Ac-43386 The Health of Richmond upon Thames 1966 RICh 35 LONDON BOROUGH OF RICHMOND UPON THAMES ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH AND PRINCIPAL SCHOOL MEDICAL OFFICER For the Year 1966 A. M. NELSON, M.B., Ch.B., D.P.H. Health Department, Elmfield House, High Street, Telephone : Teddjngton, TEDdington Lock 4411-5. Middlesex. 01-977 4411-5. CONTENTS page Vital and General Statistics 6 Infectious Diseases 10 Health Services: Care of Mothers and Young Children 16 Midwifery and Home Nursing 24 Health Visiting 28 Vaccination and Immunisation 30 Prevention of Illness, Care and After Care 31 Home Help 38 Mental Health 40 Other Information 46 Sanitary Circumstances of the Borough 53 School Health Service 74 Index 101 2 MEMBERS OF THE HEALTH COMMITTEE as at 31st December, 1966. His Worship the Mayor, Alderman H. A. Leon, M.B.E., J.P. (ex-officio). The Deputy Mayor, Councillor D. G. Harris, J.P. (ex-officio). Councillor F. D. Gilday Fox, B.A. (Chairman). Alderman L. Defries Porter, LL.B., M.B.I.M. Councillor N. F. Barrow, LL.B. Councillor D. J. Child. Councillor C. F. Garrud. Councillor M. Gold, M.R.C.S., L.R.C.P., D.Obst.R.C O.G. Councillor P. T. Griffith, A.F.R.Ae.S., A.M.I.M.E. Councillor S. Hayes. Councillor B. Hughes. Councillor R. H. Mitchison, F.V.I., M.R.S.H. Councillor B. L. Royle, J.P., A.M.I.E.R.E. Councillor Mrs. G. D. Smith. Councillor R. H. Stevens. D. R. Sinclair, Esq., M.B., B.S. (Advisory). OFFICERS Medical Officer of Health : A. M. NELSON, M.B., Ch.B., D.P.H. Deputy Medical Officer of Health : J. K. CRAIG, M.B.E., M.A., M.D., B.Ch., B.A.O., D.P.H., D.C.H,, D.I.H. Medical Officer for Special Duties : J. MADDISON, M.D., B.S., D.P.H. Senior Assistant Medical Officers : MARGUERITE E. M. JAMES, M.B.E., M.B., Ch.B., D.P.H. ELIZABETH WALES, M.B., B.S., D.C.H., D.P.H., D.R.C.O.G. (resigned 2.10.66). Chief Dental Officer : G. H. TUCKER, L.D.S., R.C.S. Chief Public Health Inspector : E. S. HERBERT, M.A.P.H.I. Chief Nursing Officer : MISS G. M. FRANCIS, S.R.N., S.C.M., H.V.Cert. Superintendent Health Visitor : MISS D. M. WOODS, S.R.N., S.C.M., H.V.Cert. Non Medical Supervisor of Midwives and Home Nursing Superintendent : MISS O. WILLIAMS, S.R.N., S.C.M., QUEEN'S NURSE. Chief Mental 'Welfare Officer : B. F. F. RADFORD, B.E.M., F.W.I., M.S.M.W.O. Chief Administrative Officer : H. J. PUGH. 3 HEALTH DEPARTMENT, ELMFIELD HOUSE, HIGH STREET, TEDDINGTON, MIDDLESEX. June, 1967. To the Mayor, Aldermen and Councillors of the London Borough of Richmond upon Thames. LADIES AND GENTLEMEN, I have the honour to submit my Annual Report for 1966. The evolution of the health department is now such that the end of the beginning is in sight. The process of blending and crystallization has continued. In fact the first tentative steps in controlled expansion are taking place. There are two complementary trends in the field of community medicine. On the one hand the working relationships between the family doctor and local authority health staff are becoming closer. On the other the further development of screening techniques in the early detection of disorder and the presymptomatic diagnosis of disease is apparent. If the premise is established that the family doctor is the personal medical attendant to a family, then the practitioners and personnel of community medicine must be closely associated. In passing, the practical definition of a family should be one individual sitting at a table, thus the elderly and the lonely are not excluded. This liaison and creation of the family health team can be brought about in a number of ways, depending on history, ecology, personalities and attitudes. The prime point of contact is in the patient's own home, and your nursing staff and family doctors have been working in this locus for many decades. The next logical step is that health visitors, district nurses and midwives collaborate on socio-medical matters in the family doctor's surgery. Every request from medical colleagues for such association has been met, but to my mind there are two limiting factors : the availability of staff; and the personalities of individuals concerned. The team must co-operate harmoniously to be effective. Eleven such liaison arrangements have been made. The family doctor can work in local authority premises for specific services, e.g. ante-natal care, child welfare and possibly the elderly. Two groups of doctors attend Essex House Clinic, Barnes, for ante-natal care in collaboration with the district midwife and health visitor. Negotiations were initiated during the year for possible general medical services from a clinic, e.g. Ham Centre. Further discussions were taking place for the ultimate in this field of co-operation — the Health Centre. You have two schemes in mind, the adaptation of Essex House, Barnes, and the Twickenham Health Centre, possibly in the grounds of St. John's Hospital, Twickenham. The latter project is exciting in that all three branches of the National Health Service would be on the one campus. By the same token it is to be hoped that the proposed Teddington clinic will be within the curtilage of Teddington Hospital. Screening techniques for the early detection of disorder and the presymptomatic diagnosis of disease have been steadily built-in to local authority services over a number of years. The very essence of the School Health Service depends on this concept, and the expansion of sweep testing for vision and hearing defects is the latest example. 4 In the infant the early detection of hearing loss and the urine testing for the metabolic disorder of phenylketonuria are already established. Developmental paediatrics in depth is the preventive arm of to-day in this regard from the observation register. Your clinic for preventive medicine for older people at Teddington under the direction of Dr. J. Maddison is now well-known. The limited start in cervical cytology in Barnes and Richmond areas has been expanded gradually. You instructed me at the end of the year to explore the further development in this field of screening for well women. In other words there is a spectrum of techniques for all age groups, which is not yet complete. One can see the day when the middle-aged man with risk of cardiac catastrophe can be advised on how to prevent or avoid the aggravation of particular health hazards pertinent to his group. The family doctor has been described as the first contact physician, who treats and cares for his patients, when illness strickens them. He has a further role to ensure that the diagnostic and intensive therapy facilities of the hospital are available to his patient, either on an out-patient or in-patient basis. He has a wider task in this early detection of disease and disorder. The grand strategy of medicine may well be shifting to this fundamental preventive style approach. These two interlinked concepts of community medicine, liaison and screening techniques offer a stimulating challenge to all interested in the health of the community. The services and resources of the hospitals, general practice, and local health authorities in these matters) are interdependent. The silent revolution in emphasis from a sickness and care service to a truly balanced National Health Service may well be under way. In accordance with Paragraph 7 (c) of Circular 1/67 from the Ministry of Health, the following is recorded : — "At the Council meeting held on the 25th January, 1966 it was resolved that the London Boroughs Committee be informed that the Council are not in favour of an approach being made to the Minister of Health for the introduction of legislation enabling the fluoridation of water supplies to be directed nationally." Grateful acknowledgment is made to the following for their help and collaboration in the common task of promoting the health of the residents of Richmond upon Thames: The family doctors. The Hospital services and staff. All voluntary organisations. The Principal Chief Officers of the Borough. The staff of the health department have shown deep loyalty. I would especially thank Dr. J. K. Craig, Mr. E. S. Herbert, and Mr. H. J. Pugh. I conclude by thanking the Health Committee, particularly the Chairman, Councillor F. D. Gilday-Fox, for their constant encouragement. I am, Yours respectfully, A. M. NELSON, Medical Officer of Health. 5 VITAL AND GENERAL STATISTICS 1966 Area in acres 13,873 Population (census 1961) 181,030 Population—estimated to mid-year (as supplied by the Registrar-General) 180,200 Number of inhabited houses 58,357 Rateable value £10,564,452 Sum represented by a penny rate £43,600 Total M. F. Live Births—Legitimate 2,523 1,324 1,199 Illegitimate 240 129 111 Total 2,763 1,453 1,310 Live Birth rate per 1,000 of estimated Population 15.33 Adjusted Live Birth rate per 1,000 of estimated Population 15.49 Illegitimate Live Births per cent. of total Live Births 8.68 Total M. F. Still Births—Legitimate 30 18 12 Illegitimate 3 2 1 Total 33 20 13 Still Birth rate per 1,000 live and still births 11.94 Total Live and Still Births 2,796 Infant Deaths (under 1 year of age):- Total M. F. Legitimate 51 34 17 Illegitimate - - - Total 51 34 17 Infant mortality rate per 1,000 live births 18.45 Legitimate Infant mortality rate per 1,000 legitimate live births 20.21 Illegitimate Infant mortality rate per 1,000 illegitimate live births — Neo-Natal deaths Under 4 weeks of age Under 1 week of age Total M. F. Total M. F. Legitimate 35 24 11 29 20 9 Illegitimate - - - - - - Totals 35 24 11 29 20 9 Neo-Natal mortality rate (deaths under 4 weeks) per 1,000 total live births 12.67 Early Neo-Natal mortality rate (deaths under 1 week) per 1,000 total live births... 10.49 Perinatal mortality rate (stillbirths and deaths under 1 week combined) per 1,000 total live and still births 22.17 Maternal mortality (including abortion) deaths 2 Maternal mortality rate per 1,000 live and still births 0.71 Total M. F. Deaths 2,331 1,106 1,225 Crude death rate per 1,000 of estimated population 12.93 Adjusted death rate 10.60 6 POPULATION The Registrar General's estimate of mid-year population for the Borough was 180,200, which is a decrease of 930 compared with 1965. The natural increase (excess of births over deaths) was 432. BIRTHS During the year 2,763 live births were registered (a decrease of 70 compared with 1965) giving a live birth rate of 15.33 per 1,000 of the population or 15,49 when adjusted by the birth comparability factor. The latter makes allowances for differences in the age and sex distribution of the population throughout the country. The birth rate for England and Wales was 17.7. DEATHS The number of deaths registered in 1966 was 2,331 (an increase of 156 compared with 1965) giving' a death rate of 12.93 per 1,000 of the population or 10.60 when adjusted by the comparability factor. The death rate for England and Wales was 11.7. The table on page 8 shows the distribution of deaths by age and cause. Main Causes of Death An analysis of the death returns reveals the following main causes of death : Disease Percentage of total deaths Death rate per 1,000 of the population Diseases of heart and circulatory system 39.08 5.05 Vascular lesions of nervous system 12.78 1.65 Bronchitis, Pneumonia, and other respiratory diseases 11.79 1.52 Cancer 20.50 2.65 Accidents, Violence 3.56 0.46 INFANT MORTALITY During the year there were 5 1 deaths of infants under one year of age, an increase of 10 on the previous year. The infant mortality rate was 18.45 per 1,000 live births compared with 19.0 for England and Wales. An analysis of the causes of death is shown on page 9. A large proportion of the deaths — 68.6% — occurred in the first four weeks of life. As expected congenital malformation, prematurity, etc., took a high toll, whilst the respiratory diseases — bronchitis and bronchopneumonia — were responsible for a number of deaths in the later age groups. MATERNAL MORTALITY There were 2 maternal deaths during the year giving a maternal mortality rate of 0.71 per 1,000 live and still births. Details of the two cases are as follows: — Case 1. Married woman. Cause of death : Haemorrhage following attemped instrumental abortion. Case 2. Married woman. Cause of death : Multiple injuries sustained when she projected herself from a window. Suicide. 7 Distribution of Deaths by Age and Cause Registrar General's Official Returns, 1966 Cause of Death Age Group Under 1 1-4 5-14 15-24 25-44 45-64 65-74 75 and over Total Grand Total M F M F M F M F M F M F M F M F M F Tuberculosis, respiratory - - - - - - - - - - 5 - 2 - 1 - 8 - 8 Tuberculosis, other - - - - - - - - - - - - - - - - - - - Syphilitic disease - - - - - - - - - 1 1 2 1 1 2 4 4 8 Diphtheria - - - - - - - - - - - - - - - - - - - Whooping cough - - - - - - - - - - - - - - - - - - Meningococcal infections - - - - - - - - - 1 - - - - - - 1 1 Acute poliomyelitis - - - - - - - - - - - - - - - - - - Measles - - - - - - - - - - - - - - - - - - - Other infective and parasitic diseases - - - - - - - - - - 1 - 3 1 - - 4 1 5 Malignant neoplasm, stomach - - - - - - - - - - 8 8 7 5 6 1 21 20 41 Malignant neoplasm, lung, bronchus - - - - - - - - 3 - 40 10 35 6 15 4 93 20 113 Malignant neoplasm, breast - - - - - - - - - 3 - 19 - 7 - 13 - 42 42 Malignant neoplasm, uterus - - - - - - - - - - - 7 - 4 - 2 - 13 13 Other malignant & lymphatic neoplasms 1 - - 1 3 - 2 2 2 2 32 40 37 32 45 53 122 130 252 Leukaemia, aleukaemia - - - - 1 - - — 1 - 2 3 2 1 2 5 8 9 17 Diabetes - - - - - - - - - - - 4 2 2 5 6 7 13 Vascular lesions of nervous system - - - - - - 1 - 3 2 11 19 22 31 62 147 99 199 298 Coronary disease, angina - - - - - - - - 5 - 114 20 85 46 83 119 287 185 472 Hypertension with heart disease - - - - - - - - - - 1 2 4 2 1 16 6 20 26 Other heart disease - - - - - - 1 - 1 - 10 8 12 18 53 142 77 168 245 Other circulatory disease - - - - - - - - 2 1 13 4 14 18 42 74 71 97 168 Influenza - - - - - - - - - - - 2 2 2 3 4 5 8 13 Pneumonia 1 2 - - 1 1 - - 1 - 5 4 14 11 39 71 61 89 150 Bronchitis 3 1 1 - - - - - - - 14 3 28 5 24 21 70 30 100 Other diseases of respiratory system - - - - - - - - - - 2 - 7 - 9 7 18 7 25 Ulcer of stomach and duodenum - - - - - - - - 1 - 1 - 1 1 6 5 9 6 15 Gastritis, enteritis and diarrhoea - - - - - - - - - - 1 - - 3 - 4 1 7 8 Nephritis and nephrosis - - - - - - - - - 1 1 1 2 - 2 2 5 4 9 Hyperplasia of prostate - - - - - - - - - - 1 - 1 - 9 - 11 - 11 Pregnancy, childbirth, abortion - - - - - - - - - 2 - - - - - - - 2 2 Congenital malformations 8 4 - 1 - 1 1 - - 2 - 1 1 2 1 - 11 11 22 Other defined and ill-defined diseases 21 9 2 - 2 - 2 1 4 2 16 16 8 10 15 63 70 101 171 M otor vehicle accidents - - - - 1 - - 2 2 1 1 1 - - 2 3 6 7 13 All other accidents - 1 - - - - 6 - 4 2 3 5 1 4 4 8 18 20 38 Suicide - - - - - - 1 1 4 3 5 8 4 3 - 2 14 17 31 Homicide and operations of war - - - - - - - - 1 - - - - - - - 1 - 1 34 17 3 2 8 2 14 6 34 22 288 182 298 215 427 779 1106 1225 2331 8 Infant Mortality, 1966. Net Deaths from stated causes at various ages under one year compiled from returns received. CAUSE OF DEATH TOTAL Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks 1-3 months 3-6 months 6-9 months 9-12 months Under one year Under four weeks M F M F M F M F M F M F M F M F Total from all causes 51 35 20 9 4 1 — 1 — — 5 1 3 2 1 2 1 1 Congenital Malformations 12 7 3 1 3 — — — — — 2 — 1 1 — 1 — — Malignant Reticulosis 1 — — — — — — — — — 1 — — — — — — — Post-Natal Asphyxia and Atelectasis 9 8 6 2 — — — — — — — — — 1 — — — — Bronchitis and Bronchopneumonia 8 1 — — — 1 — — — — 2 1 1 — 1 — 1 1 Haemorrhagic Disease 3 3 2 1 — — — — — — — — — — — — — — Prematurity 15 15 9 5 — — — 1 — — — — — — — — — — Diabetes Mellitus 1 1 — — 1 — — — — — — — — — — — — — Encephalitis 1 — — — — — — — — — — — 1 — — — — — Werdnig-Hoffman Disease 1 — — — — — — — — — — — — — — 1 — — 9 INFECTIOUS DISEASES The number of notifications received during the year, compared with 1965, may be summarised as follows: — Disease. 1966 1965 Dysentery 13 17 Erysipelas 19 9 Food Poisoning — 6 Measles 888 1992 Meningococcal Infection 1 — Acute Pneumonia 32 47 Puerperal Pyrexia 4 3 Scarlet Fever 76 69 Typhoid and Para-Typhoid 1 — Whooping Cough 80 10 The table on page 15 gives the number of cases notified under age groups. Scarlet Fever. The increase of seven cases of this disease notified during 1966 as compared with 1965 is accounted for in the first two years of life. There was a similar increase in the incidence of Erysipelas at the other extreme of life. No cause can be attributed to these increases at present. Whooping Cough. It will be seen that there was an increase of cases in 1966 compared to 1965 and this mainly in the 2 year old age group. This may be accounted for by the fact that in 1965 there was a poor uptake of the 18 months reinforcing dose of triple vaccine which improved during 1966. Alternatively, the increase of cases may indicate the present vaccine may be less effective against the current strain of the disease. Measles. Although this was not a "measles" year (minor waves of epidemics tend to occur biennially in towns in this country) nevertheless 888 cases were notified. Previous years figures are as follows: — 1959 1957 1963 1885 1960 57 1964 234 1961 1962 2422 112 1965 1966 1992 888 The distribution of cases during each quarter of the year was as follows: — M. F. Total 1st January—31st March 123 153 276 1st April—30th June 158 121 279 1st July — 30th September 54 54 108 1st October—31st December 114 111 225 Total 449 439 888 10 From the table below it will be seen that the first five; years of childhood suffer the major incidence of the disease and the sexes are affected equally : M. F. Total Under 1 year 17 19 36 1 year 44 35 79 2 years 55 60 115 3 years 65 66 131 4 years 46 70 116 5 — 9 years 211 171 382 10 — 14 years 5 8 13 15 — 24 years 3 4 7 25 + 3 6 9* T otal 449 439 888 (* includes 3 age unknown). The histogram on page 12 shows that the incidence of measles was comparatively high for a "non-measles" year. It may be that the limited trial of immunisation against the disease, started at the end of 1964 and continued through 1965, has interfered with the circulation of the wild virus. This may then represent but the beginning of the "flattening out" of the incidence curve of the disease, which it is hoped will be reduced as effective immunisation is extended to all children at risk. Food Poisoning. There were no cases of food poisoning notified during the year. 1962 14 1965 6 1963 6 1966 — 1964 8 Leptospirosis — Weil's Disease To ensure that this Authority pursues a policy similar to that of the Greater London Council in this regard, the following procedures in advising sewermen employed by the Council were put into operation : 1. The inclusion in the present handbook issued to all Corporation sewermen of a note saying how the disease can be contracted and the preventive steps which should be taken. 2. The issue of a green Medical Card to each sewerman for presentation to his family doctor whenever the former has occasion to consult the latter. This card advises men working in contact with sewage and suggests that upon receipt of the card it should be taken to the personal medical attendant for signature in the appropriate place. Notes on the disease are also included for the information of family doctors. All family doctors in the area were notified of the issue of these cards. In August 1966 a report was received from the Medical Officer of Health of Great Yarmouth regarding the death from Weil's Disease of a holiday maker in the area. Although not a resident of this Borough, it was thought that the infection might have been contracted by the deceased in the River Thames as he was a member of a local Canoe Club. 11 12 NUMBER OF CASES OF MEASLES 1959 TO 1966 One of the activities indulged in by members of the club was that of "rolling" their kayaks as practised by the Eskimos. This manoeuvre involves a complete circular motion of the canoe and its occupants laterally, so that the occupant may be underwater for a period of time according to his skill, and it is not unusual for the canoeist to swallow the river water while submerged. A full investigation was carried out by the Port of London Authority, who super vise that part of the River Thames. The Medical Officer of Health of that authority reported that he could find no evidence to support the theory that the infection had been contracted in the River Thames. No other member of the club appears to have complained of symptoms of the disease and it is known that the deceased had canoed in other waters elsewhere during estimated time of infection. Infective Hepatitis. The Chief Medical Officer of the Ministry of Health in his report on the state of the Public Health 1964 mentioned the problem of infective hepatitis. There appears to be a rapid increase in the incidence of this disease in some European countries, though how big the problem is in England and Wales it is difficult to say, as it is not generally notifiable. In order to assess the problem as it affects this Borough, family doctors were asked to notify all cases voluntarily until the end of the year. 41 cases were so notified and steps are now being taken to include infective hepatitis on the list of diseases officially notifiable and for which the local authority may pay a notification fee. Following a request from the Public Health Laboratory Service it was agreed to take part in a survey which was being carried out to try and determine the value of gamma globulin in outbreaks of infective hepatitis. This survey still continues and results are not yet to hand. (See also page 21—surveys). Smallpox (Variola Minor). During the year outbreaks of this disease were reported in the West Midlands and in Pontypool, Monmouthshire, although no connection was established between the two outbreaks. The mildness of the disease rendered its differentiation from Chicken-pox difficult in some cases. As a precautionary measure family doctors were asked to notify me of all cases of Chicken-pox which occurred in their practices. In several instances "bedside" consultations on doubtful cases were held and, fortunately, all these cases were found to be Chicken-pox. The Public Health (Leprosy) Regulations, 1966. These Regulations which came into operation on the 1st March, 1966, made leprosy notifiable by medical practitioners to the local Medical Officer of Health who is required to send details to the Chief Medical Officer of the Ministry of Health. The Medical Officer of Health has to maintain a strictly confidential record of persons suffering from leprosy. The former regulations required leprosy to be notified by medical practitioners direct to the Ministry of Health. Only one case was passed on to me by the Chief Medical Officer and upon enquiry it was found that this patient had moved from the Borough. 13 Venereal Diseases. I am indebted to Dr. J. L. Fluker and Dr. N. Rosedale for the following statistics of the patients treated at the Special Clinics at West London and West Middlesex Hospitals respectively : — West London Hospital 1966 1965 Male Female Male Female Syphilis 131 31 141 57 Gonorrhoea 1,226 400 1,077 314 Other Conditions 2,408 1,254 3,204 1,491 N.A.D 880 463 West Middlesex Hospital Syphilis — 2 16 2 Gonorrhoea 35 10 135 26 Other Conditions 108 93 580 292 Medical Arrangements for Long-Stay Immigrants. Special problems arise in connection with the health and treatment of long'Stay immigrants to this country. They are often very unfamiliar with our customs and ignorant of the scope and arrangements of the National Health Service. It is essential, therefore, to ensure that at an early date they learn how to use the Health Service and to secure by voluntary action, particularly from those whose country of origin has a high incidence of tuberculosis, a chest X-ray as soon as possible after their arrival in this country. At ports of arrival long-stay immigrants are given a pamphlet, printed in languages which they are likely to understand, encouraging them to get on the list of a medical practitioner in their place of residence. They are also asked to provide their destination addresses so that the Medical Officer of Health of the County or County Borough concerned can be advised and requested to try and persuade them to act on the advice given in the pamphlet. The following table shows the number of immigrants who gave destination addresses situated in this Borough. All the addresses were visited by Public Health Inspectors but in 12 cases it was found that the immigrant had not arrived at the address given. When the immigrant is accompanied by a child the address is visited by a Health Visitor. In no case was any immigrant found to be suffering from pulmonary tuberculosis. Country where passport issued. Number of Immigrants. Commonwealth Countries. Carribean 3 India 11 Pakistan 2 Other Asians 5 African 4 Other 8 Non-Commonwealth Countries. European 41 Total 74 14 15 Cases of Infectious Diseases Notified during the year 1966 DISEASE CASES NOTIFIED AT VARIOUS AGES (YEARS) Total Cases Notified Deaths Under I Year 2 3 4 5-9 10-14 15-19 20-24 25-34 35-44 45-64 65 and Over Age not known Diphtheria - - - - - - - - - - - - - - - - Dysentery 1 - 1 3 1 2 1 - 1 2 - - - 1 13 - Erysipelas - - - - - - - - - - 2 7 10 - 19 - Food Poisoning - - - - - - - - - - - - - - - - Malaria - - - - - - - - - - - - - - - - Measles 36 79 115 131 116 382 13 6 1 3 2 1 - 3 888 - Meningococcal Infection 1 - - - - - - - - - - - - - 1 1 Ophthalmia Neonatorum - - - - - - - - - - - - - - - - Pneumonia - - 1 - - 2 2 2 - 4 - 12 9 - 32 150 Poliomyelitis - - - - - - - - - - - - - - - - Puerperal Pyrexia - - - - - - - - - 4 - - - - 4 - Scarlet Fever 1 2 6 6 10 40 4 4 1 - 1 1 - - 76 - Smallpox - - - - - - - - - - - - - - - - Typhoid and Para-Typhoid - - - - - - - - - - - 1 - - 1 - Whooping Cough 8 7 20 12 7 19 7 - - - - - - - 80 - Totals 47 88 143 152 134 445 27 12 3 13 5 22 19 4 1114 151 CARE OF MOTHERS AND YOUNG CHILDREN Ante-Natal and Post-Natal Clinics Number of cases attended : Ante-Natal Attendances Post-Natal Attendances 705 2441 152 161 Sessions held (Medical Officer in attendance) 374. Ante-Natal relaxation and post-natal exercises are taught in all the clinics. 563 women made 3,349 attendances at these clinics during the year. In accordance with the recommendation of the Cranbrook Committee, who suggested that general practitioner obstetricians could work in the ante-natal clinics of local authorities, approval was given to a group of family doctors in Barnes for the use of Essex House on one half day per week for an ante-natal and post-natal session. The object was to incorporate their own session with the existing local authority session. Other individual or group of family doctors would be afforded the same facility if they so desired. A second group is now using the clinic. Incidence of Congenital Malformations Since 1st January, 1964 the Ministry of Health have required all congenital malformations in new-born babies to be notified by Local Health Authorities to the Registrar General, so as to enable the latter to complete statistical information from which to detect any national or regional changes in the pattern of congenital malformations. The number of babies born with defects during 1966 was 76. Puerperal Pyrexia Regulations Four cases of puerperal pyrexia were notified during the year. All occurred in domiciliary practice and subsequently recovered. Family Planning In Circular 5/66, dated 17th February, 1966, the Minister of Health urged local authorities to review current arrangements for family planning advice and treatment in their area and suggested ways in which in co-operation with the Family Planning Association and similar bodies, the local services might be further developed for the welfare of their citizens. The Council has made arrangements through the Family Planning Association for advice and treatment (including supplies) to be given to women to whom pregnancy would be detrimental to health. This service is provided free of charge to the patients, the Council accepting financial responsibility for patients in this category referred for advice and treatment by its own medical officers. During 1966 nine such patients were referred. There remains the wider need of advice and prescription for those who desire to achieve the aim of planned parenthood although no specific danger to health is involved. There is undoubtedly a very heavy demand for advice and prescription on social grounds but the local authority has no statutory powers as yet financially to assist this type of patient. The Council does not operate family planning clinics of its own but has made available to the Family Planning Association the free use of three of its clinics 16 (Hampton Wick, Whitton, and Windham Road, Richmond) for the purpose of hold' ing family planning sessions. There is close co-operation and joint planning between my department and the local branch of the Family Planning Association and consequent upon this review, the Association asked for and were offered an extension of existing facilities at Whitton Clinic and new facilities at King's Road, Richmond. The Association was also asked to comment on the possibility of facilities being made available at the Ham and Essex House, Barnes, Clinics. At the end of the year the Association had commenced an additional session at Whitton Clinic and negotiations were proceeding for a clinic to be opened at King's Road, Richmond. The Association did not wish to proceed with the possibility of a clinic at Ham because it was considered that for the present their newly opened clinic at Acre Road, Kingston, could adequately arid conveniently cater for the residents of Ham. Health education in family planning in this Borough is largely undertaken by the medical officers, nursing staff and social workers in their day-by-day educational activities and, additionally, facilities are available for talks on this subject to voluntary societies and family groups. The times and places of family planning clinics are publicised throughout the Council's clinics in the Borough and our medical and nursing staff and social workers are encouraged to make this information known in their daily work with families. Care of Unsupported Mothers and Their Babies The help given to the unsupported mother under the National Health Service Act, 1946, continues to be adequate within the terms of the service. The Council has no hostel of its own for this work and uses the voluntary hostels selected by the social welfare worker. There would seem to be a greater awareness of the need to offer a higher standard of service to the expectant and nursing mother and to create a more relaxed atmosphere. During the period under review 86 young women chose to accept this type of help, and it is satisfactory to record that only one girl left before completing her stay. There will always be a minority who find themselves totally unable to consider hostel life, despite being invited first to visit one and talk with those already resident. One solution to this problem has been found by the kindly co-operation of a few of the faster-mothers. These sensible women, who understand the problem rather more than most, have been willing for a temporary period to offer a comfortable home and friendly understanding in exchange for a moderate payment. Another means of help offered to the unsupported mother is by the provision of a temporary foster-mother for her baby. This may enable her to effect a reconciliation with her parents, and reach an unhurried decision about adoption. The girls are responsible for paying their own foster fees, but in certain cases the Ministry of Social Security has recently been empowered to help. It is not generally realised that fostering can be an effective means of enabling a girl to help herself, and several have shown great initiative in doing this. There is national concern over the number of children received annually into care, many of whom are illegitimate. It is said that some 6% of all children in care nationally are received because "the child is illegitimate and the mother is unable to provide a home". It has always been the aim of the health department to try and prevent this. It is occasionally necessary to ask the Children's Department to receive a few babies into care temporarily. So far the applications have been made in the interests of infant life protection rather than on the grounds of homelessness. Since the inception of the new Borough eight such cases have been received, and a recent enquiry showed that in each instance the child had been satisfactorily placed with adopters. 17 In the wider field one would wish to see the activities of local authorities extended on behalf of the unsupported mother, and beyond the scope of the National Health Service Act. The point at which a woman decides to keep her child is the point at which she is most vulnerable and in need of help. The responsibility for solving her dilemma must surely rest with the statutory welfare departments if she has no home to which she can go. One solution would be the provision of housing in small units within the com munity as part of a complete service, and on a permanent basis. I am indebted to Miss H. Oliver, Social Welfare Worker, for these observations on the care of the unsupported mother and her child. Total Number of Cases referred in 1966 :— Total Unsupported mothers 175 Referred by Medical Social Workers 78 Health Visitors 15 Doctors 29 Statutory Social Workers 10 Voluntary Social Workers 22 N.C.U.M.C. 19 Citizens' Advice Bureau 2 175 The Mothers Marital Status Single 157 Married 6 Separated 10 Divorced 2 Education Sec. Mod. 125 Grammar 32 Public 3 Convent 10 Training College 4 University 1 Domicile In area 134 Outside area 41 Religion C. of E. 128 Free Church 8 R.C. 37 Greek Orthodox 2 Occupation Nurses 19 Students 13 Hairdressers 14 Factory 3 3 Office Workers 59 Domestic and Hotel Workers 17 Civil Servants 5 Housewives 3 Shop Assistants 3 Pastry Cooks 3 Bus Conductresses 2 Dress Makers 2 Florist 1 Children's Nannie 1 Ages 15 years 3 16 „ 9 17 „ 21 18 „ 16 19 „ 25 20 38 21-30 52 31-40 11 Countries of origin other than G.B. Ireland 27 Holland 1 Sweden 1 New Zealand 2 Australia 2 W. Germany 1 Cyprus 2 18 Putative Fathers Marital Status Single 82 Married 41 Divorced 1 Unknown 39 Separated 12 Occupation Architect 1 Teachers 5 Students 17 Office Workers 21 Factory and Manual 47 Unknown 60 Milkmen 2 Miscellaneous 22 Ages 16 years 3 17 „ 2 18 „ 11 19 „ 23 20 „ 27 21-30 42 31-40 9 Unknown 58 Countries of origin other than G.B. Ireland 23 Pakistan 5 Fiji Islands 1 Holland 1 W. Indies 3 Sweden 1 Cyprus 2 New Zealand 2 China 2 Australia 3 S. Africa 2 Italy 2 W. Germany 1 America 3 Ways in which unsupported mothers have been helped. By admission to working girls hostels in early pregnancy 33 By admission to maternity homes and hostels 86 By admission to flatlet house for mothers and babies 1 By providing private accommodation 7 By reconciliation with parents and relatives 23 By private financial agreements and affiliation orders 31 By adoption through registered adoption agencies 65 By fostering arrangements 27 By emergency accommodation provided on behalf of the Welfare Department 4 By emergency accommodation being provided on behalf of the Children's Department 1 At the end of 1966 the mothers who decided to keep their babies were living in the following way Had returned to parents or relatives 45 Had married putative father 15 Were cohabiting with putative father 9 Married to other than putative father 2 Had accepted residential work 9 Were living in flatlet house for mother with babies 1 Were living in lodgings 2 Living in own homes 3 Mothers who parted with babies By adoption 55 Pregnancies terminated 2 Arrangements still incomplete 23 Still births 1 Miscarriage 1 Transferred to other social work agencies 2 Still fostered at the end of 1966 5 175 19 20 Surveys The department has taken part in a number of surveys in association with various research bodies during the year. These include a survey into children suffering from Spina Bifida (Greater London Council); nutrition survey of pre-school children (Ministry of Health); nutrition survey of pregnant women (Ministry of Health); study of children in temporary foster placement (Tavistock Institute of Human Relations); Home Office field tests carried out by health visitors on infants' nightdresses; investigation into the possible virus aetiology of mental deficiency (St. George's Hospital Medical School, London). Phenylketonuria A simple urine test can detect this rare but very distressing disease in the first few weeks, when it is amenable to treatment. The test is now available for all children born in the borough and is performed by the health visitor. No tests were positive. It is interesting to note that a child whose re-action to this test in 1964 was positive and as a result was immediately admitted to hospital is reported by the health visitor to be "a delightful little fellow of apparently normal intelligence". This child's sister born in October 1966, was admitted to hospital on the third day in view of her brother's history. She was confirmed as being positive to the test on the sixth day. The child is still under observation by the hospital. Early Detection of Deafness In order that children who are deaf can benefit from auditory training, testing for hearing is done by the health visitor during the first year. Ophthalmia Neonatorum (See page 48). Child Welfare Centres At the end of the year, there were 12 child welfare centres. (For location of centres etc. see map inside the cover at the end of the report). One centre has 4 sessions a week, two have three sessions a week, 6 have two sessions a week, 3 have one session a week. To augment the above the arrangement made with Surrey County Council for the use of its mobile clinic was continued. Five sessions in alternate weeks are held at sites in Hampton, Twickenham and Whitton. For details of attendances etc. during the year see page 22. Opening of New Clinic—Ham His Worship the Mayor, Alderman H. A. Leon, M.B.E., J.P., officially opened this clinic on the 21st September, 1966. It replaced two former clinics. The building has been designed and constructed to meet modern requirements and provides on the ground floor an entrance hall, reception area, offices, speech therapy unit, health visitors' unit, doctors' rooms, ante-natal care, infant welfare, and school clinic facilities. The first floor comprises a complete dental unit and a flat. Photograph on page 20. Orthopaedic Service Of the 67 children under five years of age treated at the Orthopaedic Clinic during the year, 19 were new cases seen by the surgeon, 48 were re-examinations at the surgeon's clinic. These children made 87 attendances. 21 22 Child Welfare Centres Number of children who attended during the year Number of sessions held by Total number of sessions in columns (5)-(8) Number of children referred elsewhere Number of children under observation at end of year Born in 1966 Born in 1965 Born in 19611964 Total Medical Officers Health visitors G.Ps. employed on a sessional basis (see note 2) Hospital medical staff (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 2741 2253 2276 7270 1337 47 — — 1384 253 3762 Total attendances during the year 45,825. Dental Treatment—Expectant and Nursing Mothers and Children. Mr. G. Tucker, L.D.S., R.C.S., Chief Dental Officer, reports as follows: I would very much like to see many more young children under 5 years of age attending the dental clinics. Unfortunately departmental medical officers and health visitors can only refer young children who actually attend their clinics. Those parents who do not bring their children to the child welfare centres can only be advised that their children should be dentally examined. These children are not seen, therefore, until a periodical school dental inspection takes place at their school. On average approximately 17% of children have no dental decay at this time. However in this age group each child has approximately 6 teeth decayed, filled or missing. During 1966, 88 more young children and JO more expectant or nursing mothers were examined than in the previous year. Pre-School Children Examined at clinic 439 Required treatment 221 Commenced treatment 226 Attended for treatment 625 Fillings inserted 473 Extractions 157 General Anaesthetics 80 Expectant and Nursing Mothers Examined 110 Requiring treatment 100 Commenced treatment 85 Attended for treatment 271 Fillings inserted 223 Gum treatment 30 Crowns or Inlays fitted 2 Extractions 54 General Anaesthetics 12 Dentures supplied 10 X-rays taken 3 Deprived Children In order that the health visitor can make her routine visits, when a deprived child under five has moved to a new address, my colleague the Children's Officer, notifies the health department. Nurseries and Child-Minders Regulation Act, 1948 At 31st December, 1966, 54 child-minders were receiving children under the age of five years and 29 private day nurseries (including one factory day nursery), were on the register. These nurseries are regularly visited by a senior medical officer and a health visitor. The Barnes and Mortlake Day Nursery, a private nursery with 25 places, which received a grant from the Council, closed on the 16th December, 1966 owing to staffing difficulties. Daily Minders There were no daily minders receiving fees from the authority at the end of the year. Municipal Day Nurseries There are in the Borough three day nurseries maintained by the Council for necessitous children from the age of six weeks to five years of age. 23 Admission to the day nurseries is determined by priority categories. The standard daily charge is 4/- or 6/6d. per day. Accommodation:— Castelnau, Barnes 45 children Parkshot, Richmond 53 children Gifford Lodge, Twickenham 40 children Children with defects are also admitted to the day nurseries to aid their development emotionally, physically, mentally and socially. Welfare Foods The Council is responsible for the distribution of welfare foods (National Dried Milk, cod liver oil, fruit juices, etc.) supplied by the Ministry of Health. In addition various proprietary brands of dried milk and dietary supplements are sold at the welfare centres on the recommendation of the medical officers, health visitors or family doctor. I gratefully acknowledge the work of all voluntary helpers. Cervical Cytology During the latter part of 1965, arrangements were made at the request of the Consultant Pathologist, St. Stephen's Hospital, Chelsea, for cyto-screening for cervical carcinoma by the laboratory of a limited number of specimens taken from women in the Borough clinics in Richmond and Barnes, the catchment area served by the South West Metropolitan Regional Hospital Board. This is a pilot scheme in which women are asked to co-operate in the comparison of smears taken in a standard way at the clinics by doctors and smears taken by themselves at home later and despatched to the laboratory. Each woman taking part in the scheme is issued with appropriate instruction and "do-it-yourself kits" in the form of cytopipettes and postal containers. First priority is being given to women in the over 35 age group. The Borough has been allocated 20—25 specimens a month for examination at the laboratory. The number of women attending the clinics in 1966 was 241. In October 1966, the Ministry of Health sent a memorandum to local authorities in which the Minister expressed the hope that local health authorities would co-operate fully with the hospital and general practitioner services in developing screening services on the lines indicated. Further, the Minister had approved under Section 28 of the National Health Service Act, 1946, the making of arrangements by the Council in obtaining cervical smears for cytological investigations by hospital authorities. At the end of the year negotiations were proceeding with the hospital authorities for the maximum examination facilities so that this screening service could be offered in selected clinics throughout the Borough. DOMICILIARY MIDWIFERY AND HOME NURSING SERVICES Staff 1 Non-Medical Supervisor of Midwives and Home Nursing Superintendent. 1 Deputy Non-Medical Supervisor of Midwives and Home Nursing Superintendent. 12 Full-time Midwives. 3 Part-time Midwives. (1.25)* 3 Full-time District Nurses/Midwives. 30 Full-time District Nurses. 5 Part-time District Nurses. (2.5)* * equivalent whole-time. 24 MIDWIFERY SERVICE Training Six midwives are approved as teachers. Two midwives attended refresher courses as required by the rules of the Central Midwives Board. Sixteen pupil midwives from Epsom District Hospital, King Edward VII. Hospital, Windsor, West Middlesex Hospital, Isleworth, and Queen Charlotte's Hospital, Hammersmith, completed their training on the district, and at the end of the year five were in training. Ten nurses from West Middlesex Hospital taking their obstetric training spent a half-day on the district observing the work of the domiciliary midwives. Three midwives attended a Study Day arranged by the London Boroughs Training Council. Transport All the domiciliary midwives drive cars. Two use Council vehicles; the remainder have their own cars. Ante-natal Clinics Total weekly sessions during year (midwives only present) 345 „ „ „ „ „ (medical officer present) 79 „ „ ,, „ „ at family doctors' clinics 431 Mothercraft Mothercraft and relaxation classes were held at all clinics. A total of 563 women attended Further midwives and health visitors attended the course arranged by the National Childbirth Trust on the psychoprophylactic method for childbirth. This method of preparation for motherhood is becoming increasingly popular and expectant mothers in the Borough are most anxious to attend classes at the Council's clinics. Domiciliary Deliveries Number of domiciliary confinements attended by midwives under N.H.S. arrangements. Number of cases delivered in hospitals and other institutions but discharged and attended by domiciliary midwives before 10th day (1) (2) (3) (4) Doctor not booked Doctor booked Total 14 641 655 573 This table relates to women delivered, and not, in the case of multiple births, to infants. 8,787 visits were made to these mothers. All midwives in the domiciliary midwifery service have been advised that patients, who are to have a domiciliary confinement, should be referred to their family doctor either for booking or for the latter to refer the patient to a practitioner on the obstetric list. 25 26 Premature Births Number of premature births (as adjusted by any notifications transferred in or out of the area). Weight at birth Premature live births Premature stillbirths Born in hospital Born at home or in a nursing home Nursed, entirely at home or in a nursing home Transferred to hospital on or before 28th day Total births Died Total births Died Total births Died Born within 24 hours of birth in 1 and under 7 days in 7 and under 28 days within 24 hours of birth in 1 and under 7 days in 7 and under 28 days within 24 hours of birth in 1 and under 7 days in 7 and under 28 days in hospital at home or in a nursing home (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) 1 2 lb. 3 oz. or less 5 3 1 1 — — — — — — — — 5 — 2 Over 2 lb. 3 oz. up to and including 3 lb. 4 oz 18 3 4 1 - - - - - - - - 3 - 3 Over 3 lb. 4 oz. up to and including 4 lb. 6 oz 30 1 3 - 5 - - - 2 1 - - 9 1 4 Over 4 lb. 6 oz. up to and including 4 lb. 15 oz. 29 - - 1 1 - - - 1 - 1 - 1 - 5 Over 4 lb. 15 oz. up to and including 5 lb. 8 oz 79 2 - 1 10 - - - - - - - 1 1 6 Total 161 9 8 4 16 - - — 3 1 1 — 19 2 1 = l,000g, or less, 2 = 1,001 - l,500g, 3 = 1,501, - 2,000g, 4 = 2001 - 2,250g, 5 = 2,251 - 2,500g. Notification of intention to practise Under the rules of the Central Midwives Board, 37 midwives notified their intention to practise within the Borough. Twenty-one of these were domiciliary midwives; the remainder of the midwives were practising in hospital. Medical Aid Medical aid was required for 83 patients as follows:— During Pregnancy Infant In Labour Puerperium Mild Toxaemia 2 Prematurity 2 Foetal Distress 7 Pyrexia 13 Ante-partum haemorrhage 5 Ophthalmia 5 Premature Labour 6 Thrombophlebitis 2 General illness 4 Hydramnios 1 Malformation 3 Milpresentation 4 Toxaemia 1 Post-Maturity 1 Cord infection 1 Delay in Labour 6 Malpresentation 1 Skin lesions 1 Retained placenta 3 Ruptured perineum 7 Post-partum haemorrhage 4 Twin pregnancy 1 Maternal distress 2 Emergency booking 1 Early Discharges The domiciliary midwives nursed 573 mothers and babies discharged from hospital early in the puerperium. The majority of these mothers had planned discharges. This represents an increase of over 200 early discharges (1965—360). Three thousand and sixty-six visits were made to these mothers. Maternity Outfits A maternity outfit is supplied free to each expectant mother arranging her confinement at home under the National Health Service, as well as — if requested — to those entering private nursing homes. A smaller pack is supplied to patients discharged from hospital 48 hours after delivery. Maternity Liaison Committee As Medical Officer of Health I am a member of the Maternity Services Liaison Committee Catchment Area IV, whose purpose is to discuss midwifery problems of hospital, family doctors, and the local authority health department. HOME NURSING SERVICE Training 4 District Nurses received district training. 2 District Nurses attended Refresher Courses. 3 District Nurses attended a Study Day arranged by the London Boroughs Training Committee. 67 Hospital Student Nurses spent a day visiting patients in their homes observing the work of the District Nurses. Cases and Visits Total number of cases nursed 2,752 Number of above over 65 years of age 1,179 Number of above under 5 years of age 24 Total number of visits 108,080 27 Types of Care given Number of injections 32,923 Number of dressings 13,491 Number of visits for general nursing care 23,719 Number of baths 9,949 The remaining visits were made to patients needing supervision and/or support. Marie Curie Memorial Foundation. Area Welfare Grant Scheme The Borough continues to participate in the Area Welfare Grant Scheme providing for the urgent needs of cancer patients who are being nursed at home. Such assistance is only given "in kind" and covers for a limited period, day and night nursing, special equipment, linen and bedding, clothing, extra heating and nourishment. 26 patients received help with night and/or day nursing on 186 occasions. HEALTH VISITING Staff 1 Chief Nursing Officer. 1 Superintendent Health Visitor. 21 Health Visitors (includes 2 Field Work Instructors). 3 (1.6)* Part-time Health Visitors. 9 (3.5)* Part-time Clinic Nurses. 1 Health Assistant. 1 Tuberculosis Health Visitor. 1 Student Health Visitor. * equivalent whole time. Recruitment of health visitors has not been easy. This is probably largely because there is a national shortage. Competition from other professions requiring women with similar personality and educational qualities as health visiting seems to be increasing. Four new officers have however commenced during the year, including one student who successfully completed training and passed her examination. We are sponsoring a further student for the 1966/67 training course. One health visitor attended a course for field-work instructors. We now have two suitably qualified to do practical training of health visitor students, and can undertake practical training for up to three student health visitors at a time. We continue to receive student nurses from West Middlesex, The Middlesex and Richmond Royal hospitals to observe the work of the local health authority services. Those from West Middlesex spend a whole week in clinics, visiting with district nurses and health visitors and observing as many other aspects of the work of the department as we can arrange. The nurses from The Middlesex Hospital come for three days and those from Richmond for two days. We have had several other visitors, including a Director of Nursing in Baltimore, for whom the Ministry of Health asked us to arrange a programme of observation. Three health visitors continue to attend Child Welfare sessions in the surgeries of family doctors and it is hoped to start other schemes to develop closer association between health visitors and family doctors. 28 Five health visitors attended refresher and other courses and one clinic nurse attended a course and found it of very great value. There seems to be no difficulty in recruiting clinic nurses and they are a most valuable section of the staff. Health Visiting Cases visited by health visitors Number of cases 1 Children born in 1966 2,857 2 Children born in 1965 2,557 3 Children born in 1961-64 5,151 4 Total number of children in lines 1 — 3 10,565 5 Persons aged 65 or over 455 6 Number included in line 5 who were visited at the special request of a G.P. or hospital 121 7 Mentally disordered persons 133 8 Number included in line 7 who were visited at the special request of a G.P. or hospital 44 9 Persons, excluding Maternity cases, discharged from hospital (other than mental hospitals) 25 10 Number included in line 9 who were visited at the special request of a G.P. or hospital 17 11 Number of tuberculous households visited 5 12 Number of households visited on account of other infectious diseases 8 13 Number of tuberculous households visited by tuberculosis visitors 353 29 VACCINATION AND IMMUNISATION The tables below show the numbers of children under 16 who completed vaccina' tion or immunisation procedures during 1966. The "take-up" of all available types of immunisation has continued to be satisfactory and the figures given in Table I below are generally comparable with last year's figures. Table 1. Immunisation against Diphtheria/Whooping Cough/Tetanus/Poliomyelitis (separately or combined). Type of Vaccine YEAR OF BIRTH Others Under 16 Total 1966 1965 1964 1963 1959/62 PRIMARY COURSE DIPHTHERIA 1012 1317 116 25 56 14 2540 WHOOPING COUGH 988 1276 85 16 23 — 2388 TETANUS 1010 1317 115 26 57 201 2726 POLIOMYELITIS 1003 1553 217 57 133 58 3021 RE-INFORCING DOSES DIPHTHERIA — 371 768 137 1092 250 2618 WHOOPING COUGH — 304 591 74 254 17 1240 TETANUS — 371 765 135 1087 148 2506 POLIOMYELITIS — 119 131 27 1033 82 1392 Table 2. Vaccination against Smallpox. Age at date of Vaccination Under 1 1 2—4 5—15 Total No. vaccinated 217 1426 321 84 2048 No. revaccinated — 1 28 129 158 B.C.G. Vaccination against Tuberculosis. See page 32. Measles Vaccination Approval was received from the Ministry of Health for the Council to include measles vaccination in their proposals under Section 26 of the National Health Service Act, 1946. Arrangements were made to offer vaccination to those children between the ages of nine months and two years whose parents wish them to receive it. The vaccination procedure consists of a course of two injections, one dose of inactivated vaccine followed after an interval of at least a month by a dose of live attenuated vaccine. The scheme commenced on 1st October, 1966, and by the end of the year 15 children had completed the course. Protection against Enteric Fever Children visiting abroad in school parties may obtain T.A.B. inoculation either from their family doctor or the authority's clinics in the borough. I consider that all undertaking overseas travel should be so protected. 30 PREVENTION OF ILLNESS, CARE AND AFTER-CARE Tuberculosis During 1966 there were 71 notifications of pulmonary tuberculosis and 10 notifications of non-pulmonary tuberculosis, in the Borough, compared with 56 and 5 notifications respectively, in 1965. New Cases. 1965 1966 Pulmonary 56 71 Non-Pulmonary 5 10 The total number of cases on the register at the end of the year was: Pulmonary 1362 Non-Pulmonary 174 The following table shows an analysis of cases notified in 1966: Age Periods. Respiratory Non-Respiratory M F M F 0—4 1 1 - - 5—14 - - - 1 15—24 3 3 1 2 25—44 13 8 - 2 45—64 20 5 - 2 65 and over 14 2 2 - Age unknown - 1 - - Totals 51 20 3 7 As may be seen from the Registrar General's official return 1966 on page 8> there were 8 deaths from tuberculosis in 1966. The Borough was again well served by the Chest Clinics of Ashford, Hounslow, Kingston, and the ad hoc clinic at the Richmond Royal Hospital. Mass Radiography. Mass X-ray facilities are available to the general public without appointment at the West Middlesex Hospital, Twickenham Road, Isleworth on any weekday (excluding Saturday) between the hours of 9.0 a.m.—12.30 p.m. and 1.30 p.m.—5.0 p.m. A mobile mass X-ray unit also visits the Bus Station at the rear of the Odeon Cinema, Richmond, on Thursday evenings between 5.30 p.m. and 6.30 p.m., and the Car Park. Municipal Offices, Sheen Lane, East Sheen, on Monday evenings between 5.45 and 6.45 p.m. 31 B.C.G. Vaccination against Tuberculosis. B.C.G. Vaccination of schoolchildren at about the age of 13 is carried out under Section 28 of the National Health Service Act. During 1966, 1,724 schoolchildren were skin-tested and the details are as follows:— No. skin-tested 1724 (343) No. found positive 150 (294) No. found negative 1530 (49) No. vaccinated 1513 (49) The figures in brackets show schoolchildrcn who were re-vaccinated during the year. AFTER-CARE FACILITIES. The Barnes and Richmond Chest and Tuberculosis Care Committee continued to undertake the after-care of chest cripples and extended its area of operation to include the Twickenham parti of the Borough as from the 1st June, 1966. The name of the organisation was changed to the Richmond upon Thames Chest and Tuberculosis Care Committee. I am indebted to Mrs. M. Jolliffe, Chairman, and her colleagues for the following report on the progress of the organisation during 1966 : "This Care Committee has worked in Richmond and Barnes for many years to alleviate the distress which comes with serious illness and fill the gaps inevitably left by official schemes of treatment and allowances. The patient and his family are considered as a unit and help is offered to those suffering any form of chest disease. Food, fuel, holidays, clothes, furnishings and many other items are provided. Since June, 1966, activities have been extended to the whole of the Borough of Richmond upon Thames. In addition to the work already done the Committee now has the responsibility for handling the schcme of extra nourishment for necessitous cases, agreed by the Borough Council and financed by a generous grant from them. Other kinds of help can also be given from this grant to those below the Council Grand scale. For those above this scale, but with special needs and problems, the money raised by the Committee itself is used. The build-up of work in the Twickenham area has been somewhat slow— from May to December, 1966, six families being helped, while there were 55 helped in the Richmond and Barnes area. Of this 55, in 33 cases the illness was tuberculosis and in 22 some other kind of chest disease. It is hoped with the Council grant and the help of interested people in the Borough all chest cripples in need will soon be receiving help through the Committee". 32 London Borough of Richmond upon Thames Chest and Tuberculosis Care Committee Statistics 1966 (from 1.4.66) Category of Cases. No. assisted (within scale for Council grant). No. assisted (above scale for Council grant). RICHMOND Tuberculosis Cases 34 (including 4 members of 1 family). 7 Other Chest Cripples 16 3 TWICKENHAM (from 1.6.66) Tuberculosis Cases 6 - Other Chest Cripples Note: 38 of those qualifying for Council grant had Christmas gifts at Care Committee expense. Hostel for homeless tuberculous males. This 16-place hostel at 11, Rosslyn Road, Twickenham, provides shelter and care for homeless chest cripples. Many of the residents are the responsibility of other local health authorities. During the year four cases were admitted to the hostel. In addition two cases were transferred to hospital, one of whom subsequently died. The hostel continued to receive the full support of the Consultant Chest Physician at the Hounslow Chest Clinic who also assesses the elegibility of prospective applicants. I am indebted to Dr. R. Heller and Dr. D. Mcintosh of the Hounslow Chest Clinic, for their valuable help throughout the year. Christmas extras at 10/' per head were granted to patients and resident staff. At the end of the year there were 13 patients in residence. The hostel is staffed with a warden and deputy warden, plus adequate domestic staff. The hostel is visited regularly by a health visitor and a member of the chest clinic medical staff and a general practitioner. The occupational therapist of the London Borough of Brent also visits the hostel. If their medical condition allows residents are encouraged to find employment. CARE OF THE ELDERLY. Your Borough has a large proportion of elderly people, (approximately 36,690 of 60 years of age and over) and there is little doubt thaii this number will increase along with the national average, which is steadily rising. Prevention, care and after-care for these older citizens is very much the concern of the Health Department. The prevention of ill-health and the early detection of disorder by screening techniques and the more positive approach by advice on all aspects of keeping well is of paramount importance. 33 The Council agreed to set up three satellite clinics for elderly persons in addition to the parent clinic for older people which has been operating for some time at Church Road Clinic, Teddington. It is proposed to open these satellite clinics during the financial year 1967/68. Clinic for Preventive Medicine for Older People. During the year discussions were held and agreement reached with the Local Medical Committee and confirmed by the South West London and Surrey Executive Council on the guide lines for the above Clinic and its closer liaison with family doctors within the Borough. In general the clinic caters for residents of the Borough who have attained the age of 55 years. General. To assist in the care and guidance of old people, a geriatric health visitor was appointed part-time and commenced duty on the 21st September, 1966. In addition a geriatric health visitor was appointed jointly to serve the districts of Richmond, Kingston and Esher as from 15th August, 1966. There is an impression from the practical point of view that there are insufficient hospital and welfare home beds to meet present and future needs. If beds are to be allocated on a proper basis, homes and hostels for the elderly should not be regarded as dumps for old people simply because there is no one to look after them. The suggestion that the old people should be placed in a home or the clinical ward of a hospital, parted from all their personal treasures and familiar surroundings, may appear to be an easy solution and a sop to the conscience of relatives and neighbours, but it is scarcely humane. Many of these old people can and should be cared for in the community. Part III accommodation is valuable and expensive and should only be used where absolutely necessary. The needs of old people are simple, but they break down and deteriorate sooner than need be when they are no longer able to cope with the ordinary household chores of cooking, shopping and keeping themselves and their homes clean and tidy. In the interests then of prevention how vital is the provision of an adequate home help service (See page 38—Home Help Service). It has been found that approximately 75% of the Home Help Service is now being used by the elderly and there is an ever increasing demand which all too often cannot be met. It is part of a preventive programme that the services of the home help should be available before the break-down occurs and conditions have deteriorated to such an extent that the home help is unwilling to work in such conditions, or that the old people have become suspicious, stubborn, and hostile and access is refused. One such case, a blind old lady aged 84 years who was living alone in the ground floor of a house owned by her, was visited by members of the staff in January/February 1966. The rooms were indescribably filthy. She refused to have a fire on, although there was a gas fire in her bedroom in which she was living. The cold was intense and indeed she was blue with cold. To keep warm, she kept to her bed which was covered by a few grubby blankets with no sheets and no pillow cases. Her nightdress was also filthy, although clean clothing was available in the chest of drawers. The whole room was completely blacked out by shabby curtains and everywhere was covered with dust and litter. "Meals on wheels" were provided regularly but they were not eaten and stinking remains were found in the kitchen and also in the bedroom. The old lady was very confused and could not remember whether she had eaten or not. She refused to go into a welfare home. She refused the services of a home help, because her 34 treasured things were said to be disappearing from her home. Various members of the Health Department Staff continued to visit from time to time and each time offers of help were politely, but equally firmly, refused. To use compulsory powers to have this old lady transferred to a welfare home would have been cruel even more so because of her blindness. The tenant of the upstairs accommodation, an elderly widow with a disability, was persuaded to provide some food for her each day and this arrangement continued for a while until the accusations became too unbearable for this source of help to be continued. Eventually the old lady began to deteriorate physically and mentally and after much persuasion agreed to have a home help. Finally, in November, 1966, arrangements were made for a district nurse to go in daily and now the old lady is well fed and kept clean and tidy. Compulsory Admission to Hospital. During the year an old lady was admitted to hospital under Section 47 of the National Assistance Act, 1948. She died shortly after admission. Residential Accommodation. Mr. J. D. Elliott, D.P.A., A.I.S.W., Chief Welfare Officer, comments:— "The following table shows the number of persons, analysed by age and sex, who, on the 31st December, 1966, were either accommodated in one of the Homes under the control of the Welfare Committee or for whom the Committee had accepted financ;ai responsibility in a Voluntary Home:— Age Borough Homes Voluntary Homes Total Men W omen Men Women Under 30 — — — 3 3 30—49 — 1 — 1 2 50—64 2 4 4 5 15 65—74 17 52 17 10 96 75—84 31 151 14 36 232 85 and over 24 121 7 41 193 Total 74 329 42 96 541 94 of the persons shown in the table above as being in Borough Homes were accommodated on behalf of other Local Authorities but a further 41, not included in the table, were accommodated in other Local Authorities' Homes on behalf of the Council, making a net total of 488 persons for whom the Welfare Committee was responsible as at the 31st December". My thanks are dud to Dr. James Andrews, Consultant Physician to the Geriatric Service, South West Middlesex Group, for the following personal comments:— "The Geriatric Department of the West Middlesex Hospital cares for a population of 446,000 and includes the part of the London Borough of Richmond upon Thames north of the river (Twickenham, Teddington, Hampton and Hampton Wick). Probably the most pressing needs with regard to local authority services for the elderly in Richmond upon Thames, are:— (i) For day centres to be established which, besides taking elderly people direct from their homes, would act as "holding units" for handicapped patients discharged from hospital who need care through the day and psychological stimulation to keep them both mentally and physically active. In addition this has the socially desirable features of providing relief to relatives. Diversional therapy should be organised, 35 preferably by a trained occupational therapist, but the day to day work could be carried out by voluntary or untrained personnel. On the whole, the elderly mobile in the community suffer very little compared to the handicapped, and it is essential that these day centres should take patients with quite severe locomotor disease, some of whom are only wheelchair independent. This emphasises how essential adequate transport arrangements are. (ii) That domiciliary services must not break down at week-ends and holidays. It has even been seriously suggested to me recently that patients should be admitted to hospital for the Christmas period as they cannot be maintained at home. These remarks refer particularly to Home Help and Meals on Wheels services. It is unfortunate that home helps are so very difficult to obtain for more than one or two days a week, and that Meals onj Wheels should, let alone not function at the week-end, only function twice a week, and it would certainly be an advantage if the service could be extended as soon as circumstances permit. When one is organising the geriatric services for a community it is most important that:— (a) Hospital beds should be reserved for patients who are medically ill or need heavy nursing care. (b) Local authority welfare homes should be reserved for the severely handicapped who are only partially independent. (c) Modified housing schemes with wardens attached should be reserved for the more independent who need only minimal supervision. Authorities at present often cater for a type of person who is physically and mentally healthier than those for whom the need is greatest. The fact that the London Boroughs cover domiciliary health, welfare and housing services, creates conditions, one hopes, whereby suitable schemes can be provided for the elderly, according to their degree of dependence and their consequent need". ACCIDENTAL HYPOTHERMIA. It is, of course, a well-known fact that hypothermia, or the condition of extreme cold leading to a drop in body temperature can be extremely dangerous and sometimes fatal to the elderly and very young. Having regard to the large proportion of elderly persons in the Borough, arrangements were made for emergency kits to be made available on a 24 hour basis for use by medical and nursing staff, in order to ameliorate and prevent such environmental circumstances. The hypothermia kits consist of self-heating cans of soup, sleeping bags, blankets, hot water bottles, thermometers, convector type oil heaters, matches and change for electricity and gas meters. They are stored in the Hostel at 11, Rosslyn Road, Twickenham, which is reasonably centrally placed in the Borough. The oil heaters were very kindly donated to the Borough by the Oil Appliance Manufacturers' Association. The purpose of the kits is that, in an emergency, and wherever practicable on medical advice they are used to raise the temperature of the environs prior to possible urgent admission of a patient to hospital for treatment. (See also page 39—Health Education). CHIROPODY. A revised chiropody scheme was approved by the Council and came into effect on 1st June, 1966. These facilities allow patients to be treated in the surgeries of chiropodists and, in the Twickenham area, the option of treatment at a clinic. Requests for domiciliary treatment are normally made by the patient's family doctor, and supported by a medical certificate. There has been excellent co-operation between the department and the local chiropodists. 36 The number of treaments carried out during the year was as follows:— (a) Treatments at the surgeries of private chiropodists 11,337 (b) Treatments at Borough Council Clinics 1,027 (c) Treatments at sessions arranged by Voluntary Societies 2,584 (d) Domiciliary treatments 4,155 RECUPERATIVE HOLIDAYS. During the year arrangements were made for 84 persons to be admitted to holiday homes on the South Coast. Cases referred and the origin of referral are shown below : Family Doctor referrals. Hospital referrals. Elderly Persons 19 16 Adults 18 11 Children under 5 years of age 2 — Mothers accompanied by children — Mothers 5 — Children 13 — Subsequently the arrangements for 9 elderly persons, 12 adults, and 3 children were cancelled at the wish of the patient or relatives. 3 families were sent away in collaboration with the Children's Department. HEALTH EDUCATION. Health education in the Borough continued to be promoted through the health education sub-committee under the Chairmanship of the Deputy Medical Officer of Health. The co'operation of the Borough Safety Officer on such matters as accidents in the home and water safety, etc. was much appreciated. Poster campaigns were held on different subjects each month (see below) and as far as possible these were also held in conjunction with any national campaigns that were being promoted at the time, e.g. mental health week, immunisation. HEALTH EDUCATION CAMPAIGNS, 1966 JANUARY and FEBRUARY Dangerous Pills and Drugs MARCH and APRIL Immunisation MAY Food Hygiene JUNE Mental Health JULY Water Safety AUGUST to 19th SEPTEMBER Broken Glass 20th SEPTEMBER to 30th SEPTEMBER Immunisation OCTOBER Home Safety NOVEMBER Smoking DECEMBER Dental Health 37 I am indebted to the Twickenham Branch of the British Red; Cross Society for the use of their shop window front in the centre of Twickenham. This site is a particularly good one for exhibition purposes. (See photograph page 39). Talks are arranged for voluntary associations, parent and youth groups etc. and these are invariably supported by films or slides. The health visitors are very active in this field and group teaching is held by them during clinic sessions at welfare centres. Ante-natal relaxation sessions held in association with parentcraft classes are taken by health visitors and midwives. These take the form of a short talk followed by relaxation exercises and finally a discussion. Midwives are concerned with ante-natal care in the mothers home, at welfare centres and at family doctor clinics. (See page 28— health visiting). A booklet has been published giving details of talks supported by films and other aids which the department is pleased to arrange. These booklets have been distributed to all health department staff, family doctors, and voluntary organisations throughout the Borough. As a result of this many requests have been received for talks on various subjects. HOME HELP SERVICE Staff. Home Help Organiser 1 Assistant Home Help Organisers 2 Home Helps — Whole-time 9 — Part-time 89 (Whole-time equivalent0 60.3) (Permitted establishment 100) (Budgeted establishment 70) Mrs. H. C. Rowan, Home Help Organiser, retired on the 12th December, 1966, after nearly 17 years in that capacity with the former Northern Division Surrey County Council and since the 1st April, 1965, with the London Borough of Richmond upon Thames. Mrs. J. E. M. Roberts, formerly an Assistant Home Help Organiser, was appointed in her place and commenced duty as from the 13 th December, 1966. Applications for the home help service are dealt with in the following order of priority:— 1. Acute emergency cases. 2. Domiciliary confinements. 3. The tuberculous. 4. Other cases, i.e. chronic sick, aged, infirm, mentally disordered, etc. Applicants are assessed to pay what they can afford according to financial circumstances, but persons in receipt of supplementary benefit from the Ministry of Social Security and those suffering from toxaemia in pregnancy receive the service free of charge. The standard charge for the service at the end of the year was 5/3d. per hour. Cases given help during 1966 were as follows:— Chronic sick and tuberculous 85 Mentally disordered 2 Maternity 100 Others 114 aged under 65 Aged 65 or over 805 Total cases helped 1,106 (Included above are 595 cases brought forward from 1965). 38 VO Hypothermia kit on display in shop window of the Twickenham Branch, British Red Cross Society. In 1965, 1,264 families were helped as compared with 1,106 in 1966. The reduction in the number of cases helped has mainly been due to the fact that it has been necessary to provide additional help for many aged and chronic sick patients in the borough. The recruitment of home helps showed some improvement at the end of the year (55.4 in 1965) (60.3 in 1966), but the Home Help Service although working to capacity, continued to have difficulties in meeting all requests for assistance. Generally speaking cases in the priority classes such as acute emergencies, domiciliary confinements and the tuberculous were given some assistance, but in many instances more assistance than that given was indicated. Hourly payment is made to home helps in accordance with nationally negotiated rates of pay. Additional remuneration is given for work in dirty homes and certain infectious diseases. "Dirty cases". Dirty homes do present a considerable problem and the persons concerned are very often difficult to help because of their reluctance to allow anyone inside their homes. Once entry has been gained the Home Help Organiser and the Public Health Inspectors co-operate to clear the premises of rubbish, etc. and render the premises suitablq for the home help to commence duty. It has been found appropriate to use two home helps in each dirty home and the whole operation is closely supervised by the Home Help Organiser. Brooms, mops, soap powders and disinfectant are made available. This is particularly dirty work and as previously stated home helps who will do this work are paid an extra allowance. Good Neighbour Service. A good neighbour scheme is operated to supplement the home help service thus saving wastage of valuable home help time. Good neighbours help the aged and chronic sick by doing daily chores such as shopping, cooking, seeing to fires or other forms of heating and various other necessary daily duties. The good neighbours are paid from 10/- to £2. per week according to the extent of the duties allocated by the Home Help Organiser. Good neighbour cases given help during 1966 were as follows:— 78 (including 22 cases brought forward from 1965). MENTAL HEALTH SERVICES Although active consideration was given during the year to the provision of a comprehensive mental health service in the Borough the need to rely on voluntary societies and other local authorities for the placement of the mentally disordered in training establishments and residential accommodation continued. Provision has been made in the Council's Plan for The Development of the Health and Welfare Services Over the Next Ten Years (1966-76) for the provision of establishments for the mentally disordered, but it was quite evident that the immediate need was for daily training facilities for the mentally subnormal and the provision of a day centre for the elderly mentally ill. Negotiations were started with the Hounslow, Twickenham and District Society for Mentally Handicapped Children for the possible use of Harle House, Feltham, as a temporary junior training centre. Harle House would be particularly suited for use as a training centre of this nature — it was purpose-built by the Society as a centre for mentally handicapped children and their parents. It is hoped that negotiations for this project will not be too prolonged to enable the proposed training centre to open in the latter part of 1967. 40 Mental Illness The Borough continues to be served by two psychiatric hospitals for the mentally ill as follows: Banstead Hospital, Sutton, Surrey. (Districts served Richmond and Barnes). Springfield Hospital, Beechcroft Road, Upper Tooting, S.W. 17. (Districts served : Twickenham, Teddington, Hampton and Hampton Wick). The following table shows the number of patients admitted to psychiatric hospitals under the Mental Health Act during the year: Section M F Total * Section 5 29 (16) 38 (17) 67 (33) Section 25 18 (14) 35 (15) 53 (29) Section 26 10 (1) 12 (4) 22 (5) Section 29 31 (33) 49 (45) 80 (78) Section 60 5 (2) (—) 5 (2) Total 93 (66) 134 (81) 227 (147) * Includes one male patient under 16. (Figures in brackets are those as at 31st December, 1965). Co-operation with the hospitals providing psychiatric cover for the Borough is considered to be a very important factor in the care and after-care of the mentally ill. Mental welfare officers continue to attend out-patient clinics at the West Middlesex and Richmond Royal Hospitals and ward conferences at Banstead and Springfield Hospitals. In November 1966 the Council approved arrangements being entered into with Springfield Hospital Management Committee for the services of a social worker to be allocated to Springfield Hospital for three sessions per week subject to the Council being re-imbursed the cost involved. The joint use of social workers in hospitals and the community is another important factor in this co-operation. The fieldwork for the after-care of the mentally ill is carried out by the following officers who were on the staff of the department at the end of the year:— 1 Chief mental welfare officer. 1 Senior mental welfare officer. 4 Mental welfare officers. 1 Mental health social worker. 1 Half-time social worker. One mental welfare officer is attending a full-time two year course of study for the Certificate in Social Work. Dr. Alfred Torrie, M.A., M.B., Ch.B., D.P.M., continued to hold his valuable "in-service training" sessions for mental welfare officers. From the 1st January, 1966, until 31st December, 1966, mental welfare officers made a total of 2,679 (726) home visits and approximately 72 (100) office interviews were held during the same period. 41 The total number of mentally ill persons residing in the community and under care at the 31st December, 1966, was 294 (76) i.e. 138 (8) males, 156 (68) females. The figures in brackets show comparable figures for 1965. The increase in work is mainly due to the natural evolution and organisation of the service which commenced on the 1st April, 1965, and the number of officers employed which was greater at the end of 1965 and 1966 than it was at the 1st April, 1965. Residential Accommodation for the Mentally 111. At the end of 1966 there were 21 patients, for whom the Borough had accepted financial responsibility, in mental after-care homes and hostels run by voluntary societies and other local authorities. The Mental After-Care Association is particularly helpful in this respect. Community Care of the Subnormal and Severely Subnormal. Referrals to the mental health service. During 1966 the following referrals were received : Subnormal Severely Subnormal Total Over 16 Under 16 Over 16 Under 16 M F M F M F M F Referrals under Section 57 (as amended) Education Act, 1944 — — 3 — — — 2 1 6 Referrals of educationally subnormal children requiring supervision after leaving school 8 4 - - - - - - 12 Referrals from other sources 5 4 1 - 2 2 4 7 25 Total , 13 8 4 — 2 2 6 8 43 Supervision in the Home. With support from social workers and health visitors many subnormal and severely subnormal patients of all ages are able to live satisfactorily in the community. It is essential that they and their parents are able to obtain assistance with their problems and this is readily available through visiting officers. I have had the benefit of specialist advice on individual patients from Dr. D. Watterson, M.B., Ch.B., D.P.H. The total number of subnormal and severely subnormal persons under community care at the end of 1966 was 224 compared with 225 in 1965. This does not include those patients placed in residential accommodation under Guardianship and Informal Foster Care arrangements. Guardianship and Informal Foster Care. At the end of 1966 there were three patients under the Guardianship of the Council (four at the end of 1965). There were also 15 under informal foster care arrangements in homes or hostels run by voluntary societies and private homes (12 at 31st December, 1965). In order to avoid formal guardianship procedures informal placements are made wherever practicable. The Guardianship Society, Hove, is most helpful in assisting in the placement of patients in suitable homes. 42 As Medical Officer of Health of the London Borough of Richmond upon Thames I represent the London Boroughs Association on the General Committee of the Guard' ianship Society, Hove. One subnormal female was discharged from Guardianship during 1966. The circumstances were such that the woman concerned returned to her former employment in Hertfordshire. Admissions to hospital. The Borough is in the catchment area of Normansfield Hospital, Teddington, which serves the districts of Twickenham, Teddington, Hampton and Hampton Wick; Botleys Park Hospital, Chertsey, Queen Mary's Hospital, Carshalton, and St. Ebba's Hospital, Epsom, which cover the districts of Richmond and Barnes. The majority of patients from the Richmond and Barnes area are admitted to Botley's Park Hospital. table shows the number of admissions which have taken place from 1st January, 1966, to the 31st December, 1966, all of which were on an informal basis : Subnormal Severely Subnormal Total Over 16 Under 16 Over 16 Under 16 M F M F M F M F Normansfield Hospital — — — 1 2 3 2 8 Botleys Park Hospital — 2 — — 1 1 — 4 Queen Mary's Hospital 1 1 2 Total — - 2 — 1 3 5 3 14 The number of patients awaiting admission to psychiatric hospitals for the subnormal at the end of the year was as follows : Subnormal Severely Subnormal Total Over 16 Under 16 Over 16 Under 16 M F M F M F M F In urgent need of hospital care — — — — — 5 4 1 10 Not in urgent need of hospital care Total — — — — 5 4 1 10 During the year there were 14 admissions to hospital on a permanent basis compared with 4 in 1965. The waiting lists were carefully scrutinised and it is pleasing to note that there was a total of ten patients awaiting permanent care compared with 20 at the end of 1965. I am indebted to Dr. N. Langdon Down of Normansfield Hospital, Dr. J. M. Crawford of Botleys Park Hospital, and Dr. B. Kirman of Queen Mary's Hospital, Carshalton, for their invaluable help. Temporary Care One way in which the parents can be given a measure of relief is for the department to arrange short stay care for periods of up to eight weeks in psychiatric hospitals or arrangements may be made with voluntary societies etc. for placement in private homes. During 1966 arrangements were made for 20 patients to be sent to hospitals; two patients were accommodated in privately run establishments. 43 Training (a) Attendance at junior training centres. At the present time children from the Borough attend the Hanworth Junior Training Centre, Bear Road, Hanworth, which is administered by the London Borough of Hounslow, and the Kingston Training Centre, Dukes Avenue, Kingston upon Thames, administered by the Royal Borough of Kingston upon Thames. The numbers attending these centres from the Borough are set out below: Name of Establishment. Area Served. Number attending. Kingston Training Centre Richmond and Barnes 13 Hanworth Junior Training Centre Twickenham, Teddington, Hampton & Hampton Wick 22 Total 35 Certain older girls at the Hanworth Junior Training Centre are paid monetary rewards up to 15/- per week for helping in the kitchen and with the: nursery class children within a ratio of one orderly to every 30 places. Medical inspection and treatment for children attending training centres is provided in the same way as for children attending primary and secondary schools. (b) Attendance at special care units. Certain severely subnormal children are unable, because of their unsuitability, to attend a junior training centre. These children may be admitted to a special care unit attached to the centre. These care units cater specifically for mentally handicapped children who also suffer from a physical handicap, or are very over active, and provide mothers with much needed relief and a measure of habit training for the child. (c) Attendance at adult training centres. Adult subnormal and severely subnormal patients from the Borough attend the Acton Lodge and Brentford Adult Training Centres situated within the London Borough of Hounslow, and the Kingston Training Centre, situated within the Royal Borough of Kingston upon Thames. The approximate numbers attending these centres from the Borough are set out below: Name of Establishment Area Served Number attending Acton Lodge Adult Training Centre Twickenham, Teddington, Hampton & Hampton Wick 33 Brentford Adult Training Centre Ditto 8 Kingston Training Centre Richmond and Barnes 13 TOTAL 54 44 The aim of the adult training centres is to train those attending to function at the very highest possible level whether that be to work within the centre or in outside employment. In this way the trainees become more independent and are able to lead as full a life as possible. Work is undertaken at the centres for local firms on a contract basis and includes assembly of electrical components and television parts, toy assembly, carpentry and joinery, involving the use of heavy machinery, gardening, etc., etc. At the Brentford and Acton Lodge Adult Training Centres the Trainees work a 40 hour week, i.e. eight hours daily, Monday to Friday, including a lunch break. They are paid on a scale ranging from 8/- to £2 per week according to diligence, ability, and application to the job. At the Kingston Training Centre the trainees work a 32½ hour week, i.e six-anda-half hours per day Monday to Friday, including a lunch break. The trainees are paid monetary rewards on a, scale ranging from 5/- to 30/- per week. I am indebted to Dr. R. L. Lindon, Medical Officer of Health, London Borough of Hounslow, and Dr. J. C. Birchall, Medical Officer of Health, Royal Borough of Kingston upon Thames, for the extremely fair and generous manner in which they have undertaken the provision of places for mentally handicapped children from the London Borough of Richmond upon Thames. Although sporadic, Hounslow is able to continue to take children into its training centres, but considerable difficulty is experienced with the placement of children who would normally attend the Kingston Centre. This centre has been full to capacity for the greater part of the year and it is evident that until such time as this Borough makes its own provision children living in the Richmond and Barnes areas will receive little or no training. Holiday Camps By arrangement with the London Boroughs of Hillingdon and Hounslow arrangements were made for children and adults from Richmond upon Thames to attend holiday camps as follows: Borough. Place. Dates. Number Attended. London Borough of Hillingdon (Junior Camp) Park Place Residential School, Henley-on-Thames. 24.7.66 5.8.66 1 male. London Borough of Hounslow (Adult Camp) St. Mary's Bay, Romney Marsh, Kent. 30.8.66 - 9.9.66 4 males. Arrangements had also been made for three Richmond upon Thames residents to attend the holiday camp run by the Royal Borough of Kingston upon Thames at Pirate Springs, Dymchurch, Kent, from the 23 rd July to the 30th July, but unfortunately at the last moment the camp had to be cancelled due to an infectious illness. Deaths of Mentally Subnormal Children. It is with regret that I include the following details of mentally handicapped children who died in 1966: Age. Sex. Cause of Death. 10 F Renal failure. Inferior vena caval thrombosis. Spastic paraplegia and microcephaly. 12 F Broncho pneumonia. Severe subnormality. Epilepsy. 12 M Cardio respiratory failure. Broncho pneumonia. Cerebral palsy. 45 INCIDENCE OF BLINDNESS I am indebted to Mr. J. B. Elliott, D.P.A., A.I.S.W., Chief Welfare Officer, for the following information:— A. Follow-up of Registered Blind and Partially Sighted Persons for the year ended 31st December, 1966. Cause of Disability Cataract Glaucoma Retrolental Fibroplasia Others (i) Number of cases registered during the year in respect of which Section F of Forms B.D.8. recommends: (a) No treatment 3 4 - 25 (b) Treatment (medical, surgical or optical) 12 8 - 30 (ii) Number of cases at (i) (b) above which on follow-up action have received treatment 7 8 - 21 B. Other Statistics for the year ended 31st December, 1966. Number of Forms B.D.8. received during the year 82 Number of Registered Blind Persons at 31.12.66 Male 136; Female 231; Total 367 Number of Registered Partially Sighted Persons at 31.12.66 Male 40; Female 60; Total 100 The total number on the Blind Register at 31st December, 1966, was 367, a; net increase of 43 as compared with the total at 31st December, 1965. During this period 86 persons were added to the Register, 68 of these being new cases, including 15 who were transferred from the Partially Sighted Register. The remainder were, transfers from the areas of other Local Authorities. 30 persons died during the period and 13 persons removed from the Borough. 46 The following table shows the classification of the Register by age groups and by incidence of blindness:— ] Classification by age groups. Classification by incidence of blindness. Birth — 31 Under 1 year of age 1 — Aged 1 year — 1 „ 2 years — 2 „ 3 years — 1 „ 4 years 1 — „ 5-10 years — 9 „ 11-15 „ 5 6 „ 16-20 „ 5 7 „ 21-29 „ 7 11 „ 30-39 „ 15 12 „ 40-49 „ 13 30 „ 50-59 „ 27 27 „ 60-64 „ 19 18 „ 65-69 „ 35 39 „ 70-79 „ 92 84 „ 80-84 „ 66 50 „ 85-89 „ 48 25 „ 90 and over 33 8 Age of incidence unknown — 6 It will be seen that there are 293 persons on the register who were aged 60 and over, 230 of whom did not lose their sight until they were over that age. Of the children under 16, 1 was below school age, 1 was attending a Nursery School, 2 were at special schools for the blind, 1 at a special school for the educationally sub-normal and 2 were in hospitals for the mentally sub-normal. 104 persons were suffering from other handicaps in addition to blindness, 22 were in Residential Homes under Part III of the National Assistance Act, 1948, 4 in. Hospitals for the Mentally 111 and 12 in other hospitals. Of the 67 persons aged between 16 and 59, two were still engaged in full time studies and 33 were in employment. There were also 8 persons aged 60 and over who were still working. None of the persons who are working are now employed in the special Workshops for the Blind and only 3 work under the Homeworkers Scheme. The table below shows the occupations followed by those in employment:— Professional, Technical, Administrative, etc. Masseurs, Physiotherapists 5 Musicians (including Teachers) 4 Others 2 Clerical and Related Workers Typists, Secretaries 5 Braille Copyists 1 Clerical Workers 2 Telephone Operators 1 Sales Workers Shop Managers or Assistants 3 Craftsmen, Production Process Workers, Labourers Machine Tool Operators 4 Fitters and Assemblers 3 Inspectors 1 Production Process Workers 2 Agricultural and Horticultural Workers Gardener 1 Service and Miscellaneous Workers Domestic, Cleaners, Caretakers 6 Miscellaneous 1 C. Register of Partially Sighted Persons. The Register of Partially Sighted Persons at 31st December, 1966, showed a total of 100 persons, a net decrease of 5 persons since 31st December, 1965. A total of 21 was added to the Register during the period, 14 of these being new cases and the others new residents in the Borough. 15 persons were transferred to the Blind Register, 6 died and 5 removed to other areas. The classification of the Register by age groups was as follows:— Under 5 years 1 5-15 years 3 16-20 „ 11 21-49 „ 17 50-64 „ 12 65 and over 56 Of the total on the Register, 48 were expected to become blind within the near future and 12, while not expected to become blind, were considered to be industrially handicapped. 47 Ophthalmia Neonatorum (i) Total number of cases notified during the year (ii) Number of cases in which:— (a) Vision lost — (b) Vision impaired — (c) Treatment continuing at end of year — NURSING HOMES All registered Nursing Homes within the Borough are supervised by medical and nursing officers of the Department. The number of nursing homes on the register at the end of 1966 was as follows:— Maternity Homes Nil. Other Homes 6 Total number of beds 108 There were 2 cancellations during 1966. NURSES AGENCY At the end of 1966 there were 30 State Registered Nurses and 6 State Enrolled Nurses on the register of one licensed agency. LOAN OF NURSING EQUIPMENT. The British Red Cross Society continues to operate a scheme for the loan of nursing equipment. A small charge is made for articles loaned. This enables replacements to be made. Where patients are unable to pay, the Council pays the hire charge. The health department has purchased two special beds for use on especially heavy or paralysed patients. Six "Easi-carri" hoists are in constant use. Without these the nursing at home of some of the heavy patients would present a real problem. Alternating Pressure Pads These pads known as "ripple beds" save a great deal of unnecessary suffering to bed-ridden sick patients in the prevention and healing of pressure sores. 38 were hired for varying periods during 1966. INCONTINENT LAUNDRY SERVICE. A free laundry service is provided exclusively for incontinent patients under Section 28 of the National Health Service Act and Section 84 of the Public Health Act, 1936. This service which is provided twice weekly is carried out by a commercial laundry. Sheets make up the bulk of the laundry but night clothes and other articles are included where necessary. Transport of the laundry and distribution of the sheets, etc. is carried out by the Corporation. This service has proved invaluable and is greatly appreciated by the patients and their relatives. At the end of the year there were 50 cases receiving this service, compared with 29 at the end of 1965. 48 In a Circular to Local Authorities (14/66) the Minister of Health commended to local authorities the provision of pads, waterproof pants, and knickers with disposable linings for incontinent individuals. The Borough already had a scheme in operation for the provision of such articles but as a result of the Ministry of Health Circular family doctors in the Borough were reminded of the service. Incontinent pads are used where the degree of incontinence does not require the sheet service and where the patient is doubly incontinent thus reducing the laundering of soiled bed linen. The pads are normally distributed by the district nurses, but where a laundry service for incontinent persons is also in operation, pads are sometimes delivered by the van driver. Used pads are collected and destroyed whenever disposal is requested because the householder has difficulty in dealing with this type of refuse. Soiled dressings (including maternity debris) are also collected and disposed of in the same manner, generally at the request of the domiciliary nursing staff. There is an increasing call for this service and during the year approximately 1,040 collections were made compared with approximately 900 in 1965. MEDICAL ASSESSMENTS. The assessment of medical fitness of new entrants to the Council's service continued to make heavy demands on medical and clerical time, and the number of assessments undertaken considerably increased as compared to the previous year. A completed medical questionnaire and a satisfactory chest X-ray examination undertaken within the last twelve months are required of each new entrant. A full physical examination is carried out in any case of doubt, and on all entrants to teacher training colleges. In addition, recommendations as to medical fitness to continue in the Council's service were made following consultation with the family doctors concerned and physical examinations. The number involved over the year was: Total number of medical assessments 1,636 (1,032) Total number of physical examinations 364 (350) Total number examined for continued service 53 (18) Total number found unfit for further service 2 (6) The figures for 1965 are given in brackets. WATER SUPPLY All the dwellings in the Borough are supplied from the Metropolitan Water Board's mains, and I am indebted to Dr. E. Windle Taylor, Director of Water Examination, Metropolitan Water Board, for the following report: "a). The supply was satisfactory both as to quality and quantity throughout 1966. b). (i) The supply was derived from the following works and pumping stations : River Thames via Hampton. No new sources of supply were instituted. (ii) The number of samples collected and the bacteriological and chemical analyses of the supply from the above sources after treatment are shown on page 52. No fluoride was added, and where the fluoride content is indicated it represents the naturally occurring fluoride in the water. 49 c). The supply being hard in character is not liable to be plumbo-solvent. d). All new and repaired mains are disinfected with chlorine; after a predetermined period of contact the pipes are flushed out and refilled; samples of water are then collected from these treated mains; and the mains are returned to service only after results are found to be satisfactory. The quality control from these Laboratories is carried out by means of daily sampling from sources of supply, through the treatment works or well stations, from the distribution system, and through to the consumer. Any sign of contamination or any other abnormality is immediately investigated. e). (i) The Board has no record of the number of structurally separate dwellings supplied in your area, but the population supplied direct according to the Registrar General's estimates at 30th June, 1966, was 180,186. (ii) No houses were permanently supplied by standpipe. Other observations. f). There were no changes to the general scheme of supply in your area. g). The following additions to the mains in your area took place: (i) trunk mains — 1,001 yards. (ii) other mains — 875 yards." The following water samples were taken in the Borough by Inspectors of the Health Department: Satisfactory. Unsatisfactory. Swimming bath water 77 10 Paddling pool water — 2 Domestic water supply 8 — Sewage disposal works effluent 1 — 86 12 In all cases where unsatisfactory samples of public and schools swimming bath water were obtained immediate consultation took place with the Baths Manager; and the follow up samples in all cases were satisfactory. Two samples of water from a recreation ground paddling pool were taken and although there is no specific standard laid down for these pools, the results were not considered satisfactory. Consultation took place with the Parks Department and the method of chlorination was checked and improved. Follow up samples were not obtained as by this time the pool was not refilled as the summer season was at an end. SEWERAGE & SEWAGE DISPOSAL I am obliged to (a) Mr. A. S. Knolles, B.Sc., M.Inst.C.E., M.I.Mun.E., Chartered C.E., the Borough Engineer and Surveyor, and (b) Mr. L. H. Thompson, A.M.I.C.E., A.M.I.S.P., Regional Engineer, Greater London Council for the following reports:— a) The improvements to the air compressor stations at Hampton Wick and Bell Hill, Hampton, referred to in the previous report, have now been completed, enabling the compressor station at Hampton Works to be closed down. All remaining ejector stations in the area are now undergoing a complete overhaul. In conjunction with the widening of Heath Road, Twickenham, work is proceeding on the laying of a new surface water sewer in the widened portion of the road. 50 A survey is being undertaken of all sewers in the new Borough and is likely to take several years to complete. b) The sewage from Twickenham, Teddington and Hampton is conveyed through trunk sewers now under the control of the Greater London Council for treatment at the Mogden Works, Hounslow. This plant, serving as it does the whole of the West Middlesex area, receives an average daily flow of 90 million gallons of sewage. Originally constructed between 1931 and 1936, when it was the largest and most advanced of its kind in the world, the works were extended between 1954 and 1961 mainly to counter the deleterious effects on purification of synthetic detergents. The contributing population is now about 1,400,000 and increasing water consumption, now over 50 gallons per head per day, impurity loading and the changing effects of new synthetic detergents have caused temporary over-loading of some parts of the plant in recent years. This temporary overloading was partly the cause of the smell nuisance which received wide publicity in late 1964 and 1965. The extensions and improvements, at Mogden and the associated Perry Oaks Sludge Disposal Works, which have become operational during the last eighteen months have been a major factor in achieving the present satisfactory state of affairs in regard to smell nuisance. The success of these measures may be judged by the fact that there have been no complaints from local residents for several months, and that during most of 1966 as good or better quality effluent was produced and discharged into the River Thames than at any time during the 30 years Works operation. These welcome signs of more efficient operation of the works, however, leave no room for complacency. There are still further improvement works in hand, and although no guarantee can be given that some nuisance will not recur in particularly adverse conditions, it is hoped that further trouble will be avoided. The improvements and extensions referred to are: Work completed during 1966, includes : 1. Mogden Works. (a) Additional sludge pumping equipment. (b) Additional air blowing equipment (1000 HP capable of producing 25,000 c.f.m.). (c) Conversion of existing sludge digestion tank to improve its efficiency. (d) Sundry minor plant improvements. 2. Perry Oaks Sludge Disposal Works. (a) The removal of about 500,000 cu. yds. of consolidated sludge. (b) The provision of additional lagoons of about 35 million gallons capacity. (c) The provision of 10 acres of new sludge drying beds. Work in hand at the end of 1966 includes: 1. Mogden Works. (a) Construction of additional sludge digestion tanks. (b) Conversion of further sludge digestion tanks. 2. Perry Oaks Works. (a) Reconstruction of sludge storage lagoons of about 70 million gallons capacity. (b) Sundry minor plant improvements. 51 52 AVERAGE RESULTS OF THE CHEMICAL EXAMINATION of water supplied to the London Borough of Richmond upon Thames Milligrammes per litre (unless otherwise stated) Description of the Sample Number of Samples Ammoniacal Nitrogen Albuminoid Nitrogen Nitrate Nitrogen Oxygen abs. from KMnO4 4 hrs. at 27° C. B.O.D. 5 days at 20° C. Hardness (total) CaC03 Hardness (noncarbonate) CaC03 Magnesium as Mg Sodium as NA Potassium as K. Chloride as CI Phosphate as P04 Silicate as SiO2 Sulphate as S04 Natural Fluoride as F Surface-active material as Manoxol OT Turbidity units Colour (Burgess units) pH value Electrical Conductivity (micromhos) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) Hampton 52 0.029 0.088 4.1 1.27 286 76 5 24.2 5.0 32 1.8 8 62 0.20 0.01 0.1 15 7.8 570 BACTERIOLOGICAL RESULTS — YEARLY AVERAGES, 1966 Source of supply BEFORE TREATMENT AFTER TREATMENT Number of samples Agar plate count per ml. Coliform count Escherichia coli count Number of samples Agar plate count per ml. Coliform count E. coli count 20-24 hours at 37° C. 3 days at 22° C. Per cent. samples negative in 100 ml. Count per 100 ml. Per cent. samples negative in 100 ml. Count per 100 ml. 20-24 hours at 37° C. 3 days at 22° C. Per cent. samples negative in 100 ml. Per cent. samples negative in 100 ml. Hampton 1,136 11.4 99.82 100.0 SANITARY CIRCUMSTANCES OF THE BOROUGH E. S. HERBERT, M.A.P.H.I. Chief Public Health Inspector. 1. HOUSING (1) Unfit Houses. Progress has been maintained in dealing with the unfit housing programme for the period 1966-1970 and in addition other individual unfit properties have been represented for action as the result of routine inspection on complaint. The progress made on existing Clearance Areas comprised: (a) the demolition of 1-28 (consecutive), Wilton Avenue, Richmond; (b) the demolition of 1-5 (consecutive), The Bench, Ham, Richmond; (c) the confirmation of the Clearance Order in respect of 1-7 (consecutive), Paradise Cottages, Richmond; (d) the demolition of 1-7 (consecutive), Paradise Cottages, Richmond. Dwellings reported as being unfit for human habitation and not capable of repair at reasonable expense were: 6, Adelaide Road, Richmond (basement); 25, Evelyn Road, Richmond (basement); 316, Kew Road, Richmond (whole house except basement) (basement closed 1964); 2, 3, 4 and 5, Queens Bench, Hampton; 10a, Riverdale Road, Twickenham (basement); 16, 18 and 20, Westbank Road, Hampton Hill; 88, 90, 92, 94, 96 and 98, Colne Road, Twickenham; 28, St. Leonard's Road, S.W. 14 (basement); 16a and 16b, May Road, Twickenham; 13, Gloucester Road, Teddington. The Council made Closing Orders, Demolition Orders or accepted from the owners undertakings in respect of the following premises: 3, 3a, 9 and 9a, Montagu Mews, Friars Stile Road, Richmond (Closing Orders); 6, Adelaide Road, Richmond (basement) (Closing Order); 25, Evelyn Road, Richmond (basement) (Closing Order); 316, Kew Road, Richmond (part of) (Closing Order); 2, 3, 4 and 5, Queens Bench, Hampton (Closing Order); 10a, Riverdale Road, Twickenham (basement) (Closing Order); 20, Haggard Road, Twickenham (basement) (Closing Order); 16, 18 and 20, Westbank Road, Hampton Hill (Demolition Orders); 5, Old Bridge Street, Hampton Wick (Undertaking); 41, Hill Rise, Richmond (basement) (Closing Order). 53 The following properties were made fit for human habitation during the year and in each case a Closing Order was determined or an undertaking cancelled: 30, Albion, Road, Twickenham 30, St. Leonards Road, S.W.14 7, Waterloo Place, Richmond 8, Waterloo Place, Richmond Closing Orders determined. 52, Sheen Park, Richmond Undertaking cancelled. All the dwellings included in the above report were dealt with by way of formal action under the Housing Act, 1957; in addition, repairs were effected at 245 dwellings after informal consultation with the owners, and 47 other dwellings were made fit for human habitation after the service of statutory notices under the Public Health Acts. The action taken to remedy unfit houses is summarised in the table below : (a) Clearance Areas represented to Council Nil (b) Dwellings included in (a) above Nil (c) Dwellings demolished after Clearance Orders made 40 (d) Dwellings represented for Demolition or Closing Orders 21 (e) Undertakings received to carry out repairs 1 (f) Closing Orders made in respect of — (i) Whole of building 8 (ii) Part of building 6 (g) Demolition Orders made 3 (h) Closing Orders determined on a building being made fit 4 (i) Undertakings cancelled on a building being made fit 1 (j) Dwellings in which defects were remedied after service of formal notice 47 (k) Dwellings in which defects were remedied after informal action 245 (2) Houses in Multiple Occupation In 1965 the Council adopted a standard for the amenities which should be provided for each family living in a house in multiple occupation. The standard covers the lighting and ventilation of habitable rooms, the provision of water supply, personal washing facilities, and of cooking and food storage facilities. Experience in implementing this standard during the year showed that it afforded a reasonable and adequate level of the essential amenities in properties of varying size. During the year a copy of the standard was sent to all Estate Agents having offices in the Borough, so that early advice would be available to purchasers of investment property, who intended to use the house for multiple lettings. The existence of houses in multiple occupation in the Borough comes to light generally by way of complaint from tenants or by reference from the Housing Department when considering applications for rehousing. The Housing Act, 1961 gives local authorities extensive powers for correcting unsatisfactory conditions in such houses, and among the more important are (i) the making of a Management Order the effect of which is to apply to individual houses a code of management; this power can be used where there is evidence of neglect by the owner and once an Order is made, a local authority can take legal proceedings against an owner for any contravention of the code of management: (ii) the making of a Direction which limits the number of persons who can occupy the various lettings in the house; the Direction does not require existing tenants to be dispossessed, but when a letting is vacated, the owner commits an offence if he re-lets to a family whose number exceeds that set out in the Direction. 54 (iii) the service of a notice under Section 15 of the Act requiring the owner to provide additional facilities in the house; the requirements of the notice are based on the Council's standard of amenities already referred to, and legal proceedings can be taken against an owner who does not comply with the notice, or the Council can carry out such work in default and recover the costs from the owner. The following table shows the formal action taken in connection with certain properties during the year: (1) Number of Management Orders made 2 (2) Number of Directions made 6 (3) Number of Notices served requiring additional amenities 1 In respect of two properties where Management Orders were in force, legal proceedings taken against the owner for failing to comply with the Management Regulations resulted in fines totalling ,£63 and £10 costs. (3) Certificates of Disrepair. The Rent Act, 1957 entitled owners of controlled rented properties to a prescribed rent income provided the dwelling is maintained in a reasonable state of repair having regard to its age, character and locality. The tenant is safeguarded by the Act in that he may resist the rent increase if the owner fails to carry out necessary repairs. For this purpose the tenant applies to the local authority for a certificate of disrepair, which has to be granted if the owner fails to give a satisfactory undertaking to put the house in a proper state of repair within six months, and with this certificate the tenant is entitled to make an adjustment to the amount of rent he pays the owner. The Act seems no longer to be an effective mechanism for ensuring that items of disrepair receive attention, and the following table shows that whereas an average of nearly 100 applications were received annually in the seven years following the introduction of the Rent Act, it has been almost completely ignored by landlord and tenant in recent years. Applications for Certificates of Disrepair: 1957/63 1964 1965 1966 1. Number of applications for certificates 668 10 — 6 2. Number of decisions not to issue certificates 24 1 — — 3. Number of decisions to issue certificates (a) in respect of some but not all defects 520 4 — — (b) in respect of all defects 124 5 — 6 4. Number of undertakings given by landlords under paragraph 5 of the First Schedule 415 7 — 6 5. Number of undertakings refused by Local Authority under proviso to paragraph 5 of the First Schedule 3 — — 1 6. Number of Certificates issued 232 2 — 1 Applications for Cancellation of Certificates: 7. Applications by landlords to Local Authority for cancellation of certificates 134 2 2 6 8. Objections by tenants to cancellation of certificates 54 — — 1 9. Decisions by Local Authority to cancel in spite of tenant's objection 18 — — 1 10. Certificates cancelled by Local Authority 98 — — 6 55 (4) Medical Priorities Many applications for re-housing are supported by Medical Certificates, and the applications receive special consideration in accordance with the medical evidence submitted. Medical Certificates are received either through the Housing Officer or direct from family doctors or hospital clinical staff. In order to preserve a uniform standard of judgement all applications are dealt with by the Deputy Medical Officer of Health. After the preliminary screening the number of cases requiring further investigation has been reduced to a minimum and only 146 cases required visits by either the Health Visitor or Public Health Inspector. 2. INSPECTION AND SUPERVISION OF FOOD (1) Food Inspection Eighty-seven complaints alleging unfitness in food sold or exposed for sale were received during the year. Investigations showed, as in previous years, that many of these complaints arise because of the failure of the food trader to turn over stock in a proper manner. Retailers were again reminded, by letter, early in the summer, of the value of adopting a system of visual aid coding for deliveries of pre-packed perishable foods; such a system enables the retailer to be quite sure when the "shelf-life" of the product has expired and such foods can then be withdrawn from sale and destroyed. Legal proceedings were instituted in nine cases with the following results : 1. A grocer was fined £20 with £3 3s. 0d. costs for selling a mouldy pork pie. 2. A bakery was fined £10 with £3 3s. 0d. costs for selling a loaf of bread taining a copper rivet head. 3. A bakery was fined £20 with £5 5s. 0d. costs for selling a loaf of bread taining a soiled adhesive dressing. 4. A delicatessen was fined £10 with £5 5s. 0d. costs for selling mouldy sausages. 5. A restaurant was fined £10 with £4 4s. 0d. costs for selling a flapjack ing pieces of glass. 6. A restaurant was fined £15 with £5 5s. 0d. costs for selling a meal containing an earwig. 7. A bakery was fined £30 with £10 10s. 0d. costs for selling a loaf of bread taining a piece of string. 8. A bakery was fined £15 with £10 10s. 0d. costs for selling a loaf of bread taining pieces of glass. 9. A grocer was fined £20 with £10 10s. 0d. costs for selling rotten eggs. 56 Throughout the year the Inspectors receive requests from food traders to examine doubtful consignments of food, and the following table lists the articles voluntarily surrendered and destroyed after such examination: Baby Food (tins) 169 Mincemeat (jars) 6 Bacon (lbs.) 46 Meat (tins) 870 Beef (lbs.) 208¼ Meat (fresh) (lbs.) 208 Biscuits (tins) 3 Meat (frozen) (pkts.) 679 Bread (buns) 269 Puddings (tins) 71 Cream (tins) 27 Puddings (pkts.) 17 Cheese (lbs.) 264 Pies (tins) 61 Cheese (tins) 3 Pies 71 Cereals (tins) 44 Prawns (lbs.) 45 Cereals (pkts.) 27 Preserves (40 gall, casks) 2 Cakes (lbs.) 149 Poultry (lbs.) 238 Cake mixes (pkts.) 26 Pork (lbs.) 177 Fruits (tomatoes) (lbs.) 315 Pickles, Sauces, etc. (bots.) 3 Fruit & Fruit Juices (tins) 5778 Pastry (pkts.) 388 Drinks (Minerals) (tins/bots) 1382 Sweets (pkts.) 65 Frozen Foods: Fish (pkts.) 2104 Sugar (pkts.) 35 Fish (tins) 543 Spaghetti (tins) 60 Fats (margarine/butter etc.) (pkts.) 108 Syrup (tins) 37 Ham (lbs.) 64 Spices (pkts.) 21 Ice Cream (cartons) 412 Sausages (lbs.) 50 Jellies (pkts.) 35 Soup (tins) 442 Lamb/mutton (lbs.) 146¼ Tea (lbs.) 15 Milk (tins/cartons) 146 Vegetables (tins) 984 Milk Puddings (tins) 12 Vegetables (pkts.) 1466 A report was received during the year of nine cases of mace and twenty-one bags of pepper being damaged after immersion in river water, and these products were received by a local firm for re-processing. They would normally be sold in their powdered form by grocers, but in view of possible pollution, it was thought advisable to have the oil extracted and the residue from the process destroyed. Observations were made while the processing of the material was in progress. In each case the powder was filled into a large container and washed with acetone (rather like a dry cleaning process). When the oil had been dissolved it was drained off. The mixture of acetone and oil was then distilled and the acetone drawn off. The resultant pure oil or resin which was left, was disposed of to food manufacturers and, after further processing, used by them for seasoning purposes. 57 (2) Food Premises The general classification of food premises in the Borough and the total number of visits made to each class of premises is shown in the following table. The general standard of hygiene in food premises has been maintained at a reasonably satisfactory level, but some proprietors, particularly of catering businesses, have difficulty because of staff changes and shortage in establishing the basic cleaning routines which are vitally important if clean and safe food is to be offered to the public. The control of food hawkers is exercised by registration under the provisions of Section 11, Middlesex County Council Act, 1950, and during the year 5 persons and 1 premises were registered and 38 inspections made. Food Hygiene (General) Regulations, 1960. Type of Premises. No. of Premises No. of Premises which comply with Reg. 16* No. of Premises to which Reg. 19 applies† No. of Premises which comply with Reg. 19 No. of Visits carried out. Bakehouses 31 31 31 31 164 Butchers' Shops 151 151 151 151 226 Confectioners (Flour) 72 72 — — 99 Confectioners (Sugar) 283 283 — — 80 Dairies 10 10 10 10 7 Fishmongers and Poulterers 39 39 39 39 77 Fried Fish Shops 24 24 24 24 78 Greengrocers and Fruiterers 165 165 165 165 230 Grocers 358 358 358 358 713 Ice Cream Premises—Manufacture 6 6 6 6 123 Ice Cream Premises—Sale and Storage 523 523 — — Public Houses and Licensed Premises 206 206 206 206 149 Restaurants, Cafes and Canteens 298 298 298 298 404 2166 2166 1288 1288 2350 * Regulation 16 deals with the provision of wash-hand basins for the use of all persons engaged in the handling of fo0d. † Regulation 19 deals with the provision of facilities for washing food and equipment. There are no poultry processing establishments in the Borough. (3) Food Sampling. Under the powers of the Food and Drugs Act, 1955, and in conjunction with the regulations and orders made thereunder, samples are procured for chemical analysis and for bacteriological and other examination. Samples for chemical analysis are submitted to Messrs. D. D. Moir, M.Sc., F.R.I.C., and J. A. Palgrave, B.Sc., F.R.I.C., and those for bacteriological and other examination to the Public Health Laboratory Service, Epsom. The invaluable help given by the Public Analysts and the staff of the Public Health Laboratory Service has substantially contributed to the effectiveness of sampling in the Borough. 58 During the year one hundred and nineteen samples were submitted for chemical analysis and of these five were considered to be irregular. The following table shows the various types of samples analysed and the results obtained: Articles. Number Analysed Number Irregular Biscuits 1 — Cereals 2 — Cheeses 3 — Coconut 2 — Coffee 1 — Cream and Cream Products 3 — Crystallised Fruits 5 — Drinks and Beverages 4 — Fish and Fish Products 4 — Flavourings and Essences 9 — Flour Confectionery 2 — Fruit and Vegetables 12 — Gravy Tablets 1 — Jellies 5 — Jams and Preserves 7 — Herbs and Spices 8 — Herb Tea 1 — Margarine 1 — Marzipan 2 1 Meat and Meat Products 4 — Medicinal Preparations 3 — Milk and Milk Products 3 1 Pickles and Sauces 15 — Saccarine Tablets 1 — Soups 2 — Starch Foods 5 — Sugar Confectionery 12 2 Toothpaste 1 1 Total 119 5 The irregular samples comprised:— (a) Toothpaste. The Analyst reported that this was a sample of unusual composition and physical nature, and of an acid reaction. The paste was not homogeneous and this condition was due to the separation of the paste into an oily layer near the nozzle of the tube although the bulk of the paste lower down was normal. The basis of the paste consisted of calcium phosphate and it was possible that a little acidic phosphate had been included perhaps as an impurity or that another ingredient was responsible. The matter was taken up with the manufacturers who were concerned to learn that this type of particular toothpaste, which they had ceased to produce in 1963, was still being retailed, and immediate action was taken to withdraw stocks from sale. (b) Almond Marzipan. This sample contained sorbic acid which is a permitted preservative but it was not declared in the list of ingredients on the label. The manufacturer's attention was drawn to this contravention and arrangements were made to have the labelling amended so as to include "sorbic acid" in the list of ingredients. (c) Togo. This was a sample of "low fat" Yogo but the words "low fat" did not appear on the label adjacent to the description of the product; in addition the words "Milk Solids" in the list of ingredients was considered to be an incorrect designation for 59 skimmed milk powder. The manufacturers were informed that the wording was not in accordance with the requirements of the Labelling of Food Order, 1953 and they agreed for new labelling to be introduced. (d) Liquorice Sticks. The Analyst reported that this product was flavoured with oil of anise, but no extract of liquorice could be detected and that they were not entitled to the description of liquorice sticks. It was, however, found that the article was not consigned by the manufacturers under this description but that they were being sold as such by the retailer. The retailer was informed in writing that the product was not to be sold under the description of "Liquorice Sticks". (e) Pea Shooter Sweets. The Analyst reported that this was a sample of genuine sweets for use with a pea'shooter of doubtful quality. The pea-shooter was made of a plastic material and the mouthpiece was found to have a lead content of 1100 parts per million. There was no evidence that the lead was readily extractable but it was considered undesirable that a substance of this nature should come into frequent contact with a child's mouth. The importers were consulted and arrangements were made with their manufacturers that the lead content of future supplies would not be excessive. Pesticide Residues in Foodstuffs. As a result of apparently increasing public concern regarding the contamination of foodstuffs by pesticide residues a national scheme was inaugurated whereby interested food and drugs authorities, without undue expense or duplication of effort, could undertake a systematic survey. For the purpose of the survey the country was divided into zones, of which the area of the Greater London Council was one. It was decided that the scheme should extend over a period of two years commencing on the 1st August, 1966, and that its continuation on a yearly basis thereafter would depend on the results of the first year. This authority elected to participate in the scheme and, for the first year, the following samples were obtained and submitted for analysis:— bread, oatmeal, custard powder, beef, liver, fish, milk, infant food based on milk, infant food based on vegetables and meat, apples, sugar, canned fruit, potatoes, carrots, canned vegetables, brassicas, peas and tomatoes. (4) Milk Supplies and Sampling. Licences granted authorising dealers to store and sell designated milks are as follows:— Ultra Heat Treated 23 Pasteurised 87 Sterilised 58 Untreated 27 There are no processing plants in the Borough but there is one Dairy Farm which is registered by the Ministry of Agriculture, Fisheries and Fo0d. Twenty two samples of milk were submitted for examination and all were found to satisfy the prescribed test. The samples included four raw milks which were examined for brucella abortus and brucella melitensis and mycobacterium tuberculosis. These were reported upon as being negative. (5) Ice-Cream Manufacture and Sampling. There are six manufacturing establishments in the Borough and five hundred and twenty three premises registered for the storage and sale of ice-cream. The manufacturing establishments comprise one where the ice-cream is pasteurised by heating to a temperature of not less than 160°F for at least 10 minutes and five in which a sterilised mixture is used and the process of manufacture is completed by freezing only. 60 During the year one hundred and twelve samples were taken and upon examination were graded as follows: Grade 1 — 53 Grade 2-25 Satisfactory Grade 3 — 31 Gride 4 — 3 Unsatisfactory. There is no prescribed statutory bacteriological standard for ice-cream as it is considered that no available bacteriological test is precise enough to be made statutory. The test applied, however, although only a provisional measurement of the bacterial activity in ice-cream, is a simple and valuable means for the routine grading of the product. By regulation ice-cream has to be pasteurised and, although certain organisms which are resistant to pasteurisation may be present in the ingredients of the ice-cream mix, they are seldom responsible for repeated results at Grades 3 and 4 levels. Failures are normally attributable to inadequate and unsatisfactory sterilisation of plant, equipment and servers. Sampling is concentrated on those premises where ice-cream is manufactured, and cafes and restaurants where ice-cream is served from a bulk supply. In the event of samples falling in Grades 3 and 4 investigations are carried out to ensure that efficient sterilisation is practised as a means of preventing contamination of the product after pasteurisation. (6) Other Foods. Samples of other foods for examination are selected from those recognised as suitable media for the development of organisms. Such foods include cooked meats, fish products and milk products. Thirty nine samples of these types of foods were examined and all were reported upon as being satisfactory with the exception of two samples of whipping cream. An investigation was carried out and subsequent samples proved satisfactory. (7) Food Hygiene Codes of Practice. Hygiene in the Bakery Trade and Industry. This Code of Practice was published by the Ministry of Health in conjunction with the Ministry of Agriculture, Fisheries and Fo0d. The purpose of the publication was to give advice and guidance to persons in the trade who are responsible for compliance with the Food Hygiene Regulations. Copies of the Code of Practice were issued to the proprietors of twenty five bakehouses in the Borough. (8) The Liquid Egg (Pasteurisation) Regulations, 1963. There are no egg pasteurisation plants in the district and the three samples of liquid egg taken were submitted only for bacteriological examination and not to the Alpha-Amylase test. 3. ATMOSPHERIC POLLUTION (a) The programme of establishing Smoke Control Areas continues to make satisfactory progress and by the end of the year over half the Borough was governed by Smoke Control Orders, covering an area of 7,282 acres including 38,559 premises. During the year, the following Smoke Control Orders became operative: Acreage. No. of Dwellings. No. of other Premises. Barnes No. 7 Order 453 1,288 89 Richmond No. 7 Order 152 1,330 41 Twickenham No. 5 Order 630 3,077 156 61 The following Smoke Control Orders were also made by the Council during the year and are planned to be operative in 1967: Acreage. No. of Dwellings. No. of other Premises. Barnes No. 8 Order 688 1,483 96 Richmond No. 8 Order 153 1,953 127 Twickenham No. 6 Order 2,441 4,722 526 The supply of authorised fuels continued to be adequate to meet all demands for existing areas but late in the year the Gas Boards stated that they would be unable to give assurances of adequate supplies of open-fire gas coke for future smoke control areas The Council accordingly agreed that in addition to grants for adapting coal burning fires they would give similar aid towards the adaptation of improved fires in areas designated after September. It must be emphasised, however, that the Boards have said they will honour assurances given in the past that adequate supplies of coke will be available to meet any demand in existing areas. A few occupiers of buildings in Smoke Control Areas were found to be emitting smoke through burning bituminous coal and after an informal approach they all discontinued the practice. The grant arrangements have continued whereby householders have freedom of choice in selecting appliances to replace coal fires. Within the grant scheme their preference has been as follows: 51% gas room heaters, 28% improved open fires, 14% solid fuel room heaters, 5% underfloor draught open fires and 2% electric storage heaters. These figures illustrate the trend away from inefficient open fires which, even when burning approved fuels, still contribute sulphur dioxide as an atmospheric pollutant. Solid fuel room heaters are more than twice aa efficient as open fires, burn less than half the fuel for the same heat output, and consequently reduce the emission of sulphur dioxide. The gas room heater preferred by the largest percentage of applicants for various qualities, including convenience, does not significantly add to the problem because the amount of sulphur in the gas supplied is negligible. (b) A few complaints were received concerning the emission of smoke from the burning of waste matter in open yards and gardens; the Clean Air Act, 1956 has created an offence where this practice causes a nuisance to the inhabitants of the neighbourhood and advice was given in all cases to ensure that the disposal of these materials did not contravene the Act. There are now no known industrial furnaces in the Borough which are hand fired with bituminous coal. In the past these furnaces have been notorious for adding to the air pollution problem. Today either a chain-grate or under-feed type stoker is in general use for coal firing. The former (and less common type) has given rise to no complaint, but operators of underfeed stokers have needed advice from time to time to ensure smokeless functioning of the furnaces. Oil-fired boilers must be properly maintained and operated if they are not to produce smoke and only rarely during the year has any approach had to be made concerning smoke emissions. Plans of proposed chimneys at factories were examined under Section 10 of the Clean Air Act to check that the height would be sufficient to prevent the smoke or gases from becoming prejudicial to health or a nuisance. Generally, a request had had to be made for an increase in the height. This section of the Act does not apply to residences, shops or offices, although these premises may have central heating furnaces 62 greater in size than those installed in a factory. The installation of a low chimney at these exempted premises may sometimes give rise to an undesirable level of localized pollution at the surrounding ground level. (c) The Borough is one of many local authorities taking part in a national survey of Atmospheric Pollution and there are three stations where daily measurements of smoke density and sulphur dioxide are recorded. This work normally proceeds with' out incident, but an unusual experience took place in the early part of the year when an unexpected alkali reaction was obtained from the sulphur dioxide volumetric instrument sited at the Civil Defence Centre in East Sheen. The instrument was checked thoroughly and a new lead-in tube fitted. On the 31st January the result was completely alkaline, after three days running, with the wind from the South and South-West on two days. The instrument was again checked and enquiries made at the Centre in case someone had "tampered" with the instrument. Alkaline reactions were also experienced on the 1st, 2nd, 3rd and 4th February. During this period the wind was between South and South-West. On 2nd February the aid of Warren Spring Laboratory was enlisted and a survey was made up-wind of the instrument. The survey did not reveal any "unusual occurrence" which might account for the contamination. Warren Spring Laboratory carried out an analysis of the solution, exposed for the twenty-four hours ended 2nd February. This indicated that the sulphur dioxide had been neutralised by ammonia. The results for the 7th, 8th and 9th February were also very low (probably modified by the ammonia contamination) and the wind was from the South-West. For the next eleven days the wind was predominantly from a Northerly direction and the results appeared satisfactory, thereby indicating that the source of the contamination was somewhere to the South of the instrument. Towards the end of the month a discarded absorbtion type refrigerator was found dumped in a garden some 150 yards South from the instrument, and although the wind had returned to a South-Westerly direction, the titration results remained normal. It is reasonable to postulate that the refrigerator had been gradually leaking ammonia (no doubt the reason for it being dumped) and while the wind remained in the Southern quarter, this was sufficient to affect the instrument. Presumably by the time the refrigerator was discovered all the gas had leaked away. 4. OFFICES, SHOPS AND RAILWAY PREMISES ACT, 1963 Under the provisions of the Act, which came into force in 1964, standards are set for the health, welfare and safety of employees in offices, shops and railway premises. The principal matters on which standards are laid down relate to cleanliness—overcrowding—temperature—ventilation—lighting—sanitary accommodation—seats for sedentary work—first aid facilities—safety and operation of machinery—fire precautions. All office employees are within the scope of the Act whether they work in separate office buildings or in offices forming part of other buildings (e.g. schools, factories, hotels, etc.). Shops are widely defined to include wholesale and retail trade premises, restaurants, laundrettes, dry-cleaning receiving premises and fuel storage depots. The Act does not apply to premises (a) in which only self-employed persons work, or (b) used for "family businesses", i.e. in which no-one is employed other than close relatives of the employer, or (c) in which the total time worked by employees is less than 21 hours weekly. 63 During the year 335 additional premises were registered under the Act and the total number of premises registered and inspected at the end of the year is summarised below: Total number of registered premises. Number inspected during year. Offices 694 301 Retail Shops 1,176 455 Wholesale Shops 62 38 Catering Establishments 200 102 Fuel Storage Depots 5 3 2,137 899 Although a great measure of co-operation has been received from employers in the Borough in implementing the new standards, in fifteen cases summonses were served for contraventions of the Act, but the necessary works were completed before the date of hearing. The Council has not granted any certificate exempting premises from the standards laid down. All known premises requiring registration have been registered. Some of the smaller businesses that had failed to return the registration form, required persuasion to do so. Their reluctance was due to fear that the information would be used for Selective Employment Tax purposes. All registered premises have now received a general inspection. Compliance with the requirements notified after the general inspection has, in some cases, been slow and piecemeal, and this has occasioned several revisits. However, eventual compliance has for the most part been achieved. The completion of the above inspections has enabled the inspectorate to give more time to such questions as the design of seating accommodation which had been raised by shop assistants and safety devices in machinery etc. During the year the following matters of interest arose in implementing the various provisions of the Act: 1. Temperature. Special visits were made on cold days to check temperatures, and some unsatisfactory conditions were found; few complaints were received from shops. A problem has arisen in connection with a large block of new offices erected on stilts, and exposed to the cold winds in the open space below the lowest floor. The result is a temperature of as low as 50°F in the regions of the floor of the rooms while the upper part of the rooms showed a satisfactory temperature. Although not finally solved it seems that the remedy will be the insulation of the exposed floors of such buildings from cold winds. 2. Ventilation. Few complaints of unsatisfactory ventilation were received, but in some newly built premises the ventilation appeared to be inadequate. The assessment of ventilation based on a natural system presents some difficulty, and through ventilation is looked for, but is not always possible, and the inclination was to ask for artificial methods as visual evidence that ventilation is operating. Some simple test and standard of air movement would be helpful. 3. Lighting. Basements and stairs still require special attention on re-inspection. 64 4. Sanitary Conveniences. The feature of this section was the number of requests to use accommodation away from the shop or office. Distances ranged from 20—50 yards— in one case over a windswept sportsground— and employees were outspoken in their dissatisfaction with these conditions. This lack of on-site accommodation has generally arisen from the conversion or dividing up of a larger building without regard to this matter. These ill-considered conversions also give rise to obstructions of the route to the accommodation, such as exhaust pipes of laundrettes at 4ft. 9in. high across the route, erected in such a way as to make it necessary for the employee to bend down to pass. 5. Washing facilities. Some objections were raised on the ground of cost of hot water installation. 6. Seating. A complaint was that the standard type design of the seating provided in a supermarket "check-out" caused discomfort to the backs of the assistants. This was found to be due to the unusual design of the "check-out" compartment which involved the assistant in a turning movement which caused discomfort. 7. Floors. Frequent cases of worn and defective floor covering were found but the question as to whether defective floor covering could be included in the definition of "sound construction" or "free from obstruction" was not taken to the stage where the Court could give a ruling. Nevertheless the renewal of defective floor covering is being enforced. 8. Hand Rails. These have been given special attention and it was of interest that one old employee stated he had not realized what a difference the hand rail to the basement made and how it would be missed if removed. 9. Lifting. A small number of injuries (four cases) have occurred. These have been due to a bad technique in lifting rather than the weight being above the lifter's capacity. 10. Accidents. Mainly caused by falls (fourteen cases) due to slipping. Proper steps for reaching high racks have been requested and provided, but accidents have occurred due to the use of improvised steps made of boxes, etc., and to over-reaching. Specific regulations requiring the provision of proper steps would help. There were again accidents from Gravity Feed Machines, due to holding the meat with the hand while the machine was operating. This matter is dealt with below, and such accidents should not occur if the proper machine is used. 11. Prescribed Dangerous Machines. There are still a number of Gravity Feed Machines in use which cannot be guarded and the owners have been requested to remove them and supply a, properly guarded machine. One of the latest listed Gravity Feed Machines which was supplied in place of an unlisted and outmoded one has proved satisfactory in gripping and slicing sausages such as Salami (providing the sausage is cut into two halves) and there is no longer any need for an employee to hold the sausage. 65 5. PUBLIC HEALTH INSPECTIONS The following table shows the wide variety of duties carried out during the year; although a number of vacancies on the establishment for public health inspectors have remained unfilled, considerable progress has been achieved due to the enthusiasm and interest sustained by senior and district inspectors, and by the technical and general assistants, in all branches of their work. The various services were satisfactorily maintained and the assistance given by the pupil inspectors has been greatly appreciated. Bacteriological sampling — Ice Cream 80 — Milk 20 — Other Foods 17 Clean Air Act — Inspections and Observations 9435 Control of Caravans 31 Diseases of Animals Act: Waste Food Order 14 Drainage and Sanitary fittings examination 2788 Food and Drugs Sampling 81 Houses inspected—Housing Act 543 Houses Let in Multiple Occupation 370 Housing Applications 116 Houses inspected — Public Health Act 5142 Houses inspected re Permitted Numbers 28 Houses inspected re Vermin and Disinfestation 301 Infectious Diseases enquiries, disinfection, etc. 474 Merchandise Marks Act 5 Noise Abatement Act 325 Offices, Shops and Railway Premises Act—General Inspections 1108 Offices, Shops and Railway Premises Act — Other Visits 2863 Pet Animals Act 37 Prevention of Damage by Pests Act 132 Rag Flock and Other Filling Materials Act 9 Rent Act, 1957 33 Swimming Baths — Sampling 65 Unsound food examination 523 Water Supply—Inspection 89 Water Supply — Sampling 13 Agricultural Holdings 1 Animal Boarding Establishments 23 Bakehouses 164 Butchers Shops 226 Confectioners (Flour) 99 Confectioners (Sugar) 80 Dairies 7 Factories (Mechanical) 131 Factories (Non-Mechanical) 20 Factory Canteens 36 Fishmongers and Poulterers 77 Fried Fish Shops 78 Greengrocers and Fruiterers 230 Grocers 713 Hawkers 38 Hairdressing Establishments 8 Ice-Cream premises 123 Massage and Chiropody establishments 36 Places of Public Entertainment 4 Public Houses and Licensed Premises 149 Restaurants and Cafes 368 Riding Establishments 3 Schools 90 Scrap Metal Dealers 25 Interviews 561 Miscellaneous Visits 2151 Inspections other than Houses — Public Health Act 903 Total number of visits and inspections 30986 66 The complaints received during the year are classified in the table below and they reflect a pattern similar to that of previous years. Nature of Complaint. Number Received Housing Defects 332 Choked and defective drains and sewers 567 Defective water closets 83 Accumulations of offensive matter 75 Unsound food 87 Verminous and other Infested premises: (a) Bugs 16 (b) Rats and Mice 1360 (c) Wasps 3 (d) Fleas 27 (e) Others 86 Keeping of Animals 18 Nuisance from Pigeons 9 Smoke Nuisances 78 Noise Nuisances 31 Fumigation of Rooms following Infectious Diseases 7 Miscellaneous 208 Total 2987 Every effort is made by inspectors to carry out their work through informal action, and to seek co-operation by interview and letter; in certain cases recourse to statutory proceedings is unavoidable, and a summary of notices served during the year is given below:— Subject of Notice. Public Health Act. Food and Drugs Act. Number of Informal Notices served 330 26 Number of Informal Notices complied with 245 5 Number of Statutory Notices served 78 — Number of Statutory Notices complied with 47 — 6. DISINFECTION AND DISINFESTATION Disinfection of premises and articles after infectious disease is carried out at the expense of the Local Authority and in cases other than after infectious disease at the cost of the individual. Disinfestation of premises for the eradication of bed bugs, fleas, etc. is carried out and the cost charged to the individual. There is no provision for the destruction of wasps, ants, cockroaches, beetles and ether insects whose treatment requires a specialist service. By arrangement, all persons suffering from scabies or infested with lice are sent to the Hammersmith Medicinal Baths for treatment. During the year 16 persons suffering from scabies, and 5 persons infested with lice were treated compared with 1 and 3 respectively for the previous year. Disinfestation treatments were carried out at 44 premises during the year and costs amounting to, £54 1s. 0d. were recovered. 7. PEST CONTROL The rodent control staff have continued to do much useful work in eradicating rats and mice from premises. No. of complaints received 1,360 No. of infestations found 901 Total number of visits 6,206 The treatment of foul sewers in the Richmond town area was carried out in May and November. The anti-coagulent, "Warfarin", was used and baiting was concentrated in those areas known to be infested. 67 In the Twickenham area three treatments using Fluoracetamide (direct poisoning) were carried out. It was not found possible to carry out sewer baiting in the Barnes area during 1966, but arrangements are scheduled for this in 1967. The Ministry of Agriculture, Fisheries and Food have been kept informed of the two methods of sewer baiting being used, and in 1967 it is hoped that uniformity over the whole area might be possible. Progress generally has been maintained throughout the Borough, and it is quite probable that infestation of the sewers is lower than ever. Grey Squirrels. The grey squirrel is now familiar to most people in the greater London area, and can often be seen in gardens adjoining parks and open spaces. In recent years there seems to have been an increase in the number of these pests. As in certain other species of wild life, both animal and bird, there has been a tendency to encroach on man's domain by coming nearer to the houses, and it is now commonplace in some districts to see grey squirrels running along the top of a garden fence or leaping about in the trees. If the nest or "drey" is built in the branches or in a hole in a tree, then the most serious damage likely to be caused is to young shoots and buds of trees. Young trees can be killed as a result of squirrels peeling off the outer bark in order to get at the tender inner bark. It is also partial to nuts and seeds, bulbs and roots, garden fruits, carrion and even the eggs and the young of birds. Two to three families are reared each year. There have been several recent instances of grey squirrels invading the roof spaces of buildings, and this of course gives rise to serious inconvenience, damage and possible danger to health. In severe cases the weight of the animals, litter and general debris can bring down the ceiling. They are most active at night and can cause considerable annoyance. They have no difficulty in climbing sheer walls and it makes no difference whether the walls are pointed or rendered ot even of prefabricated material. The photographs opposite show the damage done to the roof timbers in premises used for food preparation. The building was sited near a park and the squirrels were able to get access to the roof space at the eaves as shown in the top photograph. The department became aware of a possible infestation when it was reported that maggots were dropping from the ceiling into a food room. Squirrels or birds were immediately suspected and on investigation a considerable infestation was found in the roof space. A large amount of nesting material and debris was removed, together with three dead squirrels which gave rise to the maggots causing the original complaint. The damage which can be caused by the grey squirrel to roof timbers is clearly shown in the bottom photograph and it can be seen how roofs can be collapsed by these pests. There is a real danger of maggots and other filth contaminating food when such an infestation occurs, and it is well that the public should realise that grey squirrels are "tree rats", and should be dealt with in the same manner as the common rat. It should be noted that during the mating season, the female squirrel is dangerous and will attack human beings. This can be particularly dangerous in confined spaces such as lofts or false roofs. The Health Department are not under any statutory obligation to take action in the case of infestation— in fact, we have neither the powers nor the resources to carry out treatment. Advice on treatment and proofing can, however, be given by the Public Health Inspectors or the complainant can be referred to the Ministry of Agriculture, Fisheries and Food, Field Section, Guildford, or to the local Ministry Inspector at 15 West Tenter Street, London, E.I., telephone No. ROYal 6801. 68 69 8. FACTORIES ACT, 1961, Part I of the Act. (I.) INSPECTIONS, for purposes of provisions as to health. Premises Number on Register Number of Inspections Written Notices Occupiers prosecuted (i) Factories in which Sections 1, 2, 3, 4, and 6 are to be enforced by Local Authorities 54 20 — — (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 600 131 — — (iii) Other premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) 14 — — — Totals 668 151 — — (2.) Cases in which DEFECTS were found. Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of cleanliness (S. 1) 1 1 - - - Overcrowding (S. 2) - - - - - Unreasonable temperature (S. 3) - - - - - Inadequate ventilation (S. 4) - - - - - Ineffective drainage of floors (S. 6) - - - - - Sanitary Conveniences (S. 7) (a) Insufficient - - - - - (b) Unsuitable or defective 4 4 - 2 - (c) Not separate for sexes - - - - - Other offences against the Act (not including offences relating to outwork) - - - - - Totals 5 5 - 2 - Part VIII of the Act, Outwork. Nature of Work Section 110 Section 111 No of outworkers in August list required by Section 110 (1) c No. of cases of default in sending lists to Council No. of prosecutions for failure to supply lists No. of instances of work in unwholesome premises Notices served Prosecutions Wearing Apparel 48 — — — — — Electrical Fuse Makers 85 — — — — — Artificial Flowers 19 — — — — — Lampshades 27 — — — — — Total 179 — — — — — 70 9. MORTUARIES There are two mortuaries in the Borough; one provided by the former Richmond Borough Council on a site close to the Petty Sessions Court and the other provided by the former Twickenham Borough Council in the grounds of the Public Library at Hampton. The mortuary at Hampton has continued to function satisfactorily, but at the Richmond mortuary there have been difficulties regarding staffing and in respect of the suitability of the building. Despite this, considerable use was made of the unit when it is considered that for six months of the year the building was closed because we were unable to obtain a mortuary keeper. Every effort was made to improve conditions and facilities having in view that due to inherent difficulties of siting and congestion the building is not up to standard and cannot be made so. The number of bodies admitted to the two mortuaries during the year was: Richmond 154 Hampton 689 10. NOISE ABATEMENT ACT, 1960 This Act provides that noise, or vibration, which is a nuisance, shall be a statutory nuisance for the purposes of the Public Health Act, 1936. Proceedings can be taken by the Local Authority or by three or more persons, each of whom is the occupier of land or premises and is, in that capacity, aggrieved by a noise nuisance. The Act provides also that in proceedings brought in respect of noise or vibration caused in the course of a trade or business, it shall be a defence for the defendant to prove that the best practicable means have been used for preventing and for counteracting the effect of the noise or vibration. The Act does not apply to noise or vibration caused by aircraft. During the year 31 complaints of noise nuisance were received and 325 inspections carried out by Public Health Inspectors. It was not necessary to institute any legal proceedings, the informal action taken satisfying all complainants. 11. RAG FLOCK AND OTHER FILLING MATERIALS ACT, 1951 This Act is designed to secure the use of clean filling materials in upholstered articles and other articles which are stuffed or lined. All premises at which filling materials are used in the course of business must be registered with the Local Authority and there are two such premises registered in this Borough. 9 visits were paid by Public Health Inspectors to registered premises and 4 samples were taken and submitted for analysis. All were reported as satisfactory. 12. DISEASES OF ANIMALS ACT, 1950 PET ANIMALS ACT, 1951 ANIMAL BOARDING ESTABLISHMENTS ACT, 1963 RIDING ESTABLISHMENTS ACT, 1964 The Corporation of London, already acting as agents for the Council in respect of the Diseases of Animals Act, 1950, from the 1st April, 1966, extended the scope of their functions to cover all the above mentioned Acts. 71 The arrangements have worked very well and I am indebted to Mr. G. S. Wiggins, M.R.C.V.S., Veterinary Officer to the Corporation of London, for his valuable advice and help. His report on the work carried out on behalf of the Council is as follows: "Duties carried out during the period ended 31st December, 1966, comprised those concerned with the Diseases of Animals Act and also, since the 1st April, last, the associated Acts. Riding Establishments Act, 1964 Under the provisions of the above Act visits were made to five establishments for the purpose of inspection and reports submitted recommending that licences be renewed in each case. Animal Boarding Establishments Act, 1963 During the course of the year a visit was made to a premise coming under the terms of the above Act. Advice was given as to the proper fitting out and maintenance of such an establishment and it was decided to re-inspect the premises when the work had been completed with a view to the licensing thereof. Visits were also made to the following premises : Piggery, Harvey Road. On five occasions visits were made to this piggery and conditions found to be very satisfactory. Under the terms of the Diseases of Animals (Waste Foods) Order, 1957, a licence was issued in respect of the Hickey high pressure steam injection boiling plant. Farm, Petersham Road. Conditions at this farm were found to be excellent on each of seven visits. Piggery, Ham Fields Early in the year it was found that no animals were being kept on these premises, the piggery being in the process of being cleaned and painted. On a number of further visits no contact could be made with the owner, either at his home address or the piggery, and the latter appears to have been closed. Poultry Keeper, Oak Avenue At the last visit there were some 300 head of poultry and conditions were satisfactory Kosher Butcher and Poulterer Six visits were made to this shop and the owner interviewed on two occasions. Richmond and Bushy Parks Observation was kept on the cattle, sheep and deer grazing in the above parks from time to time and contact made with the stockman in charge. It is pleasing to be able to give a satisfactory report on conditions in general in respect of animals coming within the terms of the above Acts in the London Borough of Richmond upon Thames". 13. ESTABLISHMENTS FOR MASSAGE and/or SPECIAL TREATMENT 25 establishments where massage or special treatment is carried on are licensed under the Middlesex County Council Act, 1944. 72 Where applicable all applicants for a licence are now required to possess the qualifications necessary for registration by the Board established under the Professions Supplementary to Medicine Act, 1960. Certain approved conditions are incorporated in every licence granted. New Bye-laws to replace those made by the former Twickenham Borough Council and the Surrey County Council regulating these establishments were made by the Corporation in November and subsequently confirmed by the Secretary of State. 14. SWIMMING POOLS I am obliged to Mr. T. Lindley, F.Inst.B.M., Baths Manager for the following report: Swimming Pools (Open Air) Swimming facilities are provided within the Borough at the three Open Air Pools during the summer period, all properties being owned by the Council. The Twickenham Open Air Pool has a capacity of 280,000 gallons of water; Hampton Pool has a capacity of 206,000 gallons of water and the Teddington Pool has a capacity of 180,000 gallons of water. The water for all pools is supplied by the Metropolitan Water Board and is filtered by sand pressure filters at all pools. Sterilization is achieved by chlorination gas treatment operating as a "marginal" principle at the Open Air Pools. The rates of turnover at both Twickenham and Teddington Pools is every 6½ hours and that at Hampton Pool every 4 hours. Tests are taken three times daily for free-available and residual chlorine in the water, the pH values, also the shallow and deep end water temperatures, the results being recorded in a standard log-book. Bacteriological tests of the water at all Pools are made each month and all such analyses during the past year have proved entirely satisfactory. Municipal Laundry A fully automatic Municipal Laundry at Mortlake High Street, S.W.14, is available to the public. The installation consists of six 25lbs. dry weight automatic washing machines, two hydro-extractors, three tumbler dryers and three ironing tables complete with electric irons. All types of laundering can be carried out at this Establishment at very reasonable charges. Richmond Baths (Indoor and Open Air) The new Richmond Baths Establishment, of a "combination" nature, situated in the Old Deer Park, Richmond, was opened to the public in August, 1966. The establishment consists of one main Indoor Pool 110ft. x 42ft., water capacity of 210,000 gallons and a turnover rate of 3 hours; one Indoor Learner's Pool 42ft. x 24ft. water capacity of 17,000 gallons and a turnover rate of hours, and an Open Air Pool 110ft. x 42ft., water capacity of 160,000 gallons and a turnover rate of 4 hours. The filtration of all pools' water is through Pre-coat filters, and sterilization is carried out by chlorine gas treatment on "breakpoint" principle. A Plenum heating system is installed and the whole establishment is operated electrically. The: private baths suite consists of 12 private baths for both ladies and gentlemen respectively together with the necessary waiting rooms, toilets, etc. The grounds are landscaped and well laid out and provide some two acres of grass and banked areas which are available for sunbathing, games, etc.". 15. COMMON LODGING HOUSES There are no common lodging houses in the Borough. 73 ANNUAL REPORT OF THE PRINCIPAL SCHOOL MEDICAL OFFICER June, 1967. To His Worship the Mayor, Aldermen and Councillors of the London Borough of Richmond upon Thames. MR. MAYOR, LADIES AND GENTLEMEN, I have the honour to present my Annual Report on the work of the School Health Service for the year 1966. The year has been one of consolidation and increased activity, which is reflected in the tabulated information. During the year, you have been concerned with the practice of drug taking among young people. I was instructed in late 1966 to prepare a document for guidance in the detection of symptoms, which could be expected in individuals taking drugs. There are two cardinal factors to be kept constantly in mind. Firstly the basic epidemiological criteria of this social disease have not yet been firmly established. More detailed studies may be indicated. Secondly a child displaying certain symptoms is clearly in need of help for his condition, whether caused by drugs or otherwise. It follows that those of us who have suspicions should seek appropriate advice and possible further investigation for individual young persons. I wish tot acknowledge the interest and support of the Education Schools SubCommittee and their Chairman, Councillor Mrs. H. A. M. Champion and also that of the Chairman of the main Committee, Alderman E. Bostock. My colleague Mr. W. R. Wainwright, Chief Education Officer, and his staff have been very helpful in their collaboration. I wish to place on record my thanks to Dr. Elizabeth Wales, Senior Assistant Medical Officer, who resigned from your service in October, 1966, to take up the appointment of Medical Officer with the Department of Education and Science. Her contribution to the well-being of the children of the Borough was of the highest order. Yours respectfully, A. M. NELSON, Principal School Medical Officer. 74 EDUCATION COMMITTEE as at 31st December, 1966. Alderman E. BOSTOCK, MA., F.C.A. (Chairman). Councillor R. A. J. ALCOCK (Vice-Chairman). Alderman L. Defries-Porter, Councillor Mrs. M. E. Owen. LL.B., M.B.I.M. Councillor J. Paskin, M.B.E. Councillor N. F. Barrow, LL.B. Councillor B. W. C. Pride. Councillor J. H. Bedford. Councillor B. L. Royle, Councillor Mrs. H. E. Bell'Wright. J.P., A.M.I.E.R.E Councillor B. Bligh, B.A. Councillor G. J. Samuel, M.A. Councillor E. H. Campion, Councillor C. W. Sewell, B.A., Dip.Ed. M.A., F.R.Econ.S Councillor Mrs. H. A. M. Champion. Councillor Mrs. G. D. Smith. Councillor F. E. Chapman. Councillor R. H. Stevens. Councillor F. L. Eslick, F.C.C.S. Councillor G. W. Tremlett. Councillor F. D. Gilday-Fox, B.A. Councillor S. D. Wade. Councillor M. Gold, M.R.C.S., Councillor G. A. Watson. L.R.C.P., D.Obst.R.C.O.G. Councillor Miss O. J. Wilkins. Councillor H. Hall, M.P.S., F.S.M.C. Councillor J. E. Woodward, O.B.E. Councillor A. B. Hart, Ph.D. Councillor Mrs. M. A. Woodward, J.P. Councillor A. M. Leaney. Rev. F. J. Davys; Rev. T. F. Valentine, M.A.; Rev. D. Landreth, M.A.: Mrs. M. B. Davies; Dr. J. D. Mortimer, MA.; Mr. F. A. W. Counter; Mr. R. C. Feather, M.A., B.Sc.; Mr. C. Holman; Mr. L. F. Holmes, Mr. T. Telling. EDUCATION SCHOOLS SUB-COMMITTEE as at 31st December, 1966. Councillor Mrs. H. A. M. CHAMPION (Chairman). Councillor Mrs. H. E. BELL-WRIGHT (Vice-Chairman). Alderman L. Defries-Porter, LL.B., M.B.I.M. Councillor Mrs. M. A. Woodward, J.P. Councillor B. Bligh, B.A. Councillor H. Hall, M.P.S., F.S.M.C. Councillor Mrs. M. E. Owen. Councillor G. J. Samuel, M.A. Councillor Mrs. G. D. Smith. Rev. F. J. Davys. Mrs. M. B. Davies. Mr. C. Holman. Mr. L. F. Holmes. Alderman E. Bostock, M.A., F.C.A. (ex-officio). Councillor R. A. J. Alcock (ex-officio). 75 SCHOOL HEALTH SERVICE STAFF as at 31st December, 1966. Principal School Medical Officer A. M. Nelson, M.B., Ch.B., D.P.H. Deputy Principal School Medical Officer J. K. Craig, MA., M.D., B.Ch., B.A.O., D.P.H., D.C.H., D.I.H. Senior Assistant Medical Officer Margeurite E. M. James, M.B., Ch.B., D.P.H. Medical Officers. Enid G. Carson, M.B., B.Ch., B.A.O., D.C.H. Vivienne Simmons, M.R.C.S., L.R.C.P., D.C.H. Elizabeth M. Williams, B.A., M.B., B.Chir., D.R.C.O.G. Consultants in School Health Service Helena B. Casey, M.B., B.Ch., B.A.O., D.O.M.S. R. Higgins, MA., M.B., B.Chir., D.P.M. Agnes M. Main, M.B., B.S. R. H. Maudsley, M.B., Ch.B., F.R.C.S., L.R.C.P. Principal School Dental Officer G. H. Tucker, L.D.S., R.C.S. Senior Dental Officer T. A. McVey, L.D.S., R.C.S. Dental Officers A. B. Jeetoo, L.D.S., R.C.S. (Eng.), D.E.D., D.F.M.P. (France). Anne E. MacNicol, B.D.S. Senior Speech Therapist Miss K. S. Buckman, L.C.S.T., A.R.C.M., A.T.C.M., L.T.C.M. Speech Therapists Miss P. A. Knight, L.C.S.T. Mrs. S. A. Thrift, L.C.S.T. Physiotherapists Mrs. J. B. Y. Appleton, C.S.P. Miss L. M. Caink, F.C.S.P. Mrs. M. M. Waters, C.S.P. Chief Nursing Officer Miss G. M. Francis, S.R.N., S.C.M., H.V.Cert. Superintendent Health Visitor Miss D. W. Woods, S.R.N., S.C.M., H.V.Cert. Dental Surgery Assistants Mrs. S. N. Briggs. Misg W. J. Coatsworth. Miss M. D. Crosbie. Mrs. M. Goss. Miss A. Puntin. Mrs. D. Quinney. Audiometer/Vision Screeper Operator Mrs. C. W. Mathias. Audiometer Operator Mrs. I. Corteen. 76 The population of Richmond upon Thames at mid-1966 was 180,200 (1965— 181,130) of which 19,988 (1965—19,759) were school children in maintained schools. Table I. SCHOOL POPULATION (As at 20.1.67) No. of schools Number on Registers Total Boys Girls Secondary Grammar 5 1,654 1,629 3,283 Secondary Modern 15 2,640 2,409 5,049 Primary 51 5,906 5,526 11,432 71 10,200 9,564 19,764 Nursery 2 61 39 100 Day Special Schools for E.S.N, children 2 65 20 85 Day Special School for Maladjusted children 1 25 10 35 Autistic Unit 1 3 1 4 6 154 70 224 Total 77 10,354 9,634 19,988 An increase of 229 pupils compared with the number in 1965 should be noted. 77 MEDICAL INSPECTION AND TREATMENT Year ending 31st December, 1966 Table II. Medical Inspection of Pupils attending Maintained Primary and Secondary Schools (including Nursery and Special Schools). A.—PERIODIC MEDICAL INSPECTIONS. Year of Birth Number of pupils inspected Physical Condition of Pupils Inspected Satisfactory Unsatisfactory Number %of column 2 Number % of column 2 (1) (2) (3) (4) (5) (6) 1962 and later 164 164 100 — — 1961 1406 1398 99.43 8 0.57 1960 1255 1245 99.20 10 0.80 1959 213 213 100 — — 1958 106 105 99.06 1 0.94 1957 89 89 100 — — 1956 61 61 100 — — 1955 71 71 100 — — 1954 663 657 99.09 6 0.91 1953 275 274 99.64 1 0.36 1952 32 100 — — 1951 and earlier 1107 1098 99.19 9 0.81 TOTAL 5442 5407 99.36 35 0.64 B.—OTHER INSPECTIONS. Number of Special Inspections 2,987 Number of Re-Inspections 2,614 5,601 Periodic Medical Inspections. The number of children inspected at routine periodic medical inspections was 5,442 (1965—3,842) the increase is of the order of 41.6%. The increase in special examinations and re-inspections is 47.2%. 78 Physical Condition of Pupils Inspected. The general physical condition of school children remains at a very high level. Out of 5,442 children examined only 35 were found to be of unsatisfactory physical condition, compared with 15 in 1965. The co-operation and collaboration of the teaching staff is gratefully acknowledged. Without their help and understanding it would not have been possible to arrange these routine medical inspections. Table III. TABLE A. — Pupils found to require treatment at Periodic Medical Inspection (excluding Dental Diseases and Infestation with Vermin). Year of birth For defective vision (excluding squint) For any of the other conditions in table IV(A) Total individual pupils (1) (2) (3) (4) 1962 and later 1 22 23 1961 28 235 254 1960 37 256 282 1959 4 30 33 1958 10 21 31 1957 7 20 26 1956 3 8 11 1955 9 14 22 1954 73 126 181 1953 24 42 62 1952 4 2 6 1951 and earlier 145 140 267 TOTAL 345 916 1198 The 6.3 per cent of children inspected who were found to require treatment or under treatment for defective vision, compares with 8.9 per cent in 1965. 79 Table IV. Defects found by medical inspection in the year ended 31st December, 1966. TABLE A.—PERIODIC INSPECTIONS. Defect code number Defect or disease Periodic inspections Entrants Leavers Others Total (T) (O) (T) (O) (T) (O) (T) (O) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 4 Skin 67 80 23 31 47 43 137 154 5 Eyes: a. Vision 81 153 101 74 163 128 345 355 b. Squint 43 33 7 5 16 10 66 48 c. Other 10 20 5 22 5 27 20 69 6 Ears: a. Hearing 33 154 4 13 11 33 48 200 b. Otitis media 15 92 2 4 1 12 18 108 c. Other 58 20 11 5 28 11 97 36 7 Nose and throat 81 257 5 21 23 92 109 470 8 Speech 36 61 — 1 10 11 46 73 9 Lymphatic glands 3 109 — 7 2 46 5 162 10 Heart 5 80 1 22 — 28 6 130 11 Lungs 21 101 2 10 2 27 25 138 12 Developmental: a. Hernia 7 20 — — 1 — 8 20 b. Other 32 98 4 14 17 40 53 152 13 Orthopaedic: a. Posture 9 27 5 18 7 13 21 58 b. Feet 52 125 12 31 33 36 97 192 c. Other 20 52 7 21 8 23 35 96 14 Nervous system: a. Epilepsy 4 16 2 4 4 9 10 29 b. Other — 10 3 10 3 10 6 30 15 Psychological: a. Development 4 35 4 1 34 5 73 b. Stability 12 162 4 32 11 103 27 297 16 Abdomen 9 44 5 16 3 13 17 73 17 Other 76 110 33 30 66 73 175 213 (T) Requiring treatment. (O) Requiring observation. 80 Table IV. — continued. TABLE B. — SPECIAL INSPECTIONS. Defect code number Defect or disease Pupils requiring Treatment Pupils requiring Observation (1) (2) (3) (4) 4 Skin 709 32 5 Eyes: a. Vision 126 100 b. Squint 5 4 c. Other 31 8 6 Ears: a. Hearing 126 214 b. Otitis media 7 23 c. Other 54 7 7 Nose and throat 53 67 8 Speech 26 21 9 Lymphatic glands — 11 10 Heart 4 24 11 Lungs 9 43 12 Developmental: a. Hernia 2 1 b. Other 18 32 13 Orthopaedic: a. Posture 12 15 b. Feet 57 63 c. Other 40 27 14 Nervous system: a. Epilepsy 4 5 b. Other 72 10 15 Psychological: a. Development 17 35 b. Stability 40 64 16 Abdomen 9 18 17 Other 56 67 Tabulation of School Health Service Statistics. Formerly statistics relating to the School Health Service were collated in different ways. In the Surrey County Council former Northern Division of Richmond and Barnes tabulations were carried out in the divisional office; similar work in the former Middlesex County Council Area 10, which included Twickenham, was done on a computer in the former County Treasurer's department. The preparation of these statistics manually is tedious and time-consuming. During 1965, therefore, consultations took place between my department and the Medical Adviser to the Greater London Council with a view to the tabulation of these statistics by electro-mechanical methods by that Council. Arrangements were subsequently approved for this to be done as from 1st January, 1966. 81 Table V. Recorded incidence of certain defects found to require treatment at periodic inspection per 1,000 pupils examined. 1966 1965 Total children examined 5,442 3,842 Skin 25.2 23.7 Eyes: a. Vision 63.4 89.8 b. Squint 12.1 9.1 c. Other 3.7 5.5 Ears: a. Hearing 8.8 6.2 b. Otitis media 3.3 3.9 c. Other 17.8 7.5 Nose and Throat 20.0 9.1 Speech 8.5 5.2 Lymphatic Glands 0.9 0.0 Heart 1.1 1.0 Lungs 4.6 1.0 Developmental: a. Hernia 1.5 1.0 b. Other 9.7 2.3 Orthopaedic: a. Posture 3.9 7.3 b. Feet 17.8 19.0 c. Other 6.4 19.0 Nervous System: a. Epilepsy 1.8 1.6 b. Other 1.1 0.5 Psychological: a. Development 0.9 0.8 b. Stability 5.0 2.3 Abdomen 3.1 4.4 Other 32.2 3.1 Table VI. Number of children examined other than at Periodic Medical Inspections:— Pupils examined for any condition, ailment or defect 2,278 Other special examinations, freedom from infection, employment byelaws, etc. 709 2,987 Re-inspections of pupils previously found to have some defect 2,614 82 Table VII. CLINICS. School Health Service facilities available. BARNES Essex House, Station Road, Barnes, S.W.I3. Dental (including X-ray) Minor Ailments Orthopaedic (physiotherapy) Speech Therapy Vaccination and Immunisation HAM Ashburnham Road, Ham, Richmond, Surrey. Dental (including X-ray) Minor Ailments Ophthalmic Orthopaedic (physiotherapy) Speech Therapy Vaccination and Immunisation Back Lane, Ham, Richmond, Surrey. (Closed 1966). HAMPTON 24, Station Road, Hampton, Middlesex. Dental Minor Ailments Vaccination and Immunisation HAMPTON WICK 20, Seymour Road, Hampton Wick, Kingston-upon-Thames, Surrey. Dental (including X-ray) Minor Ailments Orthopaedic (Consultant) Orthopaedic (Physiotherapy) Vaccination and Immunisation MORTLAKE North Worple Way, Mortlake, S.W.14. Dental Minor Ailments Ophthalmic Orthopaedic (physiotherapy) Speech Therapy Vaccination and Immunisation RICHMOND Kings Road, Richmond, Surrey. Minor Ailments Orthopaedic (Physiotherapy) Speech Therapy Vaccination and Immunisation Windham Road, Richmond, Surrey. Child Guidance Service Dental (including X-ray) Minor Ailments Ophthalmic Orthopaedic (physiotherapy) Speech Therapy Vaccination and Immunisation TEDDINGTON Church Road, Teddington, Middlesex. Dental (Orthodontic only) Stanley Road, Teddington, Middlesex. Minor Ailments Ophthalmic Vaccination and Immunisation TWICKENHAM York House, Richmond Road, Twickenham, Middlesex. Dental Minor Ailments Ophthalmic Vaccination and Immunisation 58, Hampton Road, Twickenham, Middlesex. Child Guidance Service Speech Therapy WHITTON Hospital Bridge Road, Twickenham, Middlesex. Dental Minor Ailments Vaccination and Immunisation 83 OPHTHALMOLOGY. Dr. Helena Bridget Casey, M.B., B.Ch., D.O.M.S., Ophthalmologist, reports on the work of the ophthalmic clinics:— The ophthalmic school clinics of the Borough have been running very satisfactorily. They have been well attended and I think the service has been appreciated. The telebinocular is functioning very well for the examination of the children especially in the first years of school. Not alone does it ascertain the visual defects, but it can be operated by ancillary staff. Visual defects in these children are mostly refractive errors, with a bias towards anisometropic refractive errors. It is this unequal refraction which causes the amblyopic ex anopsia or "lazy eye". With the co-operation of parents, most of these errors can be corrected either with glasses, or glasses plus orthoptics, thus enabling the child to function better with his (or her) education and general progress. Once these children are diagnosed they are followed up and supervised satisfactorily for the rest of their school lives. Other children, however, face the problem of axial myopia between the ages of eleven and sixteen years. Frequently parents and teachers are unaware of these visual changes which are occurring. There is now a general awareness in the Borough of the necessity of early treatment for strabismus. The response of the medical officers and the health visitors is excellent. The early treatment of squint, cannot be over-emphasized. Even the suspicion that a squint might be present should be considered an adequate reason for referring the child for advice. Some parents now offer their other children for examination once one member has been diagnosed to have a squint. Lastly, some senior pupils have been planning careers without the necessary visual requirements. If in doubt of the standard requirements for certain occupations they should be advised to consult at the clinics. Table VIII. Eye Diseases, Defective Vision and Squint. Number of cases known to have been dealt with External and other, excluding errors of refraction and squint 67 Errors of refraction (including squint) 2334 2401 Number of pupils for whom spectacles prescribed 536 84 Keystone Telebinocular Vision Screener. The Keystone Telebinocular Vision Screener was used in the Twickenham schools during 1956. The instrument is operated by the audimeter/vision screener operator and a further instrument has now been purchased and will be used by the second audiometer operator in the Richmond and Barnes schools during 1967. The statistics relating to this screening procedure are given below : Table IX. Age Group. First Tests Failures TOTAL TOTAL % of Col. 2 (1) (2) (3) (4) Infants 1518 93 6.13 Junior 1515 192 12.67 Senior — — — TOTAL 3033 285 9.4 Table X. DISEASES AND DEFECTS OF EAR, NOSE AND THROAT. Number of cases known to have been dealt with Received operative treatment: (a) for diseases of the ear — (b) for adenoids and chronic tonsillitis 29 (c) for other nose and throat conditions — Received other forms of treatment 312 Total 341 Total number or pupils in schools who are known to have been provided with hearing aids : (a) in 1966 5 (b) in previous years 34 85 AUDIOMETRY. At the end of 1966 one audiometer/vision screener operator and one audiometer operator were on the staff of the department. Children have their hearing tested by audiometer three times in their school lives. The first routine test is done before the age of seven; the next in the third year in junior school, and finally in the second year in the senior school. Special instances, for example, children who are failing to make progress in school, are dealt with expeditiously. Audiometers are kept in condition by regular calibration by the manufacturers. Children who fail the audometric test are referred for further investigation. Sixty two new cases were seen and 84 re-examinations were carried out in 1966, at the Heston Hearing Clinic to which the majority of referrals are made. Table XI. (a) Audiometer Tests — Routine Age Group 1st Tests* Re-tests. Failures. Total % of Col. 1 (1) (2) (3) (4) Up to 7 yrs. 1590 258 236 14.8 10 to 11 yrs. 1533 157 126 8.2 12 to 13 yrs. 1468 163 120 8.2 Totals 4591 578 482 10.5 *In Schools. (b) Audiometer Tests—Specials Age. 1st Tests. Re-tests. Failures. Total. % of Col. 1 (1) (2) (3) (4) Under 5 44 7 21 47.73 5 184 29 95 51.63 6 227 68 152 66.96 7 210 93 118 56.19 8 194 62 91 46.91 9 174 47 99 56.90 10 121 48 60 49.59 11 59 15 24 40.68 12 60 16 39 65.00 13 75 30 51 68.00 14 70 28 46 65.71 Over 14 98 40 86 87.76 Totals 1516 483 882 58.18 86 Table XII. INFESTATION WITH VERMIN. (i) Total number of individual examinations of pupils in schools by school nurses or other authorised persons. 15,561 (ii) Total number of individual pupils found to be infested ... 164 (iii) Number of individual pupils in respect of whom cleansing notices were issued (Section 54(2), Education Act, 1944) (iv) Number of individual pupils in respect of whom cleansing orders were issued (Section 54(3), Education Act, 1944) Table XIII. DISEASES OF THE SKIN (excluding uncleanliness — see Table XI.). Number of cases known to have been treated. Ringworm: (a) Scalp 1 (b) Body — Scabies 1 Impetigo 1 Other skin diseases 382 Total 385 Table XIV. OTHER TREATMENT GIVEN. Number of cases known to have been dealt with. (a) Pupils with Minor ailments 1528 (b) Pupils who received convalescent treatment under School Health Service arrangements... 1 (c) Pupils who received B.C.G. vaccination *1562 (d) Other than (a), (b) and (c) above— Heart 22 Lungs 90 Developmental Hernia 1 Other 29 Nervous Epilepsy 16 Other 16 Abdomen 16 Lymphatic Glands 2 Psychological Development 7 Stability 19 Total 3309 *includes 49 re-vaccinations. 87 Table XV. HANDICAPPED PUPILS. Pupils ascertained during the year requiring education at a special school: (a) Blind (b) Partially sighted 4* (c) Deaf 2 (d) Partially hearing 6* (e) Educationally sub-normal 24 (f) Epileptic 3 (g) Maladjusted 32 (h) Physically handicapped 5 (i) Speech 1 (j) Delicate 5 *Includes one child partially sighted / partially hearing. 88 Table XVI. Handicapped Children maintained by the Richmond upon Thames Education Committee in Residential Special Schools as at 31st December, 1966. Blind Partially Sighted Deaf Partially Hearing Educationally Subnormal Maladjusted Delicate Physically Handicapped Speech Defects Epileptic TOTAL Maintained Schools (L/42) East Quinton 4 4 Elmers Court 3 3 Exhall Grange 1 1 Gosden House 2 2 Linden Lodge 1 1 Palingswick House 1 1 Park Place 1 1 Rayner's, Penn, Bucks 1 1 Red House 4 4 St. Michael's 1 1 St. Nicholas 4 4 Suntrap 2 2 Swaylands 7 7 Valence School 1 1 Wavendon 1 1 Wishmore Cross 1 1 Non-Maintained Schools (L/42) Larchmoor 1 1 Muntham House 2 Ovingdean 2 Red Hill 1 1 Royal Cross School for Deaf 1 1 Royal School for Deaf 1 1 St. Catherine's Home 1 1 St. John's School for Deaf 1 1 Worcester College for the Blind i 1 Recognized Ind. Schools (L/70) Arts Educational Trust 1 1 Barrow Hills Preparatory 1 1 Bethany 1 1 Bylands 1 1 Camphill, Rudolph Steiner 1 1 Convent of Handmaids of the Sacred Heart of Jesus 1 1 Falcon Manor 1 1 Frensham Heights 1 1 Ingfield Manor 2 2 Kings 2 2 Normansal 2 2 Peredur Home 3 3 Philpotts Manor 1 1 Royal Wanstead 1 1 St. Mary's 2 2 St. Mary Abbey 1 1 Sandon House 2 Sheiling Curative 1 Spinney 1 1 Staddles 1 1 Stanbridge 1 1 Wells Cathedral 1 1 Wennington 3 3 Other Independent Schools Box Hill 1 1 Caterham 1 1 Gaveston Hall 1 1 Grangewood 1 1 Heanton 1 Horncastle 1 1 New 1 1 St. Christopher's 1 1 Stinsford 2 Hospital School Lingfield 3 3 2 2 5 2 17 46 11 5 3 93 The total number of handicapped children maintained by the Richmond upon Thames Education Committee in Residential Special Schools as at 31st December, 1965, was 88. 89 90 DAY SPECIAL SCHOOLS. St. Hilda's Day Special School for Educationally Sub-normal Children, Barnes. Admissions during 1966 6 Discharges during 1966 6 Transferred to ordinary schools 3 Transferred to senior day E.S.N. school 1 Transferred to residential E.S.N. school 1 Left district 1 No. of children on roll as at 31st December, 1966 23 Clarendon Day Special School for Educationally Sub-normal Children, Twickenham. Admissions during 1966 27 Discharges during 1966 14 Transferred to senior day E.S.N. school 2 Transferred to ordinary schools 4 Transferred to Athelstan House Autistic Unit 1 Transferred to residential E.S.N. school 1 Left district 4 Found unsuitable after trial period 2 No. of children on roll as at 31st December, 1966 60 Oldfield House Day Special School for Maladjusted Children, Hampton. Admissions during 1966 15 Discharges during 1966 13 Transferred to ordinary schools 6 Transferred to senior day E.S.N. school - Transferred to residential schools 2 Transferred to Junior Day E.S.N. school - Transferred to Day Special School for delicate/maladjusted pupils 1 Left district 4 No. of children on roll as at 31st December, 1966 35 Athelstan House Autistic Unit, Hampton Admissions during 1966 3 Discharges during 1966 1 Discharged as unsuitable (referred to hospital for further investigation) 1 No. of children on roll as at 31st December, 1966 4 Handicapped Pupils. All handicapped children attending special schools, either day or residential, are medically reviewed by the School Health Service at least once a year, and sometimes more frequently so that their progress and special educational treatment can be assessed. During 1966 reports were issued to the Local Health Authority under Section 57 (4) of the Education Act, 1944, regarding three children who were found unsuitable for education at school. Information was passed to the Local Health Authority about eight educationally sub-normal children who required supervision after leaving school. CHILD GUIDANCE SERVICE. The Medical Directors of the Child Guidance Clinics, Dr. Robin Higgins, M.A., M.B., B.Chir., D.P.M., and Dr. Agnes Main, M.B., B.S., report as follows:— Dr. Robin Higgins— In the course of the year 100 new cases were referred to the Richmond Child Guidance Clinic of which 41 were seen by the psychiatrist. In addition, during the year 27 cases were given a period of regular intensive and/or group treatment and 21 maintained on a less frequent supervisionary basis. In all, 141 cases were seen. Of the new cases the patterns of incidence were as follows:— Age Distribution No. 2—3 yrs. 3 4—7 yrs. 36 8—10 yrs. 30 11—13 yrs. 19 14—154 yrs. 12 TOTAL 100 The Referring Agents Parents alone or in conjunction with another person, e.g. Head Teacher or Family Doctor 16 Head Teacher 13 Family Doctor 15 School Medical Officer 39 Probation Officer 4 Children's Officer 4 Hospital 6 Miscellaneous 3 TOTAL 100 The nature of the problems dealt with covered children's overt responses to external pressures (including anti-social or delinquent activities, poor work record, regression or withdrawal) and conflicts that were predominantly confined to the child (of a psychotic or near psychotic and psychoneurotic type). In addition there was a small group where we were primarily concerned with counselling the family about an individual child's symptoms that were not necessarily abnormal and about environmental changes including the prospects and tensions of leaving school. Dr. Agnes Main— During the year the work of the Twickenham Child Guidance Clinic has continued without any major change. The numbers of referrals remain at a relatively steady level, and our main aim continues to lie in providing help for the sick child and disturbed family relationships. Close contact is maintained with Oldfield House School for Maladjusted Children, and an interchange of visits between the Staff and Clinic members is regularly maintained. The number of children at the Unit for Autistic Children at Athelstan House has increased, and when a second teacher is appointed we shall be able to admit more. 91 Students and teachers in training for remedial work are yearly attached to the Clinic, and supervision of their work is provided. This is time-taking, but in our opinion is valuable to both the students and their future work, and in providing a form of therapy for the children allotted to them. We are interested in contacting as many agencies dealing with children as possible where we feel we can be of use in helping in the understanding and handling of disturbed children. Table XVII. Child Guidance Treatment. Number of cases known to have been treated. Pupils treated at Child Guidance Clinics 338 ORTHOPAEDIC CLINIC. Mr. R. H. Maudsley, F.R.C.S., Consultant Orthopaedic Surgeon reports:— The Hampton Wick clinic is visited once monthly by the Senior Orthopaedic Registrar from this hospital (Heatherwood Hospital, Ascot)—in the first part of the year Mr. J. C. A. Madgwick, and more recently Mr. A. R. Taylor. Between 30—40 patients are sent for to attend the clinic, and between 20—30 actually attend. In all there are 116 patients in the files, being divided into the following clinical conditions: 1) Feet, mainly valgus types 58 2) Knees, mainly genu valgum 27 3) Conditions around the hips and spine 11 4) Miscellaneous 20 The value of the attendance of an Orthopaedic Surgeon is mainly reassurance. The main problem in my mind, however, is that when children have more serious conditions requiring admission or investigation, they have a long distance to travel to Ascot and there might well be some delay in attending for treatment. Table XVIII. Orthopaedic and Postural Defects. Number of cases known to have been treated. (a) Pupils treated at clinics or out-patient departments 293 (b) Pupils treated at school for postural defects — 293 92 SPEECH THERAPY. Therapists working in the Borough were:— Miss Kathleen Buckman (Senior—Full-time). Miss Patricia Knight (Full-time). Mrs. Susan Thrift (Part-time). Miss Elizabeth Millhouse (Part-time January to April). Sessions were held at Barnes; Mortlake; King's Road, Richmond; Windham Road, Richmond; Ham; Twickenham, and in term time all three "Special" schools in the Borough were visited regularly. During the year 261 children attended, and 102 were discharged. It will be understood that those in "Special" schools are likely to remain on a treatment register for a considerable period, but speech therapy is considered invaluable in preparing such children for their future. Mrs. Thrift, who visits Clarendon E.S.N. school, is enthusiastic in her work, and in addition to speech therapy sessions, she takes part in many school activities, accompanying children on journeys, and talking to parents at ParentTeacher meetings. During school holidays interviews are arranged with the parents at one of the clinics, as if "special" school children are to progress satisfactorily there must be co-operation with their homes. St. Hilda's E.S.N. school is visited by Miss Knight. She produced a Nativity Play which was performed at the school Christmas Party, the result being so encouraging that it is intended to do more drama work on future occasions. As in the past few years it was found in 1966 that many pre-school children were being referred because of their slow speech and language development. It is proposed in the coming year to arrange a weekly group therapy session for children aged 3—5 years. Appointments for discussion with parents will be arranged at a different time from the group session. Co-operation with parents is usually good, though there have been instances where much tactful advice has had to be given. An example is the case of a child of 5 years who even on his first visit to see a therapist was sent alone in a taxi, and continued to attend in this way thoughout the whole of his treatment. Naturally the therapist visited the home, but never was there any effort on the part of the parents. When fully staffed, it is hoped next year for therapists to visit every school in the Borough. It would be ideal if the speech of every child who has been in school over six months could be examined, though it is feared in some schools this may not be practicable. Throughout the year there have been many visitors who have spent one session at a speech clinic, and two students (one from the Kingdon Ward Training School, and the other from the West End Training School) have attended each week during term time. Thoughout the year the Senior Therapist has been in touch with all the clinics, and regular meetings for therapists have been arranged. 93 Table XIX. Number of pupils treated by Speech Therapist under arrangements made by the Authority. Number of Children treated 261 Number of New Patients 91 Total Number of Attendances 3,037 Number on Waiting List, 31.12.66 32 Number of Children Discharged 102 Normal Speech 54 Improved 38 Transferred (left district) 9 Uneventuated 1 Table XX. Types of cases treated during the year. Dyslalia 196 Delayed Speech and Language Development 24 Stammering 32 Dysarthria 3 Deaf 4 Dyslexia 2 94 REPORT OF PRINCIPAL SCHOOL DENTAL OFFICER. The year 1966 saw many changes in the dental staff. Mrs. E. M. Johnson who was formerly employed by the Surrey County Council at Mortlake Clinic retired after 14 years service in June. I would likes to record appreciation of her services during these years. Mrs. M. M. Herd and Mr. A. B. Jeetoo were appointed full time dental officers in April. Mrs. Herd resigned, however, in October and Mr. Jeetoo, due to family illness, was granted 4 months leave without pay during the year. Miss A. E. MacNichol was appointed full time dental officer at the newly opened Ham Clinic in November. Mr. E. N. Daver was appointed part-time dental officer for the new dental surgery at Barnes Clinic in September. Two dental surgery assistants resigned and one was appointed during the year. Mr. E. Godman, senior dental technician, retired in February after many years of ill health due to a motor accident. Mr. T. A. McVey was made Senior Dental Officer on 1st April, 1966 and attended an Inlay, Crown, and Bridge Course at the University College Hospital Dental School from 2nd May to 6th May. Two new dental surgeries were opened, one at Ashburnham Road, Ham, in April and one at Essex House, Barnes, in September. The dental surgery at Mortlake was closed pending further developments of staffing and equipping. Three new Philips X-Ray machines were installed and X-ray facilities are now available at Ham, Barnes, Richmond and Hampton Wick clinics. A senior professional adviser from the Department of Education and Science made a formal inspection of the Dental Services of the Borough on 14th/15th June and the report subsequently presented by the Secretary of State for Education and Science to the Town Clerk stated "good progress is being made in the organisation of the Dental Service in the new Borough". Some criticisms were made which in the main have been corrected To encourage regular patients who have left school to continue to have regular treatment through the General Dental Service a letter was introduced to be sent to school leavers urging them to seek early advice or treatment with a dental practitioner. All junior and senior schools were advised that pupils who play contact sports such as football, hockey, boxing, etc. may have, if they wish, individually made mouth guards made for them at any clinic. During the year a study of the problem of preventive dentistry was made because a consistent] and disturbing feature of the dental surveys that have been carried out in Great Britain during the last two decades has been the increase in the prevalence of dental caries in the child population. The evidence of this deterioration comes from a variety of different sources, including school dental statistical returns and Ministry of Health reports. The increase in caries is general throughout the country. 84% of 5 year old children now have decayed teeth, and 75% of 12 year olds. The child population of the borough between the ages of 3 and 15 years when teeth are particularly susceptible to caries attack, is approximately 35,000 there being approximately 2,600 in each year of this group. Although there is still controversy about the causation of dental caries, the great weight of evidence implicates the production of acid in the mouth as the major factor. There is also strong evidence that carbohydrate provides the substrate from which the acid is produced by oral micro-organisms. It has been found that the total quantity of sugar consumed does not have so great an effect on the incidence of dental caries as the frequency of consumption. Children who consume sugar between meals, especially in the form of sticky sweets, have more dental decay than those who consume an equivalent amount of sugar at meal times. Between-meal snacks are usually of carbohydrate and tend to spoil the appetite for the more nutrious foods (e.g. fats and proteins) consumed at meal times. The simple sugars usually consumed in the form 95 of cakes and sweets, which stick around and between the teeth for up to an hour, are broken down to acid within a few minutes. Thiti acid tends to be stabilised by the saliva, and would not harm the teeth, if it were not for "dental plaque" or debris which collects between the teeth and in fissures in the teeth, where normal cleaning and mastication have little or no effect. It has been found from epidemiological observations, that the absorption from the gut of fluoride ions and their presence in the mouth, reduces the solubility of tooth enamel in acid. Periodontal disease is closely related to diet and its refinement. Heret there is a tendency for food to stick around the teeth, although the production of acid is not important in this case. Periodontal disease is caused by toxins from bacteria in the dental plaque seeping down into the crevice between the gum and the tooth and thence through the epithelium to the underlying connective tissues. These toxins gradually lead to the progressive destruction of the collagen fibres and alveolar bone supporting the teeth. The crevice between gum and tooth becomes deepened to form a pocket in which more debris and therefore bacteria can proliferate to accelerate the process. From the latest available information it would appear that children's teeth in the Borough conform very closely to the national picture of dental decay. Conventional dental treatment consisting of the extraction of infected teeth and removing decay from teeth and replacing it with a metal or synthetic filling has in no way prevented or controlled the disease. Similarly deep scaling and polishing of teeth by the dental surgeon can only hope to contain a condition which has been brought on by faulty diet and oral hygiene. The prevention of dental disease may be considered under the following headings: (1) Public health measures, for the whole population. (2) Social health measures, for specific sections of the population. (3) Measures taken by dental surgeons. (4) Measures taken by individuals. (1) There is only one practicable public health measure at present, which is the adjustment of the public water supply so that it contains 1.0 p.p.m. fluoride. There are many different natural concentrations of fluoride in public water supplies. The domestic water supplied to the Borough by the Metropolitan Water Board contains 0.20 p.p.m. natural fluoride as F. It cannot be claimed that an adjustment to 1 p.p.m. of fluoride will solve the dental caries problem completely, but it would probably reduce the incidence of dental caries by half. Fluoridation is relatively cheap and does not depend for its efficiency on any measure of individual perseverance and there is no proven evidence at present that it is harmful to health in any way. (2) Dental decay is almost preventable by control of diet; unfortunately the foodstuffs associated with dental disease are cheap, palatable and widely advertised. The public is unwilling to give up pleasurable habits. It would be unrealistic to imagine that widespread dental health education in the matter of diet would solve the problem of dental caries unless public opinion as a whole had a change of heart. One of the most dramatic examples of dental caries is the labial caries of deciduous teeth observed in very young children. There is much circumstantial evidence to suggest that this type of caries in children up to 2J years of age is due to the incorrect or over usage of liquid vitamin C supplements. The vitamin preparations are maintained in an acid sugar solution to prevent fermentation and their use in "dinkie" feeders or in comforting bottles is strongly to be discouraged. Mothers are continually being advised on the correct use and dosage of these supplements. A recent survey of schools in the Twickenham area showed that biscuits, sweets, ice cream and mineral waters were sold in classrooms, halls or playgrounds in 14 of 40 schools. The education authority was 96 subsequently advised of foodstuffs recommended by the Society of Medical Officers of Health as being suitable for sale in tuck shops. The list included apples, raisins, potato crisps and nuts. Dental health can be included in tha general curriculum at school, and posters displayed at intervals can be used as reminders. The general availability of drinking water during or after meal times to allow for rinsing of the mouth is most important. (3) Dental health education is an important service that the school dental officer can give to his patients by word of mouth at their routine visits for treatment. In addition, advice can be given about oral hygiene and investigations made into eating habits and suitable diet charts compiled. There is some evidence that repeated topical applications of stannous fluoride to the teeth reduces decay. (4) Regular use of a suitable tooth brush is most important in keeping the mouth clean and although there is little evidence that this practice will reduce dental caries the influence on the gums and supporting tissues of the teeth is most beneficial. In addition research is still going on into the possibility of adding compounds to toothpaste which will reduce caries incidence. There is no reason to suppose that the daily ingestion of fluoride in tablets would be less effective than the fluoridation of the public water supply. From a social health point of view, such a method would probably be ineffective and not very practical when one considers that regular daily dosing would be required for as long as ten years from the pre-natal period. The effects of dental decay on the teeth of the schoolchildren in the borough can be judged from the fact that 61 sessions for inspection at school, 1643 for treatment and 10 for dental health education were required to repair some of its ravages. The type of treatment given in the three age groups can be seen from the following table:- Table XXI. Age 5—9. Age 10—14. Age 15 + First visit for treatment 1552 1472 345 Subsequent visits 2303 3529 853 Total visits 3855 5001 1198 Additional courses commenced 270 205 81 Fillings in permanent teeth 988 3378 1180 Fillings in deciduous teeth 2264 141 — Permanent teeth filled 847 2587 857 Deciduous teeth filled 1828 112 — Permanent teeth extracted 49A 44B 82c Deciduous teeth extracted 981 400 — General anaesthetics 370 238 21 Emergencies 253 97 29 Pupils supplied with full dentures — — — „ „ „ partial „ 2 7 2 Number of dentures supplied 2 7 2 A includes 25 orthodontic extractions. B includes 270 orthodontic extractions. C includes 30 orthodontic extractions. 97 The next table shows a further breakdown of a wider range of treatment but not divided into age groups: Table XXII. No. of pupils X'Rayed 364 Prophylaxis 319 Teeth otherwise conserved 79 No. of teeth root filled 14 Inlays or crowns fitted 18 Courses of treatment completed 2978 Orthodontics: Cases pending from 1965 220 New cases commenced 127 Cases completed 58 Cases discontinued 17 No. of removable appliances fitted 230 No. of fixed appliances fitted 11 No. referred to consultant 6 The balance between inspection and treatment of pupils with regard to the available staff is a fine one. Whenever possible annual inspections are carried out. In 1966, 33 schools were inspected and 4,931 pupils were found to require treatment. Table XXIII. No. of pupils inspected at school 6827 No. of pupils inspected at clinic 3389 No. of pupils offered treatment 3832 The dental laboratory which has a staff of 1 chief technician, 6 senior technicians and 2 apprentices, supplies the needs of not only this borough but also of the London Boroughs of Brent, Ealing, Harrow, Hillingdon and Hounslow. The output from the dental laboratory was as follows:— Table XXIV. Dentures Ortho. appliances Inlays and Crowns Misc. 288 1679 145 388 98 Table XXV. ROAD ACCIDENTS TO SCHOOLCHILDREN, 1966. Mr. W. H Jones, Town Clerk, has kindly supplied the following details of road accidents to school children. Killed Seriously Injured Slightly Injured Total January - - 14 14 February — 6 9 15 March — — 13 13 April - 4 12 16 May — 5 12 17 June — 6 20 26 July — 3 12 15 August — 5 15 20 September — 3 9 12 October — 6 19 25 November 1* 4 13 18 December — 3 9 12 1 45 157 203 99 NUTRITION. I am indebted to Mr. W. R. Wainwright, B.A., D.P.A., for the following: — Meals and Milk. The number of children receiving mid'day dinners and milk at maintained schools on a selected date in 1966 was as under:— Date Number of 1/3 pints Number of % of dinners milk children children at school having dinners 20th September, 1966 *14,909 14,758 18,185 81 (approx.) * In addition approximately 1500 meals per day to Teaching, Kitchen and Cooking Staff. The number of children receiving milk at non-maintained schools on 20th September, 1966 was 2,314 (2,975 children in school). In September, 1966, meals were being cooked at 36 schools and at three central kitchens. * Pedal cyclist, male, aged 13½, killed by collision with a heavy goods vehicle whilst being overtaken. Table XXVI. DEATHS OF SCHOOLCHILDREN. It is with regret that I include the following details of local schoolchildren who died in 1966. Sex Age Cause of Death. M F 1 6 Lymphatic Leukaemia. 1 6 Gastric haemorrhage Biliary cirrhosis. 1 6 Hodgkin's Disease 1 13 Shock and haemorrhage due to multiple injuries. Cyclist run over by lorry (accidental). 1 13 Carcinomatosis Neuroglyoma 1 13 Hodgkin's Disease. 1 16 Ruptured Developmental Cerebral Aneurysm 1 17 Carbon monoxide poisoning in the form of coal gas. Self administered. Suicide. 1 17 Widespread Metastases Chondrosarcoma 100 INDEX. A Page No. Accidental Hypothermia 36, 39 Acreage 6 After-care facilities, tuberculosis and other chest illnesses 32 Animal Boarding Establishments Act 1963 71 Ante-natal Clinics 16, 25 Atmospheric pollution 61 Audiometry 86 B Baths 73 B.C.G. Vaccination 32 Births 6, 7 Births, premature 26 Birth Rate 6, 7 Blindness, Incidence of 46 C Cancer, cervical cytology 24 Cancer, Marie Curie Memorial Foundation 28 Care and after care, tuberculosis and other chest illnesses 32 Care of the Elderly 33 Care of the Elderly, General 34 Care of mothers and young children 16 Care of unsupported mothers and their babies 17 Certificates of disrepair 55 Cervical cytology 24 Chest and Tuberculosis Care Committee 32 Chest Clinics 31 Chief Public Health Inspector, report of 53—73 Child Guidance Service 91 Child Minders 23 Child Welfare Centres 21, 22 Children, physical condition of 79 Chiropody Service 36 Clean Air Act 61 Cleanliness inspections 87 Clinic for Preventive Medicine for Older People 34 Clinics, list of school health service facilities 83 Clinics, new (Ham) 20,21 Codes of practice, food hygiene 61 Committees:— Education 75 Education, Schools Sub-Com. 75 Health 3 Common lodging houses 73 Complaints received 67 Compulsory admission to hospital 35 Congenital malformations, incidence of 16 D Page No. Daily minders 23 Day nurseries, municipal 23 Deafness, early detection of 21 Death rates 6, 7 Deaths 6-9 Deaths, age and cause 8 Deaths, main causes 7 Deaths, mentally subnormal children 45 Deaths, school children 100 Deaths, tuberculosis 8,31 Dental Officer, report of Chief 23 Dental Officer, report of Principal School 95 Dental inspection 23,98 Dental laboratory 98 Dental treatment 23,97 Deprived children 23 Diphtheria immunisation 30 Diseases and defects, ear, nose and throat 85 Diseases, infectious 10—15 Diseases, venereal 14 Diseases of Animals Act 1950 71 Diseases of the skin 87 Disinfection and disinfestation 67 District Nurses 27 Domiciliary deliveries 25 E Ear, nose and throat, diseases and defects 85 Early discharges 27 Early Neo-Natal mortality 6 Education Committee 75 Education Schools Sub-Committee 75 Elderly, care of 33 Enteric fever, protection against 30 Environmental health 53-73 Establishments for Massage and/or Special Treatment 72 Eye diseases 84 F Factories Act 1961 70 Family Planning 16 Fluoridation 5,96 Food and Drugs 58 Food Hygiene, Codes of practice 61 Food Hygiene (General) Regulations 58 Food inspection 56 Food poisoning 11 Food premises 57 Food sampling 58 Foods, other 61 Foods, welfare 24 101 G Page No. General physical condition of children 79 General statistics 6 Geriatric service 33 Good neighbour service 40 Grey Squirrels 68 H Ham Clinic, opening of 20, 21 Handicapped pupils 88-90 Health Committee 3 Health education 37, 39 Health visiting 28 Hepatitis, infective 13 Holidays, recuperative 37 Home Help Service 38 Home Nursing Service 27 Home Nursing, Cases and visits 27 Home Nursing, Training 27 Home Nursing, Type of care given 28 Hospital confinements 25 Hostel for homeless tuberculous males 33 Houses in multiple occupation 54 Houses, number of inhabited 6 Houses, unfit 53 Housing 53 Housing, medical priorities 56 Hypothermia, accidental 36, 39 I Ice-cream, manufacture and sampling 60 Illegitimacy 6,17 Immigrants, medical arrangements for long stay 14 Immunisation and Vaccination 30 Incontinent laundry service 48 Infant mortality 6,7,9 Infectious diseases 10-15 Infective Hepatitis 13 Infestation with vermin 87 Inspection and supervision of food 56 Inspections :— Factory Acts 70 Food premises 57 Offices, Shops and Railway premises 63 Public health 66 Introductory letter— Medical Officer of Health 4-5 Introductory letter— Principal School Medical Officer 74 K Keystone Telebinocular Vision Screener 85 L Page No. Laundry, Municipal 73 Laundry Service, incontinent 48 Leprosy 13 Leptospirosis 11 Liquid Egg (Pasteurisation) Regulation 1963 61 Loan of nursing equipment 48 M Manufacturers, ice-cream 60 Map, Child Welfare Centres, etc. Inside back cover Marie Curie Memorial Foundation 28 Mass Radiography 31 Massage, etc., establishments 72 Maternal mortality 6,7 Maternity Liaison Committee 27 Maternity outfits 27 Meals and milk (schools) 99 Measles 10, 12 Measles vaccination 30 Medical aid 27 Medical arrangements for long-stay immigrants 14 Medical assessments, staff, etc.49 Medical inspection—school children 78—82 Medical priorities, housing 56 Medical treatment—school children 78-82 Mental health services 40-45 Mental illness 41 Mental subnormality 42 Mental Welfare Officers 41 Midwifery:— Service 24 Training 25 Transport 25 Milk in schools 99 Milk supplies and sampling 60 Mortality, early neo-natal 6 Mortality, infant 6, 7, 9 Mortality, maternal 6, 7 Mortality, neo-natal 6,7 Mortality, perinatal 6 Mortuaries 71 Mothercraft and relaxation classes 25 Mothers and young children, care of 16 Municipal day nurseries 23 Municipal laundry 73 N National Assistance Act, section 47 35 Neighbourly help scheme 40 Neonatal deaths 6,7 Noise Abatement Act 1960 71 Nose, diseases and defects 85 Notices complied with 67 Notices served 67 Notifiable diseases 10-15 Notification of intention to practise 27 Nurseries and child minders 23 Nurses agency 48 Nursing equipment, loan of 48 Nursing Homes 48 Nutrition 99 102 o Page No. Offices, Shops and Railway Premises Act 1963 63 Officers 3 Ophthalmia neonatorum 48 Ophthalmology 84 Orthopaedic and postural defects 92 Orthopaedic, clinic 21,92 Other foods 61 Other treatment given—school children 87 Outworkers 70 P Partially-sighted persons 47 Perinatal mortality 6 Pest control 67 Pesticide residues in food stuffs 60 Pet Animals Act 1951 71 Phenylketonuria 21 Poliomyelitis immunisation 30 Pollution, atmospheric 61 Population Population (school) 77 Post-natal clinics 16 Premature births 26 Premises, food 57 Prevention of illness, care and after-care 31 Proprietary foods 24 Public health inspections 66 Public Health (Leprosy) Regulations 1966 13 Puerperal pyrexia regulations 16 Pupil midwives, training 25 Pupil Public Health Inspectors 66 Pupils, handicapped 88 R Radiography, mass 31 Rag Flock etc. Act 195171 Rateable value 6 Recuperative holidays 37 Relaxation classes 25 Rent Act, 1957, certificates of disrepair 55 Residential accommodation :— Mentally ill 42 Mentally sub-normal 42 Welfare Department 35 Richmond upon Thames Chest and Tuberculosis Care Committee 32 Riding Establishments Act 1964 71 Road accidents to school children 99 Rodent control 67 S Sampling, food 58,61 Sampling, ice-cream 60 Sampling, milk 60 Sampling, water 50,52 Sanitary circumstances of the Borough 53-73 Page No. Scarlet Fever 10 School children, deaths 100 School children, road accidents 99 School Health Service 74—100 School meals, and milk 99 School population 77 Sewage disposal 50 Sewerage 50 Shops, offices, etc. 63 Skin, diseases of 87 Smallpox 13 Smallpox vaccination 30 Smoke control 61 Special schools, day 90 Speech therapy 93 Squint 84 Squirrels, grey 68 Staff 3, 24,28,38,41, 76, 86, 93, 95, 98 Statistics, general 6 Statistics, vital 6 Stillbirths 6 Student Health Visitors, training 29 Surveys 13, 21, 60 Swimming pools 73 T Telebinocular Vision Screener 85 Tetanus immunisation 30 Throat, diseases and defects 85 Training of pupil midwives 25 Training of student health visitors 29 Tuberculosis 31 Tuberculosis, deaths 8, 31 Tuberculosis, hostel for homeless males 3 3 Tuberculosis, vaccination 32 U Unfit houses 53 Unsound food 57 Unsupported mothers and their babies, care of 17 V Vaccination and immunisation 30, 32 Vaccination, B.C.G. 32 Venereal diseases 14 Vermin infestation—school children 87 Vision, defective 84 Vital statistics 6 W Water supply 49, 52 Weil's disease 11 Welfare foods 24 Whooping cough 10 Whooping cough, immunisation 30 X X-ray, mass 31 103