schools— New cases 10,509 9,377 6,471 11,257 6,107 5,336 4,963 8,229 13,296 75,545 born 1943-59 25 52 50 5 34 18 94 49 60 387 born 1933-42 30 24 33 15 26 38 22 23 27 238 New cases per 1,000 population age 5-14 259 231 207 352 212 136 97 180 258 209 born 1932 or earlier and under 40 years 14 23 34 4 7 6 18 12 12 130 Total attendances 28,046 27,896 20,400 33,226 16,677 16,409 15,644 26,099 33,526 217,923 over 40 years 1 — — — — — 4 — — 5 Maternity and child welfare— Total 225 246 198 34 107 145 548 200 244 1,947 First treatment 340 566 288 841 154 191 20 210 149 2,759 Reinforcing injections 66 72 5 1 16 34 157 108 111 570 Total attendances 1,483 2,081 1,309 3,412 607 591 65 596 537 10,681 Sabin vaccine Primary course (3 doses)— born 1960-64 5,986 6,008 4,969 4,790 3,177 4,581 5,945 6,595 6,579 48,630 born 1943-59 3,232 2,293 1,457 1,348 971 1,914 985 2,201 911 15,312 born 1933-42 545 220 431 528 223 215 171 498 204 3,035 born 1932 or earlier and under 40 years 140 155 169 133 94 118 121 674 173 1,777 over 40 years 6 42 9 2 5 7 18 40 16 145 Total 9,909 8,718 7,035 6,801 4,470 6,835 7,240 10,008 7,883 68,899 Reinforcing dose 6,238 4,430 4,228 3,059 1,820 3,781 2,380 4,816 1,880 32,632 Smallpox—Vaccinations 2,844 2,787 2,780 2,535 1,082 2,025 3,293 2,686 3,212 23,244 Re-vaccinations 661 948 390 902 330 310 513 288 618 4,960 Diphtheria—Primary course 7,050 7,417 6,341 5,420 3,595 5,247 7,062 7,206 7,252 56,590 Reinforcing injections 7,627 9,420 8,060 5,526 4,310 9,911 6,800 9,035 6,090 66,779 Whooping cough—Primary course 5,589 6,490 5,248 4,926 3,144 4,632 6,497 6,732 7,116 50,374 Reinforcing injections 3,456 3,395 3,918 3,060 2,078 3,528 4,433 4,557 4,244 32,669 Tetanus—Primary course 7,502 7,391 6,015 5,616 3,617 5,168 7,054 7,242 7,589 57,194 Reinforcing injections 6,002 6,515 6,090 5,177 3,386 7,191 5,977 7,729 5,802 53,869 * Excluding attendances at Royal Eye Hospital. 159 APPENDIX A STAFF OF THE PUBLIC HEALTH DEPARTMENT AT 31 DECEMBER, 1964 Medical Officer of Health and Principal School Medical Officer A. B. Stewart Senior Principal Medical Officer M. MacGregor Administrative Officer T. A. Wright Principal Medical Officers Maternity and child welfare Dorothy F. Egan School health R. E. C. Copithorne Epidemiology Ian Taylor Tuberculosis W. Hartston Mental health C. W. J. Ingham Staff medical examinations R. Cove-Smith Child psychiatry Jessie Parfit Chief Dental Officer and Principal School Dental Officer W. Ritchie Young Chief Nursing Officer Evelyn Robinson Scientific Adviser S. G. Burgess Principal Clerks G. Berridge N. B. Chapman Principal Clerk and Statistician C. W. Shaddick Acting Officer-in-Charge, London Ambulance Service .. N. A. Woodruff Deputy Establishment Officer R. C. Coulter Chief Inspector J. C. Clancey Principal Social Worker (Health Services) Frances C. K. Gregson Principal Mental Health Social Worker Phyllis M. Perrott Senior Officers of the Divisions Divisional Medical Division Officer 1. Eva M. Cran (Acting) 2. H. L. Oldershaw 3. W. G. Harding 4. S. King 5. A. L. Thrower 6. F. R. Waldron 7. Ann Mower White 8. W. H. S. Wallace 9. J. T. R. Lewis Divisional Administrative Officer T. A. Stone D. A. Collins (Acting) N. A. C. Bignell T. A. Maxwell E. L. Hannant L. M. Longhurst F. L. Clark D. E. Armstrong R. E. Haymes Divisional Nursing Officer Joan A. Surr Esther A. Evans Margery D. Butler Lilian E. Arrow Elizabeth J. Early Margaret V. Naunton Kathleen L. Sewell Bessie Thom Winifred M. Winch 160 APPENDIX B STAFF—SURVEY OF LONG-TERM SICKNESS 1961/63 Introduction 1. The Medical Officer of Health is responsible for the medical examination of the Council's staff: (i) as to fitness for appointment to the Council's service; (ii) after a prolonged period of sickness; (iii) after an accident on duty, and (iv) when physical fitness to remain in the Council's service is in question. There are also other minor aspects—eligibility for spouse pension, confinement leave, etc. In practice, staff on sick leave are normally referred for examination after two months' absence and after one month's absence arising from an accident on duty. Earlier arrangements apply in the case of staff reported to be suffering from tuberculosis and cases are occasionally referred earlier when physical fitness to remain in the service is under consideration. Method 2. In 1960 a pilot scheme for the indexing on punched cards of cases referred for medical examination was introduced and this was extended and made permanent in 1961. The prime purpose of the system is to provide an alphabetical index of all the cases, containing particulars of age, sex, grade, reason for examination, diagnosis and outcome: the system also provides statistics required for administrative purposes. It was decided to explore the potentialities of this scheme by carrying out a limited analysis of long-term absence from work owing to sickness (item (ii) above), for the years 1961/63 inclusive— limited because of inability to obtain all the requisite supplemental data as instanced below. 3. A major difficulty encountered was in the ascertainment of the ' exposed to risk' population for the various grades of staff employed by age and sex. In the case of some grades, information was obtained of the numbers of staff employed in mid-1964 from a computer tabulation of salaried staff by age group and sex, supplemented by manual methods in the case of weekly paid staff. This information was readily available from computer sources because the first two digits of the L.C.C. Superannuation and Provident Fund number allocated to each member of the staff are the year of birth of the staff concerned. In a few instances where individuals were not on the Council's Superannuation Fund the information was obtained by reference to departmental sources. In the case of firemen and teachers, both of which grades have special superannuation schemes, the information was not obtainable from this source as the national superannuation schemes for these two grades of staff do not employ a numbering system incorporating year of birth. For Fire Brigade personnel a manual count was made of all records of the uniformed staff. With teachers, owing to the large numbers concerned (over 20,000), a manual count was made on a sample basis from records maintained in the Education Officer's department: one card in every five was sampled. Hence the numbers of teachers shown as employed always ends in the figure 5 or 0, because the sample results had to be multiplied by five to equate them to the actual numbers in the Council's service. As it was not possible to obtain easily the numbers of other grades of staff by age and sex, the analysis was limited to A.P.T. and C. grades (administrative, professional, technical and clerical grades within the purview of the L.C.C. Interim Panel), teachers, nursing staff (including health visitors and midwives), Fire Brigade and Ambulance Service uniformed staff. 161 Results* (a) Sickness 4. Table 1, sections A to E, shows the results of this survey of sickness for these five groups of staff. The section for nursing staff is limited to females because the number of male nurses employed was too small for a meaningful analysis; for similar reasons figures for Fire Brigade and Ambulance staff have been limited to males. The table shows the number of staff employed by age and sex at mid-year 1964 related to the occurrence of long-term sickness in the years 1961 to 1963. The sickness figures should strictly have been related to a mid-1962 employed population but by the time it was decided to make this survey the opportunity had passed. The extraction of the employed population figures for two years earlier would have been both time consuming and liable to inaccuracy. Hence the 1964 figures have been used and to this extent this survey is not a strict comparsion of‘ like with like '. However, in a service the size of the London County Council, provided there has been no major change in staffing policy, this deficiency is not likely to invalidate any broad conclusions drawn from the figures. The table goes on to show the number of spells of sickness in these three years, the number of persons concerned with these (a person can be referred more than once during these three years—the maximum encountered was five spells although the most frequent number of multiple referrals in the three years was two); the percentage of persons sick in these three years, the total duration of sickness with the average per spell, the disposal of these sickness cases and finally the percentage dying or invalided from the Council's service. It must be remembered that throughout this analysis it is long-term sickness that is under discussion—something involving, with minor exceptions, at least two or more months absence from duty. It is not a quantitative measure of total sickness in the Council's service. 5. Dealing with each section of table 1 in turn, section A for the A.P.T. and C. grades shows that as between males and females there was a higher incidence of long-term sickness (column 5) in females up to age 55 years, thereafter the male figure was much higher, which is in line with national mortality experience—mortality at these ages in males is twice that of females. The number dying or invalided (P.U. = permanently unfit) in the three years reaches a figure of 14.6 per cent. for males and 17.8 per cent. for females (column 14) at ages 55—64 years, a wastage rate of some five per cent. a year. Figures for age 65 years and over may be the least reliable, because the staff employed at this age may have been subjected to the greatest change between the census of 1964 and the middle year of the survey—1962. 6. Section B for teaching staff employed shows about three and a half times as many female as male teachers under 25 years of age, nearly twice as many females at ages 25—34 years, near equality between the sexes at ages 35—54 years with a ratio of 3:2 in female/male teachers beyond that age. Doubtless this is a consequence of current events in the recruitment of teachers. Column 5 shows a higher percentage of long-term sickness in females than males at all ages. (A separate analysis of all sickness in teachers showed a similar pattern up to age 45 years.) Compared with A.P.T. & C. staff (their nearest equivalent in this survey) teachers had a lower incidence of long-term sickness and a much lower wastage rate owing to death or retirement, permanently unfit; under one per cent. a year compared with the five per cent. for A.P.T. & C. grades at ages 55-64 years. 7. Section C for nurses shows percentage sick figures nearer to female A.P.T. & C. grades than to female teachers: similarly for the percentage died and permanently unfit. 8. Firemen (including fire officers), section D, show high rates of sickness, especially under 55 years, but a lower average duration of sickness compared with other male employees—all under two months. In practice, firemen are referred to the examining medical officer before the expiration of two months sick leave and this accounts for some of * See tables on pages 167 to 169. 162 the high percentage sick figures. The percentage dying and permanently unfit was higher up to age 55 years than for any other grade of staff in this survey. The number of deaths, six in total among 2,503 firemen, was proportionately lower than in the A.P.T. & C. grades, so that the high percentages in this category were due to a higher rate of men retired permanently unfit. It must be remembered that fire-fighting requires a high physical standard and what might incapacitate a man for this activity might not impair his ability to carry on a less strenuous activity as, say, a clerical or administrative officer. 9. Ambulance staff, section E, show high rates of sickness up to 55 years of age and especially at younger ages—9.1 per cent. under 25 years of age or three per cent. a year. Again, as with firemen, the average duration of each spell of sickness under two months up to 55 years suggests earlier referral. (A survey of staff sickness for all departments 1951-53 suggested a relatively high incidence of sickness in London Ambulance Service operative staff, especially in uncertificated sickness.) This led to more frequent referral to the examining medical officer which may, in part, account for the higher figures. The percentage retired unfit (there was only one death reported) was relatively high but not as high as for firemen. 10. There is, however, a deficiency in the figure of deaths reported in these tables. These deaths are of those in staff already referred to the examining medical officer because of continued sickness absence and they take no account of sudden death in staff not so referred. A separate investigation based on the year 1964 was made to ascertain the extent of this. The results indicated that about 40 per cent. of deaths occurred in persons referred to the examining medical officer but that this proportion varied with grade of staff and was lowest for manual workers. Most of these sudden deaths were from heart conditions. (b) The causes of sickness, invaliding from and death in the service 11. Table 2, sections A to E (where applicable sub-divided into males and females) shows for the different grades of staff, by age, the causes of long-term absence on sick leave with total figures for cases permanently unfit and dying. The causes shown are the 50 causes for tabulation of morbidity of the International Statistical Classification of Diseases, Injuries and Causes of Death (seventh revision 1955). The ' Not stated ' category refers to cases in which the diagnosis was not coded; these were relatively few and arose from ‘ teething’ troubles in the early days of the scheme, the percentage figure shown in this table excludes these 'Not stated' cases. The table is related to spells of sickness, not persons; it would be difficult to do otherwise, because each spell of sickness can relate to a different cause and many of such multiple referrals in the course of the three years were of this nature. 12. For the A.P.T. & C. staff, section A, in males the principal causes were respiratory diseases (code Nos. 28-34), psychoneurotic (No. 19), heart and circulatory diseases (Nos. 23-27), tuberculosis (Nos. 01 and 02), accidents (No. 50) and cancer (No. 12) in that order; for females they were psychoneurotic, diseases of the genital organs (No. 42), heart and circulatory diseases, cancer, accidents and rheumatic diseases (No. 46). There is, of course, an age pattern in these causes which is in line with general morbidity experience. Cancer is very much a disease of age and assumes its greatest impact from age 55 years onwards; of the specific sites for cancer (not listed in the table), cancer of the lung was the principal site for males and cancer of the breast for females. It is surprising that psychoneuroses and psychoses should figure so prominently for both men and women in the A.P.T. & C. grades, spread throughout the age range. Heart and circulatory diseases rank third in order of importance for both men and women, again very much related to age. Respiratory diseases were proportionately more than twice as frequent in males as females, this difference being mainly due to bronchitis (Code No. 32), especially from age 55 years onwards. This again is a reflection of national experience. Diseases of the genital 163 organs were especially important in women, ranking second in order of importance, between the ages of 35-54 years. Arthritis and rheumatism (very much related to age), were not as important as may be generally supposed, ranking in order of importance sixth in women and seventh in males. Of the causes of death, cancer and heart disease were the most important in males whilst in females 13 of the 16 deaths recorded were due to cancer. The diseases mainly causing retirement from the service on medical grounds were in males psychoneuroses, diseases of the nervous system (strokes) and bronchitis, whilst in females psychoneuroses was the outstanding cause. 13. With teaching staff, section B, much the same sort of pattern of the cause of longterm sickness as was found in the A.P.T. & C. grades applies, except that there is proportionately more psychoneurotic disorder—in men teachers nearly twice and in women teachers one and a half times that of male and female staff in A.P.T. & C. grades. The difference between the two groups of staff in this respect is demonstrated by the following figures: No. of spells of sickness Percentages with psychoneuroses and psychoses (all ages) Spells of sickness Permanently unfit A.P.T. & C. staff Male 719 10.6 1.8 Female 671 17.7 3.3 Teachers Male 308 19.2 0.3 Female 706 22.8 1.3 14. Among nurses, section C, the biggest causes of sickness were psychoneuroses. cancer, heart and circulatory diseases, and diseases of genital organs in that order—the same sort of pattern, with minor variations in order of preference, as was found with female A.P.T. & C. grades and women teachers. Heart and circulatory diseases were the principal causes of invaliding from the service, followed by psychoneuroses; cancer was the only cause of death in the service recorded. 15. For firemen, section D, the principal causes in order of importance were accidents (not on duty), heart and circulatory diseases, psychoneuroses, diseases of the stomach and duodenum (code No. 35), arthritis and rheumatism and hernia (code No. 37). Compared with male A.P.T. & C. staff and teachers, firemen experienced proportionately less cancer, less psychoneurotic illness and far less respiratory disease; they experienced proportionately many more accidents (three times as many), more diseases of the stomach and duodenum and for the first time in these tables hernia becomes of some importance. The lower incidence of cancer and respiratory diseases can be partly explained by fire staff having a younger age composition than A.P.T. & C. staff and teachers (see table 1, sections A, B and D). The higher rate from hernia is understandable because of the standards of fitness required in their occupation: a small hernia in, say, a clerical officer might not give rise to invaliding from the service, whereas the same sized hernia in a fireman might mean permanent unfitness for duty. This in itself may also contribute to the high proportion of sickness noted earlier in this grade of staff. Heart and circulatory diseases, diseases of bones and organs of movement, arthritis and rheumatism, and accidents were the principal cause of permanent unfitness for further service. 16. Ambulance staff, section E, showed a similar pattern of sickness to firemen (including a proneness to accidents not on duty), except that they had fewer psychoneuroses (the lowest of any grade of staff in this survey) and an incidence of respiratory disease more in line with that for men A.P.T. & C. grades and men teachers—the latter can probably be accounted for by a somewhat older staff (fewer young men). Hernia again is of some importance in this grade, ranking fifth in order of importance—lifting is also very much a part of an ambulance driver's duties and hernia is therefore an invaliding condition. 164 Discussion 17. This survey was carried out more as a feasibility study of the potentialities of the punched card system for recording sickness data than as an exact analysis. Nevertheless, in spite of the difficulties encountered and the imperfections inherent in the figures, it is felt that the main findings demonstrated by this analysis justified the work involved and pointed the way to a more precise and more comprehensive survey in the future. It is clear that as well as sex, age is an important factor and that type of employment has a bearing on sickness. 18. The striking feature of this analysis is the extent of long-term sickness in the Council's service and the wastage by premature retirement or death. For convenience the essential particulars from table 1 are summarised below: Percentage of persons sick, dying and permanently unfit 1961-63 Age A.P.T. & C. grades Teachers Nurses Firemen Ambulance Staff Male Female Male Female Female Male Male Percentage sick Under 25 0.9 1.5 0.9 2.3 2.6 5.4 9.1 25-34 3.0 6.8 1.5 3.1 6.8 8.1 8.8 25-44 4.8 9.4 2.9 5.5 6.9 13.6 10.2 45-54 8.2 13.5 3.6 6.9 11.5 26.7 17.2 55-64 51.0 39.2 7.1 9.5 40.5 32.5 27.3 65 and over 57.0 32.8 10.9 14.3 42.9 25.0 All ages 8.3 9.5 3.3 5.2 8.2 13.8 14.0 Percentage died and permanently unfit Under 25 0.11 0.05 0.12 1.8 25-34 0.06 0.35 — 0.14 0.97 1.5 0.4 35-44 0.36 0.99 0.05 0.40 0.40 2.4 0.8 45-54 1.53 1.56 0.46 0.45 1.58 7.2 3.3 55-64 14.62 17.85 1.65 2.06 14.88 11.1 5.8 65 and over 17.77 9.83 2.86 14.29 — — All ages 1.73 1.83 0.38 0.57 1.44 3.0 21 19. Over a period of three years, at ages 55-64 years about one-half (rather less for females) of A.P.T. & C. staff were absent on sick leave for a period of two months or more; for teachers the proportion was much lower, rather less than one-tenth, whilst for female nurses it was two-fifths. For firemen and ambulance staff, where the circumstances of referral were slightly different, it was about one-third. The figures for premature retirement or death in the same age group are also very high. Equated to an annual basis they approximate to five per cent. a year for A.P.T. & C. grades (men and women) and for female nurses. It is true that permanent ' unfitness for duty ' may be an exaggeration for staff at these ages; it might be more appropriately termed ' premature retirement’, but there can be no such explanation for death—approximately one-third of the figures in the category 'died and permanently unfit' in persons aged 55-64 years were deaths whilst in the Council's service in the case of male A.P.T. & C. grades, teachers (both sexes) and nurses. Even so, some of the death rates recorded in this survey are not as high as those in the general population, comparative figures are: 165 Annual death rates per 1,000 population, aged 55-64 years This survey Men Women A.P.T. & C. grades 15.0 17.9 Teachers 2.4 2.5 National figures England & Wales (1961-62) 22.1 10.8 The survey figures may be minimal for the reasons given in paragraph 10 and by the fact that some of the staff retired permanently unfit may have had a comparatively short expectation of life. The low mortality rate for teachers is not altogether unexpected—they have a low occupational mortality, a standardised mortality ratio of 66 compared with the national figure of 100 for the whole population (Registrar General, Occupational Mortality, 1951). 20. Less striking, but also of some importance, are the high figures for the incidence of psychoneuroses and psychoses in A.P.T. & C. grades and teachers referred to in paragraph 13. This cause of sickness is more understandable with teachers than office staff but the figures (paragraph 13) show that as a cause of premature retirement it is higher in A.P.T. & C. grades than in teachers. Also of some concern should be the high incidence of accidents not on duty sustained by firemen and ambulance staff. 21. The high incidence of psychoses and psychoneuroses and of accidents off duty in certain categories of staff obviously calls for further study, both to confirm the validity of the problems disclosed and to elucidate their causes. Two methods of study are available. First, the study of the individual case histories of those cases brought to light in the present study (or a random sample of them); second, a prospective study beginning now and continuing into the future in which the records of certain categories of staff with certain types of illness are made in such a way that additional information will be available which may serve to confirm or refute certain hypotheses. It may be mentioned that neither the original survey that brought to light the suggestive findings nor either of the suggested methods of following-up these findings would have been possible without the special recording procedure in use during the last three years. Summary 22. This survey has shown that comprehensive recording of long-term sickness in the Council's staff is possible; in addition certain significant findings have been disclosed. In the grades of staff where the numbers were adequate for a comparison between the sexes—A.P.T. & C. group and teaching staff—the incidence of long-term sickness was generally higher in females than in males. The incidence of sickness in A.P.T. & C. grades was about twice that in teachers; in nursing staff it approximated to that in female A.P.T. & C. grades; and fire and ambulance staff had the highest incidence of all, but this may have been due to the practice within these two grades of earlier referral to the examining medical officer. The wastage rate by permanent unfitness for further duty or by death in the service amounted to as much as five per cent. a year for both men and women aged 55-64 years in the administrative, professional, technical and clerical staff. Psychoneuroses and psychoses were the principal causes of long-term sickness in female A.P.T. & C. grades, in both men and women teachers and was the second principal cause in male A.P.T. & C. grades. Fire and ambulance staffs had proportionately fewer psychoneurotic difficulties but experienced more hernias, diseases of the bone and organs of movement and accidents not on duty. Diseases of the genital organs were relatively common (8-11 per cent. of all causes) in all grades of female staff, more noticeable around the age of the menopause. 166 Table 1—Staff long-term sickness 1961-63 Numbers employed, number sick, duration of sickness and disposal by age, sex and grade Age (years) No. sick 1961-63 Persons sick per cent of total employed Duration of sickness—months Disposal—each spell of sickness No. employed mid 1964 Spells Persons Total Average per spell of sickness Fit to resume duty Resigned Permanently unfit Died Other Total No. died and P.U. as per cent of No. employed (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) A.—A.P.T. & C. staff—MALES Under 25 1,630 16 14 0.9 51 3.2 12 4 16 25-34 1,692 55 50 3.0 162 2.9 42 8 1 — 4 55 0.06 35-44 1,939 105 92 4.8 358 3.4 88 8 4 3 2 105 0.36 45-54 1,764 174 144 8.2 472 2.7 139 2 12 15 6 174 1.53 55-64 534 321 272 51.0 1,060 3.3 218 14 54 24 11 321 14.62 65 and over 107 65 61 57.0 279 4.3 28 17 15 4 1 65 17.77 Total 7,666 736 633 8.3 2,382 3.2 527 53 86 46 24 736 1.73 A.—A.P.T. & C. staff—FEMALES Under 25 1,855 28 27 1.5 63 2.3 18 6 2 2 28 0.11 25-34 1,130 85 77 6.8 256 3.0 65 15 4 — 1 85 0.35 35-44 1,623 180 153 9.4 548 3.0 142 15 14 2 7 180 0.99 45-54 1,348 206 182 13.5 615 3.0 170 8 17 4 7 206 1.56 55-64 381 174 149 39.2 566 3.3 88 8 59 9 10 174 17.85 65 and over 61 20 20 32.8 51 2.6 10 4 5 1 — 20 9.83 Total 6,398 693 608 9.5 2,099 3.0 493 56 101 16 27 693 1.83 B.—Teaching staff—MALES Under 25 550 6 5 0.9 10 1.7 6 — - 6 25-34 2,170 38 32 1.5 86 2.3 34 2 — — 2 38 35-44 2,175 72 64 2.9 175 2.4 60 9 1 — 2 72 45-54 2,180 86 79 3.6 218 2.5 71 — 3 7 5 86 0.46 55-64 1,275 106 91 711 316 3.0 68 11 12 9 6 106 1.65 65 and over 110 13 12 10.9 49 3.8 9 2 — — 2 13 — Total 8,460 321 283 3.3 854 2.7 248 24 16 16 17 321 0.38 B.—Teaching staff—FEMALES Under 25 2,030 52 46 2.3 91 1.8 37 11 1 — 3 52 0.05 25-34 3,505 123 107 3.1 442 3.6 97 13 1 4 8 123 0.14 35-44 2,255 146 125 5.5 410 2.8 118 12 4 5 7 146 0.40 45-54 2,230 164 153 6.9 465 2.8 143 8 5 5 3 164 0.45 55-64 1,845 216 176 9.5 681 3.2 149 20 24 14 9 216 2.06 65 and over 175 28 25 14.3 92 3.3 16 6 3 2 1 28 2.86 Total 12,040 729 632 5.2 2,182 3.0 560 70 38 30 31 729 0.57 167 Table 1—Staff long.term sickness 1961.63—continued Numbers employed, number sick, duration of sickness and disposal by age, sex and grade—continued Age (years) No. employed mid 1964 No. sick 1961-63 Persons sick per cent of total employed Duration of sickness—months Disposal—each spell of sickness Spells Persons Total Average per spell of sickness Fit to resume duty Resigned Permanently unfit Died Other Total No. died andP.U. as per cent of No. employed (1) (2) (3) (4) (5) (5) (7) (8) (9) (10) (11) (12) (13) (14) C.—Nursing staff—FEMALES Under 25 801 22 21 2.6 40 1.8 17 2 1 — 2 22 0.12 25-34 412 28 28 6.8 101 3.6 16 5 4 — 3 28 0.97 35-44 506 39 35 6.9 85 2.2 33 2 2 — 2 39 0.40 45-54 444 56 51 11.5 228 4.1 43 4 5 2 2 56 1.58 55-64 121 52 49 40.5 181 3.5 28 3 13 5 3 52 14.88 65 and over 7 3 3 42.9 11 3.7 — 2 — 1 — 3 14.29 Total 2,291 200 187 8.2 646 3.2 137 18 25 8 12 200 1.44 D.—Fire officers and firemen—MALES Under 25 483 27 26 5.4 41 1.5 22 5 — — — 27 — 25-34 807 76 65 8.1 138 1.8 56 6 12 — 2 76 1.49 35-44 579 94 79 13.6 182 1.9 77 2 14 — 1 94 2.42 45-54 517 169 138 26.7 294 1.7 128 1 32 5 3 169 7.16 55-64 117 46 38 32.5 83 1.8 28 2 12 1 3 46 11.11 Total 2,503 412 346 13.8 738 1.8 311 16 70 6 9 412 3.04 £.—Ambulance officers and ambulance drivers/attendants—MALES Under 25 55 5 5 9.1 2 0.4 3 — 1 — 1 5 1.82 25-34 227 22 20 8.8 28 1.3 20 1 1 — — 22 0.44 35-44 245 26 25 10.2 40 1.5 23 1 2 — — 26 0.82 45-54 209 43 36 17.2 57 1.3 31 4 6 1 1 43 3.35 55-64 121 38 33 27.3 75 2.0 28 2 7 — 1 38 5.79 65 and over 8 2 2 25.0 9 4.5 1 1 — — — 2 — Total 865 136 121 14.0 211 1.6 106 9 17 1 3 136 2.08 168 Table 2—Staff long.term sickness 1961.63—Cause of sickness by age, sex and grade. Code No. Cause of sickness Age A—A.P.T. & C. staff B—Teaching staff c.—Nursing staff D.—Fire officers and firemen E..—Ambulance officers and ambulance drivers/attendants Code No. Cause of sickness Males Females Males Females Females Males Males Under 25 25-34 35-44 45-54 55-64 65+ Total Under 25 25-34 35-44 45-54 55-64 65+ Total Under 25 25-34 35-44 45-54 55-64 65+ Total Under 25 25-34 35-44 45-54 55-64 65+ Total Under 25 25-34 35-44 45-54 55-64 65+ Total Under 25 25-34 35-44 45-54 55-64 65+ Total Under 25 25-34 35-44 45-54 55-64 65+ Total No. % No. % No. % No. '/. No. % No. %. No. % 01 Tuberculosis respiratory 2 7 17 13 15 3 57 7.9 6 6 14 7 1 1 35 5.3 1 9 16 2 3 — 31 101 4 9 4 4 — — 21 3.0 1 1 2 2 — — 6 3.1 2 — 1 2 1 — 6 1.5 1 1 2 1 5 3.7 01 Tuberculosis respiratory 02 Tuberculosis, other forms 1 3 2 2 1 — 9 1.3 2 — — 1 — 3 0.4 1 — — 1 — 2 0.6 — 1 — — — 1 2 0.3 — 1 1 — — — — — — — — — — — — — — — — — — — — — 02 Tuberculosis, other forms 03 Syphilis and its sequelae — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1 — 1 0.5 — — — — — — — — — — — — — — — — 03 Syphilis and its sequelae 04 Gonococcal infection — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1 0.2 — — — — — — — — 04 Gonococcal infection 05 Dysentery — — — — — — — — — — i — — — 1 0.1 — 3 — — — — 3 10 — — — — — — — — — — — 1 — — 1 0.5 — — 2 — — — 2 0.5 — — — — — — — — 05 Dysentery 06 Other infective diseases (intestinal) — — — — — — — — — — — — — — 1 0.1 — — — — — — — — — — — — — — — — — — — — — — 2 1.0 — — — — — — — — — — — — — — — — 06 Other infective diseases (intestinal) 07 Diseases common in children — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1 0.1 — 1 — — — — 1 0.5 — — — — — — — — — — — — — — — — 07 Diseases common in children 08 Typhus and rickettsial diseases — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 08 Typhus and rickettsial diseases 09 Malaria — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 09 Malaria 10 Diseases due to helminths • — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 10 Diseases due to helminths 11 Other infective and parasitic diseases — 1 2 1 2 — 6 0.8 — 2 2 — 2 — 6 0.9 — — — 1 1 2 0.6 5 3 1 — 2 — 11 1.6 — 2 — — 1 — 3 1.6 — — — — — — — — — 2 — — — — 2 1.5 11 Other infective and parasitic diseases 12 Cancer — — 3 9 21 4 37 5.1 — — 11 17 23 2 53 7.9 — — 3 3 6 1 13 4.2 — 1 5 18 36 4 64 9.2 — 2 4 7 8 1 22 11.4 — — 4 2 2 8 2.0 _ 1 — 1 0.7 12 Cancer 13 Non.malignant neoplasm — 1 — 3 3 — 7 1.0 — — 1 6 — — 7 1.0 — — — — 1 1 2 0.6 — — 2 3 6 2 13 1.8 — — 2 — — — 2 1.0 — 1 1 3 2 — 7 1.7 — — — 1 2 — 3 2.2 13 Non.malignant neoplasm 14 Allergic disorders — — — — — — — — — — — — — — — — — — — — — — — — — — — 1 — — 1 0.1 — — — — 1 — 1 0.5 — — — — — — — — — — — — — — 14 Allergic disorders 15 Diseases of thyroid gland — — — — 2 — 2 0.3 — 2 3 5 1 — 11 1.6 — — 3 2 3 — 8 2.6 — 2 5 6 4 — 17 2.4 — — — 1 2 — 3 1.6 — — — — — — — — — — 1 — — — 1 0.7 15 Diseases of thyroid gland 16 Diabetes mellitus — 1 — 2 3 — 6 0.8 _ 1 — 1 — 1 3 0.4 — — — — — — — — — — 1 1 1 — 3 0.4 — 2 — 1 1 — 4 2.1 — — 2 1 — — 3 0.7 — — — 1 1 0.7 16 Diabetes mellitus 17 Avitaminosis and deficiency state — — — — 1 — 1 0.1 — — 1 — — — 1 0.1 — — — — — — — — — — — 1 — — 1 0.1 — — — — — — — — — — 1 1 — — 2 0.5 — — — — — — — 17 Avitaminosis and deficiency state 18 Anaemias — — — 4 4 1 9 1.3 — 1 3 5 5 — 14 2.1 — 1 — 1 1 — 3 10 — 1 2 1 3 2 9 1.3 — 1 1 1 — — 3 1.6 — — — — — — — — — — — — — — — — 18 Anaemias 19 Psychoneuroses and psychoses 4 9 16 21 23 4 77 10.6 7 26 44 25 15 1 118 17.7 1 8 15 19 15 1 59 19.2 18 46 48 20 27 1 160 22.8 6 6 6 9 — — 27 14.0 2 6 10 9 1 — 28 6.9 — — — 2 — — 2 1.5 19 Psychoneuroses and psychoses 20 Diseases of nervous system — 3 3 8 16 3 33 4.6 — — 4 6 4 1 15 2.2 — 2 2 4 3 — 11 3.6 1 10 2 7 3 — 23 3.3 — — 1 — 2 — 3 1.6 1 7 4 5 1 18 4.5 1 2 1 1 5 3.7 20 Diseases of nervous system 21 Diseases of eye — — 4 4 5 4 17 2.4 — 2 3 3 3 — 11 1.6 — — — 2 4 — 6 2.0 1 1 — 5 10 2 19 2.7 — — — — — — — — — 6 1 3 1 — 11 2.7 — — — 2 — — 2 1.5 21 Diseases of eye 22 Diseases of ear — — — 4 6 — 10 1.4 2 — 1 1 2 1 7 1.0 — — — — 2 — 2 0.6 1 — 3 5 1 — 10 1.4 — — — 1 1 — 2 1.0 — — 2 5 — — 7 1.7 — 1 — 1 2 1.5 22 Diseases of ear 23 Rheumatic fever — — 1 1 1 — 3 0.4 — — — — — — — — — — — — — — — — — — — — — — — — — 1 — — 1 — 2 1.0 — — — — — — — — 1 — — — — — 1 0.7 23 Rheumatic fever 24 Chronic rheumatic heart disease — 1 1 2 6 2 12 1.7 — — 1 6 3 — 10 1.5 — — — 3 2 — 5 1.7 — 1 3 3 2 — 9 1.3 — — — 1 1 — 2 1.0 — — 1 — — — 1 0.7 24 Chronic rheumatic heart disease 25 Arteriosclerotic and degenerative heart disease — 1 5 21 34 8 69 9.6 — — 1 5 11 — 17 2.5 — — 5 13 20 3 41 13.3 — 1 — 3 9 4 17 2.4 — — — 1 5 — 6 3.1 — — 2 15 7 — 24 5.9 — — 2 3 3 8 5.9 25 Arteriosclerotic and degenerative heart disease 26 Hypertensive disease — — 3 5 28 9 45 6.3 — — — 6 12 1 19 2.8 — — 1 3 11 — 15 4.9 — — 2 1 17 1 21 3.0 — — — 2 3 2 7 3.6 — — 1 9 1 — 11 2.7 — — — 2 3 — 5 3.7 26 Hypertensive disease 27 Diseases of veins — — — 5 5 1 11 1.5 — 1 7 7 6 — — — — — — — — — 2 0.6 — 1 3 2 — 6 0.8 1 1 2 — — 4 2.1 —. 1 3 2 — 6 1.5 — — 3 — 1 — 4 3.0 27 Diseases of veins 28 Common cold — — — — — — — — — — — — — — — — — — — — — — 1 0.3 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 28 Common cold 29 Pharyngitis and diseases of tonsils and adenoids — — — 1 — — 1 01 — — 1 1 2 — 4 0.6 — — — 1 — — 1 0.3 — 1 1 — — — 2 0.3 — — — — — — — — — — — 1 — — 1 0.2 1 — — — — — 1 0.7 29 Pharyngitis and diseases of tonsils and adenoids 30 Influenza — i — 1 — — 2 0.3 — 1 — 1 2 — 4 0.6 — — — — — — — — — 2 2 — — 2 6 0.8 — — — — — — — — — — — — — — — — — 1 — — — — 1 0.7 30 Influenza 31 Pneumonia — — 2 1 2 1 6 0.8 — — — 2 — — 2 0.3 — — 2 4 4 1 11 3.6 1 — 2 — 4 — 7 1.0 — — — 2 1 — 3 1.6 — — 2 — — — 2 0.5 — 2 — 1 — 3 2.2 31 Pneumonia 32 Bronchitis — — 3 9 37 6 55 7.6 — 2 3 5 7 — 17 2.5 — 3 1 5 5 1 15 4.9 1 1 — — 7 — 9 1.3 — — — 4 1 — 5 2.6 — 1 — 5 1 — 7 1.7 — — 2 3 — 5 3.7 32 Bronchitis 33 Silicosis and occupational pulmonary fibrosis — — — — — — — — — — — — — — — — — — — — 1 — 1 0.3 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 33 Silicosis and occupational pulmonary fibrosis 34 All other respiratory 2 — 4 6 10 — 22 3.1 — — 3 2 — 1 — — — — — — — — 2 0.6 2 4 4 1 2 — 13 1.8 1 — 1 1 — — 3 1.6 — — — 1 1 — 2 0.5 — 2 — 2 — — 4 3.0 34 All other respiratory 35 Diseases of stomach and duodenum — 2 1 8 13 1 25 3.5 — 2 — 2 5 — 9 1.3 — — — 2 1 — 3 1.0 — 3 — 2 6 — 11 1.6 1 1 — — 1 — 3 1.6 — 3 4 17 3 27 6.7 1 1 3 2 1 8 5.9 35 Diseases of stomach and duodenum 36 Appendicitis — 1 1 2 — — 4 0.6 3 1 — 1 1 — 6 0.9 — — — 1 — — 1 0.3 1 — 3 1 3 — 8 1.1 2 — — — — — 2 10 — 2 — 1 2 — 5 1.2 — — 2 — 2 — 4 3.0 36 Appendicitis 37 Hernia — 1 2 1 8 — 12 1.7 — — 1 3 — — 4 0.6 — 3 3 — 1 2 9 2.9 — — 1 4 1 — 6 0.8 — — — 2 — — 2 1.0 1 4 2 11 5 — 23 5.7 — — 1 3 2 1 7 5.2 37 Hernia 38 Diarrhoea and enteritis — — — 3 — 1 4 0.6 — 1 1 1 1 — 4 0.6 — 1 2 — 1 1 5 1.7 — 2 1 — 3 — 6 0.8 — — — — — — — — — — — — — — — — — — . 38 Diarrhoea and enteritis 39 Diseases of gallbladder and bile ducts — 2 5 1 3 — 11 1.5 — — — 4 1 1 6 0.9 — — — 1 1 — 2 0.6 — — 1 4 2 — 7 1.0 1 — — — 2 — 3 1.6 — 1 — — 1 — 2 0.5 — — — — — — — — 39 Diseases of gallbladder and bile ducts 40 Other digestive — — 1 3 4 1 9 1.3 1 1 2 — 3 — 7 1.0 — — 2 — 1 — 2 0.6 — 1 2 1 4 — 8 1.1 — 1 — 1 2 — 4 2.1 — — 1 — — — 1 0.2 — — 1 — — — 1 0.7 40 Other digestive 41 Nephritis — — 1 — — — 1 0.1 1 5 2 2 1 — 11 11.6 — — 1 — — — 2 0.6 — 3 — — 2 1 6 0.8 1 — — — 1 — 2 1.0 — 1 1 1 1 — 4 1.0 — 1 1 1 — — 3 2.2 41 Nephritis 42 Diseases of genital organs — — 1 4 7 5 17 2.4 1 7 23 3o 8 — 77 0.7 — — — 1 1 — 3 1.0 2 2 18 26 9 — 57 8.1 4 1 10 4 1 — 20 10.4 — 1 — 1 — — 2 0.5 — — — — 3 — 3 2.2 42 Diseases of genital organs 43 Complications of pregnancy and childbirth — — — — — — — — 1 3 1 — — — 5 0.7 — — — — — — — — 3 1 1 1 — — 6 0.8 — 1 — — — — 1 0.5 — — — — — — — 43 Complications of pregnancy and childbirth 44 Boils, abscess and skin infections — — 1 1 1 — 3 0.4 — — 3 2 — — 5 0.7 — — 1 2 — — 2 0.6 — — — 3 1 — 4 0.6 — — — 1 — — 1 0.5 — 1 — 2 1 — 4 1.0 — — 1 1 0.7 44 Boils, abscess and skin infections 45 Other diseases of skin — 2 1 3 3 1 10 1.4 2 1 — 1 — — 4 0.6 — — 1 — 1 — 2 0.6 3 2 — 1 1 — 7 1.0 — — 1 — — — 1 0.5 — 5 2 6 — — 13 3.2 — 2 4 1 6 13 9.6 45 Other diseases of skin 46 Arthritis and rheumatism 1 1 3 3 20 2 30 4.2 1 2 7 9 17 4 40 6.1 — — 1 4 2 — 7 2.3 2 3 6 9 13 3 36 5.2 1 3 1 1 5 — 11 5.7 1 3 3 14 4 — 25 6.2 — — 2 2 — 4 3.0 46 Arthritis and rheumatism 47 Diseases of bones and organs of movement — 2 9 14 5 — 30 4.2 — 3 19 10 11 1 44 6.7 — 1 1 4 — — 6 2.0 — 4 6 12 8 — 30 4.2 — 1 6 1 2 — 10 5.2 4 9 15 18 4 — 50 12.4 — 3 2 3 3 11 8.1 47 Diseases of bones and organs of movement 48 Congenital malformations 1 — 1 — — — 2 0.3 — 1 1 1 3 — 6 0.9 3 1 1 — 4 — 3 1.0 — 3 — — — — 3 0.4 1 — — — — — 1 0.5 — — — 1 — — 1 0.2 — — — — 1 — 1 0.7 48 Congenital malformations 49 Other diseases — — 2 1 1 — 4 0.6 1 1 7 — 12 1.8 — — 1 — 2 — 6 2.0 — 2 3 2 3 — 10 1.4 — — — 3 3 — 6 3.1 1 2 1 — — — 4 1.0 — — — 1 — 1 0.7 49 Other diseases 50 Accidents (Not on duty) 5 13 9 5 21 7 6U 8.2 1 7 9 16 9 3 45 6.8 — 2 5 4 7 1 19 6.2 5 7 13 9 18 4 56 7.9 2 1 — 4 4 — 11 5.7 14 22 29 28 4 — 97 240 3 4 2 7 5 21 15.6 50 Accidents (Not on Duty) — Not stated — 3 1 2 10 1 17 — 1 3 6 5 7 — 22 — — 3 3 3 3 1 13 — 2 5 3 6 6 1 23 — — 1 2 2 2 — 7 — 1 1 1 4 1 — 8 — — — — 1 — — 1 — — Not stated TOTAL 16 55 105 174 321 65 736 100.0 28 85 180 206 174 20 693 1000 6 38 72 86 106 13 321 1000 52 123 146 164 216 28 729 1000 22 28 39 56 52 3 200 100.0 27 76 94 169 46 — 412 1000 5 22 26 43 38 2 136 100.0 TOTAL 169 APPENDIX C Statistics of the administrative work carried out by the Metropolitan Borough Councils in 1964. BOROUGH DWELLINGS CLEARANCE AREAS Housing Act, 1957, Part III DWELLING HOUSES Water supply to tenement houses P H (London) Act 1936 Control of movable Dwellings (L.C.C. (General Powers) Act, 1959, sec. 22) AIR POLLUTION CLEANSING AND DISINFECTION LICENSED OR REGISTERED PREMISES PUBLIC HEALTH INSPECTOR BOROUGH[7###] Erected by Borough Council Erected by other persons Total number in the Borough Inspections Repaired as a result of informal action Defects remedied after service of formal notice Houses closed in pursuance of owners' undertaking Persons displaced 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 Housing Act 1961—Houses in multiple occupation Overcrowding abated Section 90, Housing Act 1957 Complaints Observations Intimation notices served Nuisance notices served Prosecutions Smoke Control Orders confirmed Adults cleansed Children cleansed Premises disinfected Premises disinfected Establishment Employed at end of year Pupil assistants employed at end of year Technical assistants Licensed slaughterhouses Other offensive trades Common and Seamen's Lodging Houses Dairies and milk shops Ice cream premises Closing Orders substituted for Demolition Orders Management Orders made Neglect of proper standards of management made good Additional services or facilities provided Houses provided with means of escape from fire Directions made to reduce or remedy overcrowding Unfit houses Other houses Houses excluded from Clearance Orders (no longer unfit for human habitation—Section 24) Underground rooms Other rooms Underground rooms Other rooms At home At cleansing station Initial visits on complaint With a view to action under Part II of the Housing Act, 1957 Other reasons Re-inspections Public Health (London) Act, 1936 Housing Act, 1957 Demolished Persons displaced Demolished Persons displaced Houses provided with supply Prosecutions Convictions Male Female Total Male Female Total Male Female Total Number Persons displaced Number Persons displaced Number Persons displaced Number Site licences at beginning of year Site licences issued during year Number Persons displaced By owners By local authority By owners By local authority Number Persons displaced Number Persons displaced By owners By local authority By owners By local authority By owners By local authority Number Persons displaced Number of houses Persons displaced Number Persons displaced Number of houses Persons displaced Number Persons displaced Number Persons displaced Number Persons displaced Division 1 Division 1 Chelsea 60 91 17,129 — — — — — 717 — 8,336 8,217 103 45 — — — — — — — — — — — — — — — — — — — — — — 2 — — — — — — — — — — — — — — — — — — — — — — 54 17 — — — 1 — 7 4 182 487 — — — 67 91 9 8 1 9 — — — — — — Chelsea Fulham 93 7 30,184 121 § 54 § — 2,056 20 11,233 7,942 841 398 10 — — — — — — — — 1 — — — 1 2 — — — — — — — 2 — 8 — — — 2 — — — 1 — — — 3 6 — — 4 — — — — 31 132 — — — 1 — 61 4 26 281 — — — 129 232 14 13 — 13 — — — 2 — 2 Fulham Hammersmith 78 — 25,200 49 176 — — — 2,747 721 13,116 2,309 1,462 727 52 — — 2 — — — — — 13 — — — — — 2 — — — — — — 4 — — — — — 5 — — — 4 — — — 5 — — — — — 4 1 1 18 50 7 — — 1 — 190 33 12 340 — — — 130 217 14 12 1 13 2 1 3 1 — 1 Hammersmith Kensington 58 113 42,787 18 416 — — — 3,056 1,291 4,376 23,504 528 345 3 127 1 — — — — 2 4 3 — — — 29 10 6 3 2 — — — — 32 — 10 — 1 — 147 — 1 — — — — — 5 — — — 25 — — — — 36 14 — — — 1 — 187 295 183 768 — — — 195 379 24 19 — 19 2 — 2 2 — 2 Kensington Division 2 Division 2 Hampstead 176 215 25,192 — — — — — 925 31 13,727 14,307 1,005 107 — 5 3 — — 2 — — — — — — — — — 3 2 — — — — — — — — — — — — — — — — — — — — — — — — — — — — 70 135 — — — 1 — 13 — 47 355 — — — 69 251 15 13 1 14 3 — 3 4 1 5 Hampstead Paddington — 239 37,765 — — — — — 2,796 509 3,411 18,598 551 352 19 — — — — — — 1 5 44 — — — 25 — 4 — — — — — — 79 — 14 — — — 1 — — — — — 1 — 221 — — — 3 — — — — 45 72 5 — — 1 71 81 59 43 768 — — — 149 197 18 13 — 13 3 1 4 4 — 4 Paddington St. Marylebone 48 489 25,117 — — — — — 1,134 138 1,373 5,828 414 114 — — — — — — — — — — — — — 8 9 3 6 — — — — — — — — — — — — — — — — — — — — — — — 1 — — — — 53 61 9 3 — 1 — 238 261 29 351 1 — 2 99 192 15 10 2 12 1 1 2 — — — St. Marylebone St. Pancras 414 149 29,707 52 262 — — — 2,316 180 2,623 7,668 704 681 23 8 1 — — — — — — 12 — — — 31 — — — — — — — — — — — — — — — — — — — — — — — — — — 2 — — — — 103 291 — — 1 — 478 64 576 684 — — — 290 278 23 23 — 23 4 — 4 — — — St. Pancras Westminster, City of — 285 27,843 — — — — — 605 24 3,580 4,891 145 6 — — — — — — — — — 11 — — — 55 26 13 2 — — 1 — — — — — — — — — — — — — — — — 2 — — — 2 — — — — 40 516 — — — 3 — 403 5 72 — — — 2 145 280 26 14 1 15 4 — 4 2 — 2 Westminster, City of Division 3 Division 3 Finsbury 119 8 9,540 153 216 — — — 862 10 5,759 9,016 344 67 — — — — — — — 5 27 17 — 7 45 2 4 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 28 221 6 — — 1 — 107 26 97 397 — — 1 124 156 11 7 — 7 2 — 2 1 — 1 Finsbury Holborn 33 3 5,996 — — — — — 141 258 933 1,413 118 35 — 3 — — — — — — — — — — — 2 — — — — — — — — — — — — — — 1 — — — 1 — — — — — — — 6 — — — — 26 282 2 — — — 121 308 — 33 88 — 5 2 48 145 5 4 — 4 — — — 2 — 2 Holborn Islington †l72 ‡227 47,537 54 5 — — — 12,088 220 8,392 25,253 1,755 1,186 51 3 — 2 — 4 — 10 45 12 — 55 — 20 33 1 4 — — 1 — — 5 — 1 — — — 4 — — — — — — — 3 — 1 12 8 — — 9 3 53 199 93 — — 2 312 287 493 210 1,071 1 5 — 354 557 34 25 1 26 4 — 4 4 — 4 Islington Division 4 Division 4 Hackney 131 187 50,393 23 114 — — — 3,465 201 8,295 14,121 — 1,319 46 — — — — 2 2 2 3 1 — — — 21 64 25 58 — — — — — — — — — — — — — — — — — — — 225 — — — 15 — — 1 1 — — — — — — — 111 107 483 958 — 2 1 230 472 18 18 — 18 4 1 5 1 — 1 Hackney Shoreditch * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Shoreditch Stoke Newington 44 77 12,686 — — — — — 1,408 68 1,802 3,186 117 128 1 — — — — — — — — 2 — — — 5 — — — 1 — — — — — — — — — — — — — — — — — — 24 — — — — — — — — 38 26 1 — — — — 36 23 32 105 — — — 55 105 7 7 — 7 1 — 1 — — — Stoke Newington Division 5 — — Division 5 Bethnal Green 285 208 14,203 * * * * — 1,707 2,697 4,354 4,803 989 501 16 — — — — — — 20 — — — — — 13 — 26 — — — — — — 7 — — — — — — — — — — — — — — — — — — — — 15 — 26 21 8 — — 1 805 8 1 1 479 — — — 85 126 9 9 — 7 2 — 2 — — — Bethnal Green City of London — 1,015 — — — — — 4 — 72 78 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 81 75 1 — 1 — — 898 — 14 9 — — 1 33 78 23 23 — 23 — — — — — — City of London Poplar 70 423 18,921 * * * * — 2,580 1,219 5,004 7,154 1,840 387 — — — 1 8 11 47 2 9 1 — — — 2 1 — — — — — — — — — — — — — — — — — — — — — 53 255 1 7 — — — 11 4 36 23 — — — — — 42 3 104 2,113 — 1 2 108 203 9 9 — 9 4 — 4 2 — 2 Poplar Stepney 24 312 26,130 19 147 — — — 6,056 54 3,520 5,905 157 1,152 54 — — — — 2 — — — 1 — — — 9 6 — — — — — — — 58 — 16 — — — — — — — 1 — — — 11 22 53 97 4 — — 183 66 144 222 12 6 — — 103 308 23 27 480 — 18 5 209 298 18 13 — 13 4 — 4 3 — 3 Stepney Division 6 Division 6 Deptford * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Deptford Greenwich 233 264 25,012 — — — — — 2,080 10 9,104 8,166 316 87 5 — — — — — — — — 2 — — — 2 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 11 — 15 — — — — 1 2,574 1,893 128 60 1,292 — — — 99 232 10 9 1 10 3 — 3 — — — Greenwich Woolwich 345 381 46,172 110 250 13 25 — 1,427 90 5,438 6,438 585 249 — 5 — — — — — 10 40 6 1 8 — 2 3 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 14 22 1 — — 2 — 24 194 210 265 1 1 — 132 315 17 16 1 16 2 — 2 2 — 2 Woolwich Division 7 — — Division 7 Camberwell 266 593 46,667 25 — 11 12 — 5,549 303 30,463 10,491 1,452 1,093 1 22 5 — — — — — — 4 — 25 — 21 — 8 — — — — — — 20 — 2 — — — — — — — 4 — — — 20 — — — — — — 7 5 576 445 — — — 1 — 38 257 23 653 — 4 — 215 531 21 18 — 18 4 — 4 3 — 3 Camberwell Lewisham 409 * 66,307 — — — — — 1,260 14 15,245 11,709 319 268 31 9 — 5 — 10 — 6 — 1 — 4 — — — 7 10 — — — — — 6 — 1 — — — 13 — 2 — — — — — 4 — — — — — — 4 — 14 — — — — 3 — 25 85 185 386 — — — 106 374 20 19 — 19 4 — 4 — — — Lewisham Division 8 Division 8 Bermondsey 101 114 15,665 6 38 1 4 — 1,536 2 1,729 12,160 481 146 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 18 2 13 108 — — — — — 63 26 5 203 — 8 1 119 197 11 9 — 9 3 — 3 1 — 1 Bermondsey Lambeth * * 57,198 * * * * * 1,300 611 19,823 10,181 661 637 67 — — — — — — — 4 — — — 3 — — — — — — — — 10 — — — — — 55 — — — 8 — — — 88 216 3 5 — — — 1 — 57 305 — — — 3 — 61 53 187 748 — — — 297 626 21 17 1 18 3 1 4 6 — 6 Lambeth Southwark 92 49 25,211 70 374 2 5 — 2,663 37 15,714 6,538 540 427 107 — — — — 23 23 4 8 4 — 7 14 4 3 4 — 41 40 2 — — 3 — — — — — — — — — ¶ — — — — — — — — — — 2 3 11 172 8 — — — — 587 377 92 1,541 — 2 5 145 296 20 15 1 16 4 — 4 2 — 2 Southwark Division 9 1 Division 9 Battersea 14 157 28,124 28 87 78 94 — 2,361 322 6,241 5,757 364 358 10 3 — — — 3 14 1 — — — 6 — 3 5 — — — — — — — — — — — — — — — — — — — — — — — 1 — — 13 6 18 185 — — — 1 — 99 260 1,115 108 — 2 — 114 272 12 9 1 10 3 — 3 2 — 2 Battersea Wandsworth 640 764 122,000 18 166 — — — 5,474 41 21,703 19,280 788 317 8 — — 1 6 1 4 1 1 1 — — — 9 9 1 1 1 6 — — — — — — — — — — — — — — — — — 9 — — — — — — 21 2 48 318 1 — — 1 — 20 9 161 240 — — — 324 747 22 20 — 20 2 — 2 — — — Wandsworth LONDON 3,905 5,355 879,701 746 2,251 159 140 — 68,313 9,071 224,366 255,543 6,580 11,132 504 185 10 11 14 55 76 66 156 144 1 108 59 270 170 106 91 45 46 4 — — 235 — 52 — 1 — 228 — 3 — 19 — 1 — 703 499 58 121 71 — — 300 93 1,648 3,912 154 9 1 28 3,986 6,573 2,790 4,209 15,170 3 48 22 4,070 7,847 446 372 12 383 68 5 73 44 1 45 LONDON * Information not available. † 20 repair conversions. ‡ 49 L.C.C. repair conversions. § 327 (Total No. of persons displaced from both unfit and other houses). ¶ 16 premises surveyed prior to service of notice. * 1 prosecution. 170 INDEX Page Adoption of children 57 Air pollution 13 Alcoholics, hostel for 101 Ambulance service 39, 71 Ante-natal care 48 'At risk' register 49 Audiometry 125 Awards to ambulance staff 78 Bathing centres 121 B.C.G. vaccination 23 Births 4 Blind persons 34 Boarding out of children 23, 57 Cancer 9,51 Care committees 25,63, 117 Care of mothers and young children 48 Case conferences 48,56 Cervical cancer screening 51 Child guidance 125 help 66 minders 49 protection 58 welfare 48 Children at risk 49 Chiropody 86 Civil defence 79 Cleansing scheme 121 Community care of the mentally ill and the sub-normal 107 Contact scheme (Tb) 23 Cooperation with other health services 54 Créches, occasional 50 Crude spirit drinking 107 Day centres for the mentally ill 39, 104, 110 nurseries 39, 49 Deaths 4, 8, 19 Dental auxiliaries 131 health education 89 services 126 Diarrhoea and enteritis 14 Diphtheria 14,68 District nursing associations 64 Divisional medical officer's reports 140-158 statistical summary 159 Domiciliary midwifery 59 Dysentery 14 Educationally sub-normal pupils 124 Employment of schoolchildren 121, 122 Enteric fever 14 Expectant and nursing mothers 48 Families, social work with 55 Family planning 50 Family Service Units 56 Family Welfare Association 56 Fertility 5 Finance 137 Food handlers 135 Foot clinics 86 Page General practioners, cooperation with 54, 59 obstetricians 55, 59 Guardianship of the mentally ill/ sub-normal 98 Handicapped children 49, 57, 123 Health centres 37 education 88,110 surveys of pupils 120 visiting 55, 63 Home help 57, 66 nursing 64 safety 88 teaching of mentally ill 104 Hospital car service 75 confinements, scheme for early discharge 53, 60 Hospitals, co-operation with 54 Hostels, for alcoholics 101 for the mentally ill sub-normal 99,109 Housing 27, 31 loans 33 for tuberculous men 25, 40 (legitimacy 4,7 Immunisation 68 Improvement grants 33 Industrial training centres 101 Infant mortality 4,10 Infectious diseases 14, 21, 22, 122 Influenza 14 In-service training 77, 95, 135 Institute of Child Health 54 Invalid meal 36 Leptospirosis 14 Live births 4, 5, 6 London Ambulance Service 39, 71 Lung cancer 9 Maladjusted school leavers 109 Marriage guidance 58 Marriages 4 Maternal mortality 4, 12 Maternity and child welfare 48 centres 38 dental service 130 Maternity beds, early discharge 53, 60 use on social grounds 52 Meals, children 118 invalid 36 Measles 14,141,144 Medical examination of staff 136 Medical inspection of pupils 114 Medical treatment of pupils 123 Mental health services 48, 93 statistics 111 Metropolitan borough councils 170 Midwifery service 59 Midwives Act 62 Milk sampling 33 school 118 Moral welfare associations 8, 58 171 M INDEX—continued. Page Morning and evening helps 66 Mortality 4,8,10 Mother and baby homes 58 Neo-natal mortality 4,11 Night helps 66 Nurseries, day 49 Nursing home registration 35 Occasional créches 50 Open air schools 27 Ophthalmia neonatorum 14 Orthodontics 130 Partially sighted 34 Perinatal mortality 4, 11, 61 Personal hygiene of pupils 120 Phenylketonuria 49 Physical condition of pupils 118 Poliomyelitis 14, 70 Population 4,5 Premature babies 11,61 Premises 37 Problem families 56 Prophylaxis 68,123,141,144 Psychiatric day hospitals 106, 111 social clubs 103, 106 Public health laboratory 36 Recuperative holidays 27, 40, 87, 101 Rehabilitation of the mentally ill 104 the tuberculous 25 Rehousing on medical grounds 27, 31 Residential accommodation for the mentally ill/sub-normal 99 establishments for young children 57 Resuscitation certificates, award 78 Safe driving awards 79 Sanitary inspection 33 School care committees 63,117 dental service 126 health service 114 meals 118 medical inspections 114 treatment centres 38,123 Page Slum clearance 32 Smallpox 16, 69 Smoking and health 88,141 South East London general practitioners' centre 38,151 Spastic children unit 103 Special care units 102 educational provisions 124 Speech therapy 125 Staff 77,132 awards, ambulance service 78 medical examinations 136 training 77, 95, 135 Stillbirths 4, 5, 12 Student health service 125 Tetanus 68 Training centres 39,101 Training, staff 77, 95,135 student health visitors 135 Tuberculosis 23 B.C.G. vaccination 23 care and after care 25 preventive services 23 statistics 27 Unmarried mothers 8, 58 Vaccination 68 Venereal disease 88, 91 Vision tests 119 Visitors 139 Vital statistics 4, 5,17,18 Weather 13, 20 Welfare Committee establishments 36 Whooping cough 16,68 Woodberry Down health centre 37,146 X-ray examination of staff 25 Yellow fever 70 Young children in care 57 References to local activities in the sphere of chiropody, health education, mental health education, home making courses, problem families, prophylaxis, etc., will be found in the divisional medical officers' reports, pages 140-158. 172 Printed for Greater London Council Supplies Department by Waterlow and Sons Limited • London • Dunstable • Hyde 2/66 5656