AC 43397 WAN102 London Borough of Wandsworth ANNUAL REPORT of the Medical Officer of Health and Principal School Medical Officer for the Year 1965 by J. TUDOR LEWIS, M.D., D.P.H. London Borough of Wandsworth ANNUAL REPORT of the Medical Officer of Health and Principal School Medical Officer for the Year 1965 by J. TUDOR LEWIS, M.D., D.P.H. CONTENTS Page INTRODUCTION 3 VITAL STATISTICS 10 COMMUNICABLE DISEASES 15 ENVIRONMENTAL HEALTH SERVICES 25 Public Health Inspection 26 Housing 34 Food and Food Premises 36 Factories Act, 1961 45 Atmospheric Pollution 47 Miscellaneous Matters 51 PERSONAL HEALTH SERVICES 54 Services for Mothers and Young Children 54 Other Personal Health Services 65 MENTAL HEALTH SERVICE 77 SCHOOL HEALTH SERVICE 86 INDEX 98 3 ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR 1965 To the Mayor, Aldermen and Councillors of the London Borough of Wandsworth. Mr. Mayor, Ladies and Gentlemen, I have the honour to present to you the first Annual Report on the health of the London Borough of Wandsworth, covering the year ended 31st December, 1965. The London Borough of Wandsworth was constituted under the London Government Act, 1963, and the Council of the Borough was elected on 7th May, 1964. The Health Committee whose terms of reference cover all matters relating to the health of the Borough was appointed on 11th June, 1964, and the names of the Chairman, Vice-Chairman and the members are shown on page 9 of this Report. One of the first functions of the new Council was to appoint the Chief Officers of various departments and the senior officers who would work under these Chief Officers. On page 9 of this Report I show the senior officers of the Health Department who took office in the new Borough. It is the usual practice in Annual Health Reports to refer at the end to any help which the Medical Officer of Health may have received during the course of the year. On the occasion of presenting this first Annual Report I propose to reverse the procedure and to say at the beginning how much I and my senior colleagues in the Health Department have valued and relied upon the help and experience of the Chairman and the Vice-Chairman of the Health Committee, and the Committee itself, in the planning and formation of the new Department. I should also like to say, since in this early period in the life of the Borough staffing problems have loomed very large in our considerations, how much we have appreciated the guidance and help of the Chairman and Vice-Chairman of the Establishment Committee and the Town Clerk and the Establishment Officer in the recruitment of staff for the Health Department at a time when qualified and experienced staff throughout the whole of the London region have been, and remain, at a premium. To all members of the Health Department and particularly the senior members in charge of sections, I should also like to express my personal thanks for their application to their work throughout the early life of the new Council. 4 This Report is prepared along the lines directed and requested by the Ministry of Health and it covers the whole year from the 1st January, 1965, to 31st December, 1965, although in fact the Council did not become responsible for the services until 1st April, 1965. This is possible because prior to the 1st April, 1965, information had been supplied by the predecessors of the new Borough covering the first three months of the year. I have given careful consideration to the form which this and subsequent Reports should take. The purpose of the Report of the Medical Officer of Health is primarily to provide a source of information about the state of the public health of the area and to remind members of the Council of what has gone on during the year ; it also serves to acquaint many others with the conditions in the area. Various Government departments, not least, the Ministry of Health, have an interest in the information contained in the Report of the Medical Officer of Health. Apart from the current need, however, the Report should be a record reflecting the public health and social conditions of the time and should, I consider be so framed as to provide this information. I would hope, therefore, that my Report will contain information which might be of interest to future public health administrators, sociologists and others interested in the public health. This year, however, there has been little or no time to prepare detailed reports of the services under the administration of the Council and so, for the most part, this Report is statistical in form. The main parts correspond with the main sections of the work of the Department; thus the traditional division of the work of the Public Health Department into Environmental Health and Personal Health is maintained and similarly some of the main sections are divided into various sub-sections to facilitate composition, reading and presentation. With this preliminary outline of the form which I think these Reports might take, I now turn to a brief review of the work of the year. Although the Report does not include any description of the work before the 1st January, 1965, it would be naive not to mention the vast amount of preliminary planning, reports to the Committee, and the appointment of staff that was necessary to enable the Committee to carry out its functions as from the 1st April, 1965. This period of planning and preparation continued in some measure after 1st April, 1965, but since that date the main concentration has been on consolidating the preliminary work and welding the whole department into a harmonious and closely integrated whole, and altogether I think one can claim that a fair measure of success has been achieved. Suffice it to say that on the 1st April, 1965, there was no obvious disruption of the services, which were able to proceed on very much the same lines as they had the day before. Since then, although we have met difficulties, not the least of which have been those concerned with staffing, the work has proceeded and, at the time of writing, without any cause for 5 complacency, one has the feeling that the Department has now settled down to the new order. Before commenting on the statistics for 1965, it is necessary to refer to the fact that as a result of the formation of the new Borough, there are no readily available figures to form a basis of comparison with previous years. This is because the London Borough of Wandsworth was formed by the amalgamation of twothirds of the Metropolitan Borough of Wandsworth and the whole of the Metropolitan Borough of Battersea and without a considerable amount of retrospective statistical research, which would be impracticable at the present time, no comparable figures are readily available. We shall, therefore, be starting de novo but if there are any unusual variations from what experience indicates as a reasonable norm, these will be indicated. As the years go by the various rates for each year will be recorded where appropriate in the Report. Details of the vital statistics will be found in the body of the Report but the basic figures for the year are as follows. The civilian population of the new Borough as estimated by the Registrar-General is 331,660 and the birth and death rates have been based on this figure. The total number of live births was 6,490, which gave an adjusted birth rate per thousand of the population of 18.77. The number of deaths at all ages was 4,447, which gave an adjusted death rate per thousand of the population of 11.12. The total number of deaths of infants under one year of age was 143, on which figure the infant mortality rate is 22.03 per thousand live births. The perinatal mortality rate, which is based on the sum of the stillbirths and the deaths under one week per thousand total live and still births was 28.21. Four women died from causes associated with childbirth, which represents a mortality rate of 0.60 per thousand total live and still births. During 1965, infectious disease caused no particular general concern, although some single incidents did occasion some anxiety. 3,474 notifications were received but of these 2.795 were of measles cases because 1965 was a "measles" year. There was one death from this disease in a boy aged seven years. One case of poliomyelitis was notified and steps were taken in this case by local distribution of oral vaccine to prevent a spread. There were 263 cases of dysentery, concentrated mainly in day nurseries and/or day schools but in each case the spread was limited and careful checks were made of all contacts. Five cases of typhoid fever and one of paratyphoid fever were notified and it is interesting to note that in all cases the source of infection was almost certainly from abroad. There was no untoward incidence of influenza. As regards tuberculosis, there were 192 new cases notified and 18 deaths. Some description of the work of the various sections of the Department will be found in the following pages and I need only refer here to one or two matters. 6 Inevitably, staffing was, and remains, a big problem. In no section was this more so than in Environmental Health where the shortage of public health inspectors gave considerable grounds for anxiety. To some extent, this was alleviated, if not overcome, by the employment of technical assistants who work under the general supervision of the public health inspectors and relieve them of as much routine work as possible. These members of our staff gave a valuable service, particularly in relation to drainage work, houses in multiple occupation and work under the Clean Air Act. It is likely that this shortage of trained public health inspectors will be a factor in our work for a long time to come and it is fortunate that we are able to employ technical assistants to cover the more routine aspects of the work. Although I have mentioned particularly the shortage of trained public health inspectors, this problem applies to practically all technical or professional staff and it is evident that with the foreseeable expansion of the health and social services, it will be a considerable time before the supply of staff will meet the demand. It is also clear that Councils will, in the main, have to rely for their recruitment of staff on training their own either directly or by taking advantage of the various training schemes which are available. During the year, a number of staff in various categories were accepted or seconded for training. One part of our work which I must mention is that under the Clean Air Act which was vigorously carried forward. It was decided that every effort must be made to make the whole of the London Borough of Wandsworth into a Smoke Control area by or in 1970 and at the current rate of progress, this should be within our capabilities. The map facing page 48 shows the progress made to date. The most recent addition to the duties and responsibilities of Health Departments is work under the Offices, Shops and Railway Premises Act, 1963. Although this work, in most cases, is straightforward, the volume of work involved is considerable. These new duties were also actively pursued during the year although the number of inspections was not as great as was hoped but this will be rectified in the current year. The Mental Health section of the Department and work under the Mental Health Act, 1959, directed to the community care of the mentally disordered, is one of the fastest growing sectors of the public health services and during the year a good deal of thought was given to the planning of these services and to the preparation and submission of capital schemes which, if and when they come to fruition, will be a great adjunct to the mental health services locally. I hope to be able to describe the progress of these schemes in future Reports. The reorganisation of the services presented the opportunity of providing, for the first time, a co-ordinated public health nursing 7 service and every effort has been made to consolidate the main sections of the nursing service by means of meetings and discussions. Progress has been a little delayed because of the territorial separation of the headquarters of the Home Nursing Service (comprising two former voluntary Nursing Associations) from the health visitors, school health and midwifery services, but during the year considerable progress has been made by means of local meetings of nursing staff and this will be further pursued. It has long been realised that the social services departments of a Council, of which, of course, the Health Department is one, cannot, and should not, be completely self-contained and there may be some overlapping of duties and responsibilities. It is all the more important, therefore, that there should be close links at all levels between departments concerned with social services. To achieve this, the Council set up a Co-ordinating Committee of Members to which problems concerning two or more departments in the field of social welfare are referred. To advise this Committee of Members on matters of policy, the Chief Officers of the departments concerned with social services met periodically to discuss the work of their Departments. In addition to the need for close integration of the statutory social service departments of the Council, there is an equal need for the close integration of the statutory services with voluntary bodies and Government departments. This is achieved, so far as casework is concerned, by the Case Committee, a short account of whose activities is given in the body of the Report. Apart from this, I am able to say that it would seem that there is a close liaison in Wandsworth amongst all categories of personnel concerned with the social services generally. Apart from close links with other social services, the Health Department must maintain cordial ties with other health establishments in the area and particularly with the family doctors. There has always been, in this area, a happy relationship between the family doctors and the Health Departments and on the formation of the new Borough and its Health Department, His Worship the Mayor of Wandsworth gave a reception to which were invited all the family doctors practising in the area. Members of the Health Committee were present as well as senior members of the Health Department staff and it was generally agreed that the evening was a highly successful one, whereby old contacts were renewed and new ones made. The Health Department was very grateful to His Worship for arranging this function. It was not to be expected that a task of organisation such as was set by the London Government Act, 1963, could be accomplished without some "teething troubles" but in proportion to the problems presented, these were comparatively small. In the last quarter of the year, a review of the work and organisation of the 8 Health Department was commenced but no conclusion had been arrived at by the end of the year. I look forward to the growth and development in the years ahead of a fully integrated Health Service in the London Borough of Wandsworth which will give outstanding service to its citizens. I have the honour to be, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, J. TUDOR LEWIS. Medical Officer of Health and Principal School Medical Officer. 9 MEMBERS OF THE HEALTH COMMITTEE Chairman : Councillor Dr. D. L. Kerr, m.p. Vice-Chairman : Councillor Mrs. M. F. Sporle. Councillor R. F. Ash, j.p. A. H. Barton E. C. Bond Dr. J. Fairlee Mrs. O. Haines A. J. Hill K. L. Jackson (until 9th June. 1965) R. W. Joy, d.f.m. Miss J. Lestor (from 9th June, 1965) A. A. Loughton Miss G. A. Morgan Dr. B. N. C. Prichard N. G. M. Prichard, m.sc., j.p., g.l.c. F. E. Sims Mrs. J. D. Standing A. R. Tasker, l.i.b.s.t. S. F. Wellbelove, j.p. Co-opted members: Dr. D. Billig T. E. Parker, j.p. Mrs. M. Walkden, o.b.e., j.p. Ex-officio member: The Worshipful the Mayor (Alderman W. J. H. Malins, j.p.) SENIOR OFFICERS OF THE HEALTH DEPARTMENT Medical Officer of Health J. Tudor Lewis Deputy Medical Officer of Health T. A. Plumley (resigned 30th April, 1965) H. Gordon (appointed 11th October, 1965) Senior Medical Officers A. Garland E. H. Todd Principal Administrative Officer H. J. Horsnell Chief Public Health Inspector G. W. P. Weeks Principal Nursing Officer Miss W. M. Winch Principal Mental Welfare Officer Mrs. P. E. Strauss Principal Social Worker Mrs. M. J. Koolman 10 1 VITAL STATISTICS Population The overall civilian population at the middle of the year was estimated by the Registrar-General to be 331,660 and all the rates used in this Report are based on this figure. Movement of population It is perhaps not generally realised how the work of the health department is complicated by the migrant nature of a large proportion of the population. During 1965 there were over 3,000 families, all with children under five years of age, who moved into Wandsworth; during the same period over 3,500 similar families were known to leave the Borough and a further 1,700 to 1,800 families moved away without leaving any trace of their destinations. Of these last, over 400 were traced either inside or outside Wandsworth. Area Comparability Factors Each year, the Registrar-General provides area comparability factors relating to births and deaths. These factors take into account the extent to which the age and sex distribution of the local population differs from that of England and Wales as a whole and this enables valid comparisons to be made between the birth and death rates in Wandsworth and those in other areas. For the year 1965, the factor for births is 0.96 and for deaths 0.83. 11 Extracts from Vital Statistics Live Births: Male Female Total Legitimate 2,870 2,776 5,646 Illegitimate 437 407 844 Total 3,307 3,183 6,490 Rate per 1,000 population : Crude 19.56 Adjusted 18.77 Stillbirths 55 48 103 Rate per 1,000 total live and still births 15.62 Deaths: All ages 2,089 2,358 4,447 Rate per 1,000 population: Crude 13.40 Adjusted 11.12 Infant Mortality Rates: Deaths under 1 year 89 54 143 Total infant deaths per 1,000 live births 22.03 Legitimate infant deaths per 1,000 legitimate live births 21.96 Illegitimate infant deaths per 1,000 illegitimate live births 22.51 Neo-natal Mortality Rate (deaths under four weeks per 1,000 total live births) 13.86 Early Neo-natal Mortality Rate (deaths under one week per 1,000 total live births) 12.79 Perinatal Mortality Rate (stillbirths and deaths under one week combined per 1,000 total live and still- births) 28.21 Maternal Mortality Rate (per 1,000 total live and still births) 0.60 Number of deaths from Puerperal causes 4 Number of deaths from Cancer 868 Number of deaths from Tuberculosis 18 12 Births The total number of live births to residents of the Borough registered during 1965 was 6,490 comprising 3,307 males and 3,183 females. The crude birth-rate was 19.56 per 1,000 population. After taking into account the area comparability factor supplied by the Registrar-General the adjusted rate was 18.77. The live birth rate for England and Wales was 18.1. During the year there were 844 illegitimate live births to residents of the Borough, representing 13% of the total live births for the area. Stillbirths during the year numbered 103 giving a total of 6,593 live and still births for the area. Deaths There has been no unusual or excessive mortality during the year. The number of deaths assigned to the Borough, after adjustment for inward and outward transfers, was 4,447 comprising 2,089 males and 2,358 females. The crude death-rate for the year was 13.40 per 1,000 population but after applying the area comparability factor, the adjusted rate was 11.12. The death rate for England and Wales was 11.5. Table 1 is the general mortality table for the Borough and shows the number of deaths from each cause divided into sexes, age groups and locality. Table 2 shows the deaths from heart disease. 13 TABLE 1. CAUSES OF, AND AGES AT, DEATH DURING THE YEAR 1965 CAUSES OF DEATH Deaths assigned to Borough in age groups Deaths shown in localities (all ages) All Ages Males Females Under 1 year 1 and under 5 5 and under 15 15 and under 25 25 and under 35 35 and under 45 45 and under 55 55 and under 65 65 and under 75 75 and over Putney Central Battersea Tuberculosis, Respiratory 12 7 5 - - - - - 2 1 2 4 3 — 6 6 Tuberculosis, Other 6 3 3 - - - - - - 1 1 1 3 1 3 2 Syphilitic Disease 11 8 3 - - - - - - 1 2 2 6 2 5 4 Diphtheria - - - - - - - - - - - - - - - - Whooping Cough 1 1 — 1 - - - - - - - - - - 1 — Meningococcal Infections 1 — 1 - - 1 - - - - - - - - 1 — Acute Poliomyelitis - - - - - - - - - - - - - - - - Measles 1 1 - - - 1 - - - - - - - - - 1 Other Infective and Parasitic Diseases 8 4 4 1 — 1 — — 1 1 3 — 1 3 3 2 Malignant Neoplasm, Stomach 82 48 34 - - - - - 1 10 21 19 31 22 30 30 Malignant Neoplasm, Lung, Bronchus 238 190 48 — — — — 1 2 31 76 79 49 68 82 88 Malignant Neoplasm, Breast 82 2 80 — — — — 1 3 15 20 22 21 26 30 26 Malignant Neoplasm, Uterus 31 — 31 - - - - - 2 8 5 6 10 8 14 9 Other Malignant and Lymphatic Neoplasms 413 222 191 — — 4 3 6 18 41 75 112 154 115 154 144 Leukaemia, Aleukaemia 22 7 15 1 1 2 1 2 1 1 2 6 5 9 8 5 Diabetes 30 9 21 — — — — 1 2 — 5 9 13 10 10 10 Vascular Lesions of Nervous System 489 175 314 — — — 2 — 8 17 47 125 290 132 180 177 Coronary Disease, Angina 804 463 341 — — — — 1 14 54 157 247 331 248 295 261 Hypertension, with Heart Disease 37 12 25 - - - - - - 3 1 7 26 9 13 15 Other Heart Disease 676 183 493 — — — — 1 15 11 27 106 516 117 414 145 Other Circulatory Disease 251 94 157 — — — — 1 3 10 20 63 154 73 100 78 Influenza 8 4 4 1 — — — — 1 2 — — 4 3 3 2 Pneumonia 309 137 172 26 3 — 2 1 1 3 23 48 202 64 146 99 Bronchitis 243 176 67 4 — — 1 1 — 13 50 71 103 68 84 91 Other Diseases of Respiratory System 41 26 15 2 1 — 1 2 2 3 4 6 20 12 15 14 Ulcer of Stomach and Duodenum 32 17 15 - - - - - 1 4 2 9 16 7 14 11 Gastritis, Enteritis, Diarrhoea 24 6 18 4 — — — 1 1 3 5 2 8 10 7 7 Nephritis and Nephrosis 29 16 13 — — — — 1 3 6 3 12 4 8 13 8 Hyperplasia of Prostate 7 7 — — — — — — — — — — 7 2 2 3 Pregnancy, Childbirth, Abortion 4 — 4 — — — — 4 — — — — — — 3 1 Congenital Malformations 35 17 18 23 2 1 1 1 1 — 3 3 - 12 13 10 Other Defined and Ill-defined Disease 360 150 210 77 3 4 4 7 9 18 45 48 145 102 139 119 Motor Vehicle Accidents 38 21 17 1 1 3 6 3 1 4 2 5 12 10 10 18 All other Accidents 60 36 24 2 3 1 1 6 7 4 2 12 22 12 28 20 Suicide 59 46 13 — — — 3 3 21 11 12 6 3 11 25 23 Homicide and Operations of War 3 1 2 — — — — 1 2 — — — — 2 1 — All Causes 4,447 2,089 2,358 143 14 18 25 45 122 276 615 1,030 2,159 1.166 1,852 1,429 14 TABLE 2. DEATHS FROM HEART DISEASE, Males in age groups Females in age groups Grand Total under 25 25- 35— 45- 55— 65— 75 + Total | under 25 25— 35- 45 — 55— 65— 75 + j Total Coronary Disease Angina, etc. - - 14 48 121 151 129 463 - 1 - 6 36 96 202 341 804 Hypertension with Heart Disease - - - 3 1 2 6 12 - - - - - 5 20 25 37 Other Heart Disease — 1 7 4 9 40 122 183 — — 8 7 18 66 394 493 676 Total — 1 21 55 131 193 257 658 — 1 8 13 54 167 616 859 1,517 Infant Mortality There were 143 deaths of children under one year. giving an infant mortality rate of 22.03 per 1,000 live births. The infant mortality rate for England and Wales was 19.0. Table 3 shows causes of death of children under one year of age. TABLE 3. DEATHS OF CHILDREN UNDER ONE YEAR OF AGE Cause of Death Under 24 hours 1-7 days 1-4 weeks Total under 4 weeks 1-12 months TOTAL DEATHS UNDER 1 YEAR 1. Pneumonia — — 2 2 24 26 2. Bronchitis — — — — 4 4 3. Gastritis, Enteritis, Diarrhoea — — — — 4 4 4. Congenital Malformations 7 2 6 15 8 23 5. Prematurity 31 14 3 48 — 48 6. Other Causes 13 9 4 25 13 38 TOTALS 51 25 15 90 53 143 Maternal Mortality Four deaths occurred from accidents and diseases of pregnancy or child-birth. This is equivalent to a rate of 0.6 per 1,000 live and still births. 15 2 COMMUNICABLE DISEASES During the year 3,474 notifications of infectious disease were received, and a commentary on these is given below. Statistical tables are given on pages 23 and 24 and show the number of cases of notifiable infectious diseases reported arranged in age groups (Table 1) and the areas in which they occurred (Table 2). Vaccination and immunization against certain infectious diseases is one of the personal health services available to certain limited groups of people and a reference to this service will be found on page 67. Diphtheria No cases of diphtheria occurred, but five contacts of a confirmed case residing outside the Borough were investigated. Tests showed that they were not infected. Erysipelas Twenty cases were notified. Food Poisoning Sixteen cases of food poisoning were notified during the year. In 11 cases the causative organism was found to be of the following types:— Salmonella brandenburg 3 ,, derby 1 „ dublin 1 „ typhimurium 6 The causative organism of the remaining five cases was not identified. As with dysentery, the number of cases notified does not reflect fully the amount of work that is involved in investigating each notification. Food poisoning is the only disease that can be notified with the prefix "suspected" before the disease and during the year 125 suspected cases were also notified, none of which however was substantiated bacteriologically. Measles A total of 2,795 notifications were received. Measles tends to occur in increased prevalence in alternate years and 1965 was a "measles" year. There was one death from this disease in a boy aged 7 years. Meningococcal Infection Seven confirmed cases were notified during the year but they were unrelated. One proved fatal. 16 Ophthalmia Neonatorum This is an acute inflammatory condition of the eye which sometimes occurs in newborn babies and six cases were notified during the year. Acute Influenzal Pneumonia and Acute Primary Pneumonia Acute influenzal pneumonia and acute primary pneumonia are notifiable forms of pneumonia and in 1965 four of the former and 50 of the latter were notified. Poliomyelitis One case of paralytic poliomyelitis occurred in a girl aged four years. There were no associated cases. Puerperal Pyrexia. Seven cases were notified during the year. Scarlet Fever Ninety-six cases were notified. Sonne Dysentery Of the total number reported, 231 cases or associated cases occurred in outbreaks which affected four day nurseries and four schools. Details of these outbreaks are given below:— Month Outbreak No. of cases January Day Nursery 22 January Day Nursery 28 January Day Nursery 45 February School 13 February School 35 March Day Nursery 6 July School 29 September School 53 Total 231 The remaining 32 cases were single unrelated ones. The total figure of 263 cases for the year does not reflect fully the amount of work involved in visiting and following up. Many other cases reported as dysentery were investigated but most of these proved negative on bacteriological examination. 17 Tuberculosis The total number of new cases which came to the notice of the Department during 1965 was 192, the sources of information being as follows:— Primary notifications 150 Unnotified at death 6 Transfers from other areas 36 Total 192 The number of deaths certified as due to various forms of tuberculosis was 18. Particulars of the primary notifications and deaths during the year, classified by sexes and age-groups, are given in the following table : — Age Groups Primary Notifications Deaths Pulmonary NonPulmonary Pulmonary NonPulmonary M. F. M. F. M. F. M. F. Under 1 year 2 - - - - - - - 1-4 4 1 2 - - - - - 5-9 3 3 - - - - - - 10-14 — — 1 — — — — — 15-24 12 7 4 3 - - — — 25-44 23 13 5 11 1 1 — — 45-64 31 5 2 2 1 2 1 1 65 and over 9 6 — 1 5 2 2 2 Totals 84 35 14 17 7 5 3 3 During the year a total of 438 home visits were made by tuberculosis visitors. Over the past decade great advances have been made in the treatment, and hence in the prevention of tuberculosis, and the disease, as the above figures indicate, is much less of a problem than it was in years gone by. Nevertheless, its importance as a public health hazard must not be under-estimated. There are in the Borough three Chest Clinics, namely, the Wandsworth Chest Clinic situated in Municipal Buildings, the Battersea Chest Clinic at St. John's Hospital and the Balham Chest Clinic at St. James' Hospital. The Wandsworth and Battersea Chest Clinics draw their patients mainly from the Borough but the Balham Chest Clinic also draws patients from the adjoining London Borough of Lambeth. 18 It is never easy to differentiate between the prevention and treatment of an illness and this is particularly so in the case of tuberculosis. Close liaison, therefore, is necessary between the Chest Clinics and the staff of the Health Department and I am happy to state that this exists. Meetings are held from time to time between the three Chest Physicians and the Health Department medical staff, and the health visitors attached to the Chest Clinics are seconded from the Health Department so that there are close links at all levels. I am grateful to the three Chest Physicians in the Borough and their staffs for their help and guidance on matters relating to the prevention and control of tuberculosis on the occasions when we have sought their opinion. Since tuberculosis has become less of a problem so have the arrangements for the care and after-care of patients become less important, but there is still a very definite need to help patients suffering from tuberculosis. This is done in large measure in Wandsworth through the agencies of the two Tuberculosis Care Committees, the "Wandsworth Tuberculosis Care Committee" and the "Battersea Tuberculosis Care Committee". I have pleasure in appending herewith reports of the activities of these two Care Committees during the year, which will, I think, provide an indication of the extent and quality of their services. I should like to thank both Committees for the excellent work they have carried out in helping patients suffering from tuberculosis, during the year. WANDSWORTH TUBERCULOSIS CARE COMMITTEE ANNUAL REPORT FOR 1965 This year has been one of great activity and changes. We welcomed two new Members, Mrs. S. B. Morgan and Mrs. G. Cassidy, who were elected to the Committee. Mrs. Cubitt, my Vice-Chairman, resigned, and Mrs. Ireland was unanimously elected in her place. We are indebted to Mrs. Cubitt for her services and I thank her personally for her guidance and help. Again there were many calls for assistance in such items as, clothing, bedding, holidays and monetary gifts to cover a variety of needs. At Christmas we gave our usual presents to patients and their families which were greatly appreciated. The Handicraft Class turned out some excellent work at their weekly class and it sold well at our Annual Sale in November, which the Mayor, Alderman W. J. Malins, J.P., kindly opened. The proceeds were highly satisfactory, and thanks are due to the Committee and Stallholders for their efforts to make it such a success. We greatly miss Miss Catt, who, in the past, organised our Jumble Sale and who has had to resign and our thanks are due 19 now to Mrs. Morgan and Miss Leiser for taking on this work and making it again successful. We thank Mr. and Mrs. Ireland and Mrs. Morgan for accompanying the patients on the two annual outings to Eastbourne and Brighton and for bringing them safely back. The Balham and Tooting Chamber of Commerce gave a dance on our behalf at the Town Hall and handed to the Mayor a cheque for £106 who in turn presented it to me for the funds. We thank them so much for all the hard work put into it to raise such a substantial sum. The Appeal Letter was disappointing, but we hope for better results next time. We very much regret that Mr. Scott, who has been on this Committee with me since before the war, has had to send in his resignation, and Mr. Searle, through pressure of business, has also had to resign. We shall miss them both and thank them for their generous help at all times. I would like to place on record my thanks to all who have assisted and co-operated with us during the year, including the W.V.S. and Officers of the National Assistance Board and Labour Exchanges. To my Vice-Chairman, Hon. Treasurer, and all the Committee for their interest and help. I give my grateful thanks also, to Miss Oakey, Miss Macdonald and Mrs. Gilbert. DEODORA CASSELS, Chairman. BATTERSEA TUBERCULOSIS CARE COMMITTEE ANNUAL REPORT FOR 1965 In presenting our Report for the year 1965 we must record the resignation from our Committee of Dr. T. A. Plumley, Deputy Medical Officer of Health for Battersea. Dr. Plumley has been a most helpful member, and his interest in individual cases as well as in the activities of the Committee has been greatly appreciated. The year 1965 has seen the passing of the London County Council and the joining together of Battersea and Wandsworth into the London Borough of Wandsworth. The facilities hitherto provided to the Care Committee by the L.C.C. continue to be provided by the Borough. Although two Care Committees now exist for the same purpose within the new Borough of Wandsworth, the respective Chest Clinic boundaries prevent the overlapping of the work of these Committees. The Chest Clinic has continued to set the pattern for the care and after-care of patients. Early diagnosis, the speed of treatment and the re-settlement of the patient has resulted in many 20 calls for help from Care Committee funds. The provision of clothing and footwear has accounted for the largest proportion of the year's expenditure. Grants have also been made for fuel and heating costs as well as the provision of a heating appliance, towards bed linen and removal expenses, and the cost of holiday expenses. At Christmas £70 was disbursed to outpatients. Cash gifts were also made to a number of chest patients spending Christmas in the wards in St. John's Hospital. Toys received from the Evening News "Toy for a Sick Child" Fund were distributed in time for Christmas. In order to enable Committee funds to meet the various calls for help, our money-raising activities have had to be increased. The Autumn Draw this year resulted in a credit of £30—a slight decrease on the total for the previous year, but nevertheless valuable. We thank our friends for their loyal support. We are indeed indebted to Mr. T. E. Collyer, a member of our Committee, who himself arranged for two Old Tyme Dances during the year. These occasions were outstandingly successful both socially and financially, and as a result our funds benefited to the extent of £194. We are most grateful to Mr. Collyer for giving of his time and talent for organisation so generously. The collection and sale of milk bottle tops and tin foil has continued although the proceeds are much reduced. However, it is hoped that our friends will increase their efforts so that we may look forward to a more worthwhile result next year. Our close co-operation with the officers of the National Assistance Boards and the Disablement Re-settlement Officers of the Ministry of Labour has continued and has contributed in great part to the welfare of our patients. We also acknowledge with thanks the help received from the Morganite Carbon Company, the R.A.F. Benevolent Fund, the Society of St. Patrick, and Queen Mary's London Needlework Guild. We wish to record our great appreciation of the practical help given by the Battersea Park Rotary Club to individual patients; this assistance has been invaluable. We also record our appreciation of the gifts of money, clothing, books and toys donated by our many friends. The Committee has met each month and we thank the Battersea, Putney and Tooting Group Hospital Management Committee for providing us with facilities for our meetings. In conclusion we place on record our thanks to Miss R. M. Greenaway, the Committee's Secretary, and Miss M. Clifford, Health Visitor, for their work on behalf of the Committee during the year. (Mrs.) E. A. COOPER, Chairman. 21 Typhoid and Paratyphoid Fever Five cases of typhoid fever and one case of paratyphoid 'B' were notified during the year and in all cases the source of infection was from abroad. The case of paratyphoid 'B' occurred in a man aged 53 years who had just returned from a holiday in Spain. The first case of typhoid fever occurred in a boy aged 8 years who had recently arrived from Jamaica; the second case, a baby of 1½ years, had just returned from the Continent; the third case was a young man aged 20 years who had come to this country on holiday from Spain and it appeared that just prior to his leaving Spain he had felt unwell, although not so acutely as to stop him from travelling. All contacts were investigated. The remaining two cases, a boy aged 5 months and a girl aged 1½ years, were cousins and lived in the same house. In the case of the baby boy, the disease proved fatal. Whilst investigating the contacts, two carriers were discovered in the same household, the grandmother of the children from whom it was thought they contracted the disease and the young girl's mother. Both the girl and her mother responded well to medication and recovered. The grandmother, however, refused treatment and returned to Italy. With one exception, all the adult contacts living in the house worked in a hospital kitchen; this at first proved a problem, but alternative employment not connected with food or a hospital was found for them with the assistance of the Ministry of Labour. Whooping Cough Fifty-three cases were notified during the year and one child aged three months died from the disease. Smallpox No case occurred in the Borough during the year. Notifications are received from Port and Local Authorities whenever persons who may have been in contact with smallpox are known to be coming into the Borough. Observation for the necessary period is kept on these persons by members of the staff of the Health Department but no such notifications were received during the year. Under the Public Health (Aircraft) Regulations, 1952-63, persons arriving in this country by air, who are not in possession of valid international certificates of vaccination against smallpox, must be placed under surveillance for up to 17 days. With the ever-increasing flow of air travel, more and more people come to this country to stay, permanently or otherwise, and during the year 38 such persons who were proceeding to addresses in the Borough were kept under observation. 22 International Certificates of Vaccination and Inoculation During the year 4,110 requests were received from residents in the Borough for a certificate of vaccination or inoculation to be authenticated for the purpose of travel abroad. The signature of the person issuing the certificate was verified in each case as that of a registered medical practitioner practising in Wandsworth and the certificate endorsed accordingly. The risk of importation of smallpox to countries by travellers from smallpox endemic areas has caused a tightening up by most countries of their regulations in regard to vaccination, and in consequence, many more requests are now being made to Health Departments for the authentication of international certificates. Occasional requests were also received for a certificate to the effect that no recent cases of smallpox have occurred in the area. Such requests are made by persons proceeding abroad who do not wish to be vaccinated. Bacteriological Examinations All bacteriological examinations are carried out at the Medical Research Council's Public Health Laboratory at County Hall under its Director, Dr. A. J. H. Tomlinson, to whom I would like to express thanks for the help and assistance that he and his staff have given to my department during the year. A total of 5,826 bacteriological examinations were carried out during the year on specimens submitted by general practitioners and by the health department. Nature of Specimen No. Stool and urine 5,087 Nose and throat swabs 739 23 TABLE 1 NOTIFIABLE DISEASES NO. OF NOTIFIED CASES OF INFECTIOUS DISEASES IN AGE GROUPS Under 1 1—2 3—4 5—9 10—14 15—24 25—44 45—64 65 and over Total Anthrax - - - - - - - - - — Diphtheria — — — — — — — — — — Dysentery 6 27 44 104 4 20 39 14 5 263 Encephalitis, Acute — — — — — — — — — — Erysipelas — — — — — — 3 12 5 20 Food Poisoning 1 3 3 2 — 4 1 2 — 16 Malaria — — — — — — — — — — Measles 95 643 764 1,167 70 34 22 — — 2,795 Meningococcal Infection 2 — 1 — 1 2 1 — — 7 Ophthalmia Neonatorum 6 — — — — — — — — 6 Pneumonia: Acute Influenzal — — — — — — — 2 2 4 Acute Primary 2 1 1 4 2 6 7 11 16 50 Poliomyelitis, Acute — — 1 — — — — — — 1 Puerperal Pyrexia — - — — — 4 3 — — 7 Scarlet Fever — 7 12 58 11 8 — — — 96 Smallpox — — — — — — — — — — Tuberculosis 2 3 4 6 1 26 52 40 16 150 Typhoid Fever and Paratyphoid Fever 1 2 — 1 — 1 1 — — 6 Whooping Cough 11 18 20 2 — 1 1 — — 53 Total 126 704 850 1,344 89 106 130 81 44 3,474 24 TABLE 2 NOTIFIABLE DISEASES NUMBER OF NOTIFIED CASES OF INFECTIOUS DISEASES IN WARDS Total Deaths PUTNEY CENTRAL BATTER SEA Roehampton Putney Thamesfield West Hill Southfield Fairfield Earlsfield Springfield Tooting Graveney Bedford Furzedown Northcote ; Balham Nightingale St. John Latchmere St. Mary's Park Shaftesbury Queenstown Anthrax — — — — — — — — — — — — — — — — — — — — — — Diphtheria — — — — — — — — — — — — — — — — — — — — — — Dysentery — 1 — 5 7 9 20 27 31 7 41 1 6 49 6 2 3 4 1 43 263 — Encephalitis, Acute — — — — — — — — — — —• — — — — — — — — — — — Erysipelas — 2 — — 1 1 — 1 3 4 3 1 1 1 — — — — — 2 20 — Food Poisoning 1 1 — 1 — — — 3 1 1 4 — — 1 — 1 — — 1 1 16 — Malaria — — — — — — — — — — — — — — — — — — — — — — Measles 31 77 101 160 199 274 191 166 214 194 103 158 89 166 82 124 107 109 89 161 2,795 1 Meningococcal Infection — 1 — — — 2 — — — — — — — 2 1 1 — — — — 7 1 Ophthalmia Neonatorum — — — — 1 — — — 1 — 2 1 — — 1 — — — — — 6 — Pneumonia, Acute Influenzal — — — — — — — 1 1 — — — — — — 1 — — — 1 4 — „ Acute Primary — 2 2 2 6 2 3 8 4 2 1 — 1 5 2 6 — 1 — 3 50 — Poliomyelitis, Acute — — — — — — — — — — — — — — — 1 — — — — 1 — Puerperal Pyrexia — — — 1 1 1 1 — 1 — — — — 1 — 1 — — — — 7 — Scarlet Fever 5 3 1 8 7 5 3 10 10 4 3 2 2 6 1 2 5 8 8 3 96 — Smallpox — — — — — — — — — — — — — — — — — — — — — — Tuberculosis—all forms 2 7 2 9 2 5 10 10 8 9 14 8 9 5 11 5 6 6 17 5 150 18 Typhoid Fever and Paratyphoid Fever _ 1 — — — — — — — — — — 2 1 1 1 — — — — 6 1 Whooping Cough — 2 — 5 5 1 1 1 1 5 11 1 1 13 2 2 — — — 2 53 1 Total 39 97 106 191 229 300 229 227 275 226 182 172. 111 250 107 147 121 128 116 221 3,474 22 25 3 ENVIRONMENTAL HEALTH SERVICES The year under review has been unusual in that following the reorganization of the former Boroughs, the personnel of the two environmental health sections have had to be integrated, new contacts made and altered Public Health legislation, new in several respects, digested and applied. It is with pleasure that I have to report a satisfactory resolution of these matters. The shortage of public health inspectors, which is general throughout the London area, has kept the department fully extended, but the main work, I am satisfied, has been covered. Five student public health inspectors are in the course of training and it is hoped that as and when they become qualified, their services will be available to the Corporation. Technical assistants have been employed to assist in the work of drainage, smoke control and the inspection of houses in multiple occupation, under the guidance of the public health inspectors. Details of various aspects of the work are set out in the tables which follow. A Slum Clearance programme to cover the ensuing period of five years has been decided upon by the Council and work is proceeding. Housing work in connection with slum clearance had been carried out actively by the two former Boroughs and only comparatively small areas remain at the moment to be dealt with. There are, however, a number of sub-standard rented and owner-occupied properties where conditions could be improved by the installation of an internal water closet, bath and hot water supply. Some owner-occupiers have taken advantage of the standard grants available to provide additional facilities, but the owners of rented property have not been forthcoming in this connection. The making of " Direction Orders " in connection with houses in multiple occupation has resulted in the number of occupants in several overcrowded premises being reduced and inspection of this type of property is being actively carried on. The question of damage and fouling caused by pigeons has been considered but direct action has been delayed to await the deliberation of the London Boroughs Committee, with a view to joint action by all London Boroughs. Certainly some action is desirable to prevent the serious fouling and damage to the fabric of buildings apart from the possible danger to health. Work in connection with the inspection of offices under the Offices, Shops and Railway Premises Act is proceeding, although the number of inspections achieved was less than had been hoped for. However, useful experience has been gained which should be reflected in the figures for next year. 26 PUBLIC HEALTH INSPECTION Work of the Public Health Inspectors A summary of the inspections carried out during the year is given in Table 1. TABLE 1 Inspections Re- Inspections Total To investigate complaints 5,708 12,784 18,492 Offices, Shops and Railway Premises Act 620 386 1,006 Infectious Diseases 1,820 1,114 2,934 Factories Act 972 — 972 Housing Clearance Area Scheme 25 — 25 Housing Reports 1,116 — 1,116 Hairdressers 376 — 376 Other inspections 9,931 6,462 16,393 Totals 20,568 20,746 41,314 Table 2 gives details of the sanitary operations carried out in the Borough during the year. 27 TABLE 2 Putney Central Battersea Total Premises cleansed and repaired 152 184 304 640 Drains tested 88 93 286 467 Drains cleansed or repaired 175 289 258 722 Water closets cleansed, repaired or renewed 48 93 124 265 Soil pipes altered or repaired 7 24 6 37 Waste pipes provided, altered or repaired 39 64 73 176 Rainwater pipes repaired 11 14 12 37 Roofs and gutters repaired 69 87 216 372 Damp courses inserted 1 1 — 2 Damp conditions otherwise remedied 86 118 168 372 Yards drained or paved 2 11 11 24 Dustbins provided 4 39 14 57 Water cisterns cleansed, covered or repaired 1 2 10 13 Water supply reinstated 98 65 161 324 Defective stoves and fireplaces remedied 5 12 12 29 Animals improperly kept — 3 3 Accumulations of rubbish, etc., removed 14 27 13 54 Urinals cleansed or repaired — Smoke nuisances 1 1 Other nuisances 5 8 93 106 Total 805 1,135 1,761 3,701 Number of preliminary notices served 209 377 556 1,142 Number of preliminary notices complied with 205 332 367 904 Number of abatement notices served 62 148 192 402 Number of abatement notices complied with 61 131 117 309 Legal Proceedings During the year, legal proceedings were taken by the Council in five instances in connection with the abatement of nuisances. Drainage Work Plans are required to be submitted to the Council in respect of all new drainage work, or any reconstruction, alteration or repair of existing drainage systems, for approval under the Drainage Byelaws. The actual work on the site is supervised by technical assistants in co-ordination with the public health inspectors. During the year 1,563 tests were carried out in connection with drainage installations and 23 connections were made to the Council's sewers. 28 Following the reorganisation in London government, the repeal of the Public Health (London) Act, 1936, and the application of the Public Health Act, 1936, to London, placed an additional responsibility on the Council with regard to existing combined drainage systems. On 1st April, 1965, combined drainage systems were redesignated " public sewerstheir clearance and maintenance becoming the responsibility of the Council, with maintenance costs chargeable to the owners of properties connected to the public sewer. There is a close working liaison with the Borough Engineer and Surveyor's Department to implement the rapid clearance and repair of public sewers. Sewerage and Sewage Disposal The sewerage system, in common with other London boroughs, discharges into the Greater London Council's main sewers and disposal is carried out by that Council. The Corporation's brick and pipe sewers are regularly cleansed and adequate for their purpose. Water Supply The bulk of the water supply in the Borough is provided by the Metropolitan Water Board and this supply has been satisfactory both in quality and quantity throughout the year. All dwelling houses in the Borough, numbering approximately 93,000 and housing a population of 331,660 persons, have a mains water supply provided by the Metropolitan Water Board with the exception of a portion of one of the Council's housing estates, namely the Latchmere Estate, which obtains its supply from deep wells situated at the Latchmere Baths adjoining the Estate. Bacteriological examination of the well-water before chlorination, and prior to its supply to the Estate, is carried out at fortnightly intervals and chemical analysis has shown no significant change in the character of the water. At one time, water for the whole Estate was supplied from the wells, but work is in progress to provide a water supply piped directly from the mains of the Metropolitan Water Board. The Metropolitan Water Board carries out bacteriological and chemical tests of raw water and water after treatment. No specific action has been necessary in respect of contamination of water supply but following inspection of individual premises by the public health inspectors, close liaison has been maintained with the Metropolitan Water Board whenever necessary. The fluoride content of water supplied by the Metropolitan Water Board to Wandsworth is 0.2 to 0.25 parts per million, and in the case of water supplied to the Latchmere Estate 0.60 to 0.65 parts per million. During the year, consideration was given by the Health Committee to the general question of the fluoridation of the water 29 supply in the Borough, to decide whether to recommend to the Council that the Metropolitan Water Board should be asked to add fluoride to the water which it supplies throughout the London area. No decision had been taken by the end of the year but at subsequent meetings the Council decided in favour of the fluoridation of public water supplies in Wandsworth. Nursing Homes The Council now controls the registration and supervision of all nursing homes within the area and its powers in this connection are contained in the Public Health Act, 1936, the Nursing Homes Act, 1963, the Conduct of Nursing Homes Regulations, 1963, and, for mental nursing homes, the Mental Health Act, 1959. The legislation of the last few years has added considerably to the power of local authorities to require and maintain good standards in nursing homes of all kinds. There are ten registered nursing homes in the Borough with a total of 296 beds and during the year there was one application for registration on change of " keeper ". No new homes were registered and no registrations were cancelled. The accommodation and categories of the nursing homes are given below, with details of inspections made during the year:— Accommodation :— Mental nursing homes (2) 162 beds Maternity nursing home (1) 9 beds Mother and baby homes (3) 53 beds Other nursing homes (4) 72 beds Inspections:— Medical and nursing officers 10 Public health inspectors 13 Hairdressers and Barbers Before the operation of the London Government Act, 1963, legislation governing standards of cleanliness in hairdressers' and barbers' establishments was contained in byelaws made separately by the former Metropolitan Borough Councils under the London County Council (General Powers) Act, 1954. This legislation has since been repealed but by virtue of special provisions in the London Government Act, 1963, the byelaws still continue to apply in the separate areas in respect of which they were made. To regularize the position throughout the Borough consideration was given to the substitution of a new byelaw but the matter had not been concluded by the end of the year. During the year 376 inspections of such premises were made. Prevention of Damage by Pests Act, 1949 This Act gives the Council power to require steps to be taken to eradicate and, where possible, to prevent infestation by rats and 30 mice. These duties are carried out by the Rodent Officer assisted by Rodent Operatives. All infestations coming to light, whether by way of complaint or otherwise, are systematically investigated and appropriate action is taken. Where the cause of the trouble is obviously defective drains or other defects in the building, the owner is called upon to effect the necessary repairs. This aspect of the work involves close co-operation between the Rodent Control Staff and the Public Health Inspectors. In the case of private dwellings the work of disinfestation is carried out by the Rodent Control staff without charge, and on request at business premises, when the cost is charged in full. During the year, 1,391 complaints of infestation were received in respect of which a total of 6,459 visits were made by the Rodent Control staff. Offensive Trades There are two premises in the Borough at which the scheduled offensive trade of fat-melting is carried on. The firms concerned have been established for many years, and the trades are conducted satisfactorily. Pharmacy and Poisons Act, 1933 This Act is chiefly concerned with the distribution by sale or otherwise of poisonous substances. The list of poisons is contained in an Order made under the Act and is divided into two parts. The Council are not concerned with the poisons contained in Part I. since an " authorised seller" is a pharmacist registered with the Pharmaceutical Society, and enforcement is entrusted to Inspectors appointed by that Society. Substances specified in Part II may be sold by " listed sellers and these are persons who, on written application in a prescribed form, and on payment of stated fees, are recorded by the Council as " persons entitled to sell poisons in Part II of the Poisons List" at the premises recorded on the Register. The Council are required to enforce the Act and Orders so far as they relate to " listed sellers" and have appointed the Public Health Inspectors as Inspectors under the Act. At the end of the year there were 220 persons registered under the Act. Consumer Protection Act, 1961 This Act repealed the Heating Appliances (Fireguards) Act, 1952, and the Oil Burners (Standards) Act, 1960, but Regulations made under the former Act concerning fireguards on certain heating appliances offered for sale are still in force. Regulations have been made concerning oil burners, specifying standards of safety, and prohibiting the sale of oil heaters or component parts which do not comply with the Regulations. No contraventions of the Regulations were reported during the year. 31 Noise Abatement Act, 1960 Since the passing of this Act, the number of complaints concerning noise has grown considerably. Previously the law governing noise nuisance in London was contained in the London County Council (General Powers) Act, 1937, which provided that any " excessive, unreasonable or unnecessary noise which was injurious to health " could be dealt with summarily as a nuisance. The proof necessary to satisfy these requirements before Court procedure could be instituted was often difficult to obtain. The 1960 Act substitutes for these words " noise which is a nuisance and the procedure is thereby simplified. It is not necessary to prove injury to health, or that the noise was excessive, unreasonable or unnecessary. With regard to industrial noise, however, it is still a good defence to prove that the best practicable means have been used to prevent or counteract its effect. As well as the Council having authority to take action, any three persons who are aggrieved by a noise nuisance can initiate action by complaining to a Magistrate. It has been the practice in the Health Department to take appropriate action when complaints of noise have arisen in connection with a trade or business. Industrial noise clearly has a health angle, in that it is often continuous and of considerable intensity. The service of notices has not been necessary, because a letter calling attention to the complaint has had the desired results. Complaints, however, received from persons who complain that rowdy parties take place at certain times in adjoining premises, or that the person in the flat above causes undue noise, are not considered the type of complaint that should be dealt with by the public health inspectors. There would appear to be no specific health hazard but rather a personal problem arising in the majority of cases from behaviour difficulties between neighbours. This is the type of complaint that could well be dealt with by the persons aggrieved. Offices, Shops and Railway Premises Act, 1963 The administration of this Act was continued during the year despite staffing difficulties caused by retirements and resignations of public health inspectors. Initial inspections numbered 620 and the total inspections including re-inspections was 1,006. Consideration is being given to the question of the employment of technical assistants to aid the public health inspectors in this work. Non-compliance with the Act has been mainly confined to failure to display an Abstract of the Act and a lack of thermometers and first-aid boxes. Heating to the required standard was sometimes found difficult to achieve in shop premises because of the continual loss of heat due to repeated door openings and a number of premises lacked a hot water supply for washing. No difficulty has yet been experienced in obtaining compliance with the Act when contraventions have been brought to the notice of the responsible 32 persons. Accidents notified have been of a comparatively minor character and 45 notifications were received during the year. Nearly one-half of the accidents reported were caused by falls of various kinds or following collisions. The following table shows the classification and number of premises registered since the operative date of the Act, up to the end of 1965, the number of persons employed thereat and the number of inspections made during the year:— Class of Premises Number Registered Persons Employed Initial Inspections 1965 ReInspections 1965 Offices 739 7,873 124 386 Retail shops 1,911 8,467 429 Wholesale shops, warehouses 105 1,210 18 Catering establishments open to the public 258 2,021 49 Fuel storage depots 5 45 — Total 3,018 19,616 620 386 Protection of Animals Arrangements have been made with the Corporation of the City of London whereby the Council's responsibilities under the various Acts relating to the protection of animals are undertaken by the City authorities on an agency basis for which an annual retaining fee is paid plus certain additional fees for individual case work undertaken on the Council's behalf. The four main Acts under which action was taken during the year are as follows :— Pet Animals Act, 1951.—A pet shop may not be kept except under the authority of a licence granted in accordance with the provisions of the Act, the object of which is to regulate the sale of pet animals, with particular reference to their welfare whilst kept for sale. Thirty licences were issued by the Council during 1965. Animal Boarding Establishments Act, 1963.—This Act provides that no person may keep a boarding establishment for animals (defined as cats or dogs) in the Borough except under licence. Four such licences were granted during the year. Riding Establishments Act, 1964.—This Act provides for the licensing and inspection of any establishment at which a business of keeping horses for hire, for riding or for providing riding instruction is carried on. Licences in respect of three riding establishments were granted. Performing Animals (Regulation) Act, 1925.—One licence was granted during the year. 33 Common Lodging Houses There are no registered common lodging houses in the Borough, Land Charges Act, 1925 During the year the Department dealt with 5,616 enquiries relating to local land charges. These enquiries necessitate a careful search of records, drainage plans, etc., to ascertain the existence of any orders or restrictions on the properties concerned such as outstanding statutory or informal notices, certificates of disrepair under the Rent Acts, inclusion in housing building programmes, slum clearance areas, etc. 34 HOUSING Housing Act, 1957—Closing Orders During the year three Closing Orders were made under Section 17 of the Housing Act, 1957, in respect of dwelling houses and two Orders were made under Section 18 of the Act in respect of parts of dwelling houses. Houses in Multiple Occupation House-to-house inspections were commenced in the Balham area during the year, but owing to the shortage of staff it was not found practicable to continue on these lines until sufficient technical staff are available. A considerable amount of work was carried out in connection with individual houses in multiple occupation that came to the notice of the Department through the district inspectors, house purchase schemes and other sources. It is pleasing to note that an increasing number of owners and agents who purchase properties to let in this manner, have requested advice as to the standards required so that the necessary work may be completed before letting the premises. However, there is always a number of owners who for some reason either cannot or will not provide the necessary facilities for their tenants, and in this respect 11 direction orders were made during the year limiting the number of persons or families that can properly occupy the premises, bearing in mind the facilities available in the premises. Very few squalid conditions were found, the main deficiency being the absence of separate facilities, e.g. sink with water supply, means of cooking, etc., within each separate letting. Many houses which were inspected lacked only proper precautions for means of escape in case of fire, and in most cases the necessary work was carried out by the owners concerned without any undue pressure from the Health Department. Inspections carried out during the year were as follows:— Number of primary visits 584 Number of premises fully inspected 242 Number of revisits 1,309 Control of Movable Dwellings Control over the use of land in London to accommodate caravans and movable dwellings was formerly exercised under the London County Council (General Powers) Act, 1959, but, on the 35 reorganisation of London Government, that Act was repealed and the Caravan Sites and Control of Development Act, 1960, was extended to apply to London. Mobile and temporary homes provided on open sites by the Greater London Council are exempt from the licensing requirements of the Act. During the year, two caravan sites containing a total of twelve dwellings were licensed. Rent Act, 1957 This Act provides, amongst other things, for the issue by the Council of certificates of disrepair to tenants of controlled dwelling houses which are considered to be in disrepair by reason of defects which ought reasonably to be remedied, having regard to the age, character and locality of the dwelling. There is also provision for the issue, by landlords, of undertakings to remedy such defects. The following is a summary of action taken in this connection during the year :— Applications for certificates of disrepair received 7 Certificates of disrepair refused — Decisions to issue certificates of disrepair 9 Certificates of disrepair issued 8 Undertakings received from landlords 9 Application for certificates re undertakings received from landlords 12 Certificates re undertakings issued to landlords 13 Applications for cancellation of certificates of disrepair received 14 Certificates of disrepair cancelled 12 Housing Accommodation Applications Applications made to the Council are normally dealt with by the Housing Manager who refers to me those cases in which the application is based wholly or partly on health grounds. These cases include applications for transfer from Council tenants. Any case involving some special feature concerning the Health Department (e.g. fitness of basement rooms) is also referred to me. During the year 1,215 applications were considered for eligibility for additional points on health grounds in accordance with the Council's points scheme. A further 213 recommendations were made in respect of Council tenants who requested transfer to more suitable alternative accommodation on health grounds. 36 FOOD AND FOOD PREMISES In order to ensure that food businesses are supervised systematically, an up-to-date register is maintained of all premises where such business is carried on. Supervision is governed mainly by powers under the Food and Drugs Act, 1955 and regulations made thereunder but there are numerous other Acts of Parliament, etc., which relate to specific types of food. The supervision of catering establishments and premises where food is sold, stored, manufactured or prepared for sale is carried out by all public health inspectors. The district public health inspectors obtain samples of food and drugs for analysis by the Public Analyst, and a detailed report on this work appears on pages 41 to 44. The total number of food premises of all kinds on the register in the Borough is 2,627 (see Table 1) and during 1965 they were visited on 5,247 occasions (see Table 2). TABLE 1 NUMBER AND TYPE OF PREMISES WHERE FOOD IS SOLD, STORED OR PREPARED Dairies and milk dep6ts 10 Food factories 23 Restaurants, cafes and canteens 478 Bakers and confectioners 537 Butchers 184 Greengrocers 216 Fishmongers 38 Fish friers 70 Bakehouses 28 Grocers 506 Off licences 146 Public houses 174 Stalls 177 Total 2,627 TABLE 2 SUMMARY OF VISITS TO FOOD PREMISES Dairies 79 Restaurant kitchens 1,164 Ice-cream premises 109 Butchers' shops 477 Greengrocers' shops 265 Fishmongers' shops 82 Fried fish shops 140 Market stalls 1,005 Grocers' shops 1,066 Confectioners' shops 482 Bakehouses 107 Other premises 271 Total visits 5,247 37 Food and Drugs Act, 1955 Section 16(1) of this Act provides that no premises shall be used for (a) the sale, or manufacture for the purpose of sale, of ice-cream or the storage of ice-cream intended for sale or (b) the preparation or manufacture of sausages or potted, pressed, pickled or preserved food intended for sale, unless they are registered under this section for that purpose with a local authority. During the year 22 applications for registration under the provisions of Section 16(l)(a) and 5 applications for registration under the provisions of Section 16(l)(b) were submitted to the Council. In all cases the premises were found to be satisfactory and registration was granted. Food Hygiene (General) Regulations, 1960 Work in connection with food hygiene continued throughout the year, and occupiers of food premises proved receptive to suggestions made by the inspectors for necessary improvements to their premises. Work completed during 1965 to comply with statutory requirements is shown below: — Washhand basins provided 8 Sinks provided 6 Provision of hot water over sink and washhand basin 18 Accommodation for clothing provided 2 Premises repaired or redecorated 37 Notices to employees displayed 2 Dustbins provided 3 W.C. accommodation provided 3 First-aid materials provided 3 Milk Supply Milk and Dairies (General) Regulations, 1959 These regulations require local authorities to keep a register of all persons carrying on the trade of distributor in their district and of all premises within their district which are used as dairies, not being dairy farms. During the year 17 applications were received from persons to be registered as distributors of milk. In each case the certificate of registration was granted. Nine notices of cancellation of registration were received. At the end of the year there were 222 persons and two dairies on the register. The bulk of the milk sold by retail within the Borough is sent out in bottles filled in properly constructed dairies and its quality is good. 38 Food and Drugs Act, 1955 During the year one hundred and sixty-six samples of milk were submitted for analysis, to which reference is made on page 44. Milk (Special Designation) Regulations, 1963 These regulations provide for the issue of Dealers (Prepacked Milk) Licences under certain designations and the number of licences granted during 1965 is given below Special designation Number of licences issued " Pasteurised " 19 " Sterilised " 13 " Untreated " 7 Milk (Special Designation) (Amendment) Regulations, 1965 These regulations came into operation on 1st October, 1965, and provide for the issue of Dealers (Prepacked Milk) Licences under the special designation " Ultra Heat Treated", but no applications were received. Brucella Abortus No samples of raw milk were examined for Brucella Abortus during the year. Butchers' Shops There are 184 butchers' shops in the Borough. The majority are registered under Section 16 (1) (b) of the Food and Drugs Act, 1955, for the preparation or manufacture of sausages or potted, preserved, pickled or pressed foods. Visits made to these shops during the year numbered 477. Slaughter of Animals There are no licensed slaughterhouses in the Borough. Section 3 of the Slaughter of Animals Act, 1958 provides that no animals shall be slaughtered or stunned in a slaughterhouse or knacker's yard by any person who is not the holder of a licence granted by a local authority. During the year no applications from persons wishing to act as slaughtermen were received by the Council. Fish Shops Shops in which fish, either cooked or uncooked, is sold, or where the curing or smoking of fish is carried on, are regularly inspected. There are 108 such shops in the Borough and 222 inspections were made during the year. 39 Catering Establishments All restaurants, caf6s, canteens and kitchens are regularly inspected throughout the year. There are 478 such premises on the register, and 1,164 inspections were made. Food Stalls All street stalls from which food for human consumption is sold are regularly inspected and, where the food sold is stored in the Borough, the storage places are also inspected. There are 177 food stalls in the Borough, and 1,005 inspections were made during the year. Liquid Egg (Pasteurisation) Regulations, 1963 There are no egg pasteurisation plants in the Borough. Bakehouses There are 28 bakehouses in the Borough and during the year 107 visits by the food inspectors were made to these premises. Eleven of the bakehouses are in basements and, as such, are subject to the provisions of section 70 of the Factories Act, 1961. Certificates of suitability under this Act were granted in all cases. Bacteriological Examination of Food Eighty-one food samples were examined bacteriologically at the Public Health Laboratory during the year, and details are given below :— Milk 36 Ice-cream 38 Miscellaneous 7 Total 81 Milk Of the 36 samples of milk, 6 were submitted to the phosphatase test, 6 to the methylene-blue test, and 24 to the turbidity test. All samples were reported to be satisfactory. Ice-cream The 38 samples of ice-cream were examined at the Public Health Laboratory by the methylene-blue test. The grading is determined by the length of time taken to decolourize the methylene blue, grade 1 indicating the highest standard bacteriologically. 40 The following table gives a summary of the results : — Grade Number of Samples 1 25 2 6 3 3 4 4 Total 38 Miscellaneous The seven miscellaneous food samples proved to be free from pathogenic organisms. Analysis of Food and Drugs During the year 1,000 samples of food and drugs were submitted for analysis; 166 samples of milk, 755 other foodstuffs and 79 drugs. Of these, 82 were submitted as formal samples, while 918 were purchased informally. Two of the formal samples and 71 of the informal samples were found to be adulterated or below standard, representing 7.3 per cent. of the total samples submitted. Details of these 73 samples are given in the Report on the work of the Public Analyst which follows. 41 REPORT ON THE WORK OF THE PUBLIC ANALYST FOR 1%5 The analysis of samples of food and drugs purchased formally and informally under the Food and Drugs Act, 1955 is carried out by the Public Analyst, D. G. Forbes, Esq., B.Sc., F.R.I.C., and during the year 1,000 samples were submitted by the Council's food inspectors. Eighty-two of these samples were taken with the formalities required by the Act and 918 were taken informally. The number of food samples was 921 and the remaining 79 were drugs. The samples submitted for analysis included the following substances : — Beverages (cocoa, coffee, tea, etc.) 79 Cereal preparations 63 Cheese products 28 Confectionery 60 Cream 12 Fats (butter, margarine, etc.) 56 Fish (canned, etc.) 31 Fruit (canned and dried) 35 Ice-cream 8 Meat products (including sausages) 129 Milk 166 Pickles and condiments (including spices) 75 Preserves 52 Soups 16 Vegetables 27 Aspirin tablets 12 Borax and honey 3 Friars balsam 2 Glycerin of borax 3 Indigestion tablets 3 Iodine 2 Linctus 2 Oils 7 Ointments 3 Seidlitz powders 2 Throat pastilles 6 42 SAMPLES FOUND TO BE ADULTERATED OR BELOW STANDARD Case No. Nature of Sample Report Formal 11 Milk Deficient in fat 15 Ground caraway seed Deficient in volatile oil Informal 1085 Friars balsam Labelled B.P. instead of B.P.C. 1101 Chillies High acid insoluble ash 1105 Ackees Ingredients labelled in wrong order 1149 Canned cooking butter Rancid 1155 Peanut butter Labelling offence 1175 Friars balsam Labelled B.P. instead of B.P.C. 1196 Cheesy crisps Fat rancid 1203* Doughnut Contained a piece of brown paper 1237 Canned cooking fat Rancid 1251 Canned peaches Labelling offence 1308 Friars balsam Labelled B.P. 1309 Tincture of iodine Labelled B.P.C. 1934 1314 Flavoured milk Contained orange crush 1318* Bread Mould spores and hyphae 1322 Canned pork Deficient in meat 1366 Ham tivoli Deficient in meat 1368 ) 1369 | Cream cakes Contained fat other than butter fat. Further sample taken proved satisfactory 1373* Milk 45 per cent. added water 1385 Coffee and chicory blend Misleading label 1389 Orange squash (in waxed carton) High saccharin content and sample was fermenting 5 Canned cooking butter Rancid 31 Beef milano Deficient in meat 39 Ham and chicken roll Deficient in meat 55 Orange squash Repeat of No. 1389 sample was similar in analysis 80 Milk Deficient in fat 85 86 Fried chips Fat showed rancidity 50 Ground caraway seed Deficient in volatile oil 64 Canned pork Deficient in meat 68 Chicken and ham roll Deficient in meat 97 Iced lolly base Ingredients not declared 105 Beef spread with butter Deficient in butter 113 Gripe mixture Deficient in glucose 134 Milk Deficient in fat 159 Beef milano Deficient in meat 161 Ham and chicken roll Deficient in meat 168 Veal sorrento Deficient in meat 175 Ground jeera High silica content 226 Dried beef curry with rice Order of ingredients different on inner and outer packets 232 Beef milano Deficient in meat 247 Glycerin of borax Labelled B.P.C. but deleted from the 1963 edition 43 Case No. Nature of Sample Report 249 Ammoniated tincture of quinine Deficient in ammonia. Excess quinine 2551 262 263) Soft drinks Saccharin present in excess of the new regulations 279 Honey of borax Labelled B.P.C. but deleted from the 1963 edition 303* Bread Contained mineral oil, iron particles and dirt from machinery 304 Ground jeera High silica content 320 Milk Deficient in fat 330 Pork sausages Deficient in meat 331 Chunky pork Deficient in meat 339* Milk Contained mould and insect fragments 340* Minced steak Contained dyes which are not permitted in unprocessed meat 354 Ground sage High silica content 355* Bread Contained an insect 359* Milk bottle Contained mould and insect fragments 364 Brazil nuts (shelled) Incipient rancidity of fat 371* Milk Contained dirt and mould 372 Pork sausages Deficient in meat 386 Minced beef Contained added nicotinic acid 420 Ground oregano Not the " common or usual name " 423 Meat improver Ingredients not listed 441 Fibrosolsausage improver Ingredients not listed 463* Milk Contained a piece of card with a pencilled message to the milkman 473 Strawberry syrup The word " flavoured " was in much smaller type than the words " strawberry " and " syrup " 487* Orange squash Contained mould and dirt 502* Saveloy Unpleasant odour confirmed but cause not discovered 558 Mincemeat Deficient in fat 565 Ham and tongue As a meat paste, this was a good product, but it was labelled merely " Ham and Tongue ", implying 95-100 per cent. meat 567 Antipasto Name not descriptive of contents for normal purchaser The twelve samples shown above which are marked with an asterisk (*) were complaint samples submitted by members of the public and in each case the complaint was considered justified and appropriate action was taken. A further three complaint samples were submitted but, following analysis, it was considered that the complaints were not justified. Details of these cases are given below: — Case No. 1371 Canned Brislings. Complaint that they caused sickness. 44 Case No. 135 Prawns. Complaints that added colour was suspected. Case No. 173 Chocolates. Complaint that they caused sickness. Milk Samples The minimum legal standards relating to the composition of milk are as follows : — Ordinary milk Channel Islands and South Devon milk Milk fat 3.0% 4.0% Non-fatty solids 8.5% 8.5% Total milk solids 11.5% 12.5% During the year, 166 samples of milk were submitted for analysis (150 ordinary milk and 16 Channel Islands or South Devon milk). Of these, five samples of ordinary milk were found to be below the minimum standard and appropriate action was taken. 45 FACTORIES ACT, 1961 Under Section 153 (1) of the Factories Act, 1961, the Medical Officer of Health of the Council of any Borough or County District is required in his Annual Report to the Council to report upon and furnish prescribed particulars of matters under Part I and Part VIII of the Act which are administered by the Council. These particulars are given below in the form required by the Minister of Health :— Factories Act (Part I) (1) INSPECTIONS Premises Number on Register Number of Inspections Written Notices Occupiers Prosecuted (i) Factories in which Sections 1,2, 3, 4 and 6 are to be enforced by Local Authorities 158 38 — — (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 1,075 413 5 (iii) Other premises in which Section 7 is enforced by the Local Authority (excluding outworkers' premises) 55 20 — — Total 1,288 471 5 — 46 (2) DEFECTS Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of cleanliness 1 — — 1 — Overcrowding — — — — — Unreasonable temperature — — — — — Inadequate ventilation — — — — — Ineffective drainage of floors— — — — — — Sanitary Conveniences: — — — — — (a) insufficient — — — — — (b) unsuitable or defective 7 7 — 3 — (c) not separate for sexes — — — — — Other offences against the Act (not including offences relating to outwork) 1 — — 1 Total 9 7 — 5 — 47 ATMOSPHERIC POLLUTION CLEAN AIR ACT, 1956 Smoke Control Areas Following the reorganisation of the Department during the year, the opportunity has been taken to replan and bring forward the programme relating to smoke control. At present, Smoke Control Orders operate in approximately one-half of the Borough comprising, in the west, Roehampton ward and parts of Thamesfield, Putney, West Hill, Southfield and Earlsfield wards, and, in the eastern part of the Borough, Northcote ward and parts of St. John, Shaftesbury, Balham and Nightingale wards. A Smoke Control Order which awaits confirmation by the Ministry of Health has been made in respect of the remainder of West Hill ward, further parts of Southfield and Earlsfield wards and a part of Fairfield ward. The remaining half of the Borough is planned to be brought under smoke control by 1970 in the following sequence :— 1966—The remainder of Shaftesbury ward and that part of Queenstown ward north of the railway line, Springfield ward and the remainder of Earlsfield ward. 1967—Tooting, Graveney, Furzedown and Bedford wards. 1968—Balham ward and the remainder of Nightingale ward. 1969—Parts of Putney, Southfield, Fairfield and St. John wards. 1970—St. Mary's Park, Latchmere and the remaining parts of Queenstown and other wards. A map showing existing and proposed smoke control areas will be found facing page 48. Smoke, etc., Nuisances and Observations During the year, 25 complaints were made alleging nuisances from smoke, dust, grit, etc., emitted from premises in the Borough. All these complaints received careful and sometimes prolonged investigation. In addition to dealing with specific complaints, observations are kept upon the chimneys of industrial plant in the Borough and appropriate action is taken when necessary. During the year 158 such observations were made. Installation of Furnaces Notification is required under Section 3 of the Clean Air Act, 1956, of any proposal to instal a furnace with a heating capacity 48 of 55,000 or more British thermal units per hour. This Section, which does not apply to furnaces designed solely or mainly for use for domestic purposes, is designed to ensure that any new furnaces installed shall be, so far as is practicable, capable of being operated continuously without emitting smoke. Eight such notifications were received during the year. Chimney Heights A Circular and Memorandum from the Minister of Housing and Local Government places a duty on local authorities to satisfy themselves that new chimneys, to which Section 10 of the Clean Air Act applies, will be high enough to prevent, so far as practicable, smoke, grit, dust or gases emitted from the chimneys from becoming prejudicial to health or a nuisance. Guidance is given on the calculation of chimney heights, based on the amount of flue gases which the chimney is expected to emit as a function of the maximum rate of emission of sulphur dioxide. This is not applicable to all chimneys and affects only: — (a) chimneys of industrial boiler plant of maximum continuous rating greater than approximately 650 lb. steam/hr. and not exceeding 450,000 lb. steam/hr. or (b) to chimneys serving furnaces burning fuel at a maximum rate greater than approximately 100 lb./hr. of coal or 50 lb./hr. of oil, and not exceeding 50,000 lb./hr. of coal or 30,000 lb./hr. of oil. The method of calculation advised by the Minister is to be regarded more as a guide rather than a mathematically precise way of reaching a final decision on chimney height and is open to modification in the light of particular local circumstances. During the year discussions took place with the Borough Architect on this problem, following which a meeting with other authorities was held to endeavour to arrive at an acceptable standard for the Inner London area. The problem is still under consideration. Measurement of Atmospheric Pollution Daily readings of the concentration of smoke and sulphur dioxide (S02) in the atmosphere were continued during the year at the four stations throughout the Borough where recording apparatus has been installed. A record of these readings for the year under review is given in Table 1 and details of smoke and S02 concentration during the year is shown in Table 2. The readings are taken by members of the staff of the Department who pass the information to the Department of Scientific and Industrial Research for collation with data received from authorities all over the country. 49 TABLE 1 Station Roof— Municipal Buildings 207 Lavender Hill Battersea Tooting Library Queen Mary's Hospital, Roehampton Month—1965 Smoke SO2 Smoke so2 Smoke so2 Smoke so2 January 148 563 153 302 219 324 62 104 February 191 539 156 373 160 290 102 219 March 328 446 128 307 134 237 97 244 April 80 504 93 257 101 249 45 199 May 56 200 56 114 48 115 20 113 June 42 240 50 120 43 112 No recordings July 43 135 42 71 32 49 „ August 60 191 43 75 47 77 „ September 82 331 102 181 98 219 66 136 October 217 578 190 402 145 309 147 347 November 240 485 261 461 253 345 190 364 December 260 289 280 391 311 386 181 298 Average 146 382 129 255 133 226 101 224 TABLE 2 ATMOSPHERIC POLLUTION COMPARISON OF SMOKE AND SO2 CONCENTRATION 1964 and 1965 50 51 MISCELLANEOUS MATTERS Public Swimming Baths In Wandsworth there are four public baths and one open-air swimming pool belonging to the Corporation, one open-air swimming pool owned by the Greater London Council and one privately owned open-air swimming pool, to which the public may be admitted. The source of water for two of the Corporation's baths is from deep wells and, for the other baths mentioned above, from the mains supply of the Metropolitan Water Board. At all of these baths the water is chlorinated and circulates continuously through a filtration plant. Samples of water are taken at regular intervals and submitted for bacteriological examination at the Public Health Laboratory at County Hall. During the course of the year 136 samples were submitted for examination and satisfactory results were obtained in 131 instances. In the remaining samples there were slight deviations from normal, but subsequent tests proved satisfactory in all cases. Examination of water from artesian wells and taps Twenty-eight samples were submitted for examination at the Public Health Laboratory all of which proved satisfactory. Disinfection and Disinfestation Methods of Disinfection: Following the notification of a case of infectious disease requiring disinfection, an inspection is made and the following methods used. The patient's room is sprayed with a formaldehyde solution. The doors and windows are closed and the room can be used again after five or six hours. Advice is also given to the occupiers that a thorough "spring cleaning" of the room is a very effective "disinfection" process, and should be carried out in addition to the work of disinfection by the Council's staff. Bedding and clothing are collected and steam-treated at the Disinfecting Stations. Sheets, pillow cases and hand towels are exposed to formalin vapour in a special chamber prior to being washed in the Council's laundry. Books and other articles which cannot be steam disinfected are also treated by exposure to a formalin vapour. Disinfestation of Verminous Rooms: Articles in the room requiring treatment are removed for steam disinfestation. The room is sprayed with an insecticide containing Pybuthrin and Lindane/ D.D.T., which has a prolonged residual effect. Where there is heavy infestation, architraves and mouldings are required to be eased for deeper penetration of the insecticide. 52 Control of Insect Pests: The construction of large blocks of flats containing covered ducts taking hot water, plumbing and drainage pipes has raised a problem of insect infestation. These ducts form an ideal harbourage for insects which would be difficult to deal with by normal hand spraying. A Microsol Mist Generator is therefore used for the purpose and this apparatus, which has a small motor unit, is capable of spraying a fine mist or fog of insecticide to a distance of 50 feet, the mist settling on to the surfaces of the duct and the piping contained therein. Personal Cleansing Station During the year, 214 treatments were given at the Council's personal cleansing station to persons suffering from scabies—125 to adults, 56 to schoolchildren and 33 to children under school age. In addition, 36 adults, 275 schoolchildren and 29 children under school age found to be verminous were cleansed, together with their clothing. An arrangement has been made with the London Borough of Lambeth for those of their residents who require treatment or cleansing to attend the Wandsworth personal cleansing station and during the year 62 such treatments were given. Laundry Service for Incontinent Persons There is an increasing demand for the Department's Laundry service for incontinent persons, and over 40,000 articles were laundered at the Cleansing Stations during the year. This is a vital service in assisting an infirm old person to remain at home and in relieving some of the burden on relatives, who are often aged and infirm themselves. 53 Coroner's Court and Mortuary Details as to the number of inquests held at the Coroner's Court, and bodies received into the Mortuary, during 1965, are set out in the following table:— Details of Bodies Received Usual Place of Residence Total Wandsworth Elsewhere Residence unknown Post-mortem only 700 309 30 1,039 Post-mortem and inquest 108 74 5 187 Total post-mortems 808 383 35 1,226 Inquest only — — — — Total inquests 108 74 5 187 Sanitary and other reasons 1 — — 1 Total bodies received 809 383 35 1,227 Verdicts at Inquests held— Accidental and Misadventure 58 36 2 96 Alcoholism — 3 — 3 Natural causes 1 1 — 2 Industrial disease — 1 — 1 Open verdict 2 3 — 5 Suicide 43 27 3 73 Homicide 2 2 — 4 Referred to higher court 2 1 — 3 Total 108 74 5 187 In addition to the above, a further 84 inquests were held at the Coroner's Court in respect of which no bodies were received into the Mortuary. Following the decision of H.M. Coroner for Inner West London to use the Coroner's Court in Sheepcote Lane, Battersea, for inquests on the bodies of dead persons from the London Borough of Merton in addition to those from Wandsworth, financial arrangements were agreed between the two authorities which include the use of the mortuary adjacent to the Court. Crematorium Regulations, 1930 Under these regulations, 1,679 cremations were authorized during the year. 54 4 PERSONAL HEALTH SERVICES The 0Personal Health Services are those services provided by the Council, as the local health authority, under the various sections of the National Health Service Act which are directed to safeguarding the health of the individual and, should any ill-health supervene in spite of our efforts, to ameliorating the consequences of ill-health, both in the individual and the family of which he is a member. The importance of care during pregnancy and the early years of life is vital to the healthy and full development of the child and the individual, and a large part of this service is concentrated on expectant and nursing mothers and young children. Although this service is now proportionately less important than it was in days gone by and it may be said that the family and the family group, comprising all ages, is now more the unit of health than any one individual or age group in the family, it is convenient to divide, for descriptive purposes, the parts of the services into those services directed to improving the health and well-being of mothers and young children and those other health services directed not exclusively to mothers and young children. To some extent, these two categories overlap and many services described under "other personal health services" are available to mothers of young children. SERVICES FOR MOTHERS AND YOUNG CHILDREN The main features of the Council's services for the care of mothers and young children are described in the following sections. The aim is to safeguard the health of the expectant mother because on her health depends, in large measure, the well-being of her baby, and when the baby is born, to safeguard and supervise the health of her child during infancy and early childhood. Particular attention is now being paid to the diagnosis of abnormalities in the early months and years of life and the description of the work under the heading "Handicap and Observation Register" now forms a very important part of this section of the department. Maternity and Child Welfare Centres There were 17 welfare centres in the Borough at the end of 1965, one new one (Stormont Road, Battersea) being opened during the year. A wide range of health service facilities is available to help expectant mothers and nursing mothers with young children and the services available include ante-natal and post-natal clinics, child-welfare, mothercraft and relaxation classes and special toddlers' clinics. Protective inoculation against many infectious diseases is offered and there is a dental service for expectant and nursing mothers and children. 55 Ante-natal and post-natal clinics for expectant and nursing mothers The number of mothers attending the clinics following confinement is gradually diminishing and the majority now attend their own general practitioners for post-natal examinations. Sessions held during the year 619 First attendances of mothers 3,075 Total attendances of mothers . 7,847 Mothercraft and relaxation classes Relaxation classes and talks and discussion groups on pregnancy and allied subjects are held for expectant mothers in several centres, and one or two evening sessions are held to which fathers are invited. These activities, together with the showing of films covering every aspect of maternity and child care, are always greatly appreciated and are becoming an increasingly important part of the work of the clinics. Sessions held during the year 207 Total attendances 2,187 Average attendance at each session 10.5 Infant welfare clinics Infant welfare clinics have continued to attract very large attendances. In addition to health supervision, immunization and advice on health and allied matters available at these sessions, the opportunity for mothers of young children to meet together is an important factor. This is especially evident on new housing estates when young mothers are frequently rather lonely and at some distance from the help and support of relatives. Tnfant welfare sessions held during the year 1,711 First attendances of children under five years 13,454 Total attendances of children under five years 86,560 Average attendance at each session 50.6 Toddlers' Clinics Special clinics for toddlers (children aged from two to four years) are held at 12 welfare centres. The children are given routine medical examinations and if necessary are referred for treatment. Toddlers' sessions held during the year 257 Total attendances of toddlers 3,004 Average attendance at each session 11.7 Dental services A free dental service for expectant and nursing mothers and children is provided at certain of the Council's dental surgeries. During the year attendances numbered 617 comprising 206 by mothers and 411 by children under five years of age. 56 Family Planning The Council has made arrangements for advice on methods of contraception to be given to married women where pregnancy would be dangerous or detrimental to health. Sessions are organized by the Family Planning Association, who are provided with rent-free accommodation at some of the Council's welfare centres. No charge is made except for appliances supplied to the patient. During the year a total of 223 such sessions were held. Health Visiting Service The health visiting service has continued its unspectacular but nevertheless essential work throughout the year in spite of some staff shortages. Home visiting is the basis of the health visitor's work, and although the health visitors maintain some contact with all families with children under five years of age, their help is concentrated, by means of selective visiting, on the families needing the most support. The health visitors are organized in groups with offices in or close to the areas where they work so that they are convenient of access to any family in need of their help. Although a large part of the health visitors' work is concerned with giving help and advice to mothers and young children, the unit of health is now looked upon as the whole family. Accordingly, any member of a family confronted with health or social problems can obtain help and support through the health visitor who, in many cases, will be the first line of approach. This means that the health visitor must and does work very closely with all other agencies concerned with the health and wellbeing of the family or members of the family; that is to say, with family doctors, midwives, mental health social workers and the staff of the Welfare and Children's Departments. Particularly is this so in relation to the health and welfare of old people which now forms a not inconsiderable part of the health visitor's work. The importance of close links with all other agencies cannot be over-stressed and I am very happy to report that good and happy relations exist. The number of first visits made during the year to children under five years of age were:— Children born in 1965 7,557 Children born in 1964 6,308 Children born in 1960/63 11,590 Visits of all kinds paid by health visitors during the year totalled:— Effective visits 60,473 Unsuccessful visits 12,691 Domiciliary Midwifery Service The Council, through the Health Committee, is responsible for the domiciliary midwifery service and for providing "District" training facilities for pupil midwives under the Midwives Act. 57 Twenty-two midwives are employed by the Council directly and during the year 47 midwives notified their intention to practise midwifery in the Borough. The excess number of midwives over those who are employed directly by the Council represent midwives practising in hospitals and a very few who remain in private practice. During the year, our midwives attended 1,128 home confinements and, in addition, 438 mothers who, although confined in hospital, were discharged early to the care of the domiciliary midwives under the early discharge scheme described later. Maternity medical services are provided by family doctors under the National Health Service Act, 1946, doctors claiming their fees for this service from the Local Executive Committee. Most expectant mothers in the borough now book a doctor for their confinement but if by any chance the booked doctor or his deputy is not, for any reason, available at the time of the confinement or if there should be no booked doctor, another doctor on the Obstetric List is called in by the midwife and he may then claim a fee under the Midwives Act from the Council. Three such claims were met during the year. It is very important that adequate arrangements be made for a midwife to be called to an expectant mother when she goes into labour and also that in cases of difficulty the services of a Supervisor of Midwives should be available, day and night. In close liaison with the London Boroughs of Lambeth and Southwark, a shared emergency service operates so that the difficulties of relatives getting in touch with the booked midwife or the relief midwife acting for the booked midwife, who may be off duty, are reduced to a minimum. This scheme has worked extremely well and has saved much worry and anxiety to relatives. The domiciliary midwifery service had, until 1st April, 1965, been administered directly from County Hall for some 30 years. The change to a much more local form of organization might conceivably have given rise to problems and difficulties but I am happy to say that the transition took place very smoothly, although there have inevitably been some changes in routine procedures. I should like to take the opportunity of expressing my thanks to our domiciliary midwives for the excellent co-operation and help they gave in ensuring that the transition was efficiently carried out and with certainly no diminution in the high standards of the service which had traditionally been given to mothers and their babies. Maternity Beds The shortage of maternity beds in parts of the London area and their uneven distribution have been a source of anxiety for many years and medical officers and general practitioners have continued to exercise great care in the selection of cases for hospital confinement. 58 The position has improved as a result of a scheme introduced in 1963 which set up "catchment areas" for the main maternity hospitals. Expectant mothers are now booked for admission to certain hospitals which have agreed to accept cases from the mother's area of residence. This scheme has led to a greater flexibility and has gone a considerable way towards avoiding the highly unsatisfactory situation that formerly sometimes arose when it was not possible to book a bed for an expectant mother and reliance had to be made on emergency procedure for admission. There is little doubt that this scheme has proved its worth and alleviated a good deal of anxiety and worry on the part not only of the expectant mothers themselves but also of their attendants. The Maternity Liaison Committee, which represents all local interests in co-ordinating administrative and executive action, met during the year. This Committee provides a valuable meeting place where the three arms of the health service, namely, hospital, general practitioner and local health authority, can discuss mutual problems and difficulties. Early Discharge of Maternity Patients In order to make the fullest use of the hospital maternity beds available, the department continued to co-operate with the maternity hospitals by arranging for the planned early discharge of suitable patients 48 hours after confinement. Full arrangements are made well in advance of the confinement and the patients return home to the care of their own general practitioners and domiciliary midwives. The number of patients discharged under this scheme has increased over the years and this year totalled 438 and I am glad to say that our part-time midwives and district nurse midwives have covered the work admirably. Premature Infants Any child weighing 5½ lb. or less at birth is regarded as premature, and great care is taken to ensure that adequate help and advice are available for mothers with premature babies. The numbers of premature births during the year were as follows:— (a) Born in hospital 418 (b) Born in hospital and died within 28 days of birth 49 (c) Born at home or in a nursing home 18 (d) Premature stillbirths in hospital 42 (e) Premature stillbirths at home or in a nursing home 4 Of the 18 children under (c), one was transferred to hospital immediately but died within 24 hours of birth. Handicap and Observation Register In recent years it has come to be recognized that an increasing proportion of children who need special education in school, and extra help later in life, acquire their handicaps in the pre-natal, 59 neo-natal and post-natal periods of life. Arrangements have been made for hospitals, doctors and midwives to notify the Medical Officer of Health of any congenital malformation with which a child may be born. This is done on the birth notification card soon after birth. Thereafter, when the baby is discharged from hospital or when the midwife has completed her attendance, if the child is born at home, a further notification is made to the Medical Officer of Health, setting out any factors or influences which, it is thought, may have an adverse effect on the child's future health and wellbeing. Those babies who have been exposed to unfavourable heredity or adverse experience are considered to be "at risk of handicap", are given special attention by being kept under surveillance by the Department and its doctors, and are subjected to special screening tests for the purpose of early recognition of any handicaps that might develop. This surveillance usually continues until the child is aged two years, but may continue for five years in special circumstances. In order to ensure that each handicapped child makes the best of whatever assets he or she possesses, a register is compiled of children who are either handicapped or at risk of developing a handicapping condition. In 1965, 17% of children born in that year were placed on the Register. During the year, particular attention was given to this part of our work and I am indebted to Dr.E.H. Todd, Senior Medical Officer in the Department, for the following information and for supervising the compilation of the figures given in the following tables:— Incidence in 1965 of various congenital defects in children under five years of age Defect Rate per 1,000 notified live births Mongolism 1.2 Spina bifida 1.3 Hydrocephalus 0.3 Mental handicap 2.9 Cardiac malformations 3.5 Alimentary-tract malformations 1.3 Hearing defect 1.4 Fibrocystic disease 0.5 Congenital dislocation of hip 0.4 Talipes 3.1 Cleft palate 0.7 Handicapped to some degree 25.0 Babies born with congenital malformations 17.0 Premature infants (under 4 lb. at birth) 19.3 60 Analysis of Handicap and Observation Register (children under five years of age) Number of children on register 2,091 Number of children added to register during 1965 1,169 Proportion of children born and added to register in 1965 17% Number of children on register with defects 519 Number of children with multiple defects 50 Number of children on register with severe defects 12 Phenylketonuria In 1963 the Ministry of Health stressed the importance of close liaison between local medical and hospital services for effective arrangements in the early diagnosis and treatment of phenylketonuria. Screening tests on young babies are carried out as a routine by health visitors; babies thought to be at special risk are tested more often. Whenever a positive or doubtful case is found it is referred to the hospital service for further examination, the general practitioner being informed. Unmarried Mothers and Care of Illegitimate Children The unmarried mother and her baby have continued to be a problem and every help and assistance is given as required. Many unmarried mothers seek the help and advice of Moral Welfare workers who arrange admission to Mother and Baby Homes towards the end of pregnancy. There seems, however, to be a tendency for more unmarried mothers now to remain in their homes and have their babies at home. Many seek the services of health visitors and midwives in the ordinary way, although, for obvious reasons, they frequently need more help and support than do married mothers. Links between the health visitors, midwives and the Moral Welfare workers in the area are close and constant and everything is done to alleviate the inevitable difficulties which the unmarried mother must face. In Wandsworth in 1965, 844 illegitimate children were born, which represents 13% of the total live births for the area. Three voluntary Homes for unmarried mothers in the borough are registered by the Council as nursing homes and are inspected regularly by the medical officers and the public health inspectors. One of the assistant nursing officers attends as an observer at the Committee of Management to two of the Homes. The health visitors for the area keep in close touch with the Matrons of the Mother and Baby Homes, which they frequently visit, to ensure follow-up when the mothers and their babies leave. Cervical Cytology Over the past few years, there has been a growing realisation of the importance of screening tests for cancer of the womb. 61 Although in this area a limited service had been available for some time, during 1965 this was put on a firmer basis and application made to the Minister of Health for formal approval of our scheme. Considerable consultations took place with the Regional Hospital Board but the limiting factor in any large-scale expansion of the existing service is the shortage of pathologists and trained technicians experienced in the screening methods. Patients are referred by their own doctors, who receive reports on the findings of the hospital pathologists. At the end of 1965 four weekly sessions were being held and it is hoped that the service can soon be further expanded. Day Nurseries There are seven Council day nurseries with a total number of 288 places for normal children and six places in a special unit for mentally handicapped children. Admission is restricted to the children of mothers who are without the support of a husband, parents where the mother is unable to care for the child, parents whose living conditions are likely to affect the health of the child unfavourably, and widowers or deserted fathers. It is sometimes possible to offer a few places to the children of parents where the mother has to work owing to the father's unemployment or low earnings. Children in the Council's nurseries are medically examined at regular intervals. There is one day nursery run by a grant-aided voluntary body, the Battersea Central Mission. This nursery, which is run on lines similar to those of the Council's nurseries, provides places for 49 children. Throughout the year there has been a great demand for places in all the day nurseries in the Borough. From time to time all nurseries have experienced severe staff shortages, sometimes necessitating the temporary limitation of new admissions. Towards the end of the year the position had slightly improved but there is still a very rapid turnover in staff. The matrons, their deputies and other senior staff have all worked extremely hard and it is their devoted service which keeps the nurseries going in spite of staffing difficulties. We have continued to admit a number of children for short periods to tide over a family emergency, such as the admission of the mother to hospital. All cases are sympathetically and carefully considered but it has been possible to admit only cases of urgent need. There have been the usual cases of infectious disease during the year but on the whole the children's health has been good. A number of applications are made by hospitals for the admission of children on medical grounds and when it is possible to admit these children they make excellent progress. 62 Deaf children in day nurseries Children under five years of age likely to benefit from being in a hearing environment may be admitted for part-time attendance at day nurseries, no charge being made for their attendances except for any refreshments provided. They may have a hearing defect themselves, or may have deaf parents and be suffering from retarded speech owing to the lack of a hearing environment. The admissions are normally limited to children under three years of age, as children over that age are generally treated through the education service and would be admitted to day nurseries only with special justification and the prior consent of the consultant otologist. Most of the children attend up to three hours a day, but a child is occasionally allowed to stay for a whole day provided that his weekly attendance is limited to 15 hours. During the year there were four such children in the Council's nurseries, three of these being still in attendance at the end of the year. Private day nurseries and child-minders At the end of the year there were 31 private day nurseries with registered places for 734 children, 29 statutorily registered childminders with places for 189 children, and 12 voluntarily registered child-minders with places for 23 children. All three categories of minders are regularly visited by the Council's medical staff and health visitors, and advice is given on child care, immunization, etc. Occasional creches These creches provide for the children of mothers attending a clinic or class on the premises and also give occasional relief to mothers who, for various reasons, such as visits to hospitals, shopping, laundering and other domestic duties, wish to be relieved of their young children for two or three hours during the day. In addition, they provide an opportunity for an only child to mix with other children of similar age. During the year 481 creche sessions were held in the centres and attendances numbered 8,686. Adoption and boarding-out Medical advice is sought by the Children's Officer whenever a child in care is being considered for adoption or boarding-out. The number of cases dealt with during the year, and the decisions reached, were as follows:— Adoption cases: Suitable for adoption 8 Suitable for adoption subject to certain conditions 5 Boarding-out cases: Suitable for boarding-out 6 Suitable for boarding-out subject to certain conditions 5 Total 24 63 Health Surveys From time to time surveys are carried out by other bodies on some aspect of health or growth and development of children and the Health Department is asked to assist. These surveys usually mean a great deal of extra work for the staff and they may be very time-consuming but it is felt that wherever possible we must give all the help we can in the hope that the mass of detailed information provided will contribute to the success of the research or survey and thus add to our knowledge of health problems. Details of some of the surveys in which the department has participated during the year are given below:— National Survey of Health and Development This study was started in 1946, when every woman who bore a child in the first week of March of that year was interviewed as part of a survey of the economic and social aspects of childbearing. Five thousand of these babies have been followed-up from birth to the age of 19 with the aid of school nurses, health visitors, teachers, school doctors and, more recently, youth employment officers and staff at technical colleges. The mothers themselves have not been approached since 1961 and it is felt that the young people are now old enough to co-operate directly in the attempts which are being made to keep records of their health, hospital admissions and accidents up-to-date. In fact, if the information is to be accurate it is very desirable that it be obtained from the young people concerned. These records are unique as studies of the health of young people. The study is being organized by the Medical Research Unit of the London School of Economics, who have asked Medical Officers of Health to arrange for short annual visits to be made to the young people themselves to collect this information together with a few facts about employment. A number of visits were made during the year to young people living in Wandsworth who have been concerned in this survey. National Child Development Study In 1958 a survey of virtually every baby born on the 3rd to 9th March, 1958, was carried out with the co-operation of all the mothers as well as many doctors and midwives throughout the country. As a result of this study a great deal was learned about the children's growth, health and education. For this reason, it was decided to follow-up the children (some 16,000 in all, about 90 of whom are Wandsworth residents) who were included in the survey. 64 The proposals necessitated asking the school staff about each child's progress, collecting samples of his reading, writing and arithmetic, arranging a visit by a health visitor to ask some questions about the child's health and development, and a medical examination at which a parent was to be invited to be present. The second part of the survey, in which we agreed to co-operate, was launched during the summer of 1965, and many questionnaires have already been completed. Schizophrenic illness after child-birth In 1962 the Consultant Psychiatrist at Downview and Banstead Hospitals asked for help in assessing the long-term results of the hospitals' mother and baby unit, which provides treatment for this illness. The immediate results of treatment were said to be very good and the inquiry was intended to discover the later effects on the mother's health and the health of the family as a whole. For this, the hospital required the opinion of the health visitor and it was proposed that a member of the hospital staff should interview the mother at yearly intervals. For each of the patients from Downview and Banstead Hospitals, a report on a control family was required. The former London County Council undertook to assist in the work, and we have continued to co-operate during the past year. Rubella Syndrome As reported in the British Medical Journal in 1964. snecialist opinion showed that in a sample of children with congenital defects following maternal rubella, and compared with a control group of children, the children with the rubella syndrome have neutralising antibody consistently higher than their normal cohorts. Dr. Neville Butler and Dr. J. A. Dudgeon of the Hospital for Sick Children, Great Ormond Street, asked for assistance in a follow-up serological study as it was obvious that these findings might have important practical results and it was decided to follow-up certain groups of children born in 1962 and subsequently, whether or not there was a clear history of rubella. Thirty-three such cases were investigated during the year. Childhood Malignancies This survey was promoted in 1961 by the Department of Social Medicine at Oxford University after publication of work on the Aetiology of Leukaemia. During the past year, the parents of five children who died during 1964 have been interviewed by a senior medical officer and questionnaires have been completed in respect of these cases. Similar action was taken in respect of five control children. 65 OTHER PERSONAL HEALTH SERVICES There are also numerous personal health services provided which benefit persons other than mothers and young children with which I have dealt in the previous chapter and these are summarised below. Home Nursing Service On the 1st April, 1965, the Corporation assumed responsibility for the Home Nursing Service, which had previously been carried out by the South London District Nursing Association and the Ranyard Nurses. These organisations, with slightly differing traditions, had provided a high standard of home nursing in the area for many years. During the past year various changes have been made in the organization in order to provide a uniform method of working, and to reduce the time spent in travelling. The two Superintendents have given us the benefit of their experience and whilst there must be some understandable regrets at the passing of the voluntary organizations they have willingly cooperated in the building up of an integrated service. This process of integration brought a number of changes to the nursing staff and it is due to their loyal co-operation that the work has continued so smoothlv. A total of 4,103 persons were nursed during the year and the following table shows their age groups and the number of visits made:— Age First visits Revisits Total Under 5 years 253 1,152 1,405 5 to 64 years 1,443 32,163 33,606 65 years and over 2,407 97,042 99,449 All ages 4,103 130,357 134,460 Home Bathing Service Home bathing assistants were employed by both the former Battersea and Wandsworth Borough Councils. This service has now been closely linked with the Home Nursing Service so as to make the best possible use of both trained and untrained staff. The service is greatly appreciated by many elderly people and provides help for those not requiring full nursing care. Incontinence Pads Service Home nursing of incontinent persons is made much easier by means of this service and a growing number of patients are being supplied with incontinence pads. Various types are available and are supplied according to need. Most households make their own arrangements for disposal but in some cases it is necessary to arrange for collection and disposal by incineration. A laundry service for incontinent persons is also provided where necessary and this is referred to on page 52. 66 Loan of Equipment To ensure the efficient nursing of patients in their own homes the Council operates a scheme for lending, without charge, equipment as distinct from those items which can be prescribed by general practitioners. During 1965 the following articles were issued on loan:— 251 commodes 60 wheelchairs 50 walking aids 32 hoists 24 rubber sheets 24 backrests 12 hospital beds with mattresses 12 fracture boards 8 bed cradles 4 ripple beds The Council's provision of home nursing equipment is supplemented by the British Red Cross Society. In addition to commodes and wheelchairs, the British Red Cross Society provides smaller items of equipment such as air rings, bedpans, urine bottles and crutches. The Council is continuing to make a grant to the Society to assist in maintaining stocks of equipment. Home Help Service Without this service many of the other health and welfare services of the Borough would be seriously jeopardized. The overriding problem is the difficulty of recruiting sufficient staff to meet the demands and the service has to be spread so that all applicants are given some service. Whenever possible some help is provided but in many we should like to be able to give considerably more. At weekends and Bank Holidays some staff are always available to carry out emergency visits and give essential service to people who are entirely dependent on the services of a home help. Where possible neighbours, or in special cases relatives, are employed to give assistance to a particular person or group of people. Some of the work of home helps is carried out in very difficult circumstances and it is not surprising that in an area of high employment many people tend to seek a more congenial and remunerative occupation. It is therefore greatly to their credit that a large number of devoted home helps give such good service. The following table shows the number of persons who received home help service during the year:— HOME HELP PROVIDED FOR PERSONS Aged 65 years or over on first visit in 1965 Aged under 65 years on first visit in 1965 Chronic sick and tuberculous Mentally disordered Maternity Others Total 2,956 297 9 146 204 3,612 67 Immunization and Vaccination As the figures show, about 80% of the immunizations and vaccinations performed in Wandsworth are carried out at the Council's centres, the remainder being performed by general practitioners. Health visitors and school nurses keep up a constant drive to persuade parents to complete a full programme of protection against infectious diseases for their children. Now that the combined injection against diphtheria, tetanus and whooping cough is given at the same time as oral vaccine for protection against poliomyelitis, primary immunization against these diseases can be completed in three months instead of six. This should help considerably by halving the number of visits needed for immunization, and will also relieve some of the pressure on the clinics. The general pattern of prophylaxis was much as in previous years, but there are two other points worthy of mention. The first is that protection against tetanus is becoming more common as a single course, not merely as part of the triple injection; secondly during the year the Department continued the policy of the London County Council to co-operate with the Medical Research Council in their research into vaccination against measles. As a result of this research it seems probable that measles vaccination will become available for use in suitable cases. Immunization and Vaccination Statistics Smallpox vaccination—cases completed:— Primary vaccinations:— Council clinics 2,398 General practitioners 724 Total 3,122 Re-vaccinations Council clinics 219 General practitioners 110 Total 329 Diphtheria immunization—cases completed:— Primary courses:— Council clinics 4,779 General practitioners 1,086 Total 5,865 Reinforcing injections:— Council Clinics 3,682 General practitioners 1,181 Total 4,863 Whooping cough vaccination—cases completed Primary courses:— Council clinics 4,470 General practitioners 1,072 Total 5,542 68 Reinforcing injections:— Council clinics 2,476 General practitioners 815 Total 3,291 Tetanus immunization—cases completed:— Primary courses:— Council clinics 4,863 General practitioners 1,111 Total 5,974 Reinforcing injections:— Council clinics 3,632 General practitioners 1,068 Total 4,700 Poliomyelitis vaccination—cases completed:— Council clinics and general practitioners;— Salk vaccine—primary courses:— Born 1961-65 154 Born 1950-60 7 Over 15 years of age 6 Total 167 Salk vaccine — persons given reinforcing injections 187 Sabin (oral) vaccine—primary courses:— Born 1961-65 5,264 Born 1950-60 683 Over 15 years of age 218 Total 6,165 Sabin (oral) vaccine—persons given reinforcing doses 2,393 69 be provided with ambulance transport. During the year 2,293 sessions were held ; 775 people made a total of 14,897 attendances. In addition to the clinics provided by the Council much valuable work is done by the Old People's Welfare Council through the Welfare Department. The following figures show the extent of this complementary service during 1965:— Number of centres at which sessions were held 3 Number of sessions held:— (a) at clinics 207 (b) privately 104 Number of individual patients seen:— (a) at clinics 182 (b) privately 112 (c) at home 231 Number of treatments at clinics 1,583 Number of home visits made 2,003 Number of treatments at chiropodists' private surgeries 972 Venereal disease Welfare Officers are employed by six of the Inner London authorities in whose areas V.D. clinics are situated, and follow-up patients who have failed to complete treatment, with the object of persuading them to continue with treatment. Time is also spent in tracing contacts named by patients and persuading them to obtain treatment. This work is carried out on behalf of all Inner London authorities, an annual payment being paid by authorities (of which Wandsworth is one) without any venereal-disease clinics in their areas and therefore not directly employing any welfare officers on follow-up work. Health Education Health education is an important and fundamental part of the work of a Health Department but it must be approached in a practical way, with an understanding of what is possible and of existing medical knowledge and the social obligations of the community. It is also necessary to observe the well recognised educational axiom that any form of education, to be fully effective, must also be interesting. A good deal of attention was given to this question by the former Authorities which were merged to form the new London Borough of Wandsworth, and the measures undertaken by those Authorities have continued in a greater or lesser degree in the current year. We have, therefore, pursued an active policy of health education, the basis of which has been to inculcate and foster the idea of good health and well-being of both the community and the 70 individual. This has been done primarily by regarding health education as an integral part of the day-to-day work of the Health Department because the services provided by the Health and allied departments such as Education are in themselves influential means of health education. Not only can these services help parents to understand how they can bring up healthy children but they also offer many opportunities to the staff of the departments to give assistance and advice on the general rules of hygiene and personal health. If it is true that the key to effective health education lies in securing the intelligent co-operation of the individual without causing anxiety about health problems, it is also true that this purpose can best be achieved through the existing services and, except on special occasions, not allowing health education to impinge too drastically on patients or those who attend clinics. In other words, health education should be practised without its being too obvious, except where it is necessary to press home a particular lesson to achieve a particular object. Maternity and Child Welfare Services—At the maternity and child welfare clinics where mothers and their babies attend, there are many opportunities for helping the mothers by means of intelligent education on health matters. Advice on the personal problems of individual mothers can be reinforced by general talks in which groups of mothers are encouraged to take part; subjects are chosen which are of topical interest and are illustrated by demonstrations and by visual aids, e.g. film strips. These are planned to meet local needs and are arranged by the staff of the centres. Mothercraft classes are held each week and several of these take the form of mothers' clubs. Here, the mothers undertake most of the organizing and this method has been found very acceptable in many districts. These clubs and classes are one of the most fruitful means of bringing to light problems which are worrying mothers. From time to time, outside organizations send speakers to these clubs. For expectant mothers, classes are arranged which cover ante-natal care, preparation for labour and the care of the young baby, and relaxation classes are held in conjunction with these courses. At some of the welfare centres, one or two evening sessions are also included to which fathers are invited. School Health Service—The School Health Service also provides scope for giving help about healthy living and this need not necessarily be limited to advice about the particular defect for which the child has attended. At regular medical inspections, the medical officer is able to discuss problems of personal hygiene with parents and to encourage a sense of responsibility in the children. School nurses undertake regular mothercraft teaching in some of the larger schools and the questions and discussions which follow are often the most valuable part of the session. The Inner London Education Authority has made available a Health Education Officer with a mobile unit which has 71 trated on the subject of smoking and lung cancer in schools although his services are also made available to youth organizations and Parent Teachers Associations. Home Visits— By home visiting, health visitors and district nurses can follow-up in a practical way much of the teaching and advice given in the centres. Here are further opportunities for teaching about the care of children and also of the aged, the preparation of diets, personal hygiene and cleanliness in the home, and the prevention of home accidents. Similarly, the public health inspectors in their visits are able to give advice on many matters relating to health education and home safety over and above the immediate problem which was the occasion of their visit to the household. It is generally recognised, too, that general practitioners have a most important part to play in the health education of their patients and their families. Indeed, the general practitioner, having the confidence of his patients and their families, is in a particularly powerful position to influence them on matters of healthy living. Day Nurseries—When mothers attend a day nursery, either to leave or to collect their children, the matron and the mother are able to discuss any problems relating to the child. Such items as the importance of play, diet, rest and habit training and the care and upbringing of young children can be covered and much can be achieved by the establishment of good relations between mothers and staff. Similarly, doctors and health visitors, particularly during their periodic visits to private day nurseries and child-minders, are able to improve the standard of child care. Publicity Material—The display of posters and the distribution of leaflets is a useful adjunct to the more direct and personal teaching methods described above. Publications and material utilised include pamphlets and posters supplied by a variety of organizations having an interest in health education and it is necessary to exercise considerable discrimination in deciding what materials to use. Examples of the topics covered are: — Smoking and health Diet Routine immunization Fire prevention Dental health Tuberculosis Venereal disease Mental health Home safety Lung cancer Apart from posters and leaflets, films and film strips are also used. A panel of my senior colleagues meets periodically to keep the whole question of health education under review and at the same time to select suitable material and decide on the best ways to disseminate it. Special Campaigns—From time to time in the past special campaigns have been launched to deal with specific problems, generally of topical interest and importance. These have covered such sub- 72 jects as vaccination against poliomyelitis, diphtheria immunization, home safety, and smoking and lung cancer. Exhibitions have been held in the local libraries which have provided poster sites and bookmarks and leaflets through their library service. To achieve a limited objective these campaigns have an undoubted value, but experience has shown that although they may produce temporary results initially the lessons taught are soon forgotten by the general public and it is doubtful whether the long-term results achieved are commensurate with the time and expense involved in mounting this form of campaign. More permanent results are likely to follow from the steady day-to-day efforts of the Health Department staff as part of their ordinary duties. Nevertheless, certain forms of specific effort can be worthwhile, particularly if they observe the dictum that all education to be effective must be interesting. Although thought was given during the year to initiating such projects, the commitments of the staff, on whom planning and organisation of such projects would fall, was such as to make it impossible. However, as opportunities arise, further thought will be given to this. Health education about venereal diseases and smoking comes within the general outline given above. So far as smoking is concerned, consideration was given to a repeat of a useful means of health education undertaken in previous years by which prizes were offered to school-children for essays and posters drawing attention to the effects of smoking on health. However, as mentioned in the previous paragraph, the commitments of the Departments during this very busy year did not permit any plans being made. With regard to venereal disease, arrangements were made with the District Postmaster for information about facilities for treatment to be publicised at post offices in the area. In addition, a number of factory premises were visited and proprietors were requested to exhibit posters and other publicity material. The Council makes a contribution, with other London Boroughs, to the services of a social worker who is attached to one of the large V.D. centres in London and her follow-up work with contacts of cases is regarded as an important part of health education work in connection with venereal disease. During the year, the Government Report on Health Education (known as the Cohen Report) was carefully considered, particularly the question of the appointment of a Health Education Officer. There is, I think, little doubt that there is a place in a large Health Department for one person to assume direct responsibility for health education functions and that with the concentration of responsibility in one person, the whole idea of health education would be given impetus. To some extent we already have the services, through the Inner London Education Authority, of such 73 an officer in relation particularly to the School Health Service. However, in considering this question, regard was paid to the need that Health Education Officers should be properly trained and the Cohen Report recommends that the proposed Central Board for Health Education should set up training schemes for Health Education Officers. For the time being, therefore, it was felt that it would be prudent to wait to see what progress was made in the proposed training schemes for Health Education Officers and what scope there would be to second officers regarded as suitable for these posts to undertake training. Home Safety—Accidents in the home Arrangements are made for the loan of fireguards to mothers of young children where there are insufficient resources to enable the mother to make her own provision. During 1965, 24 fireguards were issued. Family casework and problem families The Council has set up a Co-ordinating Committee of Members to which are referred questions and problems related to the Social Services where more than one Standing Committee or Department may be concerned. Casework and the rehabilitation of problem families is a subject to which a good deal of attention was given during the year. The Chief Officers of the Council meet and advise on the general policy to be followed in family casework with problem families, the major aims of which are to prevent the break-up of family life and the neglect and ill-treatment of children. Decisions on action to be taken in the case of individual families falls to the Case Committee comprising representatives of the Council's Health, Children's and Welfare departments and other statutory and voluntary agencies which work with families. The Case Committee is normally attended by the Deputy Children's Officer [Chairman), Principal Social Worker (Health Services) (Secretary), Housing Manager or representative, Principal Nursing Officer, Principal Mental Welfare Officer, Deputy Chief Welfare Officer, Principal Social Worker (Welfare Services), Divisional School Care Organiser, and the Secretary of the local branch of the Family Welfare Association. Families whose problems are causing concern to more than one department are referred to the Case Committee to consider the most suitable form of help required and to decide which department or agency should assume responsibility for visiting the family. During the year, the Case Committee met on 23 occasions and discussed 92 families—48 of these were new cases and 44 were reviews of families considered previously. 74 The following table shows the source of reference of the families discussed at the Case Committee:— Referred by New Cases Reviews Total Greater London Council Housing Manager 16 15 31 Wandsworth Corporation Housing Manager 11 5 16 Principal Mental Welfare Officer 2 3 5 Principal Nursing Officer 4 2 6 Children's Officer 2 3 5 Principal Social Worker (Health vices) 1 10 11 Divisional School Care Organiser 6 2 8 Probation Officer 1 — 1 National Assistance Board 1 — 1 Other 4 4 8 Total 48 44 92 It will be seen that more than half the families discussed were referred from Housing departments and many of the problems of this group were related to rent arrears and threats of eviction. In the main, the difficulties of the families brought to the notice of the Case Committee are associated with mental disorder of the parents, erratic work or unemployment, domestic discord, poor health of parents and children or backward parents with large families. Most have chronic rent arrears and hire-purchase debts and many of the parents suffer an inability to live within their earning capacity. Some success was achieved in reducing debts ; two parents were persuaded to have mental hospital treatment and considerable supportive work has been given ; one family has shown marked improvement in both their marital relations and the treatment of their children. Two families at least remain chronic problem families. The social workers' time is spent not only in the visiting and support of problem families themselves but also working in cooperation with other agencies involved in each family. Care of Old People The effective care of the aged depends to a large degree on the close liaison and co-ordination of effort of the statutory bodies and voluntary organizations concerned in this vital work, and it is with pleasure that I record that in Wandsworth these links exist in full measure among all those concerned with the welfare of old people. In addition to the ties which exist between the Health 75 and Welfare Departments of the Council, the Old People's Welfare Council and the Women's Voluntary Service, close contact is maintained with the hospital geriatric services in the area which have proved most helpful with individual persons requiring urgent in-patient accommodation. In many cases, old people have recovered sufficiently from quite serious illnesses to be able to return home with the support of the appropriate personal health and welfare services. Requests for visits to be paid to old people are received from many sources and it is often the health visitor who pays the initial visit at which it is possible to assess the needs of the old person. Where appropriate, details are referred to the Welfare Department or Old People's Welfare Council. The health visitor continues to visit where the old person is very frail and is likely to need medical care. During the year 1,455 first visits were paid by health visitors to persons aged 65 years and over, and a further 192 persons were visited following discharge from hospital. Under Section 47 of the National Assistance Act, 1948, amended by the National Assistance (Amendment) Act, 1951, the Medical Officer of Health is empowered to apply for an Order for compulsory removal to a hospital of persons who are suffering from grave chronic disease or being aged, infirm or physically incapacitated, are living in insanitary conditions, unable to devote to themselves and not receiving from others proper care and attention. Most aged persons in need of care and attention avail themselves of the day-to-day services of the voluntary and statutory organizations. Occasionally, however, every service is refused and in these circumstances compulsory removal may become necessary, although this step is invariably taken with the greatest reluctance on the part of all concerned. In March, compulsory removal to hospital was needed in the case of a bed-ridden woman, aged 82, residing alone in distressing conditions. She was suffering from leukaemia, and succumbed to her illness six weeks after admission to hospital. STAFF TRAINING Sponsorship of students to recognized courses of training and in-service education courses are important methods of recruiting and retaining staff and maintaining a high standard of service. The London Boroughs Training Committee have assisted with the recruitment of health visitor students and have arranged a number of short courses for various grades of staff to meet special needs. The Council sponsored six students for the Health Visitors' Training Course during the year. They commenced their one-year training course in October, 1965, and should return to us as 76 fied health visitors, when they will be a very welcome addition to the staff. Two of the students are at Battersea College of Advanced Technology, two at London University Institute of Education and two at Chiswick Polytechnic. Three of our day nurseries are recognized " training nurseries " and provide fourteen places for nursery nurse students, seven first-year and seven second-year. The students attend Brixton Day College two days a week for the theoretical part of their training and receive their practical training in the day nurseries. Seven students commenced training this year and five completed their training. A number of staff attended short courses on various aspects of their work. Four health visitors attended ten-day courses for Field Work Instructors to enable them to supervise the practical training of health visitor students. Two staff attended a four-day Introductory Course for School Nurses and four home nurses and two midwives attended special study days arranged by the London Boroughs Training Committee. In addition to the above courses, arrangements were made for all midwives and health visitors due to attend refresher courses at five-yearly intervals to go on suitable courses. These are arranged by the Royal College of Midwives, the Royal College of Nursing, the Health Visitors' Association and the Central Council for Health Education and are recognized by the Ministry of Health. FACILITIES FOR STUDENT TRAINING The health visiting and public health nursing services of the Borough provide good facilities for students requiring public health or home nursing experience and we receive many requests for training and observation visits. During the year practical health visiting experience was provided for eight student health visitors from Battersea College of Advanced Technology. We have continued to provide a short period of experience of public health work for the third-year students from the Nurse Training Schools of the various local hospitals. A oneor two-day programme is planned for each student. During the year, arrangements were made for about 200 students. In addition, visits and talks were arranged for a number of students and visitors from various fields of public health or social work. The domiciliary midwifery service provided a period of three months' training for 46 pupil midwives and a single-day course for 18 student nurses taking the Obstetric Nursing Course. Visits were also arranged for a number of students from overseas. 77 5 MENTAL HEALTH SERVICE In 1965 the Mental Health Act, 1959, attained its fifth year of operation and the growing community care services for the mentally disordered began to make some impression on the problem of the mentally ill and the mentally subnormal in the community. Close links were forged with the psychiatric hospitals which serve the area and the increased number of qualified staff in the mental health team meant that in addition to more work being carried out, it was work of a higher professional standard. Nevertheless, staffing problems gave rise to a good deal of anxiety and it is likely that this will remain so in the foreseeable future in spite of the increased number of places on various forms of social work courses. During the year, a good deal of thought was given to capital building projects which, if and when they attain fruition, will greatly add to the strength of the mental health services in the area. A good deal of thought, too, was given to training methods in the Training Centres and a supply of new play material was obtained which has proved to be immensely valuable. Close contacts were maintained with the local branch of the National Association for Mentally Handicapped Children and some of the suggestions which this organisation put forward we were able to adopt. Although progress was undoubtedly made during the year, a great deal remains to be done, for the community care of the mentally disordered is probably the most rapidly growing part of the public health services. I feel, however, that we have the basis of an outstanding service in Wandsworth which, in the years ahead, should further develop. In the following, some account is given of the work during the year. STATUTORY DUTIES UNDER THE MENTAL HEALTH ACT, 1959 Statutory duties involving the admission of patients to hospital have remained heavy. Fortunately, relationships with the hospitals are such that it is possible to obtain beds for both the mentally ill and the mentally subnormal without too great difficulty, although one problem is the difficulty in obtaining beds for adolescent patients. This, however, is a nation-wide problem and it is hoped that eventually more adolescent beds will be made available. At present an adolescent boy or girl who becomes mentally ill may have to be admitted in an emergency to a large mental hospital where treatment will only be available in a ward with older and sometimes acutely disturbed patients. From 1st April, 1965, the night and weekend work was undertaken " on call" from home bases, in combination with the London Boroughs of Lambeth and Southwark, and the arrangement worked well. 78 COMMUNITY CARE OF THE MENTALLY ILL The Mental Health Social Workers continued to offer a regular casework service to selected mentally ill patients and to their families. The number receiving these visits grew throughout the year and the numbers referred for visiting are much higher than can be adequately dealt with by the team. Social clubs The value of the social clubs is considerable in that they keep in touch with a large number of patients after working hours with the minimum use of staff and the maximum economy of staff time. Many patients who are disturbed are able to live in the community and go to work regularly; the only contact they have with mental health staff must then be in the evening. If the patient is attending the social club it is possible to diagnose early signs of relapse and also to give guidance and support through any difficulty which arises at work or in the home situation. Tooting Social Club completed its fourth year and is running well, with attendances varying between 25 and 45 a week. Two large dances were held during the year, at Christmas and in the spring, and there was a summer outing to the coast. A doctor from West Park Hospital continued to attend regularly throughout the year, in addition to the two mental health social workers. The music group in the club continued to be a valuable part of the club's activities. Putney Social Club also completed its fourth year during 1965. A psychiatrist attended the club at the beginning of the year for six months, after which unfortunately it was not possible to continue attendance. Parties were held twice a year and were very successful. The club combined with the Tooting Social Club for the annual summer outing. An art group has been formed at this club and is run by a former patient. Residential hostel Further experience was gained during the year in the management of Chellow Dene, the Council's short-term psychiatric hostel at Putney. The number of beds occupied was maintained at a high level and because of the careful selection of patients the rate of success and rehabilitation was high. Some very difficult patients were absorbed into the hostel community during the year. In the spring a residents' discussion group was started one evening a week. The staff of the hostel and a psychiatric social worker from the Mental Health Office are present at this group, in addition to any patients who wish to join. Discussion has ranged over a wide number of subjects, including the community attitude to mental illness, problems faced by the mentally ill in finding 79 employment after hospital admissions, personal relationships within the hostel and family problems in relation to mental illness. This group has greatly assisted in developing a sense of community within the hostel and has strengthened the relationships between residents and staff. During the year work was started on a quiet room attached to the drawing-room in the hostel and this will greatly add to the amenities and enable patients to split up in the evenings, particularly when the television set is in use. Details of admissions and discharges during the year are set out below :- Male Female Total Patients in residence on 1.1.65 12 6 18 Admissions during the year 26 20 46 Discharges during the year 29 18 47 Patients in residence on 31.12.65 9 8 17 Occupational therapy Domiciliary occupational therapy with the mentally ill has proved itself to be a very valuable addition to the work of the mental health social workers. The chronic patients who are difficult of access can be helped and encouraged to improve their living conditions and eventually to move on to day centre attendance or possibly even to employment. The occupational therapist works in close co-operation with voluntary services and this combination has proved extremely fruitful. For very severely handicapped patients who cannot leave their homes she has found work and has also developed a number of useful contacts in the area. During the year the occupational therapist paid weekly visits to about 20 patients in their own homes. As the patients' addresses are scattered over a wide area of the borough, the number of patients referred and frequency of visiting was a degree limited by the time factor but it is hoped that this aspect can be improved in the passage of time. Day hospitals There are now three day hospitals for the mentally ill within the borough, viz :— West Park and St. George's Day Hospital, Tooting Grove Up to 60 patients can be treated here and the Council is responsible for the salary of the occupational therapist and for the halftime mental health social worker. Tooting Bec Day Hospital Approximately 50 patients are looked after from the area and the Council provides a half-time mental health social worker. 80 Springfield Day Hospital This was opened in November, 1965, and 25 places are available. Although there is no official attachment to Springfield Day Hospital, a mental health social worker visits there twice a week for the purposes of liaison with the mental health team. It would be desirable to allow further time at the Springfield Day Hospital, but at present this is not possible. Out-patient clinics The mental health social workers attend four psychiatric outpatient clinics in the area. These are held twice weekly at St. James' Hospital, once a week at St. Stephen's Hospital and once a week at West Park and St. George's Day Hospital, the last being staffed by the Medical Research Council. Liaison with West Park Hospital In order to lessen the difficulties of liaison which arise when a mental hospital is situated some distance from the catchment area it serves, each mental health social worker spends one day a week, for a period of three months, with the Senior Psychiatric Social Worker at West Park Hospital. Tn this way our staff are able to become familiar with the hospital and personally known to all the staff there. Overlapping with the West Park social workers can be avoided and patients admitted from Wandsworth can be followed-up personally. COMMUNITY CARE OF THE MENTALLY SUBNORMAL It is the aim of the mental health social workers to visit all subnormal patients known to them who live at home with their families. This work comprises rather more than half of the total case load. Special clinics During 1965 special clinics for diagnosis and counselling of subnormal children and their parents were held fortnightly at Balham Welfare Centre and monthly at St. Christopher's Centre, Battersea. A clinic in the Battersea area had long been necessary and has greatly reduced the travelling time of the mothers. In addition, a similar clinic was held every two months at Putney Health Centre. Mothers' groups The purpose of mothers' groups is to bring together mothers with young subnormal children so that they meet and discuss their common problems with mental health social workers, a health visitor also being present if possible. At certain groups outside speakers are invited and in this way the mothers are enabled to become well-informed about the services available for their children. 81 It is recognized that throughout the country comparatively little help is given to the parents of the very young subnormal child and diagnosis may be delayed by the isolation of the parents with their problem. It is thus important to concentrate the services of the mental health social worker on this age group. Over-protective attitudes developing in the mother can be prevented and early diagnosis means that the child gets every possible opportunity for stimulation and training at the earliest age. In the summer of 1965 the Putney Mothers' Group, which had been in existence for three years, was disbanded as the children had mostly reached school age and had dispersed to school or training centre and the mothers' problems had become less acute, but at the end of the year a new Mothers' Group was started in the Tooting area. Brierley Hall Club The Parents' Association in Wandsworth started a club for subnormal teenagers in January, 1965. The club meets fortnightly and the Principal Mental Welfare Officer is a member of the committee and attends the club periodically. Training Centres For many years the training centre service in London was organized on a County basis by the former London County Council which resulted in considerable interchange of trainees between areas which shared the services available. For example, the Wandsworth junior training centre is used by the London Borough of Lambeth, while 40 mentally subnormal children living in Wandsworth attend the Fulham junior training centre. As there are no adult training centre places for men in Wandsworth at present, our male trainees attend Clapham Industrial Training Centre in the London Borough of Lambeth. Our Balham training centre for women and girls of 16 years of age and over is used by trainees from Lambeth, Westminster, Kingston-uponThames, Chelsea and Hammersmith and it is likely to be some years before boroughs become self-supporting for training centre places. Wandsworth training centre—This is a junior training centre for boys and girls under 16 years of age and has a special nursery group for the under-five-year-olds. Numbers on the register fluctuated between 70 and 85 at this training centre throughout 1965. Is was possible to admit a few children under five, but on the whole there was a good deal of pressure for admission into the nursery group. The deputy supervisor started to attend a Montessori course in the evenings, her fees being paid. It has been possible to experiment with new methods of teaching and use of Montessori equipment has proved valuable. 82 In September, 1965, the assistant supervisor in the nursery group returned from the one-year course run by the National Association for Mental Health. Also in September a supernumerary assistant supervisor was appointed, normally to work at Wandsworth Training Centre, but to be available for either of the other Centres in times of staff shortage. This position greatly relieved the staffing problems within the training centres. Balham training centre—There were 60 trainees on the register throughout 1965 and during the year two left the centre to take up paid employment. Newlands training centre — This centre similarly caters for women and girls over 16 years and has accommodation for 40 trainees. Short-term care Short-term care is a means by which parents who are caring for their subnormal child at home can be relieved for up to eight weeks a year. It is valuable in times of a family crisis, such as ill-health or confinement, and gives overworked parents with large families the opportunity of a temporary relief once or twice a year. There is no doubt that plentiful use of short-term care reduces the number of families who break down and are forced to ask for permanent residential care for their children. The following numbers of children and adults were sent on short-term care during 1965 :— Under 16 years 16 Over 16 years 32 Total 48 Long-term care During the year 26 patients have been maintained in long-term care at homes run by the following organizations : — Guardianship Society 7 Mental After-Care Association 10 National Association for Mental Health 1 St. Michael's Convent 3 Richmond Fellowship 1 Hampton Manor Homes 1 Cheshire Foundation Homes 1 St. Joseph's Special School 1 Foster Home 1 83 Special care unit A problem exists in accommodating the child over five years of age who is not yet ready for a Training Centre. It is not always realistic to expect a retarded child to be toilet-trained and able to feed himself at the age of five. He may be doing very well for his mental age and yet not have reached the standard of social behaviour required in the Training Centre by his fifth birthday. For this type of child a Special Care Unit is temporarily required, and for the low-grade, helpless child a Special Care Unit may be permanently needed. There is as yet no Special Care Unit in the borough and this is a serious gap in our service, although we have arrangements for the admission of six mentally subnormal children to one of the Council day nurseries. However, in October, 1965, arrangements were made for five children who were unsuitable for our Training Centre to be transported daily to the unit at Queen Mary's Hospital, Carshalton. A guide was appointed and the cost of transport was paid by the Council. This arrangement has been of great benefit to some very heavily burdened families and has, to some extent, filled the gap in our provision. Home teaching The Department employs a Home Teacher for those mentally subnormal children who are too physically handicapped to attend the Training Centre. Her services are shared among five boroughs but she could probably be fully employed in this area alone. The Home Teacher visited 16 subnormal children once weekly during 1965. It would in some cases be helpful if visits could be paid more frequently but at present this is not possible. The Home Teacher's role is to teach the child according to his individual aptitudes and to help the parents so that they can carry on the work daily with the child. STAFF TRAINING Two senior mental health social workers attended training courses in 1965, one on the two-year North Western Polytechnic Younghusband course, who will complete his course in August. 1966, and one on the National Institute for Social Work one-year course which commenced in September, 1965. Both these senior staff were seconded on full salary and were replaced in the Mental Health team. It was possible to replace them by two qualified Psychiatric Social Workers. The qualifications of the social workers in the mental health team at the end of 1965 were as follows : — Psychiatric Social Workers 5 Social Science or Younghusband qualification 6 Qualified Mental Nurse 1 Unqualified 2 84 FACILITIES FOR STUDENT TRAINING Possibly because of the high proportion of trained staff in the mental health team many demands are made for student places in the Borough. The mental health section is used for long placements of social workers from the North Western Polytechnic Younghusband course. Six students were placed for 5½ months each during 1965. In addition, four students were placed for 6-8 weeks, two from the London School of Economics Social Science course and two from the University of London Extension course. Two students were placed for six weeks' observation placement by the National Institute for Social Work Training as part of a one-year course. In January, 1965, arrangements were made with the Springfield Hospital Nurses Training School for mental nursing students completing their third year to spend one week in the Mental Health Office. During 1965 12 nurses were accommodated under this arrangement. Nurses from the West Park Hospital Nursing School in their third year spent an afternoon a week in the Mental Health Office when arrangements were made for them to pay visits with the mental health social worker. Similar arrangements were made for St. George's Hospital nurses during their general training. MENTAL HEALTH ACT, 1959 STATISTICS for the year 1965 Persons referred Mentally ill Subnormal and severely subnormal Totals (a) By general practitioners 257 5 262 (b) By hospitals (on discharge after in-patient treatment) 146 11 157 (c) By hospitals (during or after out-patient or day hospital treatment) 67 10 77 (d) By Inner London Education Authority 10 57 67 (e) By Police and/or Courts 28 1 29 (f) From other sources 324 66 390 Totals 832 150 982 85 Admissions to hospital (Figures available from 1st April only) (a) As informal patients 79 7 86 (b) By statutory action (Sees. 25, 26 and 29) 308 2 310 (c) By Order of a Court (Sec. 60) 3 1 4 Totals 390 10 400 Persons receiving community care at 31st December, 1965 (a) Attending day training centre - 169 169 (b) Attending residential training centre - 5 5 (c) Receiving home training 17 10 27 (d) In local authority homes or hostels 20 2 22 (e) In private homes or hostels (including those of voluntary organizations) 23 30 53 (f) Receiving home visits and not in any of the foregoing categories (a) to (e) 339 323 662 Totals 399 539 938 86 LONDON BOROUGH OF WANDSWORTH 6 SCHOOL HEALTH SERVICE ANNUAL REPORT OF THE PRINCIPAL SCHOOL MEDICAL OFFICER FOR THE YEAR 1965 CONTENTS Introduction Pupils on school rolls Medical Inspection of Schoolchildren Vision Personal Hygiene Infectious Illness reported from Schools Medical Treatment of Schoolchildren Audiometry Handicapped Pupils School Nursing Service B.C.G. Vaccination of Schoolchildren School Dental Service Sanitary Conditions in Schools 87 Introduction The School Health Service is one of the most important sections of the services directed towards the prevention of illness and the maintenance of the health of children and young people. The entry of a child into school at the age of five years is a great landmark in his growth and development. For most children it is the first occasion when he will be separated from the mother and the family for any length of time and the child then begins his independent existence. He comes into contact with groups of other children so that the chances of his contracting infectious diseases are increased although at the same time, owing to his contact with his fellows, he is exposed to " small doses " of infection (latent immunization) which, in most cases, will help him to build up his resistance. He is also exposed to other influences new to him consequent upon his entering this new environment. It is very important that, during this vital period of his development, the child should be watched carefully and everything should be done to safeguard his health. At the same time, everything should be done to ensure that each child is able to take full advantage of the educational facilities to which he has a right. A child who is afflicted with a physical or mental handicap might not be able to derive full benefit from attending an ordinary school and so it is necessary to ascertain those children suffering from handicaps and to recommend the type of education which is best suited to their needs. Some children can best be educated in special schools where due regard is paid to the disability under which they are suffering. The School Health Service, being a part of the Education Service, is the responsibility of the Education Authority and in Inner London this is the Inner London Education Authority. In Wandsworth, the ultimate responsibility for the School Health Service, as for the Education Service generally, therefore, rests with the Inner London Education Authority. The service, however, is basically a local service and so it was required that the Inner London Education Authority and each Inner London Borough, including Wandsworth, should prepare a scheme for the joint administration of the Service, to be submitted for approval by the Minister of Education and Science. At the end of the year, although a scheme had been submitted it had not then been approved, although at the time of writing approval has been received. Under the scheme, although the ultimate responsibility for this Service remains, as stated above, with the Inner London Education Authority and the Medical Adviser of that authority is the final adviser on school health matters, the arrangements are such that the routine work is carried out locally. The Medical Officer of Health of the London Borough is the Principal School Medical Officer and there is a joint user of staff and premises. This is a 88 sensible arrangement since it means the full integration of the school health service, the maternity and child welfare service and the other personal health services of the Corporation. During the year, the arrangements have worked satisfactorily and some account of the work is contained in the following paragraphs covering both the medical and the dental parts of the scheme. So far as the dental health side is concerned, it had not, at the end of the year, been possible to appoint a Principal School Dental Officer but I was able to make arrangements for advice on dental matters to be available through the Senior Dental Officers of the Inner London Education Authority and for this help and advice, I am very grateful. Pupils on school rolls In January, 1966, there was a total of 45,449 pupils on the day school roll. The pupils attended a total of 129 school departments, including two schools for delicate children, three schools for the educationally subnormal, three schools concerned respectively with physically handicapped, blind and deaf children, and a school and four day classes for the maladjusted. Medical Inspection of Schoolchildren Routine medical examinations of the pupils are carried out by the Department's medical officers and the child's general practitioner is consulted when any defect in health is detected. Clinic facilities are available for further examinations of the eyes, ear, nose and throat, dental and special investigation, and treatment for minor ailments is also provided, but attendances at the last-named clinics have fallen during recent years. Educationally subnormal children are examined regularly in order to ascertain the nature and extent of their disability, the examinations being made by specially approved medical officers. The health visitors and school nurses play an important part in making arrangements for health inspections, and, in addition, carry out hygiene inspections at selected schools. Special arrangements are made to reinspect children with defects discovered at routine medical inspections ; these examinations take place either at school or at neighbouring clinics. At four primary schools, a special form of medical examination, known as a selective medical examination, was undertaken. A good deal of attention has been paid to this type of examination as an alternative to the traditional method. Under the selective method, parents are asked to complete a detailed questionnaire on the child's health in the past and close liaison is also maintained with the teachers who, being in close daily touch with the children, are often able to give a valuable opinion on the health and well-being of their pupils. 89 After assessing all these factors, only those children where there is a history of illness or ill-health, or where there appears to be a health hazard, are given a full medical examination. Opinions differ on the relative values of these two methods and further study and observation are required in order to assess the exact merits of the selective form of medical examination in schools. In the following tables details of medical inspections held during 1965 are summarised and compared with statistics, where available, for the year 1964. The available figures for 1964 are based on figures kindly made available by the Inner London Education Authority Central School Health Department, and relate to the area of the new London Borough of Wandsworth. Routine general medical inspections during 1965 totalled 17,464, compared with 16,859 in 1964. Of the 17,464 children inspected, 12.9 per cent were referred for treatment of defects, 6.1 per cent being referred for treatment of defects other than vision. The corresponding percentages for 1964 were 13.6 and 5.9. The following table shows the number of children referred for treatment or observation of the defects listed at routine general medical inspections for the years 1964 and 1965, expressed as a rate per 1,000 children inspected. Numbers examined 1964 1965 16,859 17,464 Rate per thousand Treatment Observation Treatment Observation Skin diseases 5.87 6.70 6.99 4.75 Eyes—vision * * 74.50 66.02 squint 5.04 6.58 5.04 7.27 other 2.02 2.97 2.29 1.83 Defective hearing 4.98 14.65 4.81 15.00 Otitis media 1.90 6.35 1.49 3.72 Enlarged tonsils and adenoids 7.90 28.71 8.76 31.95 Defective speech 2.31 9.85 2.00 8.93 Enlarged cervical glands 0.12 5.28 0.34 4.58 Heart and circulation 1.78 13.64 1.15 13.34 Lung diseases other than tuberculosis 2.97 13.64 2.86 13.97 Orthopaedic defects 9.37 28.06 11.56 26.91 Defects of nervous system 1.06 4.45 1.32 4.87 Psychological defects 2.08 10.74 2.35 8.13 Developmental—hernia * * 1.09 1.78 other * * 1.03 5.21 Abdomen ♦ * 0.17 0.97 * Figures not available 90 Details of non-routine medical inspections carried out in 1964 and 1965 are given below 1964 1965 Reinspections 8,586 9,007 Secondary-school annual surveys 152 174 Other non-routine inspections 5,260 5,625 (see table below) 7-plus experimental scheme inspections 64 122 Total 14,062 14,928 Total inspections 30,921 32,392 Analysis of non-routine medical inspections Nature of inspection Number inspected Bathing centre inspections: 1964 1965 Scabies — 2 Other 16 2 Employment certificates 467 533 School journeys 2,894 3,181 Recuperative holidays: Before holiday 42 89 On return 3 1 Candidates for Higher Awards 1 — Outward Bound courses 1 — Boarding Schools for the Delicate: Pre-departure inspections 12 5 On return from school 2 2 Handicapped pupils: Statutory examinations 15 16 Periodic special defect examinations 947 979 Research investigations and enquiries 64 Special examinations at request of: Head Teacher: Child's name entered in special book 140 126 Others 324 269 School Nurse: Following health survey 17 28 Others 165 109 Divisional Officer (Education) 43 62 Divisional School Care Organiser or Care Committee 29 20 Parent 101 90 All other non-routine inspections 41 47 Total 5,260 5,625 91 Physical condition of pupils Proportion satisfactory and unsatisfactory: 1964 1965 Satisfactory 99.3% 99.5% Unsatisfactory 0.7% 0.5% Attendance of parents and care committee representatives 1964 1965 Number of pupils inspected 16,859 17,464 Parent present 47.5% 49.0% Care Committee representative present 91.9% 91.9% Vision During the year vision tests were carried out on 6,678 boys and 6,453 girls, a total of 13,131 children, compared with 6,195 boys and 6,188 girls, a total of 12,383 children in 1964. The percentage of the number tested with and without glasses who were referred for treatment or observation was 18.7, compared with 20.2% in 1964. Visual acuity standards expressed as percentages of the numbers of children whose eyes were tested are set out in the following table: — Not wearing spectacles Wearing spectacles 6/6 6/9 6/12 or worse Referred for treatment 6/6 6/9 6/12 or worse Referred for treatment 1965 Boys 78.3 6.7 6.3 6.3 4.3 2.5 1.9 2.2 Girls 74.6 6.6 6.8 6.9 6.1 3.3 2.6 4.4 1964 Boys 78.6 6.6 6.6 6.2 3.7 2.0 2.5 3.6 Girls 74.8 6.7 6.6 6.3 6.4 2.9 2.6 6.1 Personal Hygiene No. examined No. found verminous Pupils found to be verminous % of number examined Annual comprehensive health surveys 27,924 244 0.87 Additional health surveys 14,389 187 1.30 During both types of survey, vermin were found on 431 occasions, representing 1.02 per cent of the total number of examinations. The number of individual pupils found to be verminous was 282, 92 or 0.62 per cent. of the school roll of 45,449. On 333 occasions the parents and/or the children were advised about treatment and in many cases were given Lorexane shampoo for home treatment. A further 98 pupils were referred to bathing centres where appropriate treatment was given. The work done at the two bathing centres in the Borough in connection with vermin, scabies and impetigo is shown below. A " case " is a child discharged after a course of treatment (e.g. a child attending three courses of treatment during the year counts as three cases). Vermin Cases treated 275 Treatments given 391 Scabies Cases treated 56 Impetigo Cases treated 4 Infectious illness reported from schools Cerebro-spinal meningitis 1 Chicken-pox 755 Dysentery, diarrhoea or enteritis 146 Food poisoning 2 German measles 168 Impetigo 18 Influenza 23 Jaundice 5 Measles 641 Mumps 82 Ophthalmia and conjunctivitis 18 Pneumonia 1 Ringworm (scalp) 2 Ringworm (body) 4 Scabies 2 Scarlet fever 52 Sore throat 79 Tonsillitis 68 Whooping cough 15 A close watch is maintained on the incidence of infectious disease, particularly Sonne dysentery. This type of disease although not usually serious has considerable nuisance value and requires prompt action and rapid application of control measures. In this context, I am indebted to the teaching staffs for supplying early information about illness in the schools and to the general practitioners, medical officers, public health inspectors and health visitors for co-ordinating the investigation and management of cases and contacts. In July, 12 cases of dysentery at a primary school required investigation. In September-October, 51 cases occurred at another primary school. 93 Medical treatment of schoolchildren The number of sessions, new cases and total attendances at school treatment centres during 1965 were as follows :— Type of clinic Sessions New cases Attendances Minor ailments (nurse) 1,149 1,278 12,775 Minor ailments (doctor) 67 437 Special investigation (i.e. enuresis, obesity and behaviour problems) 212 185 1,033 Dental 2,642 8,064 20,784 Vision 344 854 4,554 Orthoptic 201 84 646 Ear, nose and throat 73 133 578 Audiology 68 130 439 The number of children referred to the special investigation clinics has shown a slight increase this year. Of the four ear, nose and throat clinics, one has been reduced from a fortnightly to a monthly session, but the other three are still held fortnightly and have the advantage of direct admission for tonsils and adenoids operations to the South Western Hospital. Audiometry The numbers of children given " rapid sweep " audiometer tests during 1965 are as follows: Pupils given screening tests 5,737 Pupils failing screening tests given pure-tone tests 856 Pupils referred to otologist 160 Handicapped pupils Handicapped pupils who may need special educational treatment are referred from many sources. In some cases (e.g. physical handicaps, delicate children) examinations are carried out by school medical officers and recommendations made by the Principal School Medical Officer either direct to the Education Officer or to the Medical Adviser of the Inner London Education Authority. In other cases (e.g. partially sighted, blind, deaf or maladjusted) the examinations are carried out by staff of the Medical Adviser, who makes his recommendations to the Education Officer. Children who, because of some handicap or combination of handicaps, are considered not fit for education at school may be recommended for home tuition. 94 The examination of educationally subnormal children is carried out by specially qualified medical officers in accordance with Sections 34 and 57 (as amended) of the Education Act, 1944. In cases presenting no special difficulty the examination is carried out by a medical officer of the Health Department, who makes an appropriate recommendation to the Education Officer. The Medical Adviser of the Inner London Education Authority deals with all appeals against recommendations which may be made for special educational treatment, and with the placing of children who are considered to be unsuitable for education at school through disability of mind, together with any other cases presenting special difficulty. Pupils in schools for the educationally subnormal receive an annual examination to ensure that they are still correctly placed. There are nine schools in Wandsworth providing special educational treatment. Not all the pupils at these schools reside in Wandsworth, whilst some children who live in the Borough attend special schools in other areas. At the end of 1965, the numbers of children receiving special education at schools in Wandsworth were as follows:— Blind Residential 85 Day school 16 Deaf 35 Physically handicapped 79 Delicate 257 Day schools Educationally subnormal 580 Maladjusted 45 In addition, there are four schools in the Borough which hold special day classes for maladjusted children. Deaf Register. There are now 326 cases on the deaf register, 27 of which were new cases notified during 1965. School Nursing Service This service is staffed by health visitors and school nurses assisted by clinic nurses. Experience has proved that this team can make a considerable contribution to the smooth running of infants' schools where, in particular, the health visitor's knowledge of the family background is most valuable. The health visitor also contributes towards promoting health education in senior schools and co-ordinates the work of the team in this direction. All the staff work in close co-operation with the teaching staff, the School Care Committee and the Health Department Social Workers. 95 B.C.G. vaccination of schoolchildren In the autumn and spring terms the annual arrangements were made to vaccinate children against tuberculosis, with B.C.G. (Bacillus Calmette-Guerin). The group of children selected for this protective measure was aged 13 years, and the following table summarizes the results : (a) Number of 13-year-old schoolchildren 4,095 (b) Number of parental consents received 3,476 (c) Alleged contacts of known cases of tuberculosis —consents included in (b) 1 (d) Number of children tested and read by B.C.G. team 3,107 (e) Children not dealt with because of absence of refusal of consent: (i) Number 619 (ii) Percentage of (a) 15.1 (f) Positive reactors among (d): (i) Number 290 (ii) Percentage 9.2 (g) Number of negative reactors vaccinated by B.C.G. team 2,809 (Note—8 negative reactors were not vaccinated) This B.C.G. vaccination campaign was introduced in 1954 and has now become routine procedure in schools. Children whose negative results show that they have not been subject to tuberculous infection are vaccinated ; children with positive results are referred to the Chest Physicians for X-rays and any further necessary investigation and treatment. School Dental Service The arrangements in the Borough for the inspection and treatment of schoolchildren's teeth are a continuation of the experimental scheme which was introduced in this area some years ago. Every child should receive the early and regular dental care which goes so far towards preserving a healthy mouth throughout life and to this end the parents of all schoolchildren are sent an annual reminder of this need. Parents are asked to indicate whether they prefer dental examination and treatment to be undertaken at a school dental surgery or by a private dentist. Those wishing to use the school dental service are offered appointments although not all do in fact attend. 96 Information on dental sessions and attendances is given in the table below. The number of inspection sessions at schools is small as this scheme did not start to operate in Wandsworth until late in the year. The majority of initial inspections were carried out at the Council's dental surgeries and totalled 6,798 in 1965 compared with 6,243 in 1964. The proportion of children inspected who were found to require treatment was 69 per cent. and although this figure is less than for that of 1964 (75.6 per cent.) the position still leaves much to be desired. The response rate of new cases attending for treatment at 50.2 per cent. was slightly higher than in 1964, when the rate was 45.3 per cent., and for " on treatment " cases it was practically the same at 72.5 per cent. compared with 72.4 per cent. in 1964. The average number of permanent teeth restored for each permanent tooth extracted was 14.8. Revisional treatment for children who had completed a course of treatment and had been rendered dentally fit continued throughout the year. Sessions and attendances Sessions Number of treatment sessions 2,627 Number of inspection sessions in schools 15 Total 2,642 First inspections Number of first inspections in schools 800 Number of first inspections at clinics 6,798 Total 7,598 Number inspected found to require treatment 5,243 Percentage requiring treatment 69.0 Number offered treatment 5,156 Percentage of number requiring treatment offered treatment 98.3 Percentage of number requiring treatment who elected for private treatment 1.7 Reinspections Reinspections at clinics 1,306 Number reinspected found to require treatment 706 Pecentage of number reinspected found to require treatment 54.1 Number of appointments given to New cases 16,052 On-treatment cases 16,785 97 Number of attendances made by New cases 8,064 On-treatment cases 12,172 Emergencies 548 Total attendances 20,784 Response rate (attendances as percentage of appointments): New cases 50.2 On-treatment cases 72.5 Cases discharged dentally fit 6,520 Lapse rate (number not completing treatment expressed as a percentage of new cases and emergencies attending) 24.3 Sanitary conditions in schools The medical officers report annually on the sanitary conditions at every school and defects are reported to the Education Officer. Although there have been improvements, much remains to be accomplished, especially of course in the older buildings, in many of which the sanitary accommodation leaves much to be desired. In the course of these visits, the standard of hygiene in school kitchens is examined. 98 INDEX PAGE Accidents in the home 73 Adoption and boarding-out 62 Aged persons 74 Analysis of food and drugs 40 Animal Boarding Establishments Act, 1963 32 Animals, protection of 32 Ante-natal clinics 55 Atmospheric pollution 47 Audiometry 93 Bacteriological examinations 22, 28, 39, 51 Bakehouses 39 Barbers 29 Bathing centres 52,92 Baths, home 65 „ personal cleansing station 52,91 „ swimming 51 B.C.G. vaccination of schoolchildren 95 Births 11,12 Boarding-out 62 Butchers' shops 38 Cancer 11 Caravans 34 Care of old people 74 Catering establishments 39 Cervical cytology 60 Chellow Dene hostel 78 Chest clinics 17 Child-minders 62 Childhood malignancies survey 64 Chimney heights 48 Chiropody 68 Clean Air Act, 1956 47 Cleansing stations 52 Closing Orders 34 Common lodging houses 33 Communicable diseases 15 Community care, mentally ill persons 78 „ „ mentally subnormal persons 80 Comprehensive health surveys 91 Consumer Protection Act, 1961 30 Co-ordinating Committee 73 Coroner's Court 53 Crèches 62 Crematorium Regulations, 1930 53 Day hospitals 79 Day nurseries, Council 61 „ „ private 62 Deaf children 62, 94 Death, causes of 13 „ rates 11,12 99 PAGE Deaths, cancer 11 „ heart disease 14 „ infant 11,14 „ infectious diseases 15,24 „ maternal 14 „ tuberculosis 11,17 Dental services, mothers and young children 55 „ „ schoolchildren 95 Diphtheria 15 „ immunization 67 Disinfection and disinfestation 51 Domiciliary midwifery service 56 Drainage 27 Dysentery 16, 92 Early discharge of maternity patients 58 Educationally subnormal children 88,94 Environmental health services 25 Erysipelas 15 Factories Act, 1961 45 Family casework 73 Family planning 56 Fireguards, loan of 73 Fish shops 38 Fluoridation of water supply 28 Food and Drugs Acts 37 Food hygiene 37 Food poisoning 15 Food sampling 40 Food stalls 39 Food, unsound 42 Foot clinics 68 Furnaces, installation of 47 Hairdressers 29 Handicap and observation register 58 Handicapped pupils 93 Health Committee 9 Health education and publicity 69 Health surveys 63 Health visiting service 56 Heart disease, deaths from 14 Home bathing service 65 Home help service 66 Home nursing equipment, loan of 66 Home nursing service 65 Home safety 73 Home teaching (mental health service) 83 Home tuition 93 Hostel for mentally ill persons 78 Houses in multiple occupation 34 Housing 34, 35 Hygiene inspections of schoolchildren 91 Ice cream sampling 39 100 PAGE Illegitimate children 60 Immunization and vaccination 15,67 Incontinence pads service 65 Incontinent persons, laundry service 52 Infant mortality 11,14 Infant welfare clinics 55 Infectious diseases, statistics 23,24 Infectious illness in schools 92 Inquests 53 International vaccination certificates 22 Laboratory facilities, bacteriological 22,28, 39, 51 Land Charges Act, 1925 33 Laundry services 52, 65 Loan of fireguards 73 Loan of home nursing equipment 66 Long-term care (mental health service) 82 Maternal mortality 11,14 Maternity beds 57 Measles 15 „ vaccination 67 Medical inspection of schoolchildren 88 Medical treatment of schoolchildren 93 Meningococcal infection 15 Mental health service 77 „ „ „ community care of the mentally ill 78 „ „ „ community care of the mentally subnormal 80 „ „ „ day hospitals 79 „ „ „ home teaching 83 „ „ „ long-term care 82 „ „ „ mothers' groups 80 „ „ „ occupational therapy 79 „ „ „ out-patient clinics 80 „ „ „ residential hostel 78 „ „ „ short-term care 82 „ „ „ social clubs 78 „ „ „ special care unit 83 „ „ „ special clinics 80 „ „ „ staff training 83 „ „ „ statistics 85 „ „ „ students 84 „ „ „ training centres 81 Midwifery service 56 Milk sampling 38,39,44 Milk supply37 Mortality, infant 11,14 „ maternal 11,14 Mortuary 53 Mother and baby homes 60 Mothercraft classes 55, 70 Movable dwellings 34 National Assistance Act, 1948—section 47 75 National Child Development Study 63 101 PAGE National Survey of Health and Development 63 Neo-natal mortality 11 Noise Abatement Act, 1960 31 Notifiable diseases 23,24 Nursing homes 29 Occasional crèches 62 Occupational therapy, mentally ill persons 79 Offensive trades 30 Offices, Shops and Railway Premises Act, 1963 31 Old people, care of 74 Ophthalmia neonatorum 16 Outworkers 46 Paratyphoid fever 21 Performing Animals (Regulation) Act, 1925 32 Perinatal mortality 11 Personal cleansing stations 52 Personal health services 54 Personal hygiene 52,91 Pest control 29,52 Pet Animals Act, 1951 32 Pharmacy and Poisons Act, 1933 30 Phenylketonuria 60 Pneumonia, acute influenzal 16 „ acute primary 16 Poliomyeliti 16 „ vaccination 67,68 Population 10 Post-mortem examinations 53 Premature infants 58 Prevention of Damage by Pests Act, 1949 29 Problem families 73 Prophylaxis 15,67 Public Analyst, report on work of 41 Puerperal pyrexia 16 Pupils on school rolls 88 Recuperative holidays 68 Relaxation classes 55, 70 Rent Act, 1957 35 Riding Establishments Act, 1964 32 Rodent control 29 Rubella syndrome survey 64 Samples, adulterated 42 „ food and drugs 40 „ ice cream 39 milk 38,39,44 „ water 28,51 Sanitary conditions in schools 97 Scarlet fever 16 Schizophrenic illness after childbirth 64 School dental service 95 School health service 86 „ „ „ health education 70,94 102 PAGE School nursing service 94 Selective medical examinations 88 Sewage disposal 28 Sewerage 28 Short-term care (mental health service) 82 Slaughter of animals 38 Smallpox 21 „ international vaccination certificates 22 „ vaccination 67 Smoke control 47 „ „ measuring stations 48,49,50 Social clubs for the mentally ill 78 Sonne dysentery 16,92 Special care unit (mental health service) 83 Special educational treatment 93 Staff 9 Staff training 75, 83 Statistics, mental health 85 „ vital 10 Stillbirths 11,12 Students, facilities for training 76, 84 Surveys 63 Swimming baths 51 Tetanus immunization 67 Toddlers' clinics 55 Training centres (mental health) 81 Tuberculosis 17 „ deaths 11,17 „ notifications 17 Tuberculosis Care Committee Reports 18,19 Typhoid fever 21 Unmarried mothers 60 Unsound food 42 Vaccination and immunization 15,67 Vaccination, international certificates 22 Venereal diseases 69 Verminous premises 51 Vision testing 91 Vital statistics 10 Water supply 28, 51 „ „ fluoridation of 28 Whooping cough 21 Whooping cough immunization 67 Rowling & Sons Ltd. (T.U.), 34 & 36 York Road, S.W.ll