AC 43391 LONDON BOROUGH OF SUTTON THE HEALTH AND WELFARE OF SUTTON 1965 P.Westcombe MB BS DPH Medical Officer of Health and Principal School Medical Officer PAGE NUMBER INTRODUCTION 3 PART I GENERAL STATISTICS AND SOCIAL CONDITIONS 13 PART II EPIDEMIOLOGY 27 PART III PERSONAL HEALTH SERVICES 35 (National Health Service Acts) PART IV ENVIRONMENTAL HEALTH SERVICES 67 PART V SCHOOL HEALTH SERVICE 95 (Education Act) PART VI WELFARE SERVICES 113 (National Assistance Act) PART VII MISCELLANY 121 ACKNOWLEDGEMENTS 124 TO THE WORSHIPFUL THE MAYOR AND MEMBERS OF THE COUNCIL,, Mr. Mayor, Ladies and Gentlemen, The presentation of ray report for the year 1965, first for the London Borough of Sutton, is made in accordance with Circular l/66 of the Ministry of Health. It is the duty of a Medical Officer of Health to become familiar with all matters affecting or likely to affect the health of the populace at large and to advise the Lo^al Health Authority on the services necessary to prevent illness and to promote health, defined by the World Health Organisation as a state of complete physical, mental and social well-being not merely the absence of disease or infirmity. This, in the new Authority which came into full operation on 1st April, 1965? presented no small task. Services hitherto divided between the central County Council administration at Kingston-upon-Thames, the three Divisional County Offices at Epsom, Carshalton and Wallington and the Health Departments of the Sutton and Cheam, Carshalton and Beddington and Wallington Councils were, on that date, to be amalgamated into a single administrative unit. Staff, quite unfamiliar with many aspects of the work of the transferred services and totally inexperienced in regard to some, were to become responsible for their implementation. It was determined at the outset that the primary consideration would be to ensure that no person receiving health and welfare services would suffer from the transfer and it is a tribute to the loyal devotion of staff at all levels that this objective was very largely achieved. The period from January to April was occupied with setting up the new department, appointing staff, arranging office accommodation, the transfer of records and so on. During this phase the maintenance of existing services at the same time as establishing those of the future presented a major problem and I wish to record my sincere appreciation of the assistance given by the officers of all the Authorities previously responsible. The transfer was achieved with minimum disturbance to work in the field though I must confess to some apprehension at that time and during the following few weeks as to our ability to control a major epidemic of serious infectious disease. No doubt with this, as with all the many other problems which seemed insoluble at the time, a solution would have been found. So far as Health and Welfare Services are concerned one of the objects of the Royal Commission's recommendation for re-organisation was "to paper over the cracks" which were inherent in the previous Local Authority administrative structure. Very early on in the life of the new Borough invitations were extended to me for membership of various administrative and professional committees of local hospital and general practitioner services. Numerous voluntary organisations within the Borough invited representation at member and officer level to their executive committees and in all cases these were accepted. Liaison committees were also established between the Ministry of Health, the South West Regional Hospital Board and Local Health Authorities at member and officer level. The Borough Council continued the arrangement whereby a Consultant Chest Physician is appointed jointly with the Regional Board and has established the new joint appointment of a Consultant Psychiatrist. Both of these members of the hospital staff are much concerned with common ground between the hospital and community services. A close working relationship has been established with the Consultant Geriatrician responsible for the hospital geriatric service which extends into the field of domiciliary visiting. 3 The Borough Council further invited membership of the Health and Welfare Committees from voluntary organisations, the Regional Hospital Board, the Hospital Management Committee, the Local Medical Committee, the Royal College of Nursing and the Central Midwives Board0 There has, therefore, been a very significant move not only towards papering the cracks within the local authority administration but also towards the establishment of closer local liaison with allied services outside. The full significance of these links in regard to planning and day to day work has not yet begun to be appreciated but the co-operative atmosphere and the will to co-ordinate every day activity is already apparent and augurs well for the future. Within the Authority's own services a process of integration of closely allied services provided by different departments has made an encouraging start. Outside agencies do not appreciate the divisions of responsibility inherent in Local Authority administrative structure and it has already become apparent that much closer departmental relationships are possible at local level within the smaller all-purpose authority than could previously be achieved. The full potential of closer integration has not yet been achieved but it is essential that it should be accomplished if the proposed expansion of social services is to be made possible. The continuing shortage of professionally trained staff means that their skills must be deployed effectively within their own professional spheres and used to maximum advantage. This may involve some re-orientation of duties including the use of less highly trained staff working under supervision in less complicated situations. Within the Health and Welfare Department much thought is being given to the modernisation of services to bring them more into line with present day needs and conditions including those created by the newly developing closer relationships mentioned above. In each part of the report will be found comment upon the individual sections of the department's work. The statistical information in some cases refers to a full year and in some to the period from the 1st April until the end of the year, a situation which is regrettable but inevitable under the circumstances following re-organisation. The general health of the Borough is of a high standard and no major epidemics of infectious disease occurred during the year. The level of immunisation of infants against poliomyelitis, diphtheria, tetanus, whooping cough and smallpox and of adults against poliomyelitis has fallen slightly during the year in common with the national trend„ It is a sad reflection of the complacency with which these lethal diseases have come to be regarded that epidemics and fatalities seem to be necessary to stimulate and maintain acceptance of these simple immunising procedures by many people. With the ever-increasing numbers of persons travelling abroad and the speed of modern transportation between countries, it is more than ever necessary to maintain a high level of immunity. Every member of the community has a responsibility to himself, his family and to the community as a whole to obtain the protection which is so easily available. Care of the Elderly It will have been noted from the analysis of population by age groups on page 9 that 21,090 residents were over the age of sixty-five at the time of the 1961 census. Whilst the majority of pensioners are well able to care for themselves or are cared for by their families, a significant number are frail or living alone and in need of the support of community services. The primary objective of this support is to maintain physical and mental health and well being for as long as possible so that the elderly can maintain themselves in their own homes despite their advancing years and diminishing ability. This can only be achieved by the provision of adequate advice from doctors and health visitors to promote their health and detect treatable disability at an early stage before the development of permanent handicap; by skilled nursing and rehabilitation from illness5 by social support in the form of suitable housing and the prevention of loneliness, isolation and poverty and by practical support in the home such as the provision of meals and domestic help. 4 The social aspect and. the part played by voluntary organisations is described by the Chief Welfare Officer in Part VI of this report. Approximately two-thirds of the total number of persons receiving home nursing are over 65 years of age and over 90^ of those receiving chiropody treatment under the Council's scheme are elderly. The home nurses are much assisted by a scheme for the laundering of bed linen from incontinent patients, nearly the whole of these resources being needed for elderly persons. 64% of persons supplied with home help are over the age of 65 years. There is thus a very considerable proportion of available resources for domiciliary care being directed towards thehealth and welfare of old people. Additionally, a geriatric health visitor is attached to St.Helier Hospital Geriatric Unit providing an essential link between the hospital and Local Authority Service and mental health social workers devote a portion of their time to work with the elderly who are mentally ill. Nevertheless considerable expansion will be necessary in the future to cater for the increasing numbers of elderly persons in need of domiciliary care and to improve existing standards. The disadvantages of increasing disability can be very much reduced by the provision of suitable housing accommodation, particularly when this is provided with the support of a house-mother or warden to be responsible for the general welfare of those under her care. 324 are to be provided during the next 5 years. By this means disabilities which might otherwise necessitate residential care are overcome and the demands made upon places in hospitals and old people®s -homes are reduced. The Council's plans for increasing the number of flats and flatlets for elderly and handicapped persons will undoubtedly make a significant contribution towards the solution of this problem but the actual number which will be required to strike a proper balance between the differing types of provision necessary in hospital, old people's homes and housing provision is problematical. With the services for the care of the elderly in a formative stage, there is a need to consider what new developments are necessary to supplement those already in progress. Advisory Health Clinics to detect unsuspected disease to maintain health and advise on social problems have been started in some areas with the object of assisting in the prevention of mental and physical deterioration and it is hoped to provide similar centres in the Borough during 1966. With the limited services available perhaps insufficient thought has yet been given to assisting families to provide for their elderly relatives to a greater extent than is now possible. This might take the form of financial or domestic assistance, expansion of the present arrangements for the temporary care of old people to enable families take their holiday or have occasional freedom for leisure activities, assistance with laundering of bed linen and a greater number of day centres where care is available during the day. Opportunity for gainful employment to a greater age would also contribute as would preparation for retirement by earlier awareness of the changed way of life which advancing years involves and the need for new interest and activity to provide healthy stimulation for body and mindo Our community is not yet geared to the situation created by increased longevity in which it finds itself. It is necessary not only for services to be expanded but also for individuals themselves to be aware of their increased expectation^ of life and,with assistance from statutory and voluntary services, to plan their future accordingly. 5 I am indebted to Dr.G.HoHall, Consultant Geriatrician, St.Helier Hospital, for his comments which are as follows :- "As far as I can see, the main problem in the care of the elderly is the increasing age and frailty of the majority of patients now referred to the Geriatric Unit. The result of this is that in many cases rehabilitation can only produce partial independence, supervision and care being required in these cases. With the greater age of patients the relatives in turn are often in the geriatric age group0 The greater employment of married women has not helped either, in that many of the younger members of the family, friends and neighbours are now not available to help. The solution of the problem must lie in the provision of a much more comprehensive domiciliary scheme. More flatlets with adequate warden supervision, more welfare home places suitably staffed to cater for these older and less independent people. More long stay hospital beds will, in all probability be required, but the necessity to provide these beds will to a large extent depend on the scope and the quantity of the Local Authority provisions for the care of the elderly. The waiting list for the St.Helier Group Geriatric Service remained high throughout 1965 and has continued to grow. A Day Hospital of 25 places was opened at the Cotswold Wing of Sutton General Hospital in October, 1965, and it is hoped that in time this will ease the problem. The Day Hospital, however, is dependent entirely on the transport facilities made available by the ambulance authorities and as their commitments are heavy, this is limited at present. Further development will depend on the provision of additional transport". National Assistance Acts, 1948 and 1951 Sectionv57 of the 1948 Act places responsibility upon the Authority, on certification by the Medical Officer of Health, to obtain an order from the Magistrates Court for the removal to a suitable place of persons suffering from grave chronic disease or aged, infirm or physically handicapped, who are living in insanitary conditions and are not receiving proper care and attention from other persons0 Although a number of visits were paid during the year to elderly persons thought to be in need of care and attention it was not found necessary to use this procedure, the circumstances being adequately resolved by other means. The Work of Medical Social Workers Section 28 of the National Health Service Act, 1946, places responsibility upon the Council for making arrangements for the prevention of illness and the care and after care of sick persons. That much social disability leading to potential or actual family breakdown has its roots in physical or mental illness has for long been recognised. Medical social work has, therefore, become a well established part of the preventive health services as well as playing an essential part in the after care of sick persons. In order to deal with the social implications of ill-health the special experience of the medical or psychiatric social worker is essential. Through her insight into the aetiology and nature of disease processes and the implications of medical or psychiatric treatment and with her close relationships with health visitors, general practitioners and hospital colleagues, she is able to do much to prevent social breakdown. Close contact is also necessary with other agencies involved in family care and co-ordination of effort is essential to ensure the most effective woik. A good start has been made in this direction and with greater experience there is every reason to believe that improvement will continue. 6 The Care of Medically and. Physically Handicapped Persons A detailed review of the progress made by services for the handicapped will be found in those parts of this report dealing with the Welfare and Mental Health Services? reference is made to handicapped school children in my report on the School Health Service. Home nurses are also responsible for the nursing of many physically handicapped persons in their own homes and for advising on the nursing aids necessary to make life more comfortable for the disabled persons in their care, while health visitors support many families with handicapped children. Social workers are responsible for social support, occupational therapy, sheltered employment and the provision of aids to daily living. Each section of the Health and Welfare Department has, by force of necessity in the early days of the life of the Borough, developed its own part of the total service on a day to day basis. Situations had to be met and dealt with as they arose and procedures established to deal with future similar situations. In the months to come a re-appraisal will be necessary to modify and adapt those procedures to ensure the best use of available menpower and the maximum benefit to the recipients of the services. The care of handicapped and potentially handicapped children will be linked more closely with the care of handicapped adults. As the mental health services evolve they will become more closely associated with the general provisions. It is, for example, envisaged in the development plan that a sheltered workshop for both physically and mentally handicapped persons might be provided. This process of further integration will be of undoubted benefit to the Borough both financially and practically. Workers of many disciplines have valuable contributions to make to the total care of the handicapped with advantage to all. The Health of Schoolchildren The School Health Service is essentially a preventative health service for children at school. It is also specially concerned with handicapped children both in ordinary and special schools and with the medical aspects of the learning difficulties of children. In order to carry out these functions the closest possible relationship between the School Health Service and school staffs is required. This involves some invasion into school time and, whilst this is kept to the minimum necessary for efficient working, the difficulties experienced by teachers are fully appreciated. Much thought has recently been given to the continuing value of the traditional practice of medically examining all children in a number of age groups; in order that more time can be devoted to the needs of individual children a more selective type of medical examination is envisaged. This has the advantage of bringing the doctor into a closer relationship with the parents and members of the school staff concerned with the individual child, allowing more time to be devoted to the needs of those pupils most in need of medical help. Consideration is being given to this question at the present timeD The general physical condition of pupils is good, 14 only being considered unsatisfactory during the year. It is more common to find that pupils are suffering from oveiwiutrition than under-nutrition and the disadvantages of obesity are sufficiently marked to warrant early corrective action by attention to diet in these cases. Mention is made in the section of the report dealing with Health Visiting of the screening tests to detect deafness in pre-school children. School children are similarly screened during their second year at school to detect those who may have subsequently developed defective hearing! it will be noted that eleven children were supplied with hearing aids during the year. 7 The importance of the early detection of hearing defect is paramount in the proper assessment of a child's learning ability and progress in school. Deafness to sounds of certain frequency can be the cause of poor progress simply because the child does not hear all that is said and may also be responsible for defective speech. The importance of the detection of emotional disturbance in school children in connection with the prevention of mental illness in later life is well recognised. School medical officers and health visitors are well aware of the need to obtain treatment for pupils showing signs of behavious^ problems and 89 children were found to be in need of observation or treatment for psychological instability. The routine visits of educational psychologists to schools to see children referred to them by teachers on account of learning difficulty are also valuable in this respect. Health education work in schools needs to be extended and accepted as an essential part of school curricula. In "The Health of the School Child 1962 and 1963" the Chief Medical Officer of the Department of Education and Science writes: "Health Education is no longer confined to an elementary study of hygiene; it is concerned with emotional and social, as well as the physical factors that influence health in its widest meaning. Also teachers are coming to realise the help that school doctors and nurses can give them in this work and that together they will have more influence with children and their parents". There is little doubt that many parents and teachers are unable or unwilling to provide their children with knowledge of the working of their own bodies that earlier maturity and modem conditions require. Sex education should be incorporated in schemes for general education in healthy living if it is not to assume undue proportions in the minds of the pupils; in many cases help needs to be given to parents to enable them to educate their own children in these matters. Children at an ever-diminishing age are being placed in situations with which they are, through lack of knowledge and experience, ill-equipped to deal. Health education has a large part to play in helping to avoid the consequences of this situation. Environmental Health The incorporation of the Public Health Departments of the three previous Authorities responsible for environmental health services into a larger department having also responsibility for transferred services, should not be allowed to detract from the continuing importance of this section of the work. A detailed account by the Chief Public Health Inspector appears in the appropriate part of this report, from which it will be seen that the work of the public health inspectors has also expanded to include functions hitherto carried out by the County Council. Arrangements have also been made with the Greater London Council for the latter to carry out work on an agency basis where this is in the best interests of the Borough. The closer association of those responsible for environmental health and personal health services has already had many advantages; it is hoped that these will continue and increase in the future. 8 In conclusion I wish to record my appreciation of the support, tolerance and intense interest of the members of the Borough Council, officers of other departments and my colleagues in the Health and Welfare Department during the year. The full potential of the Authority in providing closely integrated and efficient services for all those in need will not he reached for a number of years; sufficient progress has, however, been made to justify optimism. It is particularly encouraging to note the keen desire of all those connected with the Authority's services in whatever form and those responsible for all the voluntary and statutory services operating within the Borough to achieve a standard of work of the highest order. With this prevailing spirit I have no doubt that this goal will be achieved. PoWESTCOMBE, M.B.,B.S.,D.P.H.f Medical Officer of Health Principal School Medical Officer. 9 GENERAL STATISTICS PART I AND SOCIAL CONDITIONS AREA ASP POPULATION Population tables are reproduced, in some detail. Although not necessarily up-to-date they contain the most recent information available for the new Borough and it was felt appropriate to include them in their present form to provide readily accessible information and for purposes of comparison in subsequent reports. Care should be exercised in comparing one table with another to differentiate between Census figures and Registrar General's estimates. It will be noted that between the 1951 and 1961 census there was a decline of 7,056 in total population of the area, an average of approximately 700 persons per year. Subsequent annual average figures between 1961 and 1965 based on Registrar General's estimated mid-year figures show a dimished rate of reduction at approximately 576 persons per year. 1 in 8 of the population was aged 65 years or over at the 1961 census. (a) District Area in Acres Census Population Registrar General's Estimate of Mid-year Population 1951 1961 1963 1964 1965 Beddington & Wallington 3045 32757 32603 32560 32590 - Carshalton 3346 62721 57484 56020 55730 - Sutton & Cheam 4338 80673 79008 78770 79500 TOTAL 10729 176151 I69095 167350 167820 - London Borough of Sutton 10729 - - - - 166790 (b) Population by Age Groups Registrar General's Estimate of Mid-year Population 1965 Under one year One to four years Five to fourteen years Over fifteen years 2440 9 360 22400 132590 Total all ages 166790 13 (c) Population by Sex and Age - Census 1961 Age Males Females Total 0-4 5,466 5,179 10,645 5-9 5,119 4,951 10,070 10 - 14 6,638 6,412 13,050 15 - 19 5,703 5,937 11,640 20 - 24 4,459 5,151 9,610 25 - 29 4,760 4,855 9,615 30 - 34 4,848 5,275 10,123 35 - 39 5,388 5,992 11,380 40 - 44 4,982 5,659 10,641 45 - 49 5,875 6,807 12,682 50 - 54 6,550 7,537 14,087 55 - 59 6,492 7,203 13,695 60 - 64 4,832 5,935 10,767 65 - 69 3,229 4,456 7,685 *21,090 70 - 74 2,004 3,467 5,471 75 - 79 1,416 2,640 4,056 80 - 84 730 1,701 2,431 85 - 89 313 800 1,113 90 - 94 60 241 301 over 95 4 29 33 TOTAL 78,868 90,227 169,095 56 of Total 60 — 64 6.12 6.58 6.3 65 - 69 4.00 4.94 4.54 *12.48$ 70 - 74 2.54 3.84 3.23 75 - 79 1.793 2.93 2.40 80 - 84 O.58 1.89 1.14 over 85 O.46 1.19 0.68 14 (a) Acreage9 Population, Private Households and Dwellings - Census 1961 Area Acreage Population Private households and dwellings, 1961 1951 1961 Private households Population in private households Structurally separate dwellings occupied Rooms occupied Density of occupation Persons Persons Males Females Persons per acre Persons per room % of per sons at more than l½ per rocm Beddington Wallington M.B. 3,045 32,757 32,603 15,227 17,376 10.7 10,927 32,456 10,354 54,685 0.60 1.8 Wards N0S. 1 Beddington Nth. 706 5,338 5,205 2,534 2,671 7.4 1,638 5,205 1,625 7,715 0.68 2.6 2 Beddington West 458 3,633 3,680 1,735 1,945 8.0 1,243 3,677 1,174 6,233 0.60 1.7 3 Beddington Cent. 157 4,829 4,436 2,072 2,364 28.3 1,510 4,436 1,431 7,030 O.64 2.2 4 Beddington South. 849 5,454 5,998 2,841 3,157 7.l 1,916 5,960 1,877 10,839 O.56 0.3 5 Wallington North 362 5,235 4,918 2,392 2,526 13.6 1,653 4,918 1,606 7,729 0.64 2.7 6 Wallington Cent. 144 4,049 3,726 1,667 2,059 25.9 1,406 3,701 1,260 6,504 0.58 1.1 7 Wallington South 369 4,219 4,640 1,986 2,654 12.6 1,561 4,559 1,381 8,635 0.54 1.8 Carshalton U.D. 3,346 62,721 57,484 27,226 30,258 17.2 17,952 55,254 17,545 81,531 0.69 4.7 Wards: Central 320 5,964 5,725 2,472 3,253 17.9 1,912 5,459 1,807 9,348 0.59 1.8 North East 330 9,940 8,949 4,418 4,531 27.1 2,877 8,925 2,812 12,490 0.72 4.8 North West 255 7,419 6,761 3,171 3,590 26.5 2,298 6,735 2,230 11,030 0.62 1.5 St.Helier North 249 8,624 7,021 3,498 3,523 28.2 2,187 6,861 2,172 8,173 0.85 10.6 St.Helier South 122 7,710 6,211 2,891 3,320 50.9 1,718 5,352 1,698 6,528 0.83 7.6 St.Helier West 211 8,064 6,606 3,295 3,311 31.3 2,118 6,593 2,086 8,183 0.81 7.8 South East 1,411 8,630 9,113 4,243 4,870 6.5 2,536 8,294 2,492 12,655 0.66 3.1 South West 448 6,370 7,098 3,238 3,860 15.8 2,306 7,035 2,248 13,124 0.55 0.8 Sutton & Cheam M.B. 4*338 80,673 79,008 36,415 42,593 18.2 26,630 77,200 25,492 128,938 0.61 2.5 Wards Nos. 1 or North West 364 8,237 8,182 3,842 4,340 22.5 2,869 8,182 2,800 13,974 0.59 0.8 2 or North 437 10,232 9,454 4,391 5,063 21.6 3,104 9,114 3,048 14,264 0.65 3.6 3 or North East 542 11,609 10,772 5,192 5,580 19.9 3,582 10,763 3,488 16,598 0.66 3.4 4 or East 342 7,892 8,239 3,890 4,349 24.I 2,830 8,219 2,621 12,632 O.66 4.9 5 or South East 361 6,231 6,081 2,621 3,460 16.8 2,264 5,945 2,054 10,777 0.57 2.1 6 or South 712 9,720 10,007 4,186 5,821 14.1 3,306 8,956 2,980 16,271 0.57 3.0 7 or South West 890 6,329 7,827 3,455 4,372 8.8 2,502 7,588 2,482 14,591 0.53 0.4 8 or East Central 285 7,571 6,793 3,216 3,577 23.8 2,294 6,780 2,237 11,062 0.62 2.4 9 or West Central 405 12,852 11,653 5,622 6,031 28.8 3,879 11,653 3,782 18,769 0.63 1.4 (e) Census 1961 (10% sample) Proportions in Socio-Economic Groups (Males) Economic Grouping Definition % Sutton Greater London Area 3 Professional workers - self-employed persons engaged in work normally requiring qualifications of university degree standard •£. r 7.4 4.7 4 Professional workers - employees, as (3) but employees not self-employed. 1 Employers and managers in central and local government, industry, commerce, etc. - large establishments employing 25 or more persons 17.5 11.6 2 Employers and managers in industry, commerce, etc. - small establishments employing fewer than 25 persons 13 Farmers - employers and managers. Persons who own, rent or manage farms, market gardens or forests, employing people other than family workers in the work of the enterprise 8 Supervisory, skilled and self-employed Foremen and supervisors - manual. Employees (other than managers) who formally and immediately supervise others engaged in manual occupations 32.1 35.1 9 12 Skilled manual workers Employees engaged in manual occupations which require considerable and specific skills. Own account workers (other than professional). Self-employed persons engaged in any trade, personal service or manual occupation not normally requiring training of university degree standard and having no employees other than family workers. 14 Farmers - own account Persons who own or rent farms, market gardens ot forests, and having no employees other than family workers. 16 Socio- Economic Grouping Definition Sutton % Greater London Area[/$$$] 5 Intermediate non-manual workers. Employees, not exercising general planning or supervisory powers, engaged in occupations ancillary to the professions but not normally requiring qualifications of university degree standardo 26.5 22.9 6 Junior Non-manual workers, Qnployees not exercising general planning or supervisory powers, engaged in clerical, sales and non-manual communications and security occupation^. 7 10 Personal service workers Employees engaged in service occupations caring for food, drink, clothing and other personal needs. Semi-skilled manual workers. Employees engaged in manual occupations which require slight hut specific skills. 10.7 14.7 15 Agricultural workers. Employees engaged in tending crops, animals, game or forests, or operating agricultural or forestry machinery. 11 Unskilled manual workers Other employees engaged in manual occupations. 5.8 11.0 16 Members of armed forces. 17 Indefinite - persons with inadequately stated occupations. 17 ( f) DEATHS Causes of death at different periods of life during 1965 (Figures in brackets are for 1064) Cause of Death Sex Total all Ages Under 4 weeks 4 weeks & under 1 year AGE IN YEARS 1 5 15 25 35 45 55 65 75 and over 1. Tuberculosis,respiratory M 6 (6) _ - 3 1 2 F 2 (2) - - - - - - - 1 - 1 - 2. Tuberculosis, other M - (1) — — - — - - - - - - — F 1 (-) - - - - - - - - - - 1 3. Syphilitic disease M 2 (-) — — — — — — — — — 1 1 F 2 (7) - - - - - - - - - 1 1 6. Meningococcal Infections M 1 (-) - - - - - - - - 1 - - F - (-) — — — — — — — — — — — 8. Measles M 1 (-) - - - l - - — — - - - F - (-) - - - - - - - - - - - 9. Other infective & Parasitic diseases M 1 (-) 1 - - - - - - - - - - F 2 (1) - - 1 - - - - - - - 1 10. Malignant Neoplasm, stomach M 24 (22) — — — — — — 1 1 11 6 5 F 22 (13) - - - - - - - 1 6 3 12 11. Malignant Neoplasm, Lung, Bronchus M 94 (92) — — — — — — 1 7 28 43 15 F 25 (22) - - - - - - 3 3 7 6 6 12. Malignant Neoplasm, Breast M - (1) — — — — — — — — — — — F 45 (47) - - - - - 2 1 11 16 6 9 13. Malignant Neoplasm, Uterus F 15 (12) - - - - - - - 1 6 2 6 14. Other Malignant & Lymphatic M 99 (92) — — — l — 1 2 6 21 28 40 F 101(105) - - 1 - - 1 3 5 26 28 37 15. Leukaemia, Aleukaemia M 6 (5) — — — l l 1 - 1 1 1 — F 9 (6) - - 1 - - - - 1 3 2 2 16. Diabetes M 4 (3) — — — — - — — 2 1 1 — F 10 (5) - - - - - - - 2 1 4 3 17. Vascular lesions of Nervous System M 105 (84) — — — — — 1 — 4 19 38 43 F 168(140) - - - - l - 1 5 15 34 112 18. Coronaiy Disease, Angina M 244(221) — — — — — — 6 21 76 76 65 F 135(138) - - - - - - - l 17 42 75 19. Hypertension with Heart Diseaseas. M 6 (8) — — - - — — - — 1 2 3 F 5 (10) - — — — 2 3 19 Cause of death Sex Total all Ages Under 4 weeks 4 weeks & under 1 year AGE IN YEARS 1 5 15 25 35 45 55 65 75 and over 20.Other Heart Disease M 88 (67) — — — — — — — 5 5 13 65 F 157(153) — — — — — - — 5 11 11 130 21. Other Circulatory Disease M 46 (45) — — — — — — — 1 11 9 25 F 65 (60) — — — - — — 1 2 3 10 49 23. Pneumonia M 30 (53) 1 1 — — — — — 2 4 6 16 F 63 (50) 2 1 — — — — — — 3 9 48 24.Bronchitis M 66 (61) — — — — — — — — 14 30 22 F 21 (23) — — — — — 1 — — 2 6 12 25. Other diseases of Respiratory System M 11 (10) — — — — — 1 — 1 3 5 1 F 3 (4) — — — — — — 1 — 1 — 1 26. Ulcer of Stomach & Duodenum M 9 (9) — — — — — — — — 3 3 3 F 2 (8) — — — — — — — — — 1 1 27. Gastritis, Enteritis and Diarrhoea M 2 (5) — — — — — — — — 1 — 1 F 6 (5) 1 — — — — — — — — 1 4 28. Nephritis & Nephrosis M 1(7) — — — — — — — — 1 — — F 3 (3) — — — — — — — — 1 — 2 29. Hyperplasia of Prostate M 9 (9) — — — — — — - — — 2 7 31. Congenital Malformations M 7 (1) 3 1 — — 1 — — — — 1 1 F 9 (6) 4 — - l 1 — — 1 1 1 — 32. Other Defined and IllDefined Diseases M 49 (56) 7 5 — — — — 3 1 5 11 17 F 71 (76) 6 2 1 — — — 1 3 8 14 36 33. Motor vehicle accidents M 12 (18) — — — 1 5 — 1 1 — 2 2 F 11 (4) — — — l 1 — 2 — 3 — 4 34. All Other accidents M 7 (11) — — — — — 2 — — 2 — 3 F 15 (9) — 1 — — — — — 1 — 2 11 35. Suicide M 4 (11) — — — — — 1 1 1 1 — — F 10 (9) — — — — 1 1 3 2 1 1 1 36. Homicide & Operations of War M - (-) — — — — — — — — — — — F 1 (-) — — l — — — — — — — — TOTAL ALL CAUSES M 934(902) 12 7 — 4 7 7 15 54 212 279 337 F 979(918) 13 4 5 2 4 5 16 45 131 187 567 20 (g) Deaths from all causes Male Female Total Crude rate per 1,000 population Adjusted rate per 1,000 population comparability factor 0.93 934 979 1913 11.47 10.66 Deaths from certain causes:- Category 1950 1960 1961 1962 1963 1964 1965 Tuberculosis, respiratory 39 9 12 5 3 8 8 Cancer, Uterus, 11 17 16 10 17 12 15 Lung, Bronchus 52 83 100 100 103 114 119 Coronary disease, angina 291 362 356 381 389 359 379 Bronchitis 75 82 95 116 135 84 88 Suicide 15 19 26 31 21 20 14 Motor vehicle accidents 13 18 14 14 20 22 23 All other accidents 26 17 23 39 29 20 22 (h) Suicide Male Female Total Suicide rate per 1,000 deaths 4.28 10.22 7.33 Total as % of total deaths 0.43 1.02 0.73 Rate per 1,000 population .8 Fourteen persons ended their own lives during 1965. A number of surveys have been carried out to determine the frequency of attempted suicide compared to that which is successful. The 1964 report of the Chief Medical Officer of the Ministry of Health records figures varying from 10 :1 to 6 :1. Applying this range of figures to the Sutton cases, between 80 and 140 people may have attempted to terminate their own lives during the year. One can only speculate on the circumstances leading up to a state of mind which drives a person towards this extreme measure, but one wonders whether the timely application of a little more tolerance or human sympathy might not have prevented tragedy in a number of cases. (i) Infant Deaths Age Males Females TOTAL Total Legit. Illegit. Total Legit. Illegit. Under 1 year of age 19 18 1 17 16 1 36 Under 4 weeks of age 12 11 1 13 13 — 25 Under 1 week of age 9 8 1 8 8 — 17 (J) Infant Mortality Rates Infant Total infant deaths per 1,000 total live births 14.41 Legitimate infant deaths per 1,000 legitimate live births 14.06 Illegitimate infant deaths per 1,000 illegitimate live births 13.2 Neo-natal Deaths under four weeks per 1,000 total live births 9.89 Early Neo-natal Deaths under one week per 1,000 total live and stillbirths 6.73 Peri-natal Stillbirths and deaths under one week combined per 1,000 total live and stillbirths 18.6 Maternal Number of deaths Nil Rate per 1,000 total live and stillbirths Nil 21 22 (k) BIRTHS 1st January to 31st December, 1965 LIVE STILL LIVE BIRTH RATE PER 1,000 POPULATION Legit. Illegit. Total Legit. Illegit. Total Crude Adjusted by Comparability factor 1.03 1212M 78M 1290M 17M 1M 18M 14.97 15.4 1134F 73F 1207F 11F 1F 12F 2346 151 2497 28 2 30 93.95% 6.05% 100% 93.33% 6.67% 100% Number of still births Males Females Total Total live and still births 18 12 30 Still birth rate per 1,000 live and still births 11.87 2,527 (l) RATEABLE VALUE Rateable value of the Borough 1st April, 1965: £9,187,614 Estimated net-product of a penny rate 1965/66: £37,600 Estimated number of separately assessed dwellings at 1st April 1965 53,851 (m) HOUSING There is no doubt that a pressing social deficiency of modern times is illustrated by the number of applicants for Council houses on the waiting list. Not all applicants are, of course, in urgent need hut many are living in circumstances which place intolerable stresses and strains on family relationships and increase the opportunity for mental and physical ill-health to occur. I am indebted to the Chief Housing Officer for the following information:- (1) During the year 244 units of accommodation were completed of which 30 were flatlets for elderly persons. (2) 19 applicants on the housing waiting list were re-housed on medical grounds following recommendation for priority made by the Medical Officer of Health. (3) On 31st December, 1965, there were 2,148 applications on the Council's housing waiting list. (4) 389 families were re-housed and a further 96 were re-accommodated from property required for demolition,, (5) Including miscellaneous properties there were 4,145 premises under the control of the Borough Council, of these 89 units are provided for elderly persons under the supervision of a warden. 11% of projected building is to be designated for elderly persons. Medical Priorities for Housing Applicants Those applicants whose housing circumstances are such that their health is seriously suffering therefrom are granted a degree of priority on the housing waiting list according to the urgency of the medical circumstances. Each case is thoroughly investigated before a recommendation is made to the Housing Committee. Between 1st April and 31st December, 1965, 134 cases were referred to the Medical Officer of Health for assessment of priorities on medical grounds. On 31st December, 1965, 100 of these references had been dealt with and priorities were recommended as follows :- Category I (immediate re-housing) 28 Category II (Priority within the points group) 50 Category III (No priority) 22 23 EPIDEMIOLOGY PART II PREVALENCE AND CONTROL OF INFECTIOUS DISEASE As previously stated there were no serious epidemics of infectious disease during the period under review. Mild cases of sonne1 dysentery continue to occur regularly in small local outbreaks mainly associated with schools where spread occurs with ease. Each case notified involves extensive bacteriological investigation of contacts and supervision until freedom from infection is established. The most effective preventive measures for this disease, which has considerable nuisance value, are early notification of all occurrences and scrupulous observance of the rules of good hygiene at all times, particularly in regard to hand-washing before meals or preparation of food and after the use of the toilet. No case of diphtheria or poliomyelitis was notified. The origin of the one confirmed case of paratyphoid fever was a holiday spent in Corfu. (a) Infectious Diseases notified during the period 1st April-31st December, 1965. Disease Under 5 5-14 15-44 45 - 64 65 or over Age Unknown TOTAL M F M F M F M F M F M F M F Dysentery 14 6 28 21 5 3 3 1 50 31 Erysipelas 1 1 1 2 1 Food Poisoning 1 1 1 1 1 2 3 Measles 169 166 91 117 4 3 264 286 Meningcococcal Meningitis 1 1 Pneumonia 1 2 1 1 1 3 4 5 Puerperal Pyrexia 87 87 Scarlet Fever 12 13 33 23 2 3 47 39 Tuberculosis (Pulmonary) 1 12 8 10 2 4 1 26 12 Paratyphoid 1 1 1 1 Whooping Cough 7 4 5 6 1 1 13 11 27 (b) Immunisation and Vaccination, 1st April-31st December, 1965 Type of Protection Completed Primary Courses Received Reinforcing doses (Booster) Diphtheria/Pertussis/Tetanus/Poliomyelitis 3 6 Diphtheria/Petussis/Tetanus 915 1,017 Diphtheria/Pertussis 2 3 Diphtheria/Tetanus 42 1,079 Diphtheria 5 28 Pertussis — 4 Tetanus 65 29 Poliomyelitis Salk vaccine 6 4 Sabin (Oral Vaccine) 1,087 735 Smallpox 958 23 Because of changes in the statistics required by the Ministry of Health and consequent upon the reorganisation of Borough boundaries, information concerning numbers of immunisations carried out for the whole year are not available. There is, however, a slight decline, estimated to be of the order of 5% Per annum in the numbers of children immunised and. vaccinated. This is regrettable and is unfortunately a nation-wide trend. Protection against smallpox, diphtheria, whooping cough, tetanus and poliomyelitis is available at all the Council's clinics and at the surgeries of all general practitioners. All mothers of young children are notified by health visitors of the need for immunisation and are constantly reminded by widely displayed posters and leaflets. In the final reckoning, however, some personal effort is involved and I cannot too strongly emphasise the importance of every child being protected against these diseases to ensure that they do not return to take their toll of life. We have recently seen the occurrence of smallpox and poliomyelitis in other parts of the country with considerable loss of life and we have no reason for complacency. This could happen in Sutton unless all parents make it their responsibility to see that their children are protected. Persons travelling abroad are strongly advised to take note of the advice given in the "Notice to Travellers" issued by the Ministry of Health, to ascertain what additional protection is advised and to obtain the appropriate inocculations. Vaccination against tuberculosis is offered to all contacts of infectious cases and carried out by the chest physician. In addition all school children who have not acquired natural immunity are offered this protection at approximately thirteen years of age. Pupils who may have acquired natural immunity are referred to the chest physician for chest x-ray to ensure that no treatment is necessary following their exposure to the infection. The recommended programme of protection is:- At age of: 3 months 1st Triple and 1st Poliomyelitis 4 months 2nd " " 2nd " 5 months 3rd " " 3rd " After 1st year Smallpox vaccination id months Reinforcing Triple and Poliomyelitis 4½ to 5 years Reinforcing Diphtheria, Tetanus & Poliomyelitis 8 to 9 years Reinforcing Diphtheria and Tetanus 13 years B.C.G. vaccination. 28 B.C.G. Vaccination 1st January-31st December 1965 School children aged about 13 years Number offered protection (a) Number Accepted (b) Number Vaccinated (c) Percentage (c) of (a) (d) 401 323 291 72.57 By chest physician Contacts 71 Others 34 TOTAL 396 Venereal Diseases New Cases - St. Helier Clinic 1965 1.4.65-31.l2.65 Male Female Total Attendances M F Total Syphilis 14(7) 15(5) 29(12) 257 170 427 Gonorrhoea 69(21) 19(10) 88(31) 418 142 560 *0ther Conditions 265(76) 248(135) 513(211) 966 581 1,547 TOTAL 348(104) 282(150) 630(254) 1,641 893 2,534 New Cases - St. Helier Clinic 1962 1963 1965 Syphilis 4 6 29(12) Gonorrhoea 55 61 88(31) *Other Conditions 510 488 513(211) TOTAL 569 555 630(254) *The great majority of these conditions are non-venereal. (-) Figures in brackets represent residents of the Boroughs. 29 There is a significant increase in the number of new cases of syphilis and. gonorrhoea notified, by the hospital clinic. This is in accordance with a national and indeed international trend. Venereal diseases are extremely resistant to control and there is a pressing need to inform all sections of the public about these diseases and their dangers. Careful consideration needs to be given to the desirability of introducing information of this sort into routine health education carried out in schools and to extending this activity into youth clubs and other organisations. Publicity is given to the availability and times of treatment clinics in the press and by display poster. It is, however, a matter of individual responsibility on the part of persons who have been exposed to the possibility of infection to avail themselves of the facilities which are available for the detection and treatment of these diseases. MASS RADIOGRAPHY The Mass Radiography Unit visited sites in the Borough during the year and I am indebted to the Director of the Unit for the following statistics :- Total x-rayed 6,930 Males 3,630 Females 3,300 As a result of these investigations one man was found to be suffering from pulmonary tuberculosis and two men from cancer of the lung. Following notification of pulmonary tuberculosis in an employee, the Unit visited two premises at my request to give the opportunity of chest x-ray to all persons working there. In addition the Unit regularly visits factories and other places where numbers of persons are employed. IMMIGRATION Under the Commonwealth Immigration Act, 1962, long stay immigrants are required to supply immigration officers with their destination address. This is forwarded to the Medical Officer of Health of the appropriate area and a visit is paid by a member of his staff. This is a useful procedure which enables contact to be made with the newly-arrived immigrant at an early stage. Health aspects of immigration are two-fold. The immigrant may be suffering from ill health which requires treatment and action to prevent the possible spread of infection or he may be exposed to infection in this country against which he has little or no immunity,, Many immigrants to the Borough are employed in local hospitals. Those who are not are advised by the health visitors of the facilities available under the National Health Service and encouraged to register with a general practitioner. 30 Where there are families appropriate arrangements are made for their protection against infectious disease and the mothers and children receive the normal health supervision available to the community as a whole. Country where passport was issued as stated by Port Health No. of advice notes received during 1965 from ports and airports relating to the arrival of immigrants. No. of first successful visits paid during 1965. No. of Pulmonary Tuberculosis notifications received in respect of immigrants during 1965. (a) Commonwealth Countries 1. Carribean 4 2 - 2. India 2 1 - 3. Pakistan 1 - - 4., Other Asian 5 2 - 5. African - - - 6. Other 3 3 - (b) Non-Commonwealth Countries 1. European 80 41 - 2. Other 4 2 - TOTAL 99 51 Nil In addition Medical Superintendents at hospitals did 25 follow-ups of immigrants joining hospital staffs. 5 immigrants were not known at the addresses given by the Port Medical Officers. One immigrant returned home immediately after arrival in this country. 31 PERSONAL HEALTH SERVICES (NATIONAL HEALTH SERVICE ACT) PART III PART III. LOCAL HEALTH AUTHORITY SERVICES MATERNAL AND CHILD WELFARE Births 1st April to 31st December, 1965 (a) In the area including those normally resident elsewhere. (b) Resident in the area including those born elsewhere i.e. (a) adjusted by inward and outward transfers Live 2,629 1,883 Still 32 20 Total 2,661 1,903 Of the 1,903 adjusted births 1,497 took place in hospitals and other institutions and 406 took place at home. 35 PREMATURITY The following table gives details of premature births and stillbirths notified in the London Borough of Sutton during the period 1st April-31st December, 1965. as adjusted by transferred notifications: Weight at Birth PREMATURE LIVE BIRTHS PREMATURE STILL BIRTHS Born in Hospital Born at home or in a Nursing Home Transferred to Hospital on or before 28th day Born at home or in a Nursing Home Born in Hospital T O T A L DIED T O T A L DIED T O T A L Within 24 hrs of Birth Between 1 & 7 days Between 7 & 28 days Within 24 hrs of Birth Between 1 & 7 days Between 7 & 28 days Within 24 hrs of Birth Between 1 & 7 days Between 7 & 28 days 2 lb. 3 ozs. or less 4 3 _ _ _ _ _ _ _ _ _ _ 1 - over 2 lb. 3 ozs. up to & incl. 3 lb. 4 ozs. 7 4 _ _ _ _ _ _ _ _ _ _ 2 _ over 3 lb. 4 ozs. up to & incl. 4 lb. 6 ozs. 17 1 1 _ 1 _ _ _ _ _ _ _ 4 _ over 4 lb. 6 ozs. up to & incl. 4 lb. 15 ozs. 21 _ _ _ 1 _ _ _ _ _ _ _ 2 1 over 4 lb. 15 ozs. up to & incl. 5 lb. 8 ozs. 47 _ 1 2 4 _ _ _ 1 _ _ _ 2 _ TOTAL 96 8 2 2 6 _ _ _ 1 _ _ _ 11 1 This table emphasises the serious loss of infant lives as associated with prematurity. The size of the problem can most simply be shown as follows: Total Non Premature Premature * Live births 1,883 1,780 103 Deaths among live births in the first month of life 42 29 13 Still births 20 8 12 The Ministry of Health's definition of a premature birth is one when the infant at birth weighs 5½ lbs or less. It will be seen that the 1,780 non-premature live births produced 29 neo-natal deaths and the 103 premature live births produced 13 neo-natal deaths. In addition 60% of still births are associated with prematurity. CONGENITAL ABNORMALITIES AND INFANTS "AT RISK" It is a responsibility of the Medical Officer of Health to submit a confidential report in standard form to the Registrar General on congenital abnormalities detected at or shortly after birth. Between 1st January and 31st March, 1965 eleven congenital abnormalities were discovered and reported and between 1st April, 1965 and 31st December 1965 twenty-four were discovered and reported. Of the thirty-five congenital abnormalities reported during the calendar year, eleven were of a comparatively minor nature and twenty-four were more serious defects. One of the thirty-five infants concerned was still-born and of the thirty-four infants bom alive, five died within ten days of birth. During the period 1st April - 31st December 1965, births at which congenital abnormalities were detected represented 1,3% of the total live and still births. A standard form of birth notification is used in the area which provides for the notification of congenital abnormalities and factors calculated to put the infant "at risk" when these are detected at birth. Similarly, reports submitted by hospital maternity units and domiciliary midwives on patients discharged from their care after confinement are in standard form providing for the easy recording of congenital abnormalities and 'at risk' factors. Those infants who are designated 'at risk' of developing handicap through some factor in the ante-natal or peri-natal period are specially noted and followed up by medical officers and health visitors until the presence or absence of defect is established. THE WORK OF CHILD WELFARE CENTRES The work of child welfare centres consists of supervision of the normal development of young children; early detection of abnormalities of development; provision of facilities for immunisation and vaccination against infectious disease; giving advice concerning the feeding and management of children and concerning the measures necessary for the promotion of family health. The nature and content of this work has changed very considerably since its inception. The emphasis is now directed away from the detection and treatment of the gross defects found in former years towards the more subtle problems of developmental abnormality and family relationships. Advice concerning behaviour problems now forms a very considerable part of the work carried out by medical officers 37 and. health visitors in their consultation clinics, work demanding very different skills to those formerly necessary. The demand for this service and the esteem in which it is held by mothers is illustrated by the continuing high attendance figures. During the year special Toddlers Clinics have been set up in all the main clinics where children are seen by appointment annually for assessment of their physical and mental development and where more time can be devoted to mothers who have problems than is possible at the general clinic sessions. Special sessions have also been arranged for immunisation and vaccination of children where the numbers attending have justified separation from general infant welfare sessions thus avoiding the long waiting previously experienced and allowing more time for consultations. The changes in administrative areas allowed the closure of two small clinics in rented premises to be projected and a new clinic building, planned, and built by Surrey County Council in the Clock House Estate area of Carshalton, was nearing completion at the end of the year. The change in the boundary whereby Purley became a part of the London Borough of Croydon area has made this clinic area somewhat isolated but it is hoped to provide a useful service for those residents in the immediate neighbourhood. At 31st December, 1965 5 purpose-built clinics and 3 adapted buildings were in use for ante-natal and post-natal clinics, mothercraft and relaxation classes and child welfare centres including toddlers® clinics and immunisation. In addition, 5 church and other types of hall were occupied on a sessional basis for child welfare clinics and immunisation. The sessional use of 2 church halls was discontinued during the year 1965:- (a) Elm Grove Church Hall, Butter Hill, Wallington (b) Methodist Church Hall, Sandy Lane North, Wallington Child Welfare Centres Number of children who attended during the period 1st April to 31st December, 1965• First attendances No.of Sessions held by: Born in 1965 Born in 1964 Born in 1960 -63 Total Total Attendances Asst. Medical Officers G.P.s employed on sessional basis Total No. of Sessions No. of Children referred elsewhere for consultant advice. No. Chil o 'at reg at of 1,908 310 990 3,208 48,667 822 140 962 50 2, 38 DISTRIBUTION OF WELFARE FOODS 1. Government Scheme The Council acts as agent for the Government for the distribution of National Dried Milk, Cod Liver Oil, Orange Juice and Vitamin A and D tablets to authorised beneficiaries. The major part of the work is handled on behalf of the Council by members of the W.R.V.S. and other voluntary workers whilst the detailed accounting for the scheme is dealt with by the Medical Officer of Health and the Borough Treasurer. There are 15 Distribution Centres in the Borough, 13 of them at Infant Welfare Centres. Issues to beneficiaries. 1st April to 31st December, 1965 National Dried Milk (tins) Cod Liver Oil (bottles) Orange Juice (bottles) A & D Tablets (packets) 18,120 1,738 36,803 2,740 2 Proprietary Welfare Foods It is customary for infant welfare clinics to hold a stock of proprietary brands of welfare foods approved by the Medical Officer of Health for sale to bona fide clinic attenders at reduced prices. Over most of the old administrative County of Surrey area these foods were bought and sold by voluntary committees attached to clinics and working in close co-operation with the professional staff at the centres and Divisional Medical Officers. The profits made by these voluntary bodies were used to further the work of the clinics. On 1st April, 1965 clinics in the Sutton and Cheam area were supported by voluntary committees whereas in the rest of the area proprietary foods were handled through official sources. Between 1st April and 31st December 1965 it was possible to arrange for all clinics in the area with one exception to benefit from the support of voluntary effort in this field. The one remaining exception at the end of the year was Green Wrythe Lane Clinic where unfortunately it has not been possible to obtain the necessary voluntary support. THE WORK OF HEALTH VISITORS AND SCHOOL NURSES In his book "The Maternity and Child Welfare Movement" Dr.McCleary ells us that John Bunnel Davis (178O - 1824) established the Universal Dispensary or Sick Indigent Children in the City of London in l8l6. He was an early pioneer of infant welfare and was anxious that the dispensary organisation should establish district committees of 'benevolent ladies’ to visit the children attending the dispensary and report upon the state of their health; it is doubtful whether the scheme was every established. The official history of health visiting dates back to 1862 in Manchester and Salford, to the Ladies Sanitary Reform Association, whose aim was to popularise sanitary knowledge and to elevate the people physically, socially, morally and religiously. Literature on health topics distributed by three or four ladies proved of little value and a respectable working women’ was engaged to go from door to door to teach and help the poorer women as opportunity offered. It would seem that. this 'respectable working women® was our first professional health visitor’. 39 They were required "to visit from house to house, irrespective of creed or circumstance, in such localities as their superintendents directed. They must carry with them carbolic powder, explain its use, leave it where it was accepted} direct the attention of those they visited tothe evils of bad smells, want of fresh air, impurities of all kinds} give hints to mothers on feeding and clothing their children} where they find sickness, assist in promoting the comfort of the invalid by personal help and report such cases to their superintendent. They must urge the importance of cleanliness, thrift and temperance on all possible occasions. They are desired to get as many as possible to join the mothers’ meetings of their districts, to use all their influence to induce those they visit to attend regularly at their respective places of worship and to send the children to school". In I89O Manchester Corporation began to pay some salaries and the Medical Officer of Health became responsible for the direction of the work of these health visitors. Miss Florence Nightingale appreciated the urgent need for special training for health visitors or "health missionsrs" as she called them. "The needs of home health bringing require different but not lower qualifications and are more varied. They require tact and judgment unlimited to prevent the work being regarded as interference and becoming unpopular.’ In 1891 - 2 she persuaded the North Buckinghamshire County Council to inaugurate the first training course for health visitors. Sixteen lectures were given followed by discussion and the syllabus covered subjects still studied by modern student health visitors. Sixteen women attended the lectures, twelve entered for the examination} only six obtained the certificate. In 1909 the Health Visitors’ (London) Order laid down the first statutory qualifications for health visitors and in 1916 the Medical Officer of the Local Government Board recommended that a health visitor should possess two of the three following qualifications: a nurse’s training, a sanitary inspector's certificate and the certificate of the Central Midwives’ Board. In 1925 the training of health visitors became the responsibility of the Ministry of Health} in 1962 the Health Visiting and Social Work (Training) Act set up the Council for the Training of Health Visitors the first duty of which was to present a new syllabus of training which came into operation in October, 1965. Although the health visitor is now a familiar figure in our daily life and times, her training and responsibilities are not always known and in this my first Annual Report I have commented on some of the background against which the service has evolved. The establishment of health visitors for the Borough is 25. On 1st April, 1965 the staff in post consisted of 17 maternity and child welfare health visitors, 2 chest clinic health visitors attached to St. Helier Hospital and one geriatric health visitor (shared with the London Borough of Merton) and the Superintendent Health Visitor. 4 sessional nurses (S.R.N.) were transferred to the Borough and 3 more were appointed during the year. By the end of the year each major clinic also had part-time clerical assistance. A public health nurse was appointed but due to the pressure of work and shortage of staff in the Welfare Section she was used mainly for urgent field welfare work. The employment of sessional nurses and clinic clerks is in accordance with the accepted policy of allocating less skilled work to less highly qualified staff as appropriate and it is hoped that the level of clerical assistance in clinics will increase in line with the development of services to allow health visitors more time for family visiting. 40 In December, 1965 the health visitors’ case load was as follows:- 0-1 years 1-5 years 0-5 years Families Total 2,513 8,561 11,074 7,982 Average caseload for staff in post (17) in April 1965 150 503 651 470 Average caseload for (2l) establishment in December 1965 120 408 528 380 (a) Screening Tests The early diagnosis of abnormalities of hearing and metabolism is essential if speech is to develop and one particular form of mental subnormality prevented. Health visitors offer screening tests to all children for whom birth notifications are received. A screening test of hearing is given to all children at the age of 8 months; from April - December, 1965 1,834 children were tested and 123 re-tested of whom 18 were referred to audiology clinic for further examinations. Phenylketonuria is a condition present at birth which leads to rapid mental retardation. Immediate treatment with successful results can be given if the condition is diagnosed early and a simple urine test has been devised for this purpose which is done between three and eight weeks of age. Although the incidence of this disease is small, the importance of diagnosis to an affected child is paramounts: health visitors offer this screening test for every child between three and eight weeks of age. From April to December 1965 they tested the urine of approximately 1,800 babies and found none to be positive. (b) Research Much of the field work for national research projects is performed by health visitors who have direct contact with the families in their homes or at the clinics. Four extensive surveys were covered in the first few months of the life of the Borough. (c) Care of Mothers and Young Children The statutory function of health visitors is the care of mothers and young babies and this is carried out by means of home visits, consultations at clinics and group discussions with parents until the child is five years of age. During the period 1st April to 31st December 1965 962 infant welfare sessions were held in clinics and 324 other clinic sessions were devoted to the care of mothers and young children apart from home visiting. The care of ante-natal and post-natal mothers is undertaken both at clinics and in homes. Special group meetings are arranged and demonstrations films and discussions take place to help prospective parents to prepare and adjust to their new roles. 41 The health visitors attended at 230 ante-natal and post-natal clinics and held 275 parentcraft meetings during April to December, 1965. (d) Family Welfare The prevention of illness and promotion of health involve the health visitor in a special interest in the continued maintenance of family life. Whether acute problems exist or where inadequancy is long term, support is necessary. Help from workers in other specialised disciplines on a long or short term basis is available to assist in this time-consuming and exhausting work but the health visitor's knowledge of the families make it imperative that she maintains the continuity of her friendship and support throughout. (e) Care of the Elderly Neighbours, old people's welfare committees, clergy and other organisations draw attention to the elderly who are lonely, ill or in need of skilled assessment. The health visitor is able to call on the services necessary to maintain them in their own homes for as long as possible and her close association with the general practitioners and hospital is particularly valuable in this respect. The geriatric health visitor attached to the Geriatric Unit at St.Helier Hospital acts as a liaison officer between the Local Health Authority services and the hospital. She works with the hospital geriatrician and social worker in the assessment of priority of need in each case referred by general practitioners and health visitors. Frequent visits are paid to patients on the waiting list for beds and day to day re-assessments are made. In conjunction with the general health visitors she supervises patients in their own homes following discharge from hospital after re-habilitation or temporary illness. Arrangements are made for short-term holidays to relieve families who are permanently caring for their elderly relatives. 1 (f) Care of the Handicapped It frequently falls to the health visitor to recognise incipient mental illness during her routine care of mothers and to maintain support during periods of potential breakdown or during rehabilitation after mental illness. Her longstanding friendship with the family and skilled knowledge make her an invaluable ally at this time. Mentally handicapped females of all ages are visited in their homes by health visitors but at sixteen years of age the care of males passes to a male mental welfare officer. 63 mentally ill and 259 mentally handicapped patients were visited by health visitors during 1965• Where physical handicap occurs the health visitor has a special responsibility to see that adequate treatment is obtained and other advice and assistance is made available should it become necessary. Intensive support may be necessary during the period of adjustment and adaptation to every day living. The two health visitors attached to the chest clinic at St.Helier Hospital care for patients in the Borough suffering from chest conditions. They work in close co-operation with the chest physicians, attend the consultation clinics and make home visits. They advise tuberculous patients and their relatives in respect of the prevention of the spread of infection and arrange follow-up examinations of contacts. Support and assistance is given in the management of the illness and throughout the re-habilitation period. Contact is maintained with the family for at least five years after diagnosis and throughout the time the patient's name remains on the tuberculosis register. 42 Care of School Children Health visitors are appointed jointly under the National Health Service Acts for the care of mothers and young children and under the Education Act for the care of school children. Continuity of care is maintained and close contact is made with the school staffs. They are concerned, not only with medical care and testing of vision and hearing, "but also with the personal hygiene and family background of each child. When difficulties other than those of an educational nature present themselves they are referred to by the school staff and whenever necessary can make home visits to assist in the resolving of medical, emotional or environmental problems. They are responsible for health education in schools and gave 50 teaching sessions during the period. All contacts with pupils and teaching staff are utilised for this purpose whenever opportunity arises. Periodic medical inspections of older school children are now arranged by sessional school nurses. During the period 1st April to 31st December 1965 the health visitors were responsible for 162 sessions in school plus 38½ sessions given to hygiene inspections. Sessional school nurses spent 252½ sessions on school medical inspections and minor ailment clinics are held for school children and attended by sessional school nurses where possible. During the period 1st April to 31st December, 1965 they attended 272½ sessions: health visitors were called upon to relieve at 15 such sessions during this periods Health Education Apart from their work in schools and clinics health visitors give formal health education talks to many and varied groups who call upon them from time to time to attend both day and evening meetings. Other aspects of this work will be found in the section of the report dealing with health education. ) Education and Training The introduction of the student nurse to preventive medicine is of paramount importance. No classroom lecture can substitute for the experience of seeing patients in their own environments. Close co-operation has therefore been given to schools of nursing despite the difficulties of maintaining the services in the face of staff shortage. Many of the allied disciplines include observation visits with health visitors in their training curricula. Student nurses from local hospitals are now being sent to spend a day with a health visitor. St.George's Hospital, London and Queen Elizabeth's Hospital for Children send students annually for observation visits and St.Helier Hospital, Queen Mary's Hospital for Children, Sutton General Hospital and St.Anthony’s Hospital have similar arrangements. During 1st April to 31st December 1965 264 students from hospital visited the Borough for observation visits. The training of health visitor students is regarded as an important undertaking and two health visitors, with an ability and liking for teaching, have been sent for training as field work instructors. They implement the theoretical and academic knowledge imparted by the training colleges and provide students with their practical experience in the field. 43 The selection of suitable candidates for training is not an easy task. The applicant needs not only a good educational and professional background but special qualities of character and personality. Although 19 applications for sponsored health visitor training were made to this Borough, only one, who later withdrew, was suitable for training. The Borough therefore has had no student health visitor on the 1965/1966 course; more promising applications have been received for the following year. It is necessary to keep all field staff constantly aware of new techniques, changing patterns of community life and fresh ideas. Regular staff meetings, lectures and in-service training are arranged and health visitors are seconded for refresher courses every five years. (j) General In this, our first year, we have continued all existing services and established separate and more concentrated efforts with regard to immunisation and the care of toddlers. A special clinic for each service has been set up at each major centre to cater for them. Recently there has been a great deal of discussion at government level with regard to the priorities of health visiting and the way in which health visiting staff should operate. Several authorities have been attaching- health visitors to firms of general practitioners and experimenting in the value of forming specialised teams to work in the field of general community care both preventive and curative. Prom the current view of these experiments it would seem that close liaison between the general practitioner and health visitor in their mutual care of families is highly desirable. Next year it is hoped that the co-operation that already exists in this Borough between doctors and health visitors will be further encouraged by the attachment of health visitors to general practitioner well-baby clinics already in existence. (k) Gases visited by health visitors, 1st January to 31st December, 1965 Children under 1 year of age Children age 1 and lander 2 years Children age 2 and under 5 years Total No. of Children Visited 2,751 2,579 6,821 12,151 DOMICILIARY MIDWIFERY AND HOME NURSES Throughout the year there were vacancies on the establishment of midwives and home nurses despite the use of part-time staff. On 31st December, 1965 28 full-time and 18 part-time home nurses and midwives were employed and there were 6 vacancies (2.5 home nurses and 3.5 midwives). This created difficulty in covering the needs of the area particularly in the midwifery field and at times midwives had to forego their off-duty time and work for long hours when relief was not available. There was some improvement in the position towards the end of the year. Not all those wishing for hospital confinement were able to be accommodated because of the continuing shortage of hospital beds. The practice of early discharge of some patients confined in hospital creates problems in the domiciliary field but, provided the cases are planned and services properly co-ordinated, a proportion can be properly dealt with in this way. This procedure, however, must not be used to diminish the numbers of mothers having their confinement at home which, in properly selected cases, has many advantages. The level of home confinements must be kept high if standards of practice are to be maintained. 44 The administrative arrangement of these services has continued on the same basis as existed prior to re-organisation. With further experience it will probably be necessary to recommend certain changes which will bring them into a policy more suited to the needs of the new Borough. Attention is also being given to the advantage of attaching home nurses and midwives to groups of general practitioners. Statistical information relating to midwifery and home nursing is contained in the tables which follow. During the period 1st April to 31st December, 1965 home nurses attended 1,513 patients of whom 24 were under the age of 5 years at the time of the first visit and 994 were aged over 65 years when first visited. During the same period domiciliary midwives employed by the Council attended 418 home confinements and cared for 179 mothers discharged from maternity units before the tenth day after confinement. Home Nursing. 1st April to 31st December, 1965 (a) Total number of persons nursed during period 1st April - 31st December, 1965 1,513 (b) Number of persons aged under 5 at first visit period 1st April - 31st December, 1965 24 (c) Number of persons aged 65 or over at first visit period 1st April - 31st December, 1965 994 Domiciliary Midwifery0 1st April to 31st December, 1965 Number of domiciliary confinements attended by midwives under N.H.S arrangements Number delivered in institution but discharged to D.M. before the 10th day. Doctor Booked Doctor not booked Total Doctor present Doctor not present 128 287 3 418 179 (a) Midwives booked cases transferred to hospital during confinement During the nine months 1st April to 31st December, 1965) 478 cases were booked by the domiciliary midwives: of these 42 were transferred to hospital consultants during pregnancy representing 8.8 per cent of all domiciliary booked cases. 18 were transferred to hospital during labour representing 3.8 per Sent of all domiciliary booked cases. 45 The following table analyses the reasons for these emergency admissions (l) In Labour Antepartum haemorrhage 1 Mai presentation 2 Foetal distress 2 *Inertia 7 Toxaemia 1 Prematurity 2 Retained placenta 2 No reason 1 *1 in first stage Total 18 6 in second stage (2) In Pregnancy Antepartum haemorrhage 5 Mai presentation 3 Post maturity 15 Toxaemia 4 Medical grounds 3 Twins 2 No reason 1 Unstable lie 5 Transferred to hospital out of area 2 Intra Uterine Foetal death at 33 weeks 1 High head at term 1 Total 42 46 (b) The 1,513 patients attended by home nurses between 1st April ana 31st December, 1965, required nursing at home for the following reasons:- Heart Disease 110 Circulatory Disease 176 Diseases of the Blood 162 Diseases of the Central Nervous System 48 Influenza 3 Diabetes 29 Scalds and Burns 5 Other Injuries 42 Varicose Ulcers 40 Rheumatic and Arthritic Conditions 79 Chest Conditions, Medical 114 Chest Conditions, Surgical 17 Abdominal Conditions, Medical 175 Abdominal Conditions, Surgical 84 Gynaecological, Medical 49 Gynaecological, Surgical 23 Urinary, Medical 25 Urinary, Surgical 18 Breast Conditions, Medical 13 Breast Conditions, Surgical 11 Skin Diseases, Medical 14 Skin Diseases, Surgical 5 Ear, Nose and Throat, Medical 38 Ear, Nose and Throat, Surgical 1 Orthopaedic, Medical 30 Orthopaedic, Surgical 23 Eye Conditions 8 Pedicures 2 Diagnostic Preparations 6 Miscarriages 6 Threatened miscarriages 8 Others 134 T.B. 15 TOTAL 1,513 (c) Refresher Courses for Midwives. District Nurses and Pupil Midwives During 1965 the non-medical supervisor of midwives, three midwives and six district nurses attended refresher courses. One student district nurse completed her training and twenty-four pupil midwives undertook three months of second period trainings (d) During the calendar year 1965 home nurses made a total of 114,272 visits as follows:- Visits paid by District Nurses and Midwives 1st January - 31st December, 1965 Ante-Natal Midwifery General Nursing Total 5,585 14,420 94,267 114,272 47 Of the 1,513 general patients attending between 1st April and 31st December 1965, 66 per cent were aged over 65 years at the time of the first visit and over 70 per cent of the general nursing visits are to patients in this age group. (e) Local Supervising Authority (Mid-wives) The Borough Council as the Local Supervising Authority are responsible for supervising the work of midwives throughout the Borough. 89 State Certified Midwives gave notice of their intention to practise as midwives in the Borough during the calendar year 1965. (f) Summoning of Medical Aid During the period 1st April to 31st December 1965 medical aid was summoned under the Midwives Act, 1951 by midwives in the following number of cases:- (i) For domiciliary cases:- (a) Where the Medical Practitioner had arranged to provide the patient with maternity medical services under the National Health 96 Service. (b) other 6 (ii) For cases in institutions 159 (g) Ophthalmia Neonatorum Between 1st April and 31st December, 1965 midwives sough'medical aid for suspected cases of Ophthalmia Neonatorum in respect of ten babies. No cases were notified by midwives. (h) Notification from Midwives During the period 1st April to 31st December, 1965 the following notifications were received from midwives:- Sending for medical aid 261 Stillbirths 3 Liability to be a source of infection (including pyrexia) 8 Death of mother or baby Nil (i) Special Investigations The non-medical supervisor of midwives undertook the following special investigations during 1st April to 31st December, 1965:- Sending for medical aid (all were concerned with condition of babies’ eyes) 10 Stillbirths 3 Liability to be source of infection (including pyrexia) 8 Death of mother or baby Nil 48 (j) Maternity Outfits A maternity outfit is supplied free on request to each expectant mother being confined at home who makes use of one or other of the arrangements for the care of expectant mothers under the National Health Service. (k) Maternal Mortality There were no deaths assigned to the London Borough of Sutton in 1965. (l) Puerperal Pyrexia During the period 1st April to 31st December, 1965 87 cases of puerperal pyrexia were reported presenting an attack rate of 45.71 per thousand live and still births. (m) The following table shows the work undertaken at the Ante and Post Natal Clinics during the period 1st April, 1965 - 31st December, 1965 Number of Sessions held by Number of women in attendance No. of attendances Total No. of Sessions Medical Officers Midwives For A.No Examination For P.N, Examination Medical Officers. Sessions Midwives Sessions Total Attendances. 230 216 606 80 1,526 2,340 3,866 446 (n) Ante-Natal. Mothercraft and Relaxation Classes Number of women who attended during 1965 Institutional booked Domiciliary Booked Total Total No. of attendances during year 330 26 356 1,886 LAUNDRY SERVICE FOR INCONTINENT PATIENTS NURSED AT HOME The scheme for a Laundry Service for incontinent patients nursed in their own homes was commenced by the Surrey County Council in February 1963. This has continued to be administered by the Borough since April 1965 and as previously includes the London Boroughs of Merton and Kingston and the Urban District of Esher the cost of running the service being borne proportionately by each Authority according to use St.Helier Hospital undertakes the sluicing of soiled sheets and laundering is done by the Central Laundry of the Regional Hospital Board at an agreed cost. The patients are issued with six draw sheets, which are changed twice weekly or according to need. A vehicle and a full-time driver are employed for the delivery and collection of the sheets and no charge is made to the patients. The following information gives the number of patients being served at the end of year:- London Borough of Sutton 34 persons London Borough of Merton 33 " London Borough of Kingston 30 " Borough of Esher 5 " TOTAL 102 Number of weekly deliveries 170 49 MY NURSERY SERVICE Children are admitted to the Council’s Day Nursery (1) Where the mother is the sole wage earner (2) When there is sickness in the family or where home conditions likely seriously to prejudice the health of the child exist (3) Where, upon consideration of individual circumstances, it appears to the Council that admission is necessary in the interests of the child. The situation of the nursery near to the North West boundary makes it inaccessable to many parts of the Borough. Consequently 27 children normally resident attended the nursery in Middleton Road by arrangement with the London Borough of Merton and 2 children attended nurseries in other Boroughs. 2 children were placed by the Council in private day nurseries. 52 places are available in the Council's nursery, the average daily attendance at which was 32.3. Children attending the nursery are medically examined at six monthly intervals and medical officers and health visitors pay frequent visits. CARE OF THE UNMARRIED MOTHER AND HER CHILD In making provision for the residential care of the unmarried mother and her child the Council rely mainly on voluntary organisations. There is an active Moral Welfare Association in Sutton which runs an 18-bed mother and baby home. The Council makes a grant to the association and in return receives the services of a moral welfare social worker and free admission of mothers up to one third of the total number of beds available. A number of girls. prefer to go to mother and baby homes some distance from their places of residence and at times the Sutton home is unable to accept all the Sutton cases. Under these circumstances, a suitable home is sought elsewhere, the Council being financially responsible for the girl's maintenance, less any contribution she may make of her own or from financial help from her parents or the putative father. The total number of Sutton girls admitted to the Sutton mother and baby home from 1st April to 31st December, 1965 was 14 and the number placed elsewhere was 17. The length of stay at a mother and baby home is normally about twelve weeks - 6 weeks ante-natal and 6 weeks post-natal. Before leaving the home mothers are assisted to find accommodation and employment and in making arrangements for the care of their babies. 50 MOTHER AND BABY HOMES Name and address of home Provided by: "The Haven, 2 Camden Road, Sutton Sutton and District Moral Welfare Association Part B Number of Cases admitted during year Number of beds at end of year Average duration of stay Ante-Natal 48 9 42 days Post-Natal 2 8 42 days Shelter - - - Total 50 17 84 days Number of Costs 9 Number of cases included above for •which Authority accepted financial responsibility 14 RECUPERATIVE HOLIDAYS Adults and children recommended for recuperative holidays are sent to convalescent and holiday home. During the period 1st April to 31st December 1965 no children under the age of five years, 7 school children and 54 adults were sent for recuperative holidays. Patients, excluding school children, are normally required to pay a standard charge towards their maintenance. FAMILY PLANNING ASSOCIATIONS There are two Family Planning Associations in the Borough, Sutton and District Family Planning Association and Carshalton Family Planning Association. Regular weekly sessions at Sutton General Hospital, at St. Helier Hospital and at Green Wrythe Lane Clinic. Mothers whose health is likely to suffer by further pregnancy are referred for family planning advice which is given free in necessitous cases. An annual grant is made by the Council to the associations to cover the cost of cases of this sort. One case was referred between 1st April and 31st December, 1965. I am appreciative of the good work carried out by the Family Planning Associations. DENTAL CARE OF MOTHERS AND YOUNG CHILDREN Dental inspection and treatment of expectant and nursing mothers and children under five was carried out by the dental officers of the Borough who devote approximately 10 per cent of their time to this service. Patients were referred by medical officers and health visitors and some were treated following personal application. At two clinics an inspection 51 by the dental officer in the dental surgery has become part of routine toddlers' examinations. This accustoms the children to the dental surgery and to the idea of dental treatment whilst helping to prevent the first visit to the dentist being associated with pain. Leaflets on oral hygiene and dental care are available and coloured posters illustrating various aspects of dental health are displayed in clinic waiting rooms. Statistics on page 42. HOME HELP SERVICE At no time during the year was it possible to recruit a full establishment of home helps. The re-organisation created particular difficulties in this connection and in the Sutton and Cheam area, previously administered from the Divisional Office at Epsom, the number available in the early weeks was considerably reduced. It will be necessary to consider methods of attracting more women to this service which is an essential part of home care for maternity cases, the sick and the elderly. No other group of workers makes a greater contribution towards domiciliary care then the home helps whose work fulfils the highest calls of public service. The scheme for Neighbourly Helps, whereby neighbours in return for payment up to £2 per week, carry out simple domestic duties for one or more persons in need living in the immediate neighbourhood has much promise; there are some who are reluctant to accept help from their neighbours and some who would be willing to give help are deterred by the legal necessity of obtaining an insurance card. I am sure this scheme is capable of expansion and additional helpers are urgently needed. Nine cases only were being helped in this way in 1965. Other statistical information concerning the Home Help Service is as follows:- Home Help to Households for Persons 1st April to 31st December, 1965 Aged 65 or over on first visit Chronic Sick and T.B. Mentally Disordered Maternity Others Total Number of Cases 563 (64%) 58 2 125 (15%) 130 878 Number of Home Helps (a) Whole time 1 31st December, 1965 (b) Part-time 92 (c) Whole-time equivalent of (b) 51.3 (d) Total 52.3 52 The following tables give details of work undertaken during the period 1st April - 31st December, 1965: (a) Numbers provided with dental care. Persons Examined Persons who commenced treatment Courses of treatment completed Expectant and Nursing Mothers 44 43 50 Children under 5 and not eligible for School Dental Service 533 222 264 (b) Forms of treatment provided during the period 1st April - 31st December, 1965: Scalings & Gum treatment Fillings Silver nitrate treatment Crowns or Inlays Extractions General anaesthetics Dentures provided Radio graphs Pull Upper or lower Partial Upper or lower Expectant and Nursing Mothers 43 87 1 2 18 6 1 4 6 Children aged under 5 and not eligible for School Dental Service 25 760 223 5 97 64 - - 1 TUBERCULOSIS AND OTHER CHEST DISEASES The chest physicians at St.Helier Hospital Chest Clinic, to whom I am indebted for the following information, hold joint Local Health Authority/Hospital appointments to which I refer in my introduction. The clinic serves a major part of the Borough and part of ‘new’ Surrey. Some Sutton patients attend at Cumberland Hospital Chest Clinic, Mitcham. Attendances of Tuberculous and Non-Tuberculous Patients during period 1st April - 31st December, 1965. New Patients 584 3,035 Old Patients 2,451 Chest Clinic Sessions Number held during period 158 Average total number of patients (T.B. and non-T.B. per doctor per session) 19 X-ray Examinations Number of examinations during period 2,596 B.C.G. Vaccinations Contacts vaccinated 71 Others vaccinated 34 Method of Diagnosis of new Cases of Tuberculosis Referred by General Practitioner 13 Mass X-ray 5 General Practitioner referral X-ray 5 Contacts 1 Others - 54 THE CARE OF THE MENTALLY HANDICAPPED The re-organisation of London Government created a greater problem for the new boroughs in regard to the care of the mentally hansticapped than in any other field of health and welfare services. The previous administrative structure had been based on County Hall and bore no relationship to the area of the new Borough. There was, therefore, no foundation upon which to build the transferred service. However, with the very considerable assistance of the Surrey County Council and the London Borough of Merton with both of whom reciprocal arrangements were made for the admission of sub-normal children and adults to training centres, the Council was able to provide a reasonably comprehensive service on the appointed day. Towards the end of the year the Council approved a development plan prepared by the Health Committee which provided for a sufficient number of junior training centre places within the Borough to meet the needs of the foreseeable future. When this comes to fruition many problems connected with the transport of children and availability of places will be solved. So far as can be seen at present it will be possible for arrangements made with Surrey County Council for the admission of adults to their Industrial Training Unit at Banstead to continue and for an increased number of places to be made available for Sutton residents. This will have advantage to both Authorities from many points of view. The community care of the mentally ill also started from very small beginnings. As will be seen from the ensuing paragraphs much has been achieved in a short time but very considerable expansion will be necessary to meet the needs of the mentally ill. In no field of work is there greater scope for development. All members of Health and Welfare department staff can make a significant contribution towards the prevention and early detection of mental illness, as also can staff of other departments whose work brings them into contact with children and families. It will be necessary to encourage training in this field when sufficient staff are available and possible arrangements for this are now under consideration. The Borough is fortunate in having had transferred to them a hostel in course of preparation for ex-mentally ill patients. This will be opened early in 1966. The experience of other Authorities suggests that there may be difficulty in appointing suitable resident staff for this and that for the first year of operation the places available in the hostel may not be fully taken up. Local Authority hostels of this sort are a comparatively new venture and experience of their use is limited. Time will be necessary to establish their value as a means of rehabilitation of the mentally ill towards resuming a normal life in the community. Experience so far gained suggests that this may be considerable. During the period 279 referrals for assistance were received from various agencies, i.e. general practitioners, hospitals, clinics and other sources. All referrals were visited and investigated resulting in 141 patients being admitted to Psychiatric Hospitals. Of these 13 were admitted on an informal basis and 128 under statutory procedures. 37 patients were being supported by the mental welfare officers at 31st March, 1966. Nine patients were supported in voluntary hostels or homes outside the Borough for varying periods during the past year and at 31st March, 1966 5 were in residence. In addition to the number of positive referrals accepted, a substantial number of enquiries and personal interviews connected with mental illness and mental subnormality were dealt with. 55 So far as sub-normal persons are concerned facilities for care, support and training are varied. 96 children and adults from the Borough were receiving day training as follows:- 40 children aged 5 - 13 years at the Morden Junior Training Centre. 15 children aged 13 - 16 at Sutton Training Centre which received children from the London Borough of Merton. 2 children at Caterham Junior Training Centre. 2 male adults at training centres in Croydon. 1 female adult at a training centre in Wandsworth 36 male and female adults at Banstead Industrial Training Unit. During the year the waiting list of adults for attendance at the Banstead Industrial Training Unit was reduced by 6. The present number of places available at Banstead is inadequate to meet our present needs but it is hoped that sufficient placements will be available next year to clear the waiting list and to take those trainees from the Sutton Centre who have attained the age of 16 years. 13 sub-normal children and adults were maintained in residential establishments for care and training, or received day training or special care and at 31st March, 1966 the position was as follows:- 3 -children resident at Lourdes House, The Society of St.Bernadette, Wallington. 3 children resident at Sendhurst Grange, Send. 1 male child resident at Roffey Place, Roffey. 1 male adult resident under the Guardianship Society at Hove. 2 children attending daily The Link Education Trust at Croydon. 1 child attending the Spastic Centre, Croydon. 1 child attending Queen Mary's Hospital for Children - Training School. 5 applications were received for permanent residential care for various reasons and all have been admitted to hospital. 9 applications were received for short-term care to enable parents to have a holiday or because of a family crisis. All were accepted and, with the co-operation of the Manor Hospital and Queen Mary's Hospital for Children, were admitted for periods ranging from 2-6 weeks. 66 male adult sub-normals and their families received support throughout the year from the Mental Health Section. Holiday arrangements for sub-normal children and adults of the Borough had been made by the Surrey County Council prior to London Government re-organisation and 10 adults and 4 children enjoyed this facility. Arrangements will be made during the early part of 1966 for adults and children to have a holiday during the summer. The staff of Sutton Training Centre will be increased by one teacher in January 1966 which will enable the number of children attending the centre to be increased to 30 by the introduction of a further class, 56 For emergency rota duty of mental welfare officers outside normal office hours at night and at weekends arrangements have been made with the neighbouring Borough of Merton. This operates very satisfactorily and it is intended that it should continue. The number of calls received which necessitated mental welfare officers taking emergency action to admit mentally ill patients to mental hospitals averaged two per week during the past year. Community Care Services The Senior Psychiatric Social Worker was appointed on 1st May and during the following eight months 46 cases of special difficulty were referred from the following sources:- Psychiatric hospitals 22 General hospitals 4 General practitioners 7 Children's Department 5 School Health Service 1 Welfare Department 1 Other Authorities 2 Self Referrals 4 At the end of the year 25 of these referrals were receiving continuous after care either through home visits or office interviews and where necessary relatives were also being contacted. Of the remaining 21: 3 left the district. 4 returned to hospital. 13 received short term care and were discharged. Close co-operation with the psychiatric hospitals and the psychiatric day centre has been encouraging. The Senior Psychiatric Social Worker and two mental welfare officers have made regular attendances at the Cumberland Hospital Psychiatric Clinic and a similar ward clinic at Belmont Hospital but it has not been possible with the present staff to cover the four Out Patient Clinics at St.Helier Hospital. The attendance of mental health social workers at these clinics has ensured immediate follow-up of some of the discharged patients. It is hoped that a greater coverage of out-patient clinics will be possible as the mental health service increases in establishment. It is in the out-patient clinics that early signs of mental illness are uncovered and it is here that preventive care should begin. Weekly seminars have taken place at the psychiatric day centre in Woodcote Road, Wallington, thus affording greater integration between hospital and community services. Contact with other statutory services and voluntary associations has been made and co-operation maintained. A keen interest has been shown in the proposed local branch of the National Association for Mental Health. 57 CHIROPODY SERVICE The Chiropody Scheme operated during the year on the lines established by Surrey County Council. The following groups were eligible for treatment (i) Elderly persons, i.e. persons of pensionable age. (ii) Handicapped persons including registered blind and partially sighted, and (iii) Expectant mothers. The Scheme was implemented in two ways:- (i) Direct Scheme in which chiropodists in private practice provided treatment at their surgeries or in the patients" homes or, on a sessional basis, attended to elderly persons resident in homes registered under the National Assistance Act, and (ii) Indirect Scheme in which the Council met the cost of chiropody sessions provided under arrangements made by the Surrey Association for the Elderly and British Red Cross Society (Surrey Branch). Patients contributed three shillings per treatment, free treatment was provided to persons in receipt of National Assistance Benefit and the Medical Officer of Health had discretion to reduce or waive fees in necessitous cases. Payment to chiropodists was in accordance with, or based on, decisions of the Whitley Council responsible for their salaries and conditions of service. In September, 1965 the Health Committee considered a detailed report on the scheme and their recommendations were approved by Council in October as follows:- 1. Authority was given for the appointment of a full-time chiropodist and for the employment of chiropodists on a sessional basis. 2. The eligibility of elderly persons, other than those in receipt of National Assistance Benefit, was limited to those holding retirement pension books, and 3. Patients" contributions were increased from 3s.od. to 4s.Od. per treatment. Whilst these decisions were not implemented during 1965 they made an important contribution to the re-appraisal of the scheme which took place during the year, the results of which will reflect in future reports. As a result of a detailed study of the scheme as transferred from Surrey County Council a new system of records and accounting was devised. Following the appointment of a Senior Chiropodist in January, 1966 this was introduced after consultation with the chiropodists providing services under the Direct Scheme. 58 The Surrey Association for the Elderly had, prior to the 1st April, 1965 expressed a wish to limit their activities to 'new' Surrey at the earliest date. Their co-operation in handling their part of the Indirect Scheme during 1965 is appreciated as is their help in transferring their arrangements into the direct administration of the Council with effect from 1st April, 1966. The two clinics run by the British Red Cross Society (Surrey Branch) will be brought into the direct administration of the Council during 1966. In every case the good-will and continued co-operation of the local organisers and voluntary workers has been given in the best traditions of voluntary service to the community and it is fitting that this report should record this together with an appreciation of the support received from chiropodists remployed in the scheme during the period under review. The following statistical table indicates the level of work carried out between 1st April, 1965 and 31st December, 1965. (a) Indirect Scheme Number of Sessions NUMBER OP TREATMENTS ELDERLY HANDICAPPED Paid Free Patients Paid Free Patients 264 1,637 C 354 D 662 C 264 D 603 8 24 c 20 C 18 Totals 1,991 926 603 24 20 18 2,917 44 C = Clinic D = Domiciliary 59 60 (b) SURGERY DOMICILIARY Number of Treatments Number of Treatments Number of Patients Treated Total Treatments given Paid Free Paid Free Handicapped 89 23 231 192 83 535 Blind and PartiallyBlind 17 15 43 30 19 105 Expectant Mothers 4 — — — 3 4 Elderly 2165 550 1087 514 903 4316 TOTALS 2275 588 1361 736 1008 4960 2863 2097 (c) Sessions at Old People's Homes Registered Under The National Assistance Act Number of Homes Number of Patients Treated Treatments Number of Sessions 6 37 167 43 N.B. The Welfare Committee makes arrangements for chiropody for elderly persons resident in Maiden Homes and Brambleacres. (d) Summary 1st April, 1965 to 31st December, 1965 (i) Total Patients Treated 1,666 (ii) Total Treatments Given 8,088 (a) Surgery 2,863 (b) Domiciliary 2,715 (c) Clinic 2,343 (d) Homes 167 MEDICAL SOCIAL WORK (l) Prevention of Break-up of Families Prior to 1st April, 1965 this work was in the hands of two divisional social workers working in separate divisions of the Surrey County Council. The urgent priority following re-organisation was to continue to support these families, now Tinder one authority, while policy and future patterns were shaped,, Since it was necessary to maintain an intensive casework service case loads had to he small. 37 families were receiving support from the social workers on 1st April, 1965 and new referrals, not including cases considered in connection with rent arrears, during the period amounted to 19. The number of rent arrears cases dealt with during the period was 39. Most families had a multiplicity of problems, the commonest of which were poor physical or mental health, personal inadequacy, marital difficulties, low income and large families, marginal employability, homelessness, excessive drinking and gambling and mis-management of finances where the income was adequate. Heavy hire purchase debts and rent arrears were frequent factors and very often the symptoms which first brought a family to the notice of social workers. Many families need a weekly visit and most even more; in a critical situation the whole of the working day may have to be devoted to one family. 61 Another important part of the work was to develop the machinery of co-ordination. With the creation of new responsibilities in health, welfare and child care which had formerly been the province of the County Council, together with the re-organisation of many existing voluntary organisations and changes in the Housing Authorities, the importance of efficient co-ordination was paramount. Case conferences were held whenever necessary between workers from the numerous statutory and voluntary agencies concerned with the family under discussion, the Senior Social Worker being responsible for arranging and minuting these meetings and following up the recommendations. The co-operation of officers of other departments and voluntary agencies necessary for this work to proceed smoothly was willingly supplied and much appreciated. (2) Chest Clinics Many patients attending chest clinics suffer from severely disabling and chronic illness or require a prolonged course of treatment. The needs for social worker support for these cases is sufficient to justify the attachment of a full-time medical social worker to the chest clinic at St.Helier Hospital who attends seven clinic sessions weekly and devotes three half-days to visiting. The Disablement Resettlement Officer from the Ministry of Labour visits weekly to discuss problems of rehabilitation, special training and employment. The type of problems presented by such patients include the following: 1. Prolonged treatment necessary creating financial difficulties for the family caused by loss of earning capacity. 2. Permanent inability to work because of a chest or heart complaint and therefore needing prolonged social support. 3. Advised to change from unsuitable employment to a different type of work. 4. Needing occupation at home because of limited physical ability to lead a normal life. 5. In need of convalesence, recuperative holidays, or family holidays following illness. Home Visits The medical social worker pays an average of twelve home visits weekly and reports that the need to visit patients suffering from lung cancer and chronic bronchitis and emphysema prevents her from visiting chronically ill and tuberculous patients as frequently as she would wish. Care Committees There are two voluntary care committees operating in the Borough, one covering the area of the old Sutton and Cheam Borough and the other the Beddington, Wallington and Carshalton area. The care committees continue to give excellent service to patients attending the chest clinics and their work on behalf of non-tuberculous chest patients and their families is now at about the same level as that for those suffering from tuberculosis. The care committees work in close association with the staff of the chest clinics and especially with the medical social worker to whom all requests for financial help are referred. 62 HEALTH EDUCATION All members of staff concerned with health services are responsible for education in health as part of their normal duties. Although each makes only a small contribution the aggregate constitutes a considerable volume of works The Council appointed a part-time officer to deal with the home safety aspect of this work and health visitors and medical officers undertake formal and informal health educational activity so far as other commitments will allow. There is no doubt that a great deal more needs to be done in educating members of the public in matters of health and this can only be achieved by the appointment of a specialist member of staff able to devote his or her whole time to this work. The appointment of such a person was allowed in the establishment approved by the Council but was later deferred on account of the general financial situation. When this improves serious consideration will have to be given to filling the appointment as soon as possible. In the meantime, so far as possible, formal invitations from groups of people for talks, discussions and films are accepted and clinic staffs make similar arrangements for the mothers who attend. Two of the main clinics have active associations of parents who meet regularly, when opportunity is taken to provide material of health educational interests. Posters and pamphlets are distributed in clinics and schools but the more positive approach of a specialist officer to direct and co-ordinate this work is highly desirable. HOME SAFETY On 20th June, 1965 representatives of the committees hitherto responsible for home safety activities met to discuss the future of home safety in the new Borough. It was agreed that those committees should continue to operate as district sub-committees, each working within their old boundaries and that a main committee should undertake the co-ordination of their activities within the Borough as a whole. Each committee agreed to nominate 3 members to the main committee which would be completed by 3 members appointed by the Borough Council and 4 co-opted members from the Fire Service, South Eastern Gas Board, South Eastern Electricity Board and Area 10 Home Safety Council. This arrangement was adopted and a part time Home Safety Officer who also acted as secretary to the committee was appointed by the Borough Council. (a) Exhibitions The Home Safety Committee and District Sub-Committees co-operated with the Fire Service during their 'open Day' on 23rd October, 1965. A large Home Safety Fire Prevention Exhibition was put on at each of the Fire Stations, with great success. (b) Lectures Ten lectures were given during this period, some with films and some with slides. (c) Literature literature on home safety matters was extensively distributed to schools, clinics, libraries, fire stations, organisations (when giving talks) doctors' surgeries, engineers and highways departments, youth clubs, health visitors, home helps and district nurses. 63 (d) Accident Returns The number of home accident casualties conveyed by ambulance to hospital between 1st April, 1965 to 31st December, 1965 was as follows:- Under 1 year 1-4 years 5-14 years 15-24 years 25-44 years 45-64 years 65+ years Age not stated Total 2 39 31 16 49 44 70 16 267 These figures relate only to those accident cases of sufficient severity to warrant the calling of an ambulance. The total of those requiring first aid or treatment by the general practitioner or who attended hospital by their own transport is unknown but is obviously much greater. Attention is drawn to the large number of home accidents involving the young and the elderly, more than half the total being made up of those over 65 years and under 15 years of age, less than a third of the total population. 64 ENVIRONMENTAL HEALTH SERVICES PART IV HOUSING. Clearance of Unfit Houses. Due to reorganisation the year under review was an unsatisfactory one and little progress was made. Some preliminary survey work was undertaken, with a view to estimating the number of houses which should be included in the Council's programme. This has shown that some two hundred families are living in houses which do not appear to satisfy the standards of the Housing Act, 1957. Attempts were made to inaugurate a co-ordinated plan of action having regard to redevelopment areas and the housing programme, and these will continue. The major difficulty is that areas are of a scattered nature and their size does not render them suitable for redevelopment. Five unfit houses, Nos. 7-15 Park Road, Cheam, which the owner had agreed not to re-let, became unoccupied and were demolished without statutory action being taken. Inspection and Action taken under Statutory Powers. (a) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 5,207 (b) Number of inspections for the purpose 7,783 1. Number of dwelling houses found not to be in all respects reasonably fit for human habitation 307 2. Remedy of defects during the year without service of formal notices. Number of defective dwelling houses rendered fit in consequence of informal action by local authority or their officers (including houses inspected during 1964) 122 3. Action under Statutory Powers during the year. (a) PROCEEDINGS UNDER SECTIONS 9, 10 and 12 OF THE HOUSING ACT, 1957. Number of dwelling houses in respect of which notices were served requiring repairs — Number of dwelling houses which were rendered fit after service of formal notices: (a) By owners — (b) By Local Authority in default of owners — (b) PROCEEDINGS UNDER PUBLIC HEALTH ACTS. (l) Number of dwelling houses in respect of which formal notices were served requiring defects to be remedied 58 (2) Number of dwelling houses in which defects were remedied after service of formal notices: (a) By owners — (b) By Local Authority 33 67 RENT ACT. 1957. The following details show the action which has been taken during the years Part I - Application for Certificate of Disrepair (l) Number of applications for certificates 3 (2) Number of decisions not to issue certificates Nil (3) Number of decisions to issue certificates (a) in respect of some but not all defects 3 (b) in respect of all defects — (4) Number of undertakings given by landlords under paragraph 5 of the First Schedule 2 (5) Number of undertakings refused by Local Authority under proviso to paragraph 5 of the First Schedule Nil (6) Number of certificates issued 1 Part II - Application for Cancellation of Certificates (7) Application by landlords to Local Authority for cancellation of certificates Nil (8) Objections by tenants to cancellation of certificates Nil (9) Decisions by Local Authority to cancel in spite of tenants' objection Nil (10) Certificates cancelled by Local Authority Nil Houses in Multiple Occupation. During the year an effort was made to co-ordinate the work commenced in the constituent Authorities and to survey the area with a view to complete inspection all houses found to be occupied by several families. To achieve uniformity the Council agreed standards for this class of accommodation to replace the three differing standards previously in use. Thirty-one houses were inspected and informal notices were served relating to twenty-three. In thirteen cases the notices were either complied with or rendered unnecessary by demolition of the houses or reduction in the number of families. At the end of the year an additional assistant was appointed to facilitate the survey and inspections. Housing Act, 1957 - Part IV (Overcrowding). All known cases of overcrowding were reviewed during the year and as a result sixteen dwellings were found to be still overcrowded, involving seventeen families with eighty-three equivalent adults in occupation. 68 Forty-four cases of overcrowding were abated, eleven formally and thirty-three informally. (a) (l) Number of dwelling houses overcrowded at the end of the year 16 (2) Number of families dwelling therein 17 (3) Equivalent number of adults dwelling therein 83 (b) Number of new cases reported during the year — (c) (1) Number of cases of overcrowding relieved during the year 44 (2) Number of persons concerned in such cases 185 (d) Particulars of any cases in which dwelling houses have again become overcrowded after the Local Authority have taken steps for the abatement of overcrowding CARAVANS. Numerous complaints were received and inspections made of sites at Green Lane, Worcester Park, and Cuddington Way, Cheam, which were being used for the parking of caravans occupied by families of travellers. The sites were found to be insanitary and lacking in facilities. The Council resolved to proceed under Section 57 of the Surrey County Council Act, 1931, to obtain Orders prohibiting the use of the land for the parking of moveable dwellings within a radius of 880 yards of the sites. By the end of the year an Order relating to the Green Lane site had been obtained. Complaints relating to caravans on the Croydon Airport land (Roundshaw) were dealt with informally. There are no authorised caravan sites in the Borough. FOOD AND DRUGS. Inspection and Supervision of Food Premises. Care was taken to ensure that the effects of reorganisation were not permitted to interfere unduly with the inspection of food premises. On the contrary, efforts were made to relieve public health inspectors of less important functions which had in parts of the Borough reduced the efficiency of supervision. Two thousand, one hundred and ninety-five inspections of food premises were made and 203 informal notices were served drawing attention to unsatisfactory conditions, In addition, 173 complaints alleging adulteration or unsoundness of food were investigated thoroughly and appropriate action was taken in each case. Legal proceedings were instituted in one case, when a fine of £10 was imposed. 69 The more interesting complaints are summarised below: Bakelite in apple pie Mould on Cornish pasty Fly-eggs in bacon Ants in gooseberry pie Piece of cardboard in bread Worm in jam Needle in bread Mould in liver and bacon croquettes Piece of wire in bread Dirty milk bottle (4) Oil and dirt in bread Piece of steel wool in milk Paper in bread (2) Grass in milk Insect in bread Mould growth in milk (2) Mould in bread (4) Dirt in bottle of milk Metal nut in bread Mould on steak and kidney pie Grit and dust on bread Mould on sausages Glass in bread roll Mould on luncheon meat Mould on corned beef Stone in veal and ham pie Dirt on sliced corned beef Grub in Weetabix In an effort to maintain satisfactory food standards, the following samples were taken for examination, as distinct from those obtained for chemical examination under Food and Drugs legislations Milk 176 Ice Cream 115 Water 56 Other Foods 101 Milk. Classification of the milk samples and the results of the tests are as follows: Designation under which sold No. of samples Methylene Blue Test Phosphatase Test Turbidity Test Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory Pasteurised 157 156 1 157 — — — Untreated 10 6 4 — — — — Sterilised 9 — — — — 9 — 176 162 5 157 — 9 — Two samples of raw milk submitted for examination were found free of tubercle bacilli or brucella after animal inoculation. 70 Ice Cream. Of the one hundred and fifteen samples of ice cream procured for bacteriological examination 92 were Grade I, 4 Grade II, 12 Grade III, and 7 Grade IV. All registered retailers draw their supplies of ice cream from reputed manufacturers outside the district. There are three manufacturer-retailers of soft ice cream. Advice was given following the receipt of unsatisfactory reports and further samples obtained until a satisfactory result was achieved. 71 Water. All the water samples were reported as satisfactory. Other Foods. Black Pudding 3 Cheese 1 Confectionery (Flour) 12 Cream 3 Fish 4 Faggots 1 Hamburger 2 Haslet 1 Meat 67 Rumbaba 1 Salad 3 Soup 1 Xmas Pudding 1 Yoghurt 1 In no case were organisms of food poisoning found. Registration of Milk Distributors. The number of Milk Distributors registered under the Milk and Dairies (General) Regulations, 1959, is 52. Designated licences in force, under the Milk (Special Designation) Regulations, 1963, (as amended), during the year were as follows:- Dealer's (Pre-packed Milk) Sterilised 69 Pasteurised 67 Untreated 52 Dealer's (Pasteuriser's) 1 Unsound Food The following quantities of food found to be unsound, diseased or unwholesome and unfit for human food were surrendered and destroyed or so disposed of as to prevent them from being used for human food. lbs. Butter 18 Confectionery (Flour) 130 Cheese 3 Cream 3 Fat 16 Fish 965 Fruit 850 Fruit Juice 8 Ice Cream 2 Jam 9 Meat (including canned meat) 4,731 Milk 16 Mineral Water 1 Rice 5 Sauce 8 Soup 12 Vegetables 724 The usual method of disposal is by burning in the Council's refuse destructor. Slaughterhouses. There are no slaughterhouses in the Borough. Adulteration of Food. During the year, 495 samples of various foodstuffs and drugs were purchased for examination by the Public Analyst, Mr. D.D. Moir, M.SC., F.R.I.C., to whom I am indebted for the following observations on the year's work and for his valuable and ready advice at all times. Public Analyst's Comments. In these comments, which I used to contribute annually to the Report of the Medical Officer of Health for the Borough of Sutton and Cheam, I have always attempted to survey in as few words as possible the field of consumer protection as far as it applies to Pood and Drugs; to note helpful changes in the law and sometimes to criticise trends which I believe to be against 72 the interests of the purchaser. The work of the Public Analyst is often not spectacular but it is usually of vital and absorbing interest to those directly involved. I venture to say it is sometimes too absorbing and the chance to get outside it and look at it objectively is always welcome. I am very grateful to Dr. Westcombe for giving me the opportunity to continue with these comments now that I have the honour to serve the new London Borough of Sutton in place of two of its former components. In looking back on the year 1965 I feel it to be one of little actual change, but of immense preparation for change, both on the part of the Ministry of Agriculture, Fisheries and Pood in preparing for new legislation and revision of old, and on my own part in striving to keep up with new techniques, new instrumental methods of analysis, and to sift the immense mass of scientific literature covering both Food Science and Drugs which continues to pour out in an ever increasing flow from the relevant Journals. Forthcoming legislation is envisaged in the proposals for Regulations issued by the Ministry relating to Canned Meats, Meat Pies, and Sausage and other Meat Products. These are long overdue and even now, at the time of writing, official Regulations have not appeared. It must be remembered that in all these matters and wherever the composition of a foodstuff is not covered by a standard, it is the duty of the Public Analyst to put forward his own, like a coconut for everybody to shy at. It is to the credit of my colleagues up and down the country that in most of those cases where legislation has recently been made or about to be made the standards erected by them have been adopted with little variation. During the year the Food Standards Committee Report (No.l) on the Labelling of Food has been published and has been followed by proposals for revised Regulations. Although the main provisions of the existing Labelling of Food Order are likely to be followed, there will probably be considerable alteration in detail particularly in regard to the declaration of the so-called 'Additives', preservative colouring matter, antioxidants, emulsifiers, and sweetening agents. It is proposed too that this declaration will be required in connection with many foods which are not pre-packed. The Food Standards Committee has also issued a Report on Flavouring Agents and, contrary to the usual conception of having a permitted list of additives, all others being forbidden, have recommended that for the time being a prohibited list of 16 substances which could be used as flavouring agents be promulgated and that by inference all other flavours be allowed. Of the Regulations which have been passed into law during 1965> mention should be made of the Dried Milk Regulations, 1965, the provisions of which have caused a certain amount of confusion in the labelling of many of the newer products of the "instant dried milk" variety which have been a recent development of food technology. Two of these, Samples Nos. 4 and 165, are mentioned in the Chief Public Health Inspector's detailed report. Frequent cases of 'milk' bread being made with skimmed milk are also met with in my experience, and one of these, Sample No. 242, was also found by a Sampling Officer of the Borough. The wide variety of samples taken and examined can be gauged by a study of the complete list. The numerous 'complaint' samples submitted by members of the public continue to grow and to take a very large proportion of my time. I feel, however, that this is consumer protection at its best and in making my reports on such samples I always aim to be completely fair to both the 73 manufacturers and members of the public. The ever growing number of modem drugs have also received attention in the samples submitted and, perhaps contrary to the belief in some quarters, it is rare for any fault to be found in any of these as regards accuracy of manufacture and composition. It is perhaps significant that two cases, Nos. 82 and 83 (Tincture of Iodine and Ammoniated Tincture of Quinine) where older type drugs have been sampled, a fault has been found. Perhaps this indicates that there is now no demand for such articles and that they linger on the shop shelves too long. Food Samples - Chemical Analysis 1965 Formal Informal Adulterated Total Formal Informal Beverages 22 29 2 51 Cereals 5 1 5 Cheese 1 15 1 16 Condiment 3 1 1 4 Confectionery Flour 16 21 2 37 Confectionery Sugar 2 12 14 Cream 4 4 Drugs 1 52 2 53 Fat and Oils 4 12 16 Fish 1 8 9 Fruit 19 1 19 Ice Cream 16 6 22 Meat 9 21 1 30 Milk 75 57 1 3 132 Preserves 1 7 8 Sauce 9 9 Sausages 9 1 9 Soup 6 6 Spices 9 9 Vegetables 1 5 6 Miscellaneous 3 33 36 164 331 2 14 495 TOTAL 495 The samples described as adulterated or irregular were reported upon by the Analyst as follows and action was taken as indicated: Informal Sample - Ammoniated Tincture of Quinine. The sample contained ammonia (NH3) 0.52 per cent w/v, instead of 0.85 - 1.05 per cent w/v as quoted in the British Pharmaceutical Codex. The vendor stated that in his opinion the deficiency of ammonia was due to the age of the sample and that all old stock had been destroyed. Informal Sample - Buttermilk Drink Fat Free. The Public Analyst regarded this sample as one of cultured skimmed milk and that although in his opinion prejudice to the purchaser would be extremely difficult to prove he wished the attention of the manufacturer to be drawn to his objection to the term Buttermilk being used. The manufacturer was informed accordingly and in reply stated that he disagreed with the Public Analyst's opinion. A formal sample will be obtained. Informal Sample - Cake Fruit Mixture. The container of the mixture of sultanas, currants, seedless raisins and cut mixed citrus peel was not labelled in accordance with Article 4 of the Labelling of Food Order, 1953. The vendors stated that their Branch Managers were instructed to comply with the Labelling Order by affixing labels on pre-packed articles. Informal Sample - Calves Liver Pate. The ingredients specified on the label of the container as "made from pure liver, pork and selected spices". Liver is a generic and not a specific description which is required by the Labelling of Food Order, 1953. Informal Sample - Coffee White. The milk content of the sample was 15 per cent by volume and in the opinion of the Public Analyst white coffee should contain not less than 50 per cent by volume of milk. Informal Sample - Danish Pasteurised Cream Cheese Spread with Pineapple. A sample containing cream cheese, vegetable gum and pineapple. The term 'vegetable gum' is not an appropriate designation for the purpose of the Labelling of Food Order, 1953. The manufacturers submitted a copy of a new label specifying vegetable gum as "CAROBGUM". Informal Sample - Devon Fancies. A sample of small fancy cakes or pastries comprising a pastry case filled with cake substance with a layer of jam at the bottom and topped with various forms of icing and decorations. The Public Analyst was of the opinion that the term 'Devon Fancies' should be applied only to cakes that are either peculiar to or originate from Devon. 75 Formal Sample - Hot Milk. A sample of hot milk containing added water to the extent of 8 per cent. The explanation of the vendor that the added water was due to heating the milk by steam injection was accepted. The vendor agreed to discontinue that method of heating. Informal Sample - Instant Low Fat Milk (Skimmed). A genuine sample of dried skimmed milk containing 1.0 per cent of milk fat. The labelling of the envelope container of the article was not in accordance with the provisions of Schedule 2 of the Dried Milk Regulations, 1965, nor with the rules laid down in the Schedule to Dried Milk Regulations, 1923 to 1948. A draft of a new label was submitted by the manufacturers and proved acceptable to the Public Analyst. Informal Sample - Instant Low Fat Milk (Skimmed). A sample of dried skimmed milk containing milk fat 0.5 per cent. The labelling of the article was not in accordance with the provisions of Schedule 2 of the Dried Milk Regulations, 1965. Informal Sample - Milk Bread. A sample of bread made with skimmed milk powder but contained no whole milk solids and therefore did not satisfy the requirements of the Bread and Flour Regulations, 1965, which stipulate a minimum of 6 per cent of whole milk solids in milk bread. The vendor stated that full cream milk powder was being used and a formal sample taken at a later date satisfied the requirements. Informal Sample - Non Brewed Condiment. A sample of non brewed condiment contaminated with a small mould growth which was discharged from the bulk container during the filling of the container in which the condiment was sold. A formal sample taken two weeks later proved to be satisfactory. Formal Sample - Pork Sausages. Pork sausages containing 160 parts per million by weight of sulphur dioxide and sold without the declaration of added preservative. A warning letter was sent to the vendor regarding future compliance with the requirements of the Preservatives in Food Regulations, 1962. Informal Sample - Rich Thick Danish Milk. The labelling of the container of the article was not in accordance with the Labelling of Food Order, 1953. New labels printed by the manufacturer were approved by the Public Analyst. Informal Sample - Tincture of Iodine. A medicament containing total iodine compounds expressed as iodine (I2) 2.92 per cent w/v, but contained no free iodates. The sample was labelled 'Decolourised Tincture' and was prepared in accordance with a formula in the British Pharmaceutical Codex 1934. 76 Informal Sample - Short Cut Macaroni. An Italian paste made from wheat flour and artificial colouring and described as 'Short Cut Macaroni'. The Public Analyst was of the opinion that the description of the article was not appropriate and that the two ingredients as set out in the form of a statement, did not satisfy the requirements of the Labelling of Food Order, 1953. The distributors of the article passed the observations of the Public Analyst to the manufacturers in Israel. 77 78 INSPECTION OF FOOD PREMISES AND ACTION TAKEN Sanitary Accommodation Food Storage & preparation Rooms Number of premises Number of premises registered under Sec,i6 of Food & Drugs Act Number of Inspections made Repaired Cleaned and/or decorated Lighting provided Wash basin provided Water supply provided Nail brush and soap provided Wash your hands notices Repaired Cleansed and/or decorated Lighting provided Ventilation provided Washing facilities for food & equipment First Aid materials provided Accommodation for clothing provided Accumulations removed Bakehouse 3 — 72 — — — — — — — — — — — — — — — Bakers & Confectioners 47 6 111 1 — — — — — — 1 1 — — — — — — Butchers 103 94 342 3 4 2 2 3 3 — 3 4 — 1 — 1 1 — Canteens 106 — 227 1 3 — — — 1 4 4 4 — 2 1 3 2 — Chemists 37 1 18 — — — — — — — — — — — — — — — Confectioners (Sugar) 203 180 159 — 1 — — 1 1 — — — — — — — — — Fishmongers 40 18 121 — — — — 1 — — 2 2 — — — — — — General Stores 16 11 157 — — — — — — — — — — — — — — — Greengrocers & Fruiterers 112 22 183 — 2 — — — — — 1 1 — 1 — — — 1 Grocers (lncl. Corn chandlers) 231 123 328 4 8 1 — 1 1 1 3 8 1 1 — 1 2 — Licensed premises 52 7 81 — — — — — — — — 2 — — — — — — Milk storage depots 3 — 16 — — — — — — — — — — — — — — — Restaurants & Cafes 91 57 276 3 3 3 — 1 1 — 7 5 — 2 — 1 2 — Factory Food 3 1 2k — — — — — — — — — — — — — — — Stalls - food — 53 — — — — — — — — — — — — — — — Vehicles - Food — 15 — — — — — — — — — — — — — — — Vehicles - ice-cream — 12 — — — — — — — — — — — — — — — 520 2,195 12 21 6 2 7 7 5 21 27 1 7 1 6 7 1 CLEM AIR ACT. 1956 - SMOKE CONTROL AREAS. At the 1st April, 1965- ten Smoke Control Areas which had been established under Orders made by the former constituent Authorities were in operation. Three Smoke Control Orders previously confirmed by the Minister of Housing and Local Government came into operation during the year: Carshalton No.5 141.36 acres 1,247 dwelling Beddington & Wallington No.5 120 " 1,159 ,, Sutton & Cheam No.3 100 " 1,289 ,, Surveys on two further areas, designated London Borough of Sutton No. 14 and No. 15 continued; the Smoke Control Order in respect of No.14 Area being confirmed on 31st December, 1965. At the end of 1965, thirteen Smoke Control Orders covering 2,851 acres and including 18,901 premises, were in operation, and one further Order (London Borough of Sutton No.14) covering 116 acres and including 1,003 premises had received Ministry confirmation. Each of the former Authorities kept daily records of atmospheric pollution by smoke and sulphur dioxide by means of sulphur dioxide apparatus, and of grit deposit by deposit gauges. Volumetric S02/Smoke filter apparatus is installed at: (1) Wallington Town Hall (2) The Library, Manor Road, Sutton (3) The Lodge, Honeywood Walk, Carshalton Grit deposit gauges (5) are sited at: (1) Buckhurst Avenue Pumping Station, Carshalton (2) Winchcombe Road School, Carshalton (3) Crown Road School, Sutton (4) Sutton General Hospital, Brighton Road, Sutton (5) Cheam Hospital, London Road, Cheam. The recordings taken during 1965 were as follows: 79 80 SUMMARY OF AIR POLLUTION MEASUREMENTS FOR 1965 Station BEDDINGTON & HALLINGTON NO. 1. CARSHALTON NO. 4. SUTTON & CHEAM NO. 8. Highest Lowest Average Highest Lowest Average Highest Lowest Average Smoke S02 Smoke SO2 Smoke So2 Smoke So2 Smoke So2 Smoke S02 Smoke SO2 Smoke SO2 Smoke SO2 JAN. 183 378 05 25 55 141 289 331 04 15 45 71 202 392 10 30 76 174 FEB. 237 556 08 57 77 233 83 132 03 29 35 84 303 683 27 96 106 301 MAR. 121 290 03 32 38 126 74 247 04 39 19 85 119 386 06 34 38 126 APL. 69 259 04 33 29 93 98 266 03 30 45 96 88 326 10 30 39 103 MAY 40 84 01 13 13 45 64 89 06 13 21 46 54 99 04 18 20 48 JUNE 55 166 03 15 17 62 72 173 o4 18 22 70 76 172 05 12 20 58 JLY. 20 60 03 07 08 30 23 71 04 18 12 42 21 159 03 06 09 40 AUG. 37 114 03 19 l4 40 70 100 06 23 23 44 37 80 07 12 16 42 SEPT. 59 96 o4 18 21 40 60 115 10 23 27 46 52 109 12 19 27 45 OCT. 133 235 04 21 54 103 149 257 08 13 62 120 190 336 06 18 66 145 NOV. 169 331 07 l4 60 127 l60 336 12 13 84 141 208 449 12 18 83 172 DEC. 186 311 06 14 51 84 286 366 13 10 86 104 215 354 09 16 63 117 ALL FIGURES REPRESENT QUANTITIES EXPRESSED IN MICRO (MILLIONTHS) GRAMMES PER CUBIC METRE OF AIR. SUMMARY OF RAINFALL AND DEPOSITED MATTER 1965 Site Crown Road school Sutton General Hospital Brighton Road, Sutton Cheam Hospital London Road, Cheam Wlnchcombe Road school Carshalton Buckhurst Avenue Carshalton Bowl D 517 D 520 D kk90 D 12lj6 D 1967 Gauge 2 6 7 B C Rainfall in ins. Total Solids (Tons per sq. mile) Rainfall in ins. Total Solids (Tons per sq. mile) Rainfall in ins. Total Solids (Tons per sq. mile) Rainfall in ins. Total Solids (Tons per sq. mile) Rainfall in ins. Total Solids (Tons per sq. mile) JAN. 2.6k 10.97 2.80 11.55 1.61 8.97 2.64 12.92 2.21 8,79 FEB. 0.55 9,k1 0.47 7.41 0.55 9.04 0.51 7.55 0.55 7.7 MAR. 1.65 17.00 1.61 8.36 1.50 l0.44 1.30 13.7k 1.50 13.39 APL. 1.54 16.20 1.54 7.61 1.54 8.00 1,38 12.72 1,k8 12.25 MAY 1.23 8.32 1.60 7.27 1.39 5.66 1.10 6.01 1.k3 9.0 JUNE 1.77 11.33 1.54 8.63 1.81 8.87 1.14 6,k9 1.30 7.72 JLY. 2.44 9.45 2.56 8.53 2.44 8.36 2.36 8.16 2.33 8.22 AUG. 1.70 7.69 2.31 6.52 1.70 5.07 1.6k 8.04 1.70 8.69 SEPT. 5.05 10.89 5.36 9.81 4.65 7.00 5.20 9.26 5.05 9,96 OCT. 0.77 9.44 0.79 5.17 0.88 9.87 0,80 9.35 0,90 6,88 NOV. 3.12 12,19 3.26 11.36 3.04 12.70 4.00 9.45 3.06 10.00 DEC. 3.84 7.98 4.04 7.71 3.56 6.30 3.76 6.73 3.71 6.65 TOTAL 26.30 130.77 27.96 99.93 24.67 100.28 25.83 110.k2 25.22 109.29 MEAN 2.19 10.90 2.33 8.33 2.05 8.36 2.15 9.20 2.10 9.11 WATER SUPPLY. All houses in the Borough have piped water supply. The majority are supplied by the Sutton District Water Company, a few near the northern boundary are supplied by the Metropolitan Water Board. There are private wells at hospitals, factories and a school. The average fluoride content of the water is 0.1 parts per million. The Sutton Company draws its supplies from wells in the chalk at Woodmansterne, Sutton and Cheam, and is under statutory obligation to soften the water to 9° of hardness. The following is a copy of a routine sample taken by the public health inspectors Report on Examination of a Sample of Water Sources Sutton District Water Company Date Received: 15th March, 1965 Particulars on Labels Sutton & Cheam 145. Drinking Water from 158 Sutton Court Road, Sutton. 11 a.m. 15.3.65. Physical Characters: Reaction (pH)s 7.5 Taste Normal Odour None Colours Greenish Blue Appearances Bright and Clear Electrical Conductivity at 20°C. 240 reciprocal megohms. Chemical Characters: Parts per million (.milligrams per litre) Total Solids dried at 180°C 160 Chlorine in Chlorides as Chlorion 16 Nitrite Nitrogen trace Nitrate Nitrogen 4.2 Ammoniacal Nitrogen 0.00 Albuminoid Nitrogen 0.00 Oxygen absorbed in 4 hours at 27°C 0.00 Alkalinity as CaC03 71 Hardness as CaCO3 Carbonate 71 Total 108 Non-Carbonate 37 Free Carbon dioxide as CO2 Residual Chlorine None Iron None Other Metals None 82 Bacteriological Examination: Number of colonies developing per millilitre of water: on agar in 2 days at 37°C 1 on agar in 3 days at 22°C 112 Bacteria of indication enumerations Organisms of the coliform group 0 in 100 ml. Streptococci 0 - " - CI. welchii 0 - " - Remarks: This water is attractive in appearance, of excellent organic purity, and is free from contaminating metals. It has the general characteristics of a softened water from a chalk supply. The bacteriological condition of the water is satisfactory, the organisms developing at 22°C being harmless types of no adverse significance. As judged by this examination the water is pure and wholesome and suitable for the public supply. (signed) Daniel D. Moir, M.Sc., F.R.I.C. Public Analyst. I am indebted to Mr. E.G.B. Gledhill, B.Sc., M.I.Mech.E., M.I.W.E., A.M.I.C.E. A.M.I. Struc.E., Engineer and Manager of the Sutton District Water Company, for his comments which are as follows: Maximum and Minimum Temperatures: The maximum temperature of 83°F„ occurred on Friday, 14th May, 1965. The lowest temperature during the year, of 21°F,, occurred on 27th December, 1965. Rainfall - (Sutton. Carshalton Road): Rain fell on 181 days in 1965. The heaviest rainfall amounted to 2.19 inches on Friday, 3rd September. The total rainfall during the year amounted to 27.62 inches compared with the 35 year average of 25.72 inches. Consumptions: Maximum daily consumption - Saturday, 4th May, 1965. 15,234,000 gals. Average daily consumption throughout the area during the year 11,396,000 " second highest annual average. All domestic premises in the London Borough of Sutton, to the best of my knowledge, have a piped supply. An unrestricted supply of water was maintained at all times throughout 1965 to all consumers. Over 2,500 samples were examined by the Company's Chemist and Bacteriologist in 1965. R3 PREVENTION OF DAMAGE BY PESTS ACT. One thousand, three hundred and thirty-two complaints of rat or mouse infestation were received and investigated. At 1,256 premises infestation was confirmed and treatments were carried out. Twenty-one informal notices were served under Section 4 of the Act. NOISE ABATEMENT. Eighty-seven complaints indicating nuisance from noise were investigated; 356 visits to premises being made for this purpose. Informal action was taken in appropriate cases to reduce the noise level. SHOPS ACT, 1950. There are 1,750 shop premises on the register and 3,569 inspections which were made during the year were mainly in conjunction with the survey being carried out under the Offices, Shops and Railway Premises Act, 1963. OFFICES. SHOPS AND RAILWAY PREMISES ACT. 1963. During the year, 140 premises were registered in accordance with the Act, making the total number 1,457. The number of persons employed in the classes of premises as reported to the Minister of Labour at the end of the year is as follows: Class of Premises Total Number Registered at end of Year Number of Persons Eknployed Offices 417 5,133 Retail Shops 932 5,472 Wholesale Shops, Warehouses 29 291 Catering Establishments and Canteens 77 678 Fuel Storage Depots 2 20 Total 1,457 11,594 84 Preliminary notices were served relating to non-compliance with the Act in respect of the following: Contravention Notices Complied Overcrowding 12 5 Ventilation 42 5 Cleanliness 86 22 Temperature (incl. thermometers) 286 87 Lighting 37 13 Sanitary Conveniences 168 50 Washing Facilities 193 52 Water Supply 7 4 General Conditions 15 7 Stairs/Passages 65 19 Clothing Storage 62 19 Drying Facilities 49 14 Seats 9 2 Machinery 9 2 First Aid Equipment 265 68 Notices 296 72 Canteen Facilities 9 2 Factories and Outworkers. Inspections for the purpose of provisions as to health: Premises No. on Register Number of - Inspections Written Notices Occupiers Prosecuted (1) (2) (3) (4) (5) (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 99 40 2 - (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 519 432 17 - (iii) Other premises in which Section 7 is enforced by the Local Authority *(excluding outworkers' premises) 18 40 2 - 636 512 21 - * Electrical Station (Section 123 (1)), Institutions (Section 124) and sites of Building Operations and Works of Engineering Construction (Section 127). Slaughterhouses, (Section 175 (0 (d) and (e) and Railway Running Sheds (Section 175 (2) and (10) ). 85 Cases in which Defects were Found. Premises Number of cases in which defects were found Number of cases in which prosecutions were Found Remedied Referred - To HoMo Inspector By H.Mo Inspector (1) (2) (3) (4) (5) (6) Want of cleanliness - 1 - _ _ Overcrowding - - - - - Unreasonable temperature - - - - - Inadequate ventilation - - - - - Ineffective drainage of floors - - - - - Sanitary Conveniences: (a)Insufficient 3 - _ - - (b)Unsuitable or defective 16 3 - - - (c) Not separate for sexes - - - - - Other offences against the Act (not including offences relating to Outwork) 1 - - - - Total 20 4 - - - Outwork (Sections 133 and 134.) Nature of Works Section 133 Section 134 No. of outworkers in August list required by Sect. 133(l)(c) No. of cases of default in sending lists to the Council No. of prosecutions for failure to supply lists No. of instances of work in unwholesome premises Notices Served Prosecutions (1) (2) (3) (4) (5) (6) (7) Wearing apparelMaking etc. 39 - - - - - Boxes (Cardboard) 1 - - - - - Paper Hats 8 - - - - - Cosaques 16 - - - - - Tool Assembly 1 - - - - - Art Jewellery 1 - - - - - Total 66 - - - - - 96 SWIMMING BATHS. Visits were made to the three public swimming baths and five school pools during the year. Twenty-one samples of water were submitted for bacteriological examination. Checks for pH value and free chlorine were made, in appropriate cases. The close co-operation which exists between the Borough Engineer, the Chief Education Officer and this Department is much appreciated. One private school pool was voluntarily closed following unsatisfactory reports on the condition of the water. DISEASES OF ANIMALS ACT. 1950. Functions of the Council in connection with the Diseases of Animals Act, 1950, are carried out on an agency basis by the Council of the City of London, through that Council's Veterinary Officer. In addition to those functions, an offer by the Council of the City of London to make inspections required in connection with applications for licences under the Animal Boarding Establishments Act, 1963, Animals Act, 1951, and the Riding Establishments Act, 1964, was accepted. DISEASES OF ANIMALS (WASTE FOODS) ORDER. 1957. Where conditions satisfied the requirements of the Diseases of Animals Order, 1954, new licences were issued by the City of London in respect of nineteen premises where waste food is treated for animal feeding. ANIMAL BOARDING ESTABLISHMENTS ACT, 1963. Three licences have been issued for the boarding of cats and dogs. PET ANIMALS ACT. 1951. Twelve licences have been issued to persons to keep Pet Shops. RIDING ESTABLISHMENTS ACT. 1964. Establishments in the district formerly used as riding establishments were inspected during the year but no licences were issued, since information received from the Veterinary Officer indicated that they were not at the time of inspection so usedo No applications for licences were received. REGISTRATIONS. Establishments for Massage and Special Treatment. Twenty-seven licences were renewed during the year, four of which were for chiropody only. Forty-six visits of inspection indicated that all were being conducted satisfactorily. 87 Pharmacy and Poisons Act, 1933. One hundred and sixty applications for retention of names on the Council's list of sellers of Poisons listed in Part II of the Poisons List were dealt with, and twelve new applications for names to be added to the List were granted. Rag Flock and Other Filling Materials Act, 1951. Four premises used for upholstery are registered in accordance with Section 2 of the Rag Flock and Other Filling Materials Act, 1951. Two samples of unused cotton felt were taken and proved satisfactory. The prescribed Analyst is Mr. George Noel Ginger of R.T.S.A. (Chiltern Research), Westfield House, Henley on Thames, Oxfordshire. Refreshment Houses Acts, 1860 and 1964. Two licences, being renewals of licences previously issued by the Surrey County Council, were granted during the year. OTHER MATTERS. Fertilisers and Feeding Stuffs. Two informal samples of Broiler Breeder Poultry Food were taken during the year. One sample was reported by the Public Analyst to be unsatisfactory due to the oil content being in excess of the limits of variation allowed. All the public health inspectors of the Borough have been approved by the Ministry of Agriculture, Fisheries and Food as Inspectors and Official Samplers under the Fertilisers and Feeding Stuffs Act, 1926. Hairdressers and Barbers. Bye-Laws - Public Health Act. 1961 - Section 77. The Council decided to apply to the Ministry of Housing and Local Government for approval of Bye-Laws to secure cleanliness in Hairdressers and Barbers Establishments. The Bye-Laws are expected to be in operation early next year. Mortuaries. The Council maintains two Mortuaries, one at Mill Lane, Carshalton, and the other at Cemetery Road, Sutton Common Road, Sutton, both of which are equipped with refrigeration storage and facilities for post-mortem examination. From the 1st April, 1965. only the Mortuary at Sutton Common Road has been used. R8 The number of bodies, on all of which autopsies were performed, admitted during the year was as follows? Ambulance removals 76 From local Hospitals 122 From homes within the Borough _221 425 Summary of Complaints., Inspections and Work Done. Investigations were made with regard to 5,006 complaints as follows: Accumulations 78 Animals so kept etc 3 Burst pipes 3 Caravan Sites 13 Clean Air - Contraventions 118 Dampness 56 Drainage defects 83 Drains obstructed 1,287 Dustbins 32 Food contaminated 58 Food unsound 115 General defective conditions 171 Insects and Pests 1,236 Litter Act Contraventions 4 Miscellaneous 24 Noise Abatement Act 87 Obnoxious effluvia 135 Overcrowding 11 Refuse collection 29 Rivers 8 Rodents 1,332 Roofs defective 45 Sewer obstructions 34 Shops Act - Contraventions 7 Sink waste pipes 8 Verminous premises 17 Water supply 12 5,006 Nineteen thousand and thirty-three visits of inspection and re-inspection were made for the purposes set out below: Animal Boarding Establishments 1 Caravan Sites 4 Clean Air Act 679 Consumer Protection Act 3 Diseases of Animals Act 3 Employment Agencies 13 Establishments for Massage and Special Treatment 46 Factories (Mechanical Power) (incl. laundries) 432 Factories (non-Mechanical Power) 40 89 Factories (Building Sites) 40 Fertilisers and Feeding Stuffs 6 Food and Drugs (inc. Food Bye-Laws) 1,220 Food Poisoning Enquiries 7 Food Premises : Bakehouses 72 Bakers & Confectioners 111 Butchers 342 Canteens 157 Canteens - Schools 70 Chemists 18 Confectioners (Sugar) 159 Factory food 2 Fishmongers 121 General Stores 157 Greengrocers & Fruiterers 183 Grocers 312 Licensed premises with catering facilities 50 Licensed premises without catering facilities 31 Milk storage depots 16 Ice-cream factories 22 Ice-cream vehicles 12 Restaurants and Cafes 276 Stalls, food 53 Tea packer 16 Vehicle Ss, food 15 2,195 2,195 Hairdressers 46 House drains tested 23 Housing Act 708 Housing Land Charges 368 Infectious Disease Premises 843 Insect Pests 312 Licensing Act 20 Merchandise Marks Act 159 Noise 356 Offices, Shops and Railway Premises Act 1,462 Outworkers Premises 70 Pet Animals Act 23 Pharmacy and Poisons Act 5 Piggeries 75 Premises re cesspools 14 Public conveniences 280 Public Health Act (houses) 4,499 Public Health Act re-inspections 2,576 Rent Act 17 Riding Establishments Act 1 Rodents 1,768 Rag9 Flock and Other Filling Materials Act 3 Rivers9 Ditches and Ponds 6l Schools 52 Shops 478 Verminous Premises 31 Water Sampling 94 19,033 90 One thousand, three hundred and eight notices were served concerning the following matters: Accumulations and deposits 23 Animals so kept 1 Caravans 6 Clean Air Act 7 Drainage defects 110 Dustbins 10 Factories Act 42 Food and Drugs Act (incl. Food Hygiene) 203 General defective conditions 158 Housing Act 52 Miscellaneous 11 Noise Abatement Act 9 Offices, Shops and Railway Premises Act 633 Prevention of Damage by Pests Act 21 Rivers and Ditches and Ponds 3 Shops Act 15 Water Supply 4 1,308 Formal notices were served by authority of the Council under the following Acts: Public Health Act, 1936, Section 24 26 " " " " " 39 10 " " " "45 1 " " " " " 93 20 Sutton & Cheam Corporation Act, Section 42 1 Clean Air Act, 1956. Section 12 . 32 90 As a result of investigations made and notices served, the following work was carried out: Accumulations removed 12 Brickwork repaired 6 Ceilings cleansed 30 Ceiling plaster repaired and/or made good 8 Chimney flues repaired 5 Damp conditions remedied 21 Doors and frames repaired, including locks and fasteners 1 Drainage repaired and/or reconstructed 15 Drainage inspection chambers repaired 11 Inspection chamber covers renewed 3 Soil pipes renewed 4 Drains tested 32 Drains cleared 1,287 Waste gullies repaired, renewed or provided 6 Waste pipes repaired, renewed or provided 5 91 Surface water drainage provided 6 Dustbins provided 11 Fireplaces, ranges or stoves repaired or renewed 6 Floors renewed or replaced 11 Food storage accommodation provided 5 Roofs repaired and made weatherproof 26 Downpipes, guttering repaired and/or renewed 13 Stairs repaired 3 Sinks renewed 1 Walls rendered or rendering repaired 5 Replastered and/or repaired 14 Cleansed and redecorated 31 Wash basin and baths provide 4 Water supply renewals or repairs 19 W.c. provided 1 W.c. lighting provided 5 W.c. accommodation repaired 18 W.c. pans and seats repaired, renewed or provided 8 Flushing apparatus repaired or renewed 11 Windows repaired and/or renewed 27 Ventilation provided 2 92 school health service PART V (education act) THE SCHOOL HEALTH SERVICE AREA AND POPULATION The Council became the Local Education Authority for primary, secondary and further education for the whole of the Borough on 1st April, 1965. Prior to that date the Surrey County Council were the Local Education Authority and in the report which follows the statistics refer to the year 1st January, 1965 to 31st December, 1965. The Registrars-General's estimated population of the Borough at mid-year 1965 was 166,790 of whom 22,400 were children between the ages of 5-14 inclusive. The number of children on the register of local education authority schools was l8,950. There are 18 private schools in the Borough and the number of children attending was 3,412. The number of children continuing fulltime education at school after the compulsory school leaving age of 15 years continue to increase. MEDICAL INSPECTION (a) Maintained Schools Under the provisions of the Education Act, 1944, it is the duty of the local Education Authority to provide for the medical inspection, at appropriate intervals, of pupils in attendance at any school or county college maintained by them and the Authority may require the parent of any pupil in attendance at such school to submit the pupil for medical inspection in accordance with the arrangements made by the Authority. Medical officers and health visitors are employed jointly by the Health and Education Committees thus achieving continuity of medical supervision from birth until school leaving age. Arrangements for medical inspection at present in force are Primary School 1. On entry - complete medical examination. 2. At age of six years - hearing test. 3. During the year in which the age of eight years is reached - complete medical examination. Secondary School l. On entry aged 11 - 12 years - complete medical examination. 2. During the year in which the age of 13 years is reachedvision test only. 3. During the year in which the age of 15 years is reachedcomplete medical examination. 4° During the year prior to leaving school if more than two years after last routine inspection - complete medical examination. The number of children examined in primary and secondary schools was 6,773. 3,695 parents were present at these examinations (i.e. 54.5%) (b) Independent Schools Medical inspection and treatment and dental inspection of children attending independent schools are made available on application by the Principal of the school and subject to the school itself being recognised as efficient by the Department of Education and Science. 95 The following schools have taken advantage of these facilities which are offered free of charge St.Hilda's School, Carshalton Dinorben School, Wallington. Wallington Independent Grammar School. Medical Inspection of Pupils attending Maintained Primary and Secondary Schools (including Nursery and Special Schools) Table A. Periodic Medical Inspections 1st January - 31st December, 1965 Age Groups Inspected (by year of birth) No.of Pupils who have received a full medical examination Physical Condition of;Pupil* Inspected No. of Pupils found not to warrent medical examination Pupils found to require treatment (excluding dental diseases and infestation witih vermin Satisfactory Unsatisfactory No. No. For defective vision (excluding squint). For any other condition Total individ ual Pupils (l) (2) (3) (4) (5) (6) (7) (8) 1961 & later 142 142 - - - 25 25 1960 1,307 1,301 6 - 52 235 268 1959 538 535 3 - 17 91 103 1958 74 74 - - 4 13 14 1957 1,283 1,280 3 - 97 174 221 1956 229 229 - - 13 29 41 1955 49 49 - - 4 4 8 1954 883 883 - - 27 30 51 1953 588 586 2 - 83 86 156 1952 105 105 - - 12 18 25 1951 86 86 - - 19 9 25 1950 & earlier 1,489 1,489 - - 249 251 393 TOTAL 6,773 6,759 14 - 577 965 1,330 96 DISEASES AND DEFECTS Of the 6,773 pupils examined, at periodic medical inspections 1,330 pupils (percentage of total 19.62) were found to be in need of treatment for 1,612 defects. Table on page98 shows the nature of the defects found; it will be seen that 577 were defects of vision. (a) Special medical inspections and re-inspections There were 1,242 special inspections, i.e. pupils referred to the school medical officers by head teachers and health visitors or requested by the parents. These pupils were either seen at school or at general medical clinics. There were 1,204 re-inspections, that is re-examination of children who were found at the previous medical examination to have defects requiring either treatment or observation. (b) Physical condition Of the 6,773 children examined at routine medical inspection, the physical condition of only 14 was considered to be unsatisfactory, (0.2%). (c) Personal hygiene The routine inspection of personal hygiene of pupils each term has been carried out at the school nurses' discretion or at the request of the school and these examinations are mainly confined to children who have been in contact with cases of infestation. 5,546 children were examined by the school nurses and 48 individual children were found to be infested during the year. In all cases the parents carried out the appropriate treatment satisfactorily and without delay. 97 Defects found by Periodic and Special Medical Inspections during the year 1st January to 31st December, 1965 NOTE:- All defects, including defects of pupils at Nursery and Special Schools, noted at period and special medical inspections are included in this table, whether or not they were under treatment or observation at the time of the inspection. This table includes separately the number of pupils found to require treatment (T) and the number of pupils found to require observation (0). Defect Code No Defect or Disease Periodic Inspections Special Inspections Entrants Leavers Others Total 4 Skin T 36 54 113 203 364 0 52 51 43 146 21 5 Eyes-a. Vision T 69 249 259 577 103 0 116 83 272 471 40 b. Squint T 29 9 29 67 8 0 15 4 16 35 2 c. Other T 6 2 14 22 15 0 5 16 12 33 1 6 Ears-a. Hearing T 12 5 27 44 162 0 74 12 25 111 19 b. Otitis Media T 9 6 8 23 10 0 36 2 11 49 2 c. Other T 8 13 13 34 25 0 17 17 23 57 4 7 Nose and Throat T 65 3 52 120 40 0 310 26 165 501 15 8 Speech T 35 4 13 52 28 0 62 4 24 90 2 9 Lymphatic Glands T 14 3 3 20 1 0 114 4 72 187 — 10 Heart T 4 1 4 9 1 0 26 11 33 70 3 11 Lungs T 16 6 17 39 30 0 45 10 44 99 2 12 Developmental a. Hernia T 5 1 6 12 3 0 8 2 13 23 - b.Other T 9 8 10 27 9 0 53 30 75 158 1 13 Orthopaedic a. Posture T 10 14 41 65 35 0 13 44 42 99 8 b. Feet T 59 1 66 126 91 0 70 33 76 179 8 c. Other T 28 1 33 62 24 0 65 33 58 156 6 14 Nervous System a. Epilepsy T 1 - 1 2 4 0 3 1 9 13 - b. Other T 3 1 3 7 5 0 18 5 8 31 2 15 Psychological a. Development T 2 9 5 16 85 0 23 3 20 46 3 b. Stability T 3 2 4 9 10 0 39 2 38 79 11 16 Abdomen T 1 2 9 12 29 0 9 7 18 34 14 17 Other T 21 17 16 54 181 0 42 36 88 166 23 98 medical treatment Medical treatment is the responsibility of general practitioners and. the hospital service. The Local Education Authority arranges preventive physiotherapy and actinotherapy and, by arrangement with the Executive Council, treatment for defective vision and squint. These forms of treatment are carried out when requested by the family doctor or after his consent has been obtained except in the case of defective vision when reference for treatment is direct. Certain minor ailments are also treated at the Authority's clinics. (a) Minor ailments The principal minor ailments treated are diseases of the skin and ear and external disease of the eyes. One of the school medical officers has specialised in the treatment of diseases of the skin and many cases are referred to her by general practitioners. A total of 6l8 pupils were treated for minor ailments excluding skin diseases. It is interesting to note that there were no cases of ringworm of the scalp or body and no cases of scabies. There were only 7 cases of impetigo. Skin diseases treated were mainly verrucae (plantar warts) and tinea pedis (athlete's foot). A total of 361 pupils were treated for skin diseases. (b) Eye diseases, defective vision and squint 1,427 pupils were treated for these defects, 53 for external eye diseases and 1,374 for defective vision including squint. Spectacles were prescribed for 413 pupils. Ophthalmic surgeons carried out sessions at the following clinics in the.Borough:- Sutton Clinic Green Wrythe Lane Clinic Rochester Road Clinic. (c) Diseases and defects of ear, nose and throat The total number of children treated for these defects was 235, of whom 33 had operative treatment. The total number of pupils in school known to have been fitted with hearing aids was 48, 11 of which were provided during 1965. (d) Orthopaedic and postural defects There are no sessionally employed orthopaedic surgeons attending any of the clinics. After consultation with the family doctor pupils requiring orthopaedic treatment are referred to the orthopaedic surgeons at Queen Mary's Hospital for Children or St.Helier Hospital. Sessionally employed physiotherapists undertook remedial exercises for minor defects at the following clinics Priory Crescent Rochester Road Stonecot Hill Green Wrythe Lane Sutton Clinic Shotfield Sessions are also held at Carew Manor Special School. 99 (e) Ultra-violet light treatment Facilities are available for ultra-violet light treatment carried out by physiotherapists at the following clinics s- Sutton Clinic Shotfield Clinic, Wallington, Priory Crescent Clinic, North Cheam. A total of 22 children attended. (f) Health Visitors The policy commenced during 1961 by the Surrey County Council as part of a general review of health visitors' duties for the employment of state registered nurses on a part-time basis to relieve health visitors of those duties able to be carried out by others less highly qualified was continued. Six sessionally employed state registered nurses (the equivalent of 2 full-time nurses) were employed during the year for routine medical inspection duties in secondary schools, minor ailment clinics, immunisation sessions at both primary and secondary schools etc. It is not intended by this policy that the time devoted to the school health service by health visitors should diminish but that some of their time should be available for other duties such as health education and visiting the homes of pupils found to have defects at medical and hygiene inspections when necessary. 100 SCHOOL DENTAL SERVICE I am indebted, to the Chief Dental Officer for the following report: On 31st December, 1965 the dental officer's staff consisted of 2 full-time and 1 part-time salaried officers, and 7 sessionally employed officers, bringing the total to an equivalent of 4.8 full-time officers. It is very difficult to find young and enthusiastic full-time dental officers and clinics must be modern and well equipped to encourage their recruitment. Orthodontic sessions are held at three of the five clinics, the orthodontist attending each of these clinics once a week. Most of the cases were treated by removable appliances and these were supplied by the Surrey County Council laboratory at Kingston. Most of the schools were inspected during the year and 43.1% of children were found to be in need of dental treatment at the time of their first inspection. This figure shows only the need for dental treatment; towards the end of the year a survey of the five year old children was commenced which it is hoped will provide a more accurate picture of the dental condition of this age group. The acceptance rate for treatment at the clinics varies a little but has increased in the Wallington area since the new clinic opened at Shotfield. This is a further indication that modern buildings and equipment and the combination of all medical and dental services in one building encourages the attendance of patients as well as the recruitment of staff. The number of patients attending the clinics for emergency treatment during the year was 365, a very small number, averaging 1½- patients per week per clinic. It is an indication that the parents are truly 'tooth conscious' and that the majority of children attend regularly for dental treatment. 101 School Dental Service, 1st January to 31st December, 1965 1. Attendances and. Treatment Ages 5 to 9 Ages 10 to 14 Ages 15 and over Total First Visit 1,926 1,494 382 3,802 Subsequent Visits 3,116 2,937 692 6,745 Total Visits 5,042 4,431 1,074 10,547 Additional courses of treatment commenced 621 341 77 1,039 Fillings in permanent teeth 1,397 2,848 951 5,196 Fillings in deciduous teeth 3,681 293 - 3,974 Permanent teeth filled 1,285 2,544 759 4,588 Deciduous teeth filled 3,319 251 - 3,570 Permanent teeth extracted 60 327 145 532 Deciduous teeth extracted 784 237 - 1,021 General anaesthetics 446 225 38 709 Emergencies 232 104 29 365 Number of Pupils x-rayed 291 Prophylaxis 840 Teeth otherwise conserved 603 Number of teeth root filled 16 Inlays - Crowns 13 Courses of treatment completed 3,820 2. Orthodontics Cases remaining from previous year 181 New cases commenced during year 172 Cases completed during year 56 Cases discontinued during year 11 No. of removable appliances fitted 104 No. of fixed appliances fitted 1 Pupils referred to Hospital Consultant 2 3. Prosthetics Ages 5 to 9 Ages 10 - 14 Ages 15 and over Total Pupils supplied with F.U. or F.Lo (first time) - - 3 3 Pupils supplied with other dentures (first time) - 2 8 10 Number of dentures supplied - 2 11 13 4. Anaesthetics General Anaesthetics administered by Dental Officers Nil 5. Inspections (a) First inspection at school. Number of Pupils 16,526 (b) First inspection at clinic. Number of Pupils 1,660 Number of (a) + (b) found to require treatment 7,899 Number of (a) + (b) offered treatment 6,579 (c) Pupils re-inspected at school clinic 1,441 Number of (c) found to require treatment 1.122 6. Sessions Sessions devoted to treatment 1,825.7 Sessions devoted to inspection 185.8 Sessions devoted to Dental Health Education 2.0 102 SPECIAL FORMS OF TREATMENT (a) Audiology Service The early diagnosis of children with partial hearing is essential and the great majority of cases are diagnosed by hearing screening tests before the child begins school. Those children initially referred on account of speech defects which may be associated with partial deafness have a hearing test by the audiometrician before speech therapy is commenced and all pupils have a further screening test during their second year at school. Those children who show any defect in hearing are referred to the school medical officer who decides whether it is necessary for them to be referred for further investigation and treatment. Since the more serious cases of partial hearing are detected before school age, only a small number of school children are seen by the audiologist. The total number seen for the first time in 1965 was 25. Appropriate treatment was recommended by the audiologist. In cases where there is a severe loss of hearing the pupil is referred to an ear, nose and throat specialist and a decision made regarding the supply of a hearing aid. In a small number of cases the pupil is considered sufficiently handicapped to require special educational treatment at a partial hearing unit or special school for the deaf. In the less serious cases it may only be necessary to request the head teacher to make certain that the pupil sits near the front of the class and in those cases with loss of hearing in one ear, be placed with the good ear towards the teacher. The co-operation of teachers in this respect is much appreciated. 11 new cases were supplied with hearing aids during the year 1965 and a total of 48 pupils are registered as having been so fitted. The total number of children seen by the audiometrician was 2,433 of whom 200 were found to have defective hearing of varying degree and referred to the school medical officers. (b) Child Guidance Service The Child Guidance Clinic is situated at 25 Worcester Road, Sutton. Until 31st August, 1965 the service was shared with Surrey County Council. There is a national shortage of specialist staff for child guidance clinics but it was possible to maintain a full service by the employment where necessary of part time staff. The child psychiatrist has been supported in her work by a psychotherapist, educational psychologists and psychiatric social workers and has maintained a close contact with family doctors, head teachers, child care officers etc. The education psychologists devote part of their time to the School Psychology Service paying routine visits to schools and part to work in the child guidance clinic. Pupils are referred to them from three main sources:- (a) By the child psychiatrist. (b) By the Principal School Medical Officer for the ascertainment of educationally sub-normal children and those children who are thought to be unsuitable for education at school. (c) By head teachers of children who appear to be of average or above average intelligence, but who are retarded in one or more subject, in some cases due to emotional problems. 103 Two sessions per week are devoted to the re-assessment of children attending Carew Manor E.S.N. School. Close co-operation has been maintained with the remedial teachers. A total of 78 children were selected for teaching in remedial groups from primary schools in remedial groups of 5 or 6 children so that more individual help can be given to each child. (c) Speech Therapy Speech Therapy Clinics were held at Priority Crescent Clinic, North Cheam Rochester Road, Clinic, Carshalton Green Wrythe Lane Clinic, Carshalton Shotfield Clinic, Wallington 25 Worcester Road, Sutton There is a national shortage of speech therapists and it has been necessary to employ all the speech therapists on a part-time basis. The total number of children attending for speech therapy during 1965 was 155 of whom 22 were discharged as cured and 17 discharged as greatly improved„ One of the speech therapists carried out 4 sessions weekly at Carew Manor E.S.N. School. (d) Infectious Diseases Pull information concerning infectious disease is given on page 19 of the report. It should be noted that there were no cases of serious infectious disease in schools during the year and it was not necessary to carry out any special investigation in respect of cases of pulmonary tuberculosis in members of school staffs or pupils. There were minor outbreaks of sonne dysentery all of which were fully investigated. The Education Committee resolved that all members of the staff of schools should have a satisfactory chest x-ray before commencing work and that school meal staff should have bacteriological examination of stools before commencing work. Although the latter examination causes a few days delay in the taking up of post, it is considered essential that any person handling food should not be a carrier of either the enteric fevers or dysentery. IMMUNISATION AND VACCINATION Responsibility for immunisation and vaccination is placed on the local health authority by Section 26 of the National Health Service Act, 1946. Statistics relating to this work appear on pages20/2l of the report. Sessions are held regularly at primary schools mainly for reinforcing injections for protection against diphtheria and tetanus. B.C.G. vaccination against tuberculosis is carried out at the age of approximately 13 years in secondary schools. The Education Committee decided on a policy of adequate protection against enteric fevers and smallpox for those children going abroad in school parties. This policy has been carried out, the protection necessary being dependent upon the country to which the party was travelling. It was also considered necessary to recommend poliomyelitis vaccination for parties going abroad. 104 Unfortunately the percentage of children adequately immunised against diphtheria and poliomyelitis is gradually decreasing. It is hoped that all teachers will help to improve this position by emphasing the necessity for adequate protection whenever they are in contact with parents. HANDICAPP3D PUPILS It is the duty of the Council to make suitable provision for handicapped pupils in the Borough. The Handicapped Pupils and Special Schools Regulations, 1959, specify ten categories of handicapped pupils, namely:- Blind, Partially sighted, deaf, partially hearing, educationally sub-normal, epileptic, maladjusted, physically handicapped, delicate and speech defect. Children who are handicapped in one or more of these ways require special educational treatment since they cannot be educated satisfactorily under the normal conditions of an ordinary school. The majority, however, do not require to attend a special school since suitable arrangements can be made for them to receive appropriate education in ordinary schools. The Table on page 92 gives full information regarding the number of handicapped children newly assessed in 1965 and the total number as at 31st December, 1965. attending special schools. There are two special schools in the Boroughs Carew Manor, Wallington, for educationally sub-normal children and North Downs, Belmont, a small unit for maladjusted children. (a) Carew Manor School This special school is a day school for 140 educationally sub-normal boys and girls aged from 7-16 years. The average number of pupils attending during 1965 was 130. The headmaster of the school has reported that it was not possible for the numbers to be increased to the maximum of 140 since there was a shortage of staff. Before a child is admitted to this or any other special school for educationally sub-normal children a full medical examination is carried out and reports are obtained from an educational psychologist and if necessary from a psychiatrist. Every child attending the school has a physical examination annually and is psychologically assessed every 2 years. At the request of the headmaster or the parents these examinations can be arranged at short notice at any time. In addition to a regular weekly session at the school by a school medical officer and educational psychologist two physiotherapy sessions are held each week and 4 sessions are devoted to speech therapy. Before any pupil leaves the school at the age of 16 a full medical and psychological investigation is carried out and, in conjunction with the headmaster, a decision is made regarding the type of employment that might be suitable for the pupil. In some cases because the pupil might not be accepted into employment or may drift from one job to another, supervision and community care by mental health social workers is recommended. To assist in finding suitable employment the Principal Youth Employment Officer devotes several sessions at the school to interviewing school leavers and their parents. 105 It is regrettable that educationally sub-normal pupils cannot be admitted to Carew Manor School before the age of 7 years. An increasing number of pupils at ordinary schools arenow ascertained as educationally sub-normal by the age of 6 years and these children have to be found places in schools in neighbouring Authorities. (b) North Downs Unit, Belmont. This unit caters for 15 maladjusted children. The children remain on the register of their ordinary school and attend the unit from varying periods from two to four days each week. The children recommended for admission to the unit are carefully selected in conjunction with the child psychiatrist and the head teacher of the unit. The unit is situated in an unsuitable building. It is hoped that better premises will be found during 1966 and the unit enlarged to take up to 30 pupils. When these are available it will be possible to admit more maladjusted pupils to a day school where they have valuable continued contact with their parents instead of to residential school as is at present the case. In addition to these two special schools there are hospital schools in the grounds of Queen Mary's Hospital for Children, Carshalton and Belmont Hospital, Sutton. I take this opportunity of expressing my appreciation of the work carried out for sick children by the head teacheis and their staffs. (c) Queen Mary's Hospital School When a child is admitted to hospital it is essential to continue his or her education as soon as he or she has sufficiently recovered from illness to do so. There is an excellent hospital school attached to Queen Mary's Hospital. Some of the pupils can attend classrooms but the majority have individual tuition in bed. A number of children are only in hospital for a short time but a large percentage are in hospital for a period of months or even years. In addition to the head teacher there are 29 assistant teachers and the curriculum at the school is as varied as in any other school. The total number of children on the register at 31st December, 1965 was 168. (d) Belmont Hospital School At Belmont Hospital there is a diagnostic unit basically for deaf children. The children are referred from a very wide area in the South of England and the unit specialises in the examination of children for deafness. Many of these children are found to be not suffering from deafness but to be non-communicating (autistic) children. A number may be in the unit for a few days only when the diagnosis has not proved difficult but others remain for a period of months. There are 12 beds in the hospital for these children, the beds almost always being occupied, and the children suitable for education attend classes run by a teacher of the deaf who is attached to the unit. 106 107 Handicapped Pupils requiring Education at Special Schools approved under Section 9(5) of the Education Act, 1.944 or Boarding in Boarding Homes During the year 1st January to 31st December, 1965 Blind Partially sighted Deaf Partially hearing Physically handicapped Delicate Maladjusted E.S.N. Epileptic Speech defects total Children assessed as needing special educational treatment at special schools - - 2 3 4 12 6 16 - - 43 Number of children receiving special educational treatment ins- (a) Boarding Schools 3 1 4 4 7 18 21 18 1 1 73 (b) Day Schools - 4 6 3 13 6 2 117 - - 151 (e) Home Tuition Some children may be so severely handicapped as to be unable to attend a day school During the waiting period for admission to a residential school or if the handicap is only of a temporary nature the education of the children is continued in their own homes. During the period 1st April - 31st December, 1965 home tuition was arranged for 9 children. (f) Convalescent Treatment School children are recommended for convalescence or recuperative holidays either by the family doctor, hospital or school medical officer. Holidays were arranged for 15 children during 1965• The normal holidays vary from two to four weeks. I am grateful to the Chief Education Officer for the following information :- (a) MPLOYMENT OF CHILDREN OF SCHOOL AGE Between 1st April and 31st December, 1965 there were 212 applications for employment. Three withdrew before being called for medical examination, 8 were employed in adjoining districts, and 4 could not be granted as the work was in a registered factory. 7 warning letters have been issued for minor infringements in connection with employment by-laws. The by-laws regulating the employment of children provide for their medical examination prior to employment and annual re-examination. 205 children were medically examined during the period 1st April - 31st December, 1965. (b) PHYSICAL EDUCATION IN SCHOOLS At the nursery stage much of the child's learning is through physical activity, aided by climbing apparatus, large toys, sand, water, balls, paint and music. Through the infant and junior stages skills are developed in gymnastic movement, games and dance. Many of our primary schools still lack sufficient provision for the development of skills and agilities which challenge and stimulate the child. This is particularly regrettable for the top junior child because of his great zest for physical activity. The results achieved by children in schools where varied apparatus is available offer evidence to justify the provision. The period between 9 and 11 is the time when children most easily learn to swim. All our schools with children of junior age have the opportunity for at least one year for pupils to receive swimming instruction. Instructors are provided at the baths to supplement the work of the class teacher. The number of children learning to swim is encouraging but could be improved still further by a greater allocation of time at the public baths or by the development of learner pools. What can be done is illustrated by one junior school situated very near to a public bath who have taught all their school-leavers for the past three years to swim. Three schools have their own learner pools and here again the number of children able to swim is high, since it is possible to start the development of water confidence with the infants. 103 Opportunities for physical education vary very much at the secondary stage, as not every school has all the basic equipment needed. However, this position is somewhat relieved by making use of outside facilities. For senior pupils the programme is being widened and schools are moving away from the traditional diet of team games. The aim now is to allow the pupils to choose a recreative activity for which they feel well suited and which they will he disposed to continue after leaving school. Children vary considerably in their physical abilities and interests and teachers are giving opportunities for them to develop as individuals at all stages. HEALTH EDUCATION I have referred to health education on page 52 of this report. Information on health matters in the form of materials and advice on the teaching of health subjects especially on dental health and smoking has continued to be furnished to pupils and teachers. The work of the teachers is augmented by health visitors, medical officers and dental officers. PROVISION OF MEALS AND MILK The number of day pupils receiving mid-day meals and milk, both at maintained and non-maintained schools in September 1965 was :- Milk 16,104 Meals 13,620 109 welfare services part vi (national assistance act) NATIONAL ASSISTANCE ACT - WELFARE SERVICES Introduction The Borough is an all-purpose welfare authority and is responsible for the welfare of the aged, the blind and partially-sighted, the deaf and the physically handicapped, as well as dealing with homeless families. Whilst in the main these responsibilities are carried out by the Council, there is co-operation with the many voluntary organisations engaged in the various fields in the Borough. The first year's working has proved that a comprehensive welfare scheme using both statutory and voluntary effort is more than a possibility; in Sutton it is fact. This section of the report covers the period 1st April, 1965 to 31st March, 1966. 1. SERVICES FOR THE ELDERLY (a) Residential Accommodation Elderly people living at home may need special support to enable them to cope with their infirmities and to prevent isolation. As their capabilities diminish they may need such services as home help, laundry services, ready cooked meals and chiropody. Loss of mobility brings a need for friendly visiting, transport to social clubs and occupation centres and arrangements for holidays. At the stage in an elderly person's life when the support which family and neighbours can reasonably provide is no longer sufficient and whilst admission to hospital is not necessary, it is then that accommodation in a residential home is needed. The provision of residential old people's homes is a statutory duty of the new authority. The latest figures show that there are over 21,000 people over pensionable age in Sutton, and whilst only a small percentage (1.9%) need to be admitted into care, this means that in Sutton it will be necessary to provide some 432 places in old people's homes in the next five years. The Council owns and controls two old people's homes, (a) Brambleacres (43 places) and Maiden Homes (112 places). It has a lien on 83 places at St.Anne's, Redhill, owned by the Surrey County Council. The total complement of 238 places is stretched to the limit and further old people's homes are 'on the drawing board'. It is hoped that the figure of 365 places will be reached by 1972. As well as those old people's homes owned and controlled by the Council there are in Sutton 22 privately owned old people's homes, accommodating 295 people, registered by the authority and from time to time inspected by its officers. These homes vary in size, standards of accommodation and charges but offer residential accommodation to old people who can afford to meet the fees from their private incomes. There are also 7 old people's homes owned and controlled by voluntary organisations in the Borough offering a total of 211 places to old people seeking accommodation in this way., The Chief Welfare Officer is responsible for admission to Council owned homes and offers assistance to anyone seeking admission to the other types of old people's homes. (b) Social Welfare Officers Despite admission to old people's homes of one type or another there are an indeterminate number of elderly persons whose social support in their own homes presents a sizeable task in the 113 Boroughs. To meet this task the Borough has been divided into four operational districts and a social welfare officer appointed to each districts The districts are roughly equal to the four geographical quadrants of the Borough. The officers arrange admissions to old people's homes, supporting services, e.g. home help, laundry services, mobile meals, chiropody, etc. and, generally speaking, stay with the case until the problems are resolved. Whilst the district welfare officers have the care of the elderly as their main task, nevertheless, they are simply a part of a fully Integrated team of 10 welfare officers and specialist officers able to deal with a wide range of needs. The social welfare officers primarily concerned with the care of the elderly in the year under review made approximately 3,500 visits to old people, arranged for the admissions of 101 old people into residential accommodation on a permanent basis, arranged for 27 old people to be admitted on a temporary basis and have kept in touch with 698 old people who require occasional supervision at home. This team operates a 24 hour on-call system, a social welfare officer being on duty for emergency purposes at any time of day or night and the whole resources of the Department can be mustered very quickly to meet greater emergencies, such as fire, flood or other disasters. (c) "Meals-on-Wheels" In conjunction with the Women's Royal Voluntary Services and the Old People's Welfare Committee, the new Borough operates a fairly comprehensive "meals-on-wheels" service. The three main meals' centres are at Sutton, Carshalton and Wallington each serving its respective areas those of the three former authorities. The "meals-on-wheels" services provide about 1,000 meals per week and whilst the service operates on different days in different areas, nevertheless all people using the service pay a minimum of l/6d per meal. "Meals-on-wheels" can be obtained by contacting any one of the three old people's welfare committees, the W.R.V.S. or the department. (d) Voluntary Associations Prior to April 1965 Sutton and Cheam, Carshalton and Beddington and Wallington had their own old people's welfare committees engaged in the support of old people in their own homes and these activities continue in the new Borough. The variety of tasks undertaken by the voluntary bodies included friendly visiting, holiday schemes, winter fuel and outings. The Sutton Council of Social Service played its part by bringing together all the local voluntary organisations in the new Borough and providing a forum where common problems are discussed and ideas and plans exchanged. (e) Central Register The Welfare Section operates a central register of old people "at risk" and receives referrals from many sources in the Borough, This process is gradually building up a picture of the needs of old people and the extent to which it is possible to meet these needs. 114 Statistics (l) Estimated number of people over pensionable age in the Borough 21,090 (2) Number of old people in care of this authority in directly controlled old people's homes (or in other authority's home where we have a sharing arrangement). 237 Number of old people of Sutton origin elsewhere in old people's homes 133 Under 60 60/70 70/80 80/90 90/100 over 100 - 7.5% 29.71% 49.l% 12.6% l.l% (3) Number of places available in private registered old people's 295 homes. (4) Number of places available in old people's homes run by 212 voluntary bodies in the Borough Waiting List There were on 31st March, 1966 120 elderly persons awaiting admission to Council homes and these fall into the following age categories j- Under 60 60/70 70/80 80/90 90/100 over 100 - 10% 32.5 % 50/o 7.5$ - 2. SERVICES FOR THE HANDICAPPED Introduction The Borough is charged with the responsibility of providing welfare schemes for the blind, deaf or dumb and other persons who are substantially and permanently handicapped by illness, injury and congenital deformity. (a) The Physically Handicapped In the year there have been 336 referrals of new cases from all sources, i.e. from hospitals, general practitioners, other authorities, voluntary bodies, health visitors and so on. All those seeking the aid of the handicapped welfare services are put on a statutory register but registration as such is not compulsory. Within the definition given the number on the statutory register as at the 31st March, 1966 stood at 577. 115 It is possible to be of service to handicapped people in many ways and the great variety of 'aids to daily living' promote a feeling of independence and are of great assistance to the handicapped person in accepting his disability. Particular adaptations to the homes of handicapped people also play a great part in this work. Guide rails and guard rails, hoists, the extra w.c., ramps, curb crossings and garages for their invalid tricycles are great blessings and much has been done in this field in the first year. 81 handicapped people are visited in their own homes by the occupational therapist and help given to them in the ultimate sale and disposal of the articles they make. Some handicapped people are engaged in industrial outwork in their own homes and the setting up of a work centre to cater for them is keenly awaited. It is intended in due course to provide a purpose-built work centre for the physically handicapped, meanwhile a search is proceeding for temporary premises. Visits by Welfare Officers Social work with the physically handicapped and registration 1,236 Aids and adaptatxons 362 Occupational Therapy 673 Industrial outwork 185 (b) The Deaf So far as this Borough is concerned, welfare of the deaf is in its infancy, but some progress has been made and the statutory register of deaf and hard of hearing now stands at 94. (c) The Blind and Partially-Sighted Work with the blind and partially-sighted proceeded satisfactorily during the year, the number of new referrals was higher than anticipated. Qualified home teachers for the blind are available to help blind people overcome their disability and to live a more normal and active life. Instruction in Braille and Moon and various handicrafts is available and courses of social and industrial rehabilitation in conjunction with voluntary organisations and other authorities are used as necessary. A register of the blind and partially-sighted is required to be kept by statute and all those using the services are so registered. Registration is not compulsory. Visits by Home Teachers for the Blind Blind and partially-sighted 1,926 Number of lessons in Braille, occupational therapy,etc. 204 Escort duties to hospitals, etc. 248 (d) Transport arrangements The Department has a specially designed ambulance capable of carrying handicapped people in their wheelchairs to and from their own homes to work centres, hospitals, etc. and has proved invaluable in the year under review. 116 (e) Statistics Physically Handicapped Number of new registrations in the year 336 Number on register as at 31st March, 1966 577 Number of gadgets and aids to daily living issued during the year 118 Number of cases where adaptations to the home were necessary 47 Number of disabled drivers' car badges 67 Blind Number of referrals in the year 96 Number of new registrations in the year 50 Number on register as at 31st March , 1966 324 Number of gadgets - aids to daily living, issued during the year 189 Partially-Sighted Number of new registrations in the year 8 Number on register as at 31st March, 1966 59 3. DISPOSAL OF THE DEAD This authority is under a duty to dispose of the bodies of those who have died or who are found dead in this area where it appears that no suitable arrangements for the disposal of the body have been, or are being, made. In the year under review it has been necessary to use this power 6 times. 4. REGISTRATION OF OLD PEOPLE'S HOMES AND HOMES FOR THE DISABLED Registration of homes for old people or disabled people is required by statute whether the home is carried on by private owners or voluntary bodies. There are 22 private registered homes in the Borough and 7 registered homes run by voluntary bodies. One new registration and two cancellations of registration were dealt with. 5. RECEIVERSHIP AND CARE OF MOVEABLE PROPERTY It is the duty of the authority, when a person is admitted to any hospital or to any old people's home, to take steps to protect his property where it appears that there may be 'danger of loss of or damage to' such property and no other suitable arrangements have been, or are being, made. Generally speaking this means no more than making buildings safe and arranging for the safe custody of moveable valuables; 4 cases have been dealt with in the year. In certain other cases where mental illness is involved it may be necessary to apply to the Court of Protection for a Receivership to be set up so that a person's property and affairs can be adequately handled whilst he is unable to do so himself. During the year one case has been dealt with in this way. 117 MISCELLANY PART VII NURSING HOMES The following registered nursing homes are situated in the Borough:- Carshalton Nursing Home Ltd., 28 Salisbury Road, Carshalton 103 Woodcote Road, Wallington Dunollue, 38 Woodcote Road, Wallington The Avenue, 32 The Avenue, Cheam The Red House, 40 Burdon Lane, Cheam St .Margaret's, 17 Overton Road, Sutton * Woodcote Grove House. Woodcote Park, Coulsdon (Friends of the Poor and Gentlefolk's Help) * A new registration in 1965. The following establishments are also registered as "nursing homes" :St.Anthony's Hospital, Cheam Lourdes House, Wallington (re-registered during 1965) (For Mentally Subnormal Children) The Haven, Camden Road, Sutton (Mother and Baby Home) Nursing homes are visited regularly by medical officers, the Superintendent Health Visitor and Superintendent of Home Nursing and Midwifery. NURSES' AGENCIES ACT. 1957 There are 3 nurses' agencies licensed under this Act in the Borough The Etapire Nursing Association Worcester Trained Nurses' Co-operation Carshalton Nurses' Co-operation. Licences are issued annually subject to re-inspection and satisfactory report. NURSERIES AND CHILI) MINDERS REGULATION ACT. 1948 Applications are received for registration in accordance with the above Act. Suitable applicants are registered as daily minders when the number of children is under 10 and as day nurseries when the number of children to be cared for is 10 or over. During the year 4 child minders and 6 day nurseries were approved for registration by the Health Committee. The following table gives the numbers registered as at 31st December, 1965: 121  Nurseries & Child Minders Regulation Act, 1948 National Health Service Act, 1946 Section 22. Premises registered at end of year Daily Minders registered at end of year. Daily Minders receiving fees from the Authority at end of year Factory Other Nurseries (a) Number - 18 20 2 (b) Number of places & number of children minded at end of year. - 413 173 2 MEDICAL ARRANGEMENTS FOR CHILDREN'S HOMES AND RESIDENTIAL NURSERIES There are four children's homes under the control of the Children's Committee:- Reception Home, 10 Throwley Road, Sutton Malvern House, Kenley. Camperdown Children's Home, Wallington Dean House, Merstham. and one residential nursery - Hayes Court, Kenley. A general practitioner residing near the homes has been appointed medical officer and is responsible for examination of new admissions and of discharges as well as for medical treatment. A school medical officer carries out routine medical inspections every 6 months paying particular attention to the progress being made by the children and ensuring that all the children have been adequately immunised, This officer is also responsible for any special investigations which may.be necessary. The children's homes are inspected every 6 months and a report -on environmental conditions and the health of the children submitted to the Children's Committee, STAFF MEDICAL EXAMINATIONS (a) Officers A medical examination to ascertain fitness for employment is carried out by the Medical Officer of Health or a member of the medical staff as soon as possible following interview and before an appointment is confirmed, 122 The medical examination includes a routine x-ray examination of chest for all members of the staff having close contact with children and those who have been exposed to tuberculous infection. X-ray examination of other members of the staff is carried out when the examining medical officer considers it is desirable. Bacteriological and other investigations may be required at the discretion of the Medical Officer of Healths. (b) Manual Staff A medical examination to ascertain fitness for employment is carried out by the Medical Officer of Health or a member of the medical staff within 6 months of first being employed and no further medical examination is required prior to acceptance into the Superannuation Scheme. Manual staff who are in close contact with children and those who have been exposed to tuberculous infection have an x-ray examination of chest and at the discretion of the Medical Officer of Health, bacteriological examination of stools or any other investigation considered necessary. (c) Employees of the Council Certain members of the staff having close contact with children are required to have an x-ray examination of chest annually, e.g. health visitors, district nurses, home helps. It is hoped that similar conditions will be introduced for the teaching and other staff at schools, child care officers and any other member of the staff in close contact with children. Members of staff making application for extension of sick leave are referred to the Medical Officer of Health for an independent medical examination and report to the Establishment Committee. Members of staff referred by Chief Officers to determine fitness to continue employment are medically examined. Members of staff who wish to continue employment after the age of 65 years are required to pass a medical examination and are re-examined annually. The following medical examinations were undertaken during 1965:- Officers (excluding teachers) 282 Teachers 141 Manual staff 67 Extensions of sick pay 23 Retirement due to ill-health 2 Extensions of service 15 TRAINEE TEACHERS It is part of the duty of school medical officers to medically examine entrants to teachers. training colleges. 113 such examinations were carried out in 1965 and the reports were forwarded to the Principals of the training colleges concerned. 123 I wish to acknowledge the assistance of the following officers in the compilation of this Report:- Dr. W-H. Kinstrie, M.B., Ch.B., D.P.H., Deputy Medical Officer of Health and Deputy Principal School Medical Officer; Mrs. B.M. Stewart, L.D.S., Chief Dental Officer; Mr. H. Geo. Cripps, M.R.S.H., F.A.P.H.I., Chief Public Health Inspector; Mr. W. France, A.C.C.S., A.I.S.W., Chief Welfare Officer; Mr. D.S. Clapson, D-P.A.(Lond.), L.M.R.S.H., Chief Administrative Officer; Miss M.E. Turner, S.R.N., S.C,M,, H.V. Cert. Superintendent Health Visitor; Miss Sammonds, S.R.N., S.C.M., Q.N., Superintendent of Home Nurses and Non-medical Supervisor of Midwives; MLss G.E. Bridger, A.I.M.S,W., Senior Social Worker; Mr. L.C.E. London, Senior Mental Welfare Officer; Miss S.M. Bourne, A.A.P.S.W., Senior Psychiatric Social Worker. 124