WAN 109 AS-43397 London Borough of Wandsworth ANNUAL REPORT of the Medical Officer of Health and Principal School Medical Officer for the Year 1972 by HASTINGS E. A. CARSON M.D., S.M. (Harvard), F.F.C.M., D.P.H. London Borough of Wandsworth ANNUAL REPORT of the Medical Officer of Health and Principal School Medical Officer for the Year 1972 by HASTINGS E. A. CARSON M.D., S.M. (Harvard), F.F.C.M., D.P.H. CONTENTS Page INTRODUCTION 1 Members of the Health Committee 25 Senior Officers of the Health Department 25 Health Department Premises 26 Part 1-VITAL STATISTICS 28 Part 2-COMMUNICABLE DISEASES 34 Part 3-ENVIRONMENTAL HEALTH SERVICES 41 Public Health Inspection 43 Housing 53 Food and Food Premises 56 Factories Act, 1961 72 Atmospheric Pollution 75 Miscellaneous Matters 77 Part 4—PERSONAL HEALTH SERVICES 82 Part 5—SCHOOL HEALTH SERVICE 124 PHOTOGRAPHIC SUPPLEMENT Centre Pages Plate A-DODDINGTON CHILD HEALTH CENTRE - A foot clinic in progress. Plate B-DODDINGTON CHILD HEALTH CENTRE - The staff common room. Plate C.—CERVICAL CYTOLOGY - The mobile cytology unit. Plate D-CERVICAL CYTOLOGY - The interior of the mobile cytology unit. Plates E and F-DENTAL HEALTH EDUCATION - Schoolchildren watching a puppet show depicting "Mr.Toothbrush" defending "PeterMolar" against "Jimmy Germ". INDEX 142 1 ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR 1972 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 eighth Annual Report on the health of the London Borough of Wandsworth covering the twelve months ended the 31st December, 1972. In the year in which the preliminary reports of the 1971 Census appeared it seems wholly appropriate to adhere to the tradition of giving pride of place in the Annual Report to those vital statistics regarded as broad indices of the state of the public health; to facilitate ready comparison the figures for the previous year are shown in parentheses in this paragraph. Even allowing for the quite appreciable fluctuations in mortality rates which must be expected when comparatively small numbers are involved, 1972 proved somewhat disappointing statistically. Although the size of the incidentally highly mobile resident population increased marginally - the mid-year estimate rising from 300,530 to 302,258 - compared with 1971 there were over four hundred fewer births, some twenty additional stillbirths, and sixty-six more deaths at all ages including an extra twenty in the first year of life. Thus, in contrast to the fall in the birth rate to 13.40 (15.70), the general death rate rose to 11.70 (11.20) attributable at least in part to the impact on an ageing population of sharp i nfluenza outbreaks in the first and last quarters of 1972. As in the previous year only one death ascribed to pregnancy or childbirth occurred, the maternal mortality rate remaining virtually unchanged at 0.22 (0.20), but an appreciable increase was recorded in the overall infant mortality rate, 23.0 (17.0) and in the stillbirth rate, 14.0 (9.0); more particularly the neonatal mortality rate, related to deaths under the age of one month, and the perinatal mortality rate - which is based on the number of stillbirths and deaths within the first week of life per thousand total live and stillbirths - rose to 15.0 (11.0) and 26.0 (19.0) respectively. Clearly the prenatal influences which are to the fore where perinatal deaths are concerned remain a fertile field for research. Much also remains to be learned concerning the causes of the acute respiratory infections which can strike so dramatically and fatally during the remainder of the first year of life - a need vividly illustrated by the fact that an increase in deaths from pneumonia accounted for all but one of the ten extra fatalities which occurred in 1972 in these still vulnerable remaining eleven months of infancy. Taking infant health as a whole there is cause for neither alarm nor 2 cency save in regard to illegitimacy. The slightly lower illegitimate infant mortality rate, 21,0 (23.0) - surprisingly enough rather less than the corresponding rate for legitimate infants, 23.0 (16.0) - albeit welcome, cannot offset the concern which must be felt in any community where the proportion of illegitimate births approaches one in six as it does in Wandsworth and indeed in Inner London as a whole. Even in the latter third of the twentieth century, held to be so enlightened compared with previous eras, all the evidence indicates that the handicap of illegitimacy is very real. The more the publicity given to the adverse effects which such a serious initial disadvantage may confer on the future of these wholly innocent victims of human irresponsibility, the greater the prospect in the long run of a more thoughtful approach being adopted by the public both as individuals and as citizens. Once again the local mortality statistics for 1972 focus attention on the human tragedy which the self-inflicted wounds of physical indulgence and lack of insight in personal relationships with fellow human beings represent. Diseases of the circulatory system continue to be responsible for nearly one in two deaths, 1,907 out of the grand total of 4,063, and all forms of malignancy for approximately one death in every five. The toll from cancer of the lung rose noticeably - 291 deaths compared with 240 in the previous year - and the 842 deaths from malignant disease in 1972 also included 77 from cancer of the breast (three times as many fatalities as from cancer of the womb). Tobacco, alcohol, excess weight, lack of exercise and failure to seek medical advice early enough all have much to answer for in this context; so too do the human carelessness, recklessness and ignorance reflected in the 71 accidental deaths recorded, and the similar number of fatalities from suicide and mental disorders constitutes a sharp reminder of the scale of the problem represented by psychiatric illness today. Leaving aside the influenzal episodes already mentioned (which caused 18 deaths directly and undoubtedly contributed in addition to the rise in mortality from pneumonia and bronchitis), all other infectious diseases including tuberculosis accounted for less than 1% of the sum total of deaths in the Borough during the year. When so many major easily recognizable preventable factors exerj such a dominating influence on the existing pattern of ill-health in this country it is difficult yet all-important to avoid the self-defeating attitude of the "kill-joy". A patent enthusiasm for and belief in the benefits to be derived from physical fitness, mental agility and emotional stability, stemming from a 3 factory and satisfying home, recreational, educational and working environment, is likely to prove the healthiest of contagions if conveyed with good humour and becoming sensitivity. Thus health education — the imparting of information in a persuasive manner so as to promote mental and physical health by providing the facts and stimulating the will to act upon them assumes an ever-growing relevance to the daily activity of doctors, dentists and nurses in alliance with teachers, social workers and all the many other disciplines and groups concerned with the welfare of the community. How fitting therefore that the photographic supplement occupying the centre pages of the Report depicts the new Doddington Child Health Centre, where excellent facilities for health education are a prominent feature; the mobile cytology unit of the Women's National Cancer Control Campaign kindly loaned to the Council for the month of September as an instrument of health education as well as of service in the field; and a puppet show which has proved for both pupils and staff at primary schools in the Borough a most popular means of dental health education. Within the Health Department responsibility for the development of a continuing and comprehensive programme of health education rests with a Principal Medical Officer (Dr. Church) supported by the Divisional Nursing Officer (Miss Hughes) and a Senior Administrative Assistant (Mr. Frank Smith). This trio exercises day-to-day responsibility for the planning, coordination and evaluation of all health education activity; for liaison with outside organizations, head teachers in schools and the Health Education Unit of the I.L.E.A.; and for the fostering and supervision of the arrangements for in-service training in health education. Fuller details will be found in the body of the Report. A significant increase in the health education budget of the department enabled essential equipment to be purchased or renewed and intensive publicity campaigns to be launched in the fields of family planning and cervical cytological screening. Additional impetus to the health education effort locally was given by the Council in approving the use of the mobile cytology unit mentioned earlier and in agreeing to collaborate with the Health Education Council in a major campaign aimed at reducing the incidence of venereal diseases in general, and of gonorrhoea in particular, in Wandsworth and the adjoining Borough of Lambeth with special emphasis being placed on the education of the younger age-groups. The outcome of this collaborative pilot venture will be of special interest for success 4 in changing attitudes and, equally important, in manifestly altering behaviour patterns - as the result of sober presentation of the basic facts may lead to the effective application of similar health education techniques in relation to other unhealthy habits such as the abuse of alcohol or drugs or addiction to cigarette smoking. It is indeed disheartening to record for the second year in succession that gonorrhoea is the commonest serious infectious disease in Wandsworth. During 1972 the number of local residents attending special treatment clinics rose from 5,173 in 1971 to 5,466, as many as 845 of these having contracted gonococcal infection compared with 817 in the previous year. No fewer than one in five patients with gonorrhoea became infected again within a year of treatment. Effective speedy contact tracing and prompt treatment are of the essence and the Council meets the cost of tracing contacts in relation to Wandsworth patients attending venereal disease clinics in the neighbouring Borough of Lambeth, there being no such special treatment centres located in the Borough at the moment. Happily, the number of cases of syphilis remains virtually stationary but this is the only bright feature of a steadily darkening scene with all its baleful implications for the quality of family life. The picture in relation to notifiable infectious disease is healthier, a further fall occurring in the total notifications received which numbered 1,173 compared with 1,207 in the previous year. It is true that the number of cases of sonne dysentery — fortunately a mild disease, more of a nuisance than a menace — increased from 60 in 1971 to 142 mainly attributable to an outbreak in a primary school and adjoining residential nursery. The incidence of measles and tuberculosis remained virtually unchanged and there was a marked reduction in the number of whooping cough notifications. Once again no cases of smallpox, diphtheria or poliomyelitis were reported in Wandsworth. However the need for continuing vigilance in this basic public health activity of communicable disease control in a steadily contracting globe (in terms of ease and speed of travel) is undiminished — witness the cases of malaria and typhoid fever imported from overseas. Incidentally this caveat is equally applicable to the home front in view of the persistent occurrence of quite unnecessary episodes of food poisoning. Thus there can be no relaxing of the primary defences comprising early detection and treatment, prompt notification, speedy disinfection or disinfestation where indicated, the rapid followup of contacts, and the vigilant surveillance of suspects 5 (including in this latter category travellers, students or immigrants arriving in this country from abroad). The value of such routine activities, and food safety and food hygiene should not be overlooked in this regard, undertaken by the staff of the Health Department - albeit a silent service so far as the great majority of the public is concerned - is hard to overestimate. Rich tribute is due to Dr. Fleck and his colleagues at the Public Health Laboratory at St. George's Hospital, Tooting, for their ever-ready assistance and advice; no fewer than 2,275 specimens were examined bacteriologically in 1972. Similar recognition of the sterling work undertaken at the three Chest Clinics in the Borough in relation to diseases of the chest generally with particular reference to tuberculosis is equally appropriate and in this regard I welcome the opportunity to express the warm thanks of the Department to Dr. Anderson, the Physician in charge of the Balham Chest Clinic at St. James' Hospital, who retired at the beginning of March after many years of distinguished service to the local community; he was succeeded by Dr. Millard. The continued help and advice of Dr.Citron and his colleagues at the Battersea and Wandsworth Chest Clinics is also greatly appreciated. Full details of the work of the Chest Clinics — in which the prophylaxis of pulmonary tuberculosis through the medium of B.C.G. vaccination of susceptible children looms large - and of the voluntary support given by the Battersea and Wandsworth Care Committees are given in the body of the Report. Where feasible and desirable, by far the most satisfactory protection against serious communicable diseases is provided by active immunization unless as mentioned in my Annual Report for 1971 the position has been reached as in the case of smallpox where the occasional adverse effects of routine vaccination in infancy and early childhood outweigh the risk of developing the disease in this country. Accordingly, to encourage a healthy state of immunity against diphtheria, whooping cough, tetanus, poliomyelitis, german measles and tuberculosis, a revised routine schedule of immunization procedures - conforming to the recommendations of the Department of Health and Social Security and designed to synchronise (as far as early childhood is concerned) with the timing generally recognised as appropriate for periodic developmental paediatric assessment examinations — was introduced early in the year. This change inevitably affected the overall immunization statistics for 1972 and another year must elapse before the success of the new schedule can be judged. Nonetheless the decline of a third in the number of 6 measles immunizations and of nearly two-thirds in the total of rubella vaccinations performed was disappointing to say the least since such marked reductions could not be attributed to a schedule which hardly affected the timing of these particular prophylactic procedures. An intensification of the campaign to provide protection against these infections is clearly called for. The poor response to rubella vaccination at school was under close scrutiny at the end of the year in view of the importance of girls being adequately protected in later life. A high standard of environmental sanitation provides another important bulwark against the spread of infection. Thanks to the adequate protection of water supplies and the generally satisfactory facilities for the disposal of sewage the importation of two cases of cholera into England but fortunately not into the Borough, in 1972 had no adverse repercussions. The manner in which a large number of Asian immigrants from Uganda - some of whom came to Wandsworth - were catered for in the latter part of the year reflected extremely creditably upon the health and welfare services. Environmental Health remains a prime community activity and much was achieved in the Borough in 1972 in spite of increasing recruiting difficulties. Notwithstanding staff shortages all complaints were promptly investigated and the total number of visits paid by the public health inspectorate and their supporting technical assistants ran into six figures, being 112,016 compared with 103,089 the previous year. The varied activities are reflected in the statistics to be found in Part 3 of the Report from which it will be noted that routine but none the less desirable inspections of food premises and offices were affected adversely by the lack of manpower. All sections of the environmental health divisions were kept busy during the year, special features of note including a marked increase in new drainage applications; an appreciable rise in mice infestation; more noise complaints (119 compared with 70 in 1971); the coming into operation of two more smoke control orders and the making of a sixth order to take effect in November 1973; and, last but not least, the continued striking success of the campaign against unsatisfactory living conditions in houses in multiple occupation. Housing remains the major environmental health problem — to which the figures in the text of the Report relating to the medical assessment of priority claims for rehousing testify only too eloquently - and this acquired a new facet in 1972 in the form of the accommodation to be provided for gipsies in the Borough; no definite conclusion regarding a suitable site had been reached by the end of the year. 7 With the evident success of the Clean Air Campaign in Greater London, where pollution by smoke has been reduced by fourfifths and that from sulphur dioxide halved in the past fifteen years, the public is rightly becoming increasingly intolerant of other environmental nuisances such as unpleasant smells - the odours from a glucose plant receiving much attention during the year - contamination of the soil by dangerous chemicals or industrial waste, and aircraft noise. These are but a few examples of the growing community awareness of the need to balance the advantages of technological progress against the price to be paid in terms of unedifying pollution of the environment. To end on a progressive and uncontroversial note the incontinent laundry service expanded appreciably (5,749 bags each containing about 10 lb of soiled linen being collected, laundered and returned as opposed to 4,739 bags in 1971) and much needed improvements to the mortuary and coroner's court Sheepcote Lane were approved by the Council at the beginning of the year. Great credit is due to the Chief Public Health Inspector, Mr.Winton, for his able leadership of the environmental health division in an exceptionally busy twelve months. His election in September to the Executive Council of the National Society for Clean Air was a richly deserved recognition of his contribution over many years to the cause of a healthier environment. Increasing attention is being paid throughout the world to the implications of population growth in terms of both human wellbeing and environmental conservation. In this context family planning is rightly regarded as a key service and steady progress was achieved in this vital sphere in Wandsworth in 1972, thanks to the efforts of the medical, nursing, administrative and clerical staff of the South-West London Branch of the Family Planning Association, acting as the agent of the Council. Three new weekly sessions were introduced during the year - one each at the Doddington and Stormont Child Health Centres and, a welcome innovation, at St.George's Hospital, Tooting. The numbers of new patients seen at clinics, of total clinic attendances, and of new domiciliary patients all increased impressively (from 3,336 to 4,109; 20,318 to 23,935; and 154 to 192 respectively compared with 1971) thanks no doubt in part to an intensive publicity campaign launched in the spring. However the increase (27%) in the attendance of new patients was less than half of that experienced in Lambeth following the introduction of a completely free service in that Borough. Accordingly the Council decided to abolish all charges in relation to the attendance of local residents at Family Planning Association Clinics within or without Wands- 8 worth and at Brook Advisory Centres (which cater especially for young people), with effect from the beginning of 1973. Nonresidents working in the Borough and attending such clinics in Wandsworth were also to be eligible for this free service. Cervical cytological screening continues to be a regular feature of the work of the family planning clinic. This important activity also flourished during the year at the eight cervical cytology clinics provided for the general public by the Council, an average number of seven patients being seen at each session. Of the 2,409 women examined (including 71 at a local factory) approximately four in every thousand were found to have a positive cervical smear and nearly one-third of all those attending these screening clinics had some minor but troublesome local abnormality or infection requiring attention. The outstanding features in this sphere in 1972 were the introduction at the beginning of the year of the National Recall Scheme for Routine Cervical Cytology; the commencement in February of two early evening clinics at Tooting and Victoria Drive respectively for the general public; and the use in the autumn of a mobile cervical cytology unit kindly loaned by the Women's National Cancer Control Campaign. Full details of these new developments are given in Part 4 of the Report but it is worth emphasizing in relation to the latter project the vaiuable information gained concerning the effectiveness of the various publicity media available and of the potential contribution of voluntary effort in this field. Finally, another piece of useful research which continued during the year concerned the asymptomatic bacteriuria survey undertaken at both family planning and cervical cytological screening clinics in Wandsworth in association with the Department of Medicine of Charing Cross Hospital. In the first fifteen months of the project seven of the 743 women volunteering to be screened were found to have a significant abnormality of the renal tract, constituting just over one-fifth of the 30 women in whom symptomless urinary infections were detected. A final assessment of the value of this screening venture was awaited at the end of the year. Maternal and child health services, including the family planning, cervical cytology and immunization activities already mentioned, are provided by the local health authority in support of the general practitioner who is a key figure in all these fields. In the sphere of midwifery 92 confinements — five more than in 1971 — in the general practitioner obstetric unit at the Weir Maternity Hospital were attended by Wandsworth midwives. Not unexpectedly the number of home midwifery confinements fell 9 once more but conversely the rise in early discharges from hospital following delivery continued the steady upward trend of recent years. Thus the overall total of patients attended in their own homes in the Borough in relation to confinement and/or the puerperium by the domiciliary midwifery service exceeded one thousand; in addition no fewer than 924 specimens of blood were were obtained from infants for the performance of the Guthrie test so important in excluding the presence of the serious metabolic disorder which results in phenylketonuria and, if undetected at a very early stage, permanent mental retardation. Five midwives attended antenatal clinics held by general practitioners in their own surgeries. Continued support for the family doctor in the field of child health was provided in the child health centres, the number of children attending the clinic sessions held there again exceeding 12,000. In relation to both the infant and the toddler increasingly the medical emphasis is being placed on developmental paediatric assessment at key ages to ensure the early detection of defective hearing, impaired vision, neurological or other physical abnormalities, and mental impairment so that, in consultation with the general practitioner, remedial measures can be instituted promptly and special educational arrangements anticipated where appropriate. At the end of 1972 a total of 1,456 children under the age of 5 - 289 handicapped children (of whom 84 had multiple handicaps) and 1,167 children considered to be at risk on account of genetic, pre-natal or peri-natal factors - out of some 25,000 children in this pre-school agegroup were under regular surveillance, their names being included to this end in a special handicap and observation register. To facilitate attendance at these developmental clinics, embracing assessment, counselling and routine immunization, evening sessions were introduced at Tooting and Chatham Hall and the whole-time medical establishment of the Department was augmented. A major landmark in the child health services provided by the Council was the opening at the beginning of February of the new Doddington Child Health Centre; in addition to the traditional infant and toddler clinic sessions this most welcome purpose-built building caters for audiology, orthoptics, antenatal supervision, mothercraft and relaxation classes, cervical cytology, family planning, chiropody and health education. Other notable milestones, of which full details are given in the body of the Report, included the forging of even firmer links with the paediatric departments of local hospitals and the Braidwood Audiology Unit, the launching in collaboration with the Social Services Department of a day observation unit at a children's home in Blackshaw Road, and the provision of physiotherapy assistance at the Summerley Day Nursery Special 10 Care Unit. Furthermore, under the able supervision of Mr.Weedon, the Principal Dental Officer, there was a marked expansion in the dental service provided at child health centres for expectant and nursing mothers and pre-school children. Child health is part of family health - to echo the Sheldon Report - and in recognition of this ideal special attention was paid to the provision of training facilities for local general practitioners interested in developmental assessment techniques. A warm invitation was also extended to all family doctors in Wandsworth to attend the Extended Course of Lectures (mainly covering child health topics) arranged by the Health Department as part of in-service training for medical, nursing and other members of the staff. This series - which was officially recognised by the British Postgraduate Medical Federation - proved extremely popular, attributable no doubt to the excellence of the speakers and the relevance of their subjects. As a corollary to the focussing of medical attention on the early detection of handicapping defects - the priority to be attached to this task can be judged from the informed estimate of the British Paediatric Association based on the Newcastle survey that one in ten children leaving school will have either intellectual limitation, physical handicap, recurrent or established illness, educational inadequacy or difficulties in emotional control - responsibility for giving advice on infant feeding, hygiene, clothing and general management will rest increasingly (unless there are special problems) with the health visitor who will also contribute to screening activities. Thus the undertaking of child health developmental assessment in the setting of general practice is undoubtedly helped by the attachment of health visiting staff. It is particularly pleasing therefore to record an increase in the number of such arrangements in 1972 which also stimulate incidentally the routine home visiting of the elderly. During the year the total of effective home visits made by health visitors fell just short of 46,000 and included 3,880 to old people. With the growth in attachment schemes, of necessity the role of the school nurse is being evaluated afresh as mentioned in Part 5 of the Report since the findings of the Newcastle survey also highlight dramatically the continuing contribution which needs to be made in the field of school health. In this context the need for the closest liaison between the school health service and general practice is self-evident; satisfactory links with the hospital and social services must also be fostered. 11 Field nursing attachments to general practices and links with local hospitals have also developed satisfactorily in relation to district nursing. The number of home nurses attached to general practitioners doubled in 1972 as this highly desirable development gathered momentum with the ultimate objective of universal attachment in support of primary medical care. In addition at the beginning of the year a planned early discharge scheme of surgical patients - based on their clinical condition, home circumstances, and the community supporting services available was introduced at Queen Mary's Hospital, Roehampton, in consultation with the hospital staff, general practitioners and home nurses concerned. Such joint ventures are in the true spirit of an integrated service. The grand total of home nursing visits paid reached the record figure of 125,096 and to this achievement must be allied the splendid support given by the increased force of nursing auxiliaries whose contribution entailed far more than the mere provision of a home bathing service. Over 80% of the patients nursed were aged 65 or more. The home nursing commitment in relation to renal dialysis, first mentioned in the 1971 Annual Report, continued to be met effectively and the implementation of the Mayston Report recommendations regarding the management structure of the local health authority nursing services proceeded smoothly and unspectacularly throughout the year. The Chief Nursing Officer, Miss Harding, is to be congratulated on the able and unostentatious manner in which she coped with the problems inevitably associated with such a major reorganisation. Two other valuable services for the elderly which flourished during 1972 were the supply of incontinence pads - 185,900 being issued compared with 132,000 the previous year — and the provision of chiropody facilities in clinics, old people's residential accommodation, individual homes and private surgeries. The Council is indeed fortunate to have such an enthusiastic and talented Chief Chiropodist as Mr.Trenter; the statistics in Part 4 of the Report testify to his zeal and leadership and, characteristic of the breadth of his interest, he undertook in collaboration with Dr.Michael Church a pilot survey of children's feet and footwear at various schools in the Borough which, not surprisingly, revealed only too frequently the wearing of shoes undoubtedly detrimental to foot health. The moral is clear - prevention of needless deformity in early life may be the means of ensuring that mobility so conducive to enjoyment of old age. Few can doubt that the provision of primary medical and nursing care in purpose-built general practice premises or health 12 centres offering facilities on the premises for the variety of activities previously outlined in relation to the new Doddington Child Health Centre is in the true interest of the individual patient, the individual practitioner, the community, and the nation. Pooling of skills in a multidisciplinary setting and greater convenience for the public are two prime advantages the closure a year ago of Battersea General Hospital and the closing of the Casualty Department of the Bolingbroke Hospital in 1972 served as sharp reminders of the need to cater for as many patients as possible, including those sustaining minor injuries, in other than a hospital setting. In this context preparations in relation to the three firm health centre projects in the Borough — at Bridge Lane, Battersea; Brocklebank, Central Wandsworth; and Larch Road, Balham - proceeded surely during the year and the possibility of two further such projects, at Burtop Road and in association with St.George's Hospital at Tooting, were being actively examined in the light of the interest expressed by local general practitioners. One feature especially worthy of mention was the formation of the League of Friends of the Bridge Lane, Battersea, Health Centre — the first of its kind in the country - with the aim of providing financial and other assistance to residents within the Queenstown, St.Mary's Park and Latchmere wards of the Borough, all general practitioners practising in or adjoining North Battersea being informed to this effect. During the year the Council endorsed proposals for improvements relating to the Fairfield, Chatham Hall and Tooting Child Health Centres. Clearly if care in the community is to become a reality rather than a pious hope, local interlocking of the health and social services is quintessential. Here in Wandsworth it is heartening to record that the liaison committee established in 1971 to foster such collaboration continued to meet at quarterly intervals throughout 1972 and to discuss fruitfully topics of mutual interest, for example, the improvement of communications between hospitals, general practitioners and the community health and social services; the production of a local information booklet; the provision of telephones for the severely handicapped and of other services under the Chronically Sick and Disabled Persons Act, 1970; the need for wide publicity in relation to the family planning facilities available; and last but not least the value of co-operative ventures such as the Blackshaw Road Day Observation Unit. A detailed review prepared in the summer of 1971 of the current fields of activity of major local authorities in which it seems likely that there will be a continuing need for medical and/or nursing advice is appended to this preface (Appendix 'A'). The challenge to community medicine and 13 nursing is very real and accordingly also annexed to these prefatory remarks is a paper (Appendix 'B') delivered at a meeting of the Royal Society of Health specially convened in July to consider the Hunter Report referred to in the succeeding paragraph. Change has dominated the scene in 1972 in breath-taking manner. In August the long awaited White Paper on the Reorganisation of the National Health Service in England was published proposing within a national, regional and area framework to achieve the aims of integration; co-ordination within and without the N.H.S.; planning in relation to need no matter where services are provided; more effective professional participation in operation and planning; more uniform standards of care; opportunities for rapid implementation of improvements; flexible, clear career structures; and effective education and training. Preceded in the spring by the Report of the Working Party on Medical Administrators under the chairmanship of Dr.R.B.Hunter outlining the contribution of the new specialty of community medicine and of the training and career structure required to meet demands at regional, area and district level - the White Paper was quickly followed in the autumn by the publication of the study commissioned by the Secretary of State for Social Services of the Management Arrangements considered desirable for the Reorganised National Health Service. These arrangements embraced six key features, namely, integration on a district basis (the district comprising the population served by community health services supported by the specialist services of a district general hospital); participation by clinicians whilst retaining clinical autonomy; co-ordination of the planning and operation of health services by multidisciplinary teams; clear allocation of authority and accountability; decentralization of services balanced by strategic direction; and, last but not least, the recognition of the need for flexibility of approach in view of the variety in size of both Areas and Regions. By the end of the year the National Health Service Reorganisation Bill was well launched on its Parliamentary journey and, having given special consideration to the problems presented by Greater London, the Secretary of State had announced that one of the sixteen area health authorities to be created within the Metropolis would serve the populations of the three London Boroughs of Merton, Sutton and Wandsworth. The first meeting of the Joint Liaison Committee, designed to pave the way for this particular area health authority and on which all interested parties would be represented, was scheduled to take place in the first week of 1973. 14 So far as training preparations for the health service were concerned the existi ng management courses for consultants and Medical Officers of Health organized by the King's Fund were augmented by multi-professional integration courses and special courses for medical administrators sponsored by the Department of Health and Social Security. The pace of reorientation quickened steadily throughout the year. Not to be overlooked in this spate of special preparation for the future was the invaluable contribution which continued to be made by the London Boroughs' Training Committee in sponsoring joint training arrangements for health and social service workers in spheres of mutual interest. No praise is too high for the sterling work performed by the Director of Training, Miss Margery Taylor, and her colleagues in fostering that close collaboration in the field based upon mutual understanding and respect - on which the future depends so heavily. In this regard the Report of the Working Party on Collaboration between the National Health Service and Local Government also established by the Secretary of State for Social Services was keenly awaited at the end of the year. This has indeed been a full and exacting year in which the community health services in Wandsworth have expanded hearteningly in preparation for the future. It is therefore a special pleasure to express my profound gratitude to His Worship the Mayor, to the Chairman and Members of the Health and Social Services Committees, and to Members of the Council, generally, for their unfailing kindness and encouragement. To the Chief Executive and Town Clerk and to my colleagues in other Departments of the Council and in the health service as a whole, I extend my warm thanks for their ever-ready help. Finally, in a year in which I have been absent attending a variety of reorganisation courses, I am especially conscious of the debt which I owe to the staff of the Health Department - and not least to my Deputy, Dr.Gordon, and the Principal Administrative Officer, Mr.Horsnell - for their cheerful, loyal and able support. I have the honour to be, Mr.Mayor, Ladies and Gentlemen, Your obedient servant, HASTINGS E.A.CARSON, Medical Officer of Health, and Principal School Medical Officer. 15 APPENDIX A CURRENT FIELDS OF ACTIVITY OF MAJOR LOCAL AUTHORITIES IN WHICH THERE WILL BE A CONTINUING NEED FOR MEDICAL AND/OR NURSING ADVICE ENVIRONMENTAL HEALTH (a) Communicable disease control including:- Follow-up of cases and contacts of infectious disease after notification. Disinfection and Disinfestation. Immunisation against serious infectious diseases. International Vaccination Certification. (b) Food Hygiene including:- Prevention of contamination. Assessment of fitness of food for consumption. Investigation of food poisoning episodes. (c) Housing including:- Assessment of medical priority to be accorded applications for rehousing on health grounds. Adaptation of homes for renal dialysis outside hospital. Suitability of elderly person to continue to live at home where health hazard feared and need where necessary for compulsory removal to hospital or other residential accommodation. (d) Inspection of Nursing Homes (e) Refereeing of cremation certificates (f) Post-mortem facilities in public mortuaries 16 (9) Control of Environmental Pollution with particular reference to:- Atmospheric Pollution. Noise. Radiological Safety in relation to use of ionizing radiations. Pesticides. Protection of water supplies. (h) Consumer Protection including in particular safety aspects. (i) Accident Prevention (j) Fluoridation (k) Health Education EPIDEMIOLOGY General epidemiological work in detecting and ameliorating local adverse influences upon health. STAFF HEALTH (a) Scrutiny of medical questionnaires and arrangement where necessary of medical examinations prior to employment in local government. (b) Investigation of prolonged sickness absence in relation to future fitness tor work. (c) Medical aspects of staff welfare (occupational health) 17 SCHOOL HEALTH - AN INTEGRAL PART OF CHILD HEALTH (a) General health and nutrition of school children including:- Arrangements for routine medical examinations and comprehensive health surveys (including screening of vision and hearing) of all school pupils supplemented by special investigation or regular observation where considered necessary. (b) Health aspects of the needs of handicapped children in relation to education including both ascertainment and continuing supervision while at school. (c) Hygiene embracing general sanitation and physical environmental comfort as well as communicable disease control measures. (d) Health Education (e) Health Counselling in relation to students attending colleges of further education. SOCIAL SERVICES (a) Maternal Health with particular reference to:- Family Planning advice. Care of unmarried or unsupported expectant mothers throughout pregnancy and both during and after confinement (or following termination of pregnancy). (b) Child Health including:- Promotion of healthy physical, mental and emotional growth and development with special attention being paid — through careful observation and regular examination - to children considered to be at risk of developing a handicapping condition. Early ascertainment of handicapped children to enable suitable provision (including regular medical supervision) to be made in the pre-school period, throughout school life and on leaving school. Detection and remedying of the "Battered Baby" situation. Health aspects of adoption, childminding and other forms of day care (including the need for priority admission to day nurseries or play groups on health 18 grounds and for individual children attending day nurseries to receive speech therapy or physiotherapy), and of residential care in foster homes, nurseries or children's homes. (c) Health Aspects of Youth Counselling (including family planning advice). (d) Mental Health including:- The ready availability of medical advice in relation to both individual needs and the development of the community mental health services generally will be a key factor in promoting the care of the mentally ill and the mentally handicapped as outlined in the recent White Paper. Close collaboration between health and social services locally is indispensable to success in this extremely important field. One new development of interest is that adult training centres for the mentally handicapped may now be registered under the Factories Acts, entailing the appointment of Appointed Factory Doctors to undertake the regular medical examination of young persons between the ages of 15 and 18 years and to give other medical advice as appropriate. This responsibility can be regarded as a continuation of the special medical supervision exercised at junior training schools and can thus fittingly be assumed by school doctors already familiar with the special problems of mental handicap. (e) The Adult Chronically Sick and Physically Disabled To cater adequately for the needs of this very important group will require the same degree of close co-operation already referred to in relation to mental health. Both medical and nursing advice will be needed regarding both the need for and the use of special aids and appliances at home. (f) The Care of the Elderly including:- Promotion of healthy old age (with particular reference to the health education role of the health visitor). Provision of the incontinent laundry service. To further close collaboration between the health and social services in catering for the needs of the physically and the mentally infirm„ 19 SUPPORT AT PRESENT PROVIDED FOR THE GENERAL PRACTITIONER (AND THUS FOR THE SOCIAL SERVICES) WHICH WILL BECOME THE RESPONSIBILITY OF THE NEW AREA HEALTH AUTHORITIES (a) Public health nursing comprising the services of health visitors, midwives, district nurses, clinic nurses, and nursing auxiliaries. (b) Attachment to general practitioners of health visitors, home nurses and midwives who will thus be in a particularly favourable position to act as alerting agencies in ensuring that all necessary aid obtained for the disabled, the elderly and others in need of social service support. Family practice is potentially the ideal setting for health education. (c) Development of health centres thus encouraging a high standard of primary medical and nursing care and a close association with the social services. (d) A clinic and domiciliary chiropody service to meet in particular the needs of the elderly and the disabled. (e) Provision of family planning, cervical cytological screening and immunisation services for the general public. CONCLUDING COMMENTS Some of the medical advice needed in relation to the above activities will properly be given by the family doctor or the hospital consultant but much of it will need to be sought through the community physician of the future if the effort of the new health and social services is to be fully effective. Similarly, mutual collaboration in in-service training of staff is equally essential if all engaged in the health and social services are to play their respective parts to the full. Nursing advice must also be freely available. Finally, there will be a continuing need for dental advice in relation to expectant and nursing mothers, pre-school and school children, which is currently provided by the major local authorities. In this regard the school dental service looms large. It hardly needs emphasising that the integrated health service of the future will be in equal need of the skilled advice and support of the members of the staff of the new Social Services Departments of the major local authorities. 20 APPENDIX B THE IMPLICATIONS FOR MEDICINE OF THE HUNTER REPORT "This be the verse you grave for me: Here he lies where he longed to be; Home is the sailor, home from sea. And the hunter home from the hill" Robert Louis Stevenson (1850-1894) These words composed by one of our great literary figures who was born within a year or two of the appearance of organized public health on a national scale in this country and who was to succumb prematurely to the then "captain of the men of death" and inscribed at his request on his tombstone beneath the starry skies of the South Pacific, have a special meaning in these very different times for the medical administrator. The authors of the Hunter Report do not "claim to write on tablets of stone". Nonetheless, in spite of the difficulties under which they laboured in not knowing with any certainty the managerial structure of the unified health service of the future, the members of the working party have brought home, I believe, a message of fundamental importance not only to medical administrators (or specialists in community medicine, to use the broader designation favoured by Hunter) but to the medical profession as a whole. THE SETTING FOR HUNTER This message must be read against a backcloth far removed from the insanitary era in which Robert Louis Stevenson lived and died. Today, nearly a century later, thanks to the great advance in medical knowledge and the concomitant rise in the general standard of living and of education, an increasingly sophisticated industrial urban and ageing population entertains ever higher expectations in the field of health and welfare. In 21 this latter part of the twentieth century infection has long ceased to be the leading cause of death. Mortality and morbidity are now dominated by the degenerative diseases of middle and old age, the hazards of trauma, and the strain of living in an increasingly competitive and congested world — aided and abetted by the indiscipline of over-indulgence and of environmental pollution, the unthinking or wilful neglect of human relationships, and last but not least the failure of those most in need to take full advantage of the facilities available for medical care and advice. It can truly be said that never before has the health of the man in the street rested so largely in his own hands, whether as private individual or as citizen - for the importance of communal health measures must not be overlooked, as witness the modern triumph of the clean air campaign. Never has prevention been more relevant. Never has there been so much help available to the young and the old, the mentally disordered and the physically handicapped. Never have so many been in need of support. Finally, never has medical care in hospital been more expensivethe inevitable outcome of matching the complexity of the challenge posed by contemporary disease and disability. Thus the demand upon the national resources which health, education and social services make grows steadily and the financial implications are well spelt out in the excellent foreword to the Hunter Report. Inevitably the informed public gaze will focus more and more on health rather than disease, prevention of illness rather than its treatment, care rather than cure, ability rather than disability, and above all on the patient as a whole person and a member of a family and larger community rather than as an individual case. The message for medicine is clear. THE MESSAGE OF HUNTER This is of multiple import. In the first place it conveys in no uncertain terms the reality of the years ahead, namely, that medicine will perforce need to compete ever more vigorously with other pressing claims upon the public purse both within and without the field of health, education and welfare. To do so effectively will, demand good husbandry: the requirement to ensure that the resources already available are used to the greatest advantage will hold equally true for the unified health service now looming large on the horizon. 22 Secondly, it emphasizes the need for teamwork within the medical profession, within the health service as a whole, and most importantly within the intricate complex of community services embracing health, education, welfare, housing and the protection of the environment. Intimate collaboration between the health and social services, for example, is indispensable to the fruitful development of the growth points of health care of the immediate future — primary medical and nursing care in the home; mental and/or physical handicap in child and adult; the mentally ill; the chronically sick; and the aged. The increasing emphasis on teamwork must of necessity lead to a reappraisal of the specific roles and thus of the deployment of members of the healing and caring professions in providing the highest standard of service practicable, both qualitatively and quantitatively. Hence the need for careful planning and skilled evaluation; for smooth organization and purposeful administration; in other words, for informed and efficient management. Thirdly, in the twin context of making the most effective use of the resources available and of fostering the closest collaboration between interdependent services, it endorses unreservedly the need for highly trained specialists in community medicine with attractive career prospects embracing a wide variety of interests including medical administration. This need— the major theme of the Report — is examined in depth in relation to the wise planning and sound operation of health services. These key objectives cannot be attained without a continuing review of major fields of activity entailing in turn critical evaluation of the results achieved; searching assessment of priorities; and appropriate allocation of the resources available, in terms of manpower, equipment and accommodation, to meet the field commitment to the satisfaction of both the individuals served and the staff engaged in the enterprise. The measurement of problems and of the success or lack of success in dealing with them is dependent upon the development of suitable yardsticks — based on grass roots knowledge — and their subsequent refinement in the light of experience. Suitable records must be kept so that the necessary pool of relevant information is accumulated. Accurate data are essential to progress. Full participation by all concerned in the field is vital therefore to the effective planning and operation of services. No large enterprise can thrive unless the grass roots are continually nourished. Here the free flow of information is crucial, for collaboration and communication go hand in hand. Good communications are of the essence of management. Genuine teamwork is the prerequisite for effectiveness and efficiency. 23 Lastly, Hunter highlights in relation to community medicine the importance of appropriate undergraduate and postgraduate training and of a career structure designed to match the calibre required. In this regard it cannot be emphasised too strongly that the relevance of the task and the quality of performance represent the only true security in times of change. No epoch has been more dynamic than the twentieth century in which we live. The pace of advance shows no sign of slackening. THE WAY AHEAD The study of the natural history of health and disease has an honourable place in the annals of medicine. Clinical measurement and management of individual illnesses has long been recognized as a potent instrument of progress with ultimate benefit to countless fellow sufferers. Much more recently the study of the natural history of the organization and delivery of health care has come to the fore and the very real need for all in medical practice to contribute towards a more purposeful overall approach is gaining increasing recognition. The recently published Second Report of the Joint Working Party on the Organization of Medical Work in Hospitals testifies to the heartening progress which has been made towards this objective, admirably defined in a leading medical journal 1 as "a flexible administrative structure - linking medicine and management — in which the energies and ideas of hospital doctors can be harnessed to make the best use of our limited N.H.S. resources". This fine definition is equally applicable to every part of the health service. When all is said and done what matters is the standard of service rendered. The best interests of the individual, whether as patient or citizen, cannot be assured unless, collectively, the medical profession - along with all other professions engaged in or associated with the health service - gives top priority to relevance, competence and teamwork. It bears reiterating in this context that, although the tasks of collection and analysis of information, of furthering evaluation and collaboration in the field, and of rendering advice to allied local and central government services will be of prime concern to specialists in community medicine, all doctors have a contribution to make to the shaping of the health service. Standards acceptable to the profession and the public alike must be developed from within. Much will depend upon the relationships established at the vital grass roots level. Management is an art as well as a science. 24 Fears have been expressed in many quarters that a purposeful managerial approach to the running of a health service will prove incompatible with clinical freedom. Such misgivings are unlikely to survive a visit, for example, to the Programmed Investigation Unit of the Manchester Royal Infirmary — a tonic experience for all who believe that the destiny of medicine is best fashioned by medical hands. Today this means active involvement of the profession in management. A healthy portent, to which I can testify personally, is the popularity of the Management Courses for Consultant Medical Staff held in London under the auspices of the King's Fund. Equally important for the future is the fostering in medical schools of a holistic view both of health and of care in the community of which the hospitals form part. Now, at the approach to integration of the hitherto tripartite health service, Hunter has charted the course for postgraduate training in community medicine in which the universities, the health services, and the newly formed Faculty of Community Medicine will need to blend their efforts to ensure a smooth voyage. CONCLUSION The toil of Hunter, albeit hampered by lack of exact knowledge of the far-reaching changes in the National Health Service which lie immediately ahead, will not have been in vain if in the end it leads to a coherent combined effort — eschewing excessive clinical or adminstrative pride - in which self is submerged in that noblest of ventures, the prevention and relief of suffering. Hunter has come, I hope, not to rest on well-deserved laurels but to unite our endeavours within and without the discipline of medicine in furthering to the limit of our ability the health and welfare of the individuals whom it is our privilege to serve. Some words of another of our literary giants of the nineteenth century come to mind in relation to the hunter and the quest — "To strive, to seek, to find, and not to yield". Alfred, Lord Tennyson (1809-1892) 1 Reference British Medical Journal, 1972, 2, 193. MEMBERS OF THE HEALTH COMMITTEE (at 31st December, 1972) Chairman: Councillor J.T. Dixon. Vice-Chairman: Councillor Mrs.T.S.H.Tilley Alderman H.D.Lester Miss G.A.Morgan R.Noble Councillor W.J.Ballantine, M.A., F.C.I.S., M.l.P.M. Mrs.P.F.B.Campbell P.D.Donoghue S.P.Dougherty B.C.Dwyer Mrs.E.D.Goatley L.W.Holmes Mrs.M.E.Marshall Mrs.J.A.Nicholas Mrs.E.M.Rackham Mrs.D.M.Smith J.V.Tilley Mrs.S.K.Ward Mrs.Margaret Williams M.R.Williams Ex-Officio Members The Worshipful the Mayor (Alderman Mrs.Jean Standing, J.P.) Alderman D.T.L.Mallam, A.R.I.C.S., M.R.S.H. Councillor I.McGarry, SENIOR OFFICERS OF THE HEALTH DEPARTMENT (at 31st December, 1972) Medical Officer of Health H.E.A.Carson Deputy Medical Officer of Health H.Gordon Principal Medical Officers M.A.Church A.L.Frenkiel R.D.Graham Principal Administrative Officer H.J.Horsnell Chief Public Health Inspector K.J.Winton Chief Nursing Officer Miss D.A.Harding Principal Dental Officer A.F.Weedon Acting Principal Social Worker Mrs.A.E.Fraser (Health Services) 26 LIST OF HEALTH DEPARTMENT PREMISES Administrative Headquarters Municipal Buildings, Fairfield Street, S.W.18. Environmental Health Section Lyon House, 102 Wandsworth High Street, S.W.18. Disinfecting Station and Pest Control Sheepcote Lane, S.W.11. Mortuary Sheepcote Lane, S.W.11. Personal Cleansing Station Sheepcote Lane, S.W.11. Chest Clinics Balham, St.James' Hospital, Sarsfeld Road, S.W.12. Battersea, St.John's Hospital, St.John's Hill, S.W.11. Wandsworth, Municipal Buildings, Fairfield Street, S.W.18. Centres for Health Services (including Child Health and School Treatment) * Balham, 91 Bedford Hill, S.W.12. Chatham Hall, Chatham Road, S.W.11. * Doddington, 311 Battersea Park Road, S.W.11. * Earlsfield, 102 Earlsfield Road, S.W.18. * Eileen Lecky, 2 Clarendon Drive, S.W.15. * Fairfield, Municipal Buildings, Fairfield Street, S.W.18. Gatton, Gatton Road, S.W.17. Minstead Gardens, Christian Community Centre, Minstead Gardens, S.W.15. * Nightingale Lane, 56 Nightingale Lane, S.W.12. (Health visitors office only) Patmore, Tenants' Clubroom, Patmore Estate, S.W.8. Putney Vale, Tenants' Clubroom, Stroud Crescent, S.W.15. * St.Christopher's, Wheeler Court, Plough Road, S.W.11. 27 Southfields, King George's Park Sports Centre, Burr Road, S.W.18. * Stormont, Stormont Road, S.W.11. * Tooting, 63 Bevill Allen Close, S.W.17. * Victoria Drive, 67 Victoria Drive, S.W.19. Wandsworth School Treatment Centre, 315 Garratt Lane, S.W.18. * William Harvey, 313 Cortis Road, S.W.15. (* includes Health Visitors' Office) Home Nursing Service Municipal Buildings, Fairfield Street, S.W.18. 28 PART 1 VITAL STATISTICS Population The civilian population at the middle of the year was estimated by the Registrar-General to be 302,258. Movement of Population The work of the Department continued to be made more complex by the continual movement into and out of the Borough of children under five years of age. The records show that during 1972 nearly 2,400 children arrived in Wandsworth and about 2,800 moved out. There was a marked reduction in the number who moved without leaving any apparent trace - 1,591 compared with 1,908 for the previous year; of these, 475 were finally traced by means of persistent inquiries. The number of internal movements increased from 2,752 in 1971 to 3,188 in 1972. Statistics — Assignment of births and deaths From 1972, the Registrar General has introduced a change in the rules governing the assignment of births and deaths to local authority areas for statistical purposes. Hitherto, where the mother's or deceased person's usual residence is stated as an address outside England and Wales, the birth or death has been assigned to the local government area of occurrence. From 1972 onwards, any such cases are dealt with as outward transfers from the area of occurrence, but are not assigned to any other area. This means that live birth, stillbirth and death figures for local authority areas now exclude persons who are not normally resident in England and Wales. The effect so far as Wandsworth is concerned is likely to be negligible. 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 1972 the factor for births is 0.90 and for deaths 0.87. 29 Table 1 Extracts from Vital Statistics Live Births Male Female Total Legitimate 1,934 1,780 3,714 Illegitimate 432 342 774 Totals 2,366 2,122 4,488 Rate per 1,000 population Crude 14.8 Adjusted 13.4 Stillbirths 40 23 63 Rate per 1,000 total live and still births 14 Deaths: All ages 1,919 2,144 4,063 Rate per 1,000 population Crude 13.4 Adjusted 11.7 Infant Mortality Rates Deaths under 1 year 56 47 103 Total infant deaths per 1,000 live births 23. Legitimate infant deaths per 1,000 legitimate live births 23. Illegitimate infant deaths per 1,000 illegitimate live births 21. Neo-natal mortality rate (deaths under 4 weeks per 1,000 total live births) 15. Early neo-natal mortality rate (deaths under 1 week per 1,000 total live births) 13. Perinatal mortality rate (stillbirths and deaths under 1 week combined, per 1,000 total live and still births) 26. Maternal mortality rate (per 1,000 total live and still births) 0.22 Number of deaths from puerperal causes 1 Number of deaths from cancer 842 Number of deaths from tuberculosis 23 30 Births The total number of live births to residents in the Borough registered in 1972 was 4,488, comprising 2,366 males and 2,122 females. The crude birthrate was 14.8 per 1,000 population. The rate as adjusted by the area comparability factor was 13.4. The live birthrate for England and Wales was 14.8. During the year there were 774 illegitimate live births to residents in the Borough, representing 17 per cent of the total live births for the area. The national average was 9 per cent. Stihbirths during the year numbered 63, giving a total of 4,551 live and still births for the whole 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 4,063, comprising 1,919 males and 2,144 females. The crude death-rate was 13.4 per 1,000 population, and the adjusted death-rate, after application of the area comparability factor, 11.7. The death rate for England and Wales was 12.1. Table 2, which is shown on pages 32 and 33, is the general mortality table for the Borough, and shows the number of deaths from each cause divided into sexes, age groups and localities. Table 3 shows the deaths from heart disease. The causes of death shown in Table 2 are based on the International Abbreviated List of 50 causes (B List), with some sub-divisions, from the World Health Organisation's Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death (8th revision, Geneva, 1969). 31 TABLE 3 DEATHS FROM HEART DISEASE Males in age groups Females in age groups Grand Totals Under 25 25 35- 45 55 65- 75 Totals Under 25 25 35 45 55 65 75 Totals Chronic rheu matic heart disease 2 4 7 10 23 3 1 8 15 15 42 65 Hypertensive disease 5 1 1 14 1 1 41 1 5 9 28 43 84 Ischaemic heart disease 1 1 4 37 122 159 150 483 1 10 28 90 270 399 882 Other forms of heart disease 1 2 4 12 26 45 1 1 2 20 103 1 27 172 Totals 1 15 46 141 192 197 592 5 13 43 134 416 61 1 1,203 Infant Mortality There were 103 deaths of children under one year, with an infant mortality rate of 23 per thousand live births. The infant mortality rate for England and Wales was 17. TABLE 4 DEATHS OF CHILDREN UNDER ONE YEAR OF AGE Causes of death Under 24 hours 1-7 days 1-4 weeks Totals under 4 weeks 1-12 months TOTAL DEATHS UNDER 1 YEAR Pneumonia 1 1 13 14 Enteritis and other diarrhoeal diseases 1 1 1 Congenital anomalies 4 6 4 14 5 19 Prematurity 16 4 20 20 Other causes 15 1 1 5 31 18 49 Totals 35 22 10 67 36 103 Maternal Mortality One death occurred from accidents and diseases of pregnancy or childbirth. This is equivalent to a rate of 0.22 per thousand live and still births. The patient concerned was 30 years of age, and the cause of death was a ruptured ectopic pregnancy with internal haemorrhage. 33 32 TABLE 2. CAUSES OF. AND AGES AT. DEATH DURING THE YEAR 1972 CAUSES OF DEATH Deaths assigned to the Borough in age groups Deaths shown in localities (all ages) All ages Males Females Under 1 year 1-4 5-14 16-24 25-34 35-44 45-54 55-64 65-74 75 upwards Putney Central Battersea Cholera — — — — — — — — — — — — — — — — Typhoid fever — — — — — — — — — — — — — — — — Bacillary dysentery and amoebiasis — — — — — — — — — — — — — — — — Enteritis and other diarrhoeal diseases 3 3 — 1 1 — — — — — 1 — — 1 1 1 Tuberculosis of respiratory system 12 7 5 — — — — — — 2 2 5 3 5 3 4 Other tuberculosis 8 4 4 — — — — 1 — 2 2 3 — 1 3 4 Tuberculosis late effects. 3 — 3 — — — — — — 1 2 — — 1 1 1 Plague — — — — — — — — — — — — — — — — Diphtheria — — — — — — — — — — — — — — — — Whooping cough — — — — — — — — — — — — — — — — Streptococcal sore throat and scarlet fever — — — — — — — — — — — — — — — — Meningococcal infection 3 1 2 1 1 — 1 — — — — — — — 1 2 Acute poliomyelitis — — — — — — — — — — — — — — — Smallpox — — — — — — — — — — — — — — — — Measles — — — — — — — — — — — — — — — — Typhus and other rickettsioses — — — — — — — — — — — — — — — — Malaria 1 — 1 — — — — 1 — — — — — — — 1 Syphilis and its sequelae 1 — 1 — — — — — — — — — 1 1 — — All other infective and parasitic diseases 7 4 3 1 — — — — — 2 1 2 1 2 3 2 Malignant neoplasm. Buccal cavity and pharynx 6 5 1 — — — — — 1 1 1 2 1 4 1 1 Oesophagus 18 13 5 — — — — — — 6 4 4 4 4 7 7 Stomach 72 46 26 — — — — — 3 6 13 24 26 19 16 37 Intestine 98 53 45 — — — — — 5 6 20 33 34 42 21 35 Larynx 7 6 1 — — — — — — — 1 2 4 2 3 2 Lung, bronchus 291 230 61 — — — — — 5 22 73 123 68 97 82 112 Breast 77 — 77 — — — — 1 6 7 15 24 24 21 28 28 Uterus 26 — 26 — — — — 1 3 4 7 4 7 7 9 10 Prostate 31 31 — — — — — — — — 3 13 15 12 11 8 Leukaemia 20 10 10 1 1 — 1 — 2 3 4 4 4 7 5 8 Other malignant neoplasms 196 89 107 — — 1 1 6 5 17 48 71 47 56 65 75 Benign and unspecified neoplasms 7 3 4 — — — — 3 — 2 1 1 — 5 1 1 Diabetes mellitus 37 14 23 — — — — 1 2 2 1 14 17 10 16 11 Avitaminosis and other nutritional deficiency ... — — — — — — — — — — — — — — — — TABLE 2 CAUSES OF AND AGES AT. DEATH DURING THE YEAR 1972 — comd Other endocrine nutritional metabolic diseases 9 1 8 — — — — 1 — 2 — 2 4 2 5 2 Anaemias 10 1 9 — 1 — — — — 1 — — 8 3 6 1 Other diseases of blood and blood forming organs 2 1 1 — — — — — — — — 2 — 1 1 — Mental disorders 32 8 24 — — — — 2 1 1 2 5 21 7 1 7 8 Meningitis 4 1 3 2 — — — — — — — 1 1 1 2 1 Multiple sclerosis 13 6 7 — — — — 1 3 2 3 4 — 10 2 1 Other diseases of nervous system and sense organs 38 17 21 — — — — 2 2 2 3 0 20 10 15 13 Active rheumatic fever 1 1 — — — 1 — — — — — — — 1 — — Chronic rheumatic heart disease 65 23 42 — — — — — 3 3 12 22 25 23 20 22 Hypertensive disease 84 41 43 — — — — — — 6 16 23 39 20 30 34 Ischaemic heart disease 882 483 399 — — — — 1 15 47 150 249 420 308 236 338 Other forms of heart disease 172 45 127 — — — — — 2 3 6 32 129 64 49 59 Cerebrovascular disease 479 170 309 — — — — 1 2 18 42 101 315 160 138 181 Other diseases of the circulatory system 224 80 144 — — — 1 — 3 6 18 47 149 72 75 77 Influenza 18 8 10 1 — — — — — — 3 6 8 6 5 / Pneumonia 366 134 232 14 1 1 1 — 4 7 17 66 255 116 119 131 Bronchitis, emphysema 228 145 83 — — — — — — 6 32 70 120 61 78 89 Asthma 6 — 6 — 1 — — — 1 — 2 1 1 2 i 3 Other diseases of the respiratory system 42 20 22 5 1 — 3 — — — 4 9 20 11 1 3 1 8 Peptic ulcer 33 17 16 — — — — — — 1 3 10 19 1 4 10 Appendicitis 2 1 1 — — — — — — — — 1 — 1 1 — Intestinal obstruction and hernia 23 9 14 3 1 1 — — — — 1 5 1 2 7 10 6 Cirrhosis of liver 15 7 8 — — — — — — 6 3 4 2 5 7 3 Other diseases of the digestive system 39 16 23 3 — — — 1 1 2 6 7 19 11 1 5 1 3 Nephritis and nephrosis 21 10 11 — — — — — — — 7 5 8 10 7 4 Hyperplasia of prostate 11 11 — — — — — — — — 1 4 6 4 4 3 Other diseases of genito urinary system 18 7 11 — — — — — — 3 3 3 9 4 7 7 Abortion — — — — — — — — — — — — — — — — Other complications of pregnancy, childbirth and puerperium 1 — 1 — — — — 1 — — — — — — — 1 Diseases of the skin and subcutaneous tissue 3 — 3 — — — — — — — — 1 2 1 2 — Disease of the musculo skeletal system and connective tissue 36 4 32 — — 1 — — — — 5 7 23 8 18 10 Congenital anomalies 31 14 17 19 2 1 1 — 1 1 1 4 1 1 6 7 o Birth injury, difficult labour and other anoxic and hypoxic conditions 24 14 10 24 — — — — — — — — — 5 5 14 Other causes of perinatal mortality 21 16 5 21 — — — — — — — — — 4 6 11 Symptoms and ill defined conditions 63 12 51 2 — — — 1 — — — 4 56 10 36 1 / Motor vehicle accidents 29 18 11 — 1 2 5 1 2 2 2 7 7 13 8 8 All other accidents 42 30 12 4 — 4 3 1 3 2 10 6 9 16 4 22 Suicide and self inflicted injuries 39 24 15 — — — 5 9 9 4 7 4 1 13 13 13 All other external causes 13 5 8 1 — 1 2 3 1 1 2 — 2 5 5 3 Totals 4 063 1.919 2.144 103 11 13 24 39 86 210 560 1.050 1.967 1.317 1.258 1.488 34 PART 2 COMMUNICABLE DISEASES During the year, 1,173 notifications were received compared with 1,207 in 1971. The total number of confirmed cases of notifiable disease, arranged in age groups and the areas in which they occurred is shown in Tables 6 and 7 which follow. A commentary on the notifications is given below. Vaccination and immunisation against serious infectious diseases is an important feature of communicable disease control and details of this personal health service will be found in Part 4 of the Report. Acute encephalitis Only one case was reported during the year and occurred in an eight-month-old baby. A coxsackie virus was the causative organism. Acute meningitis During the year ten cases were notified, comprising three adults and seven children, the causative organisms being:- 4 meningococcal 2 pyogenic 3 viral 1 haemophilus influenzae The child suffering from the haemophilus influenzae infection died following admission to hospital. Cholera No cases were reported during the year, but nine persons who had returned to this country from endemic areas without valid international certificates of vaccination were kept under surveillance. Dysentery A total of 276 notifications was received and, following bacteriological examination, 142 were confirmed. 35 Two outbreaks of dysentery occurred during the year, one at a primary school and the other at a nearby residential nursery. At the school investigation revealed 33 children to be infected and in addition eight positive home contacts were identified. A similar investigation at the nursery showed eleven children and eight members of the staff to be suffering from dysentery and no new admissions were therefore accepted for an appropriate period. The fact that some of the children attending the school had younger brothers or sisters suggested that the two episodes were related. The remaining 82 cases were single isolated incidents. Food poisoning One hundred and thirteen notified cases were investigated during the year but, after bacteriological examination, only 49 cases were confirmed, four in a luncheon club, 24 in family outbreaks, the remaining 21 being single unrelated cases. The causative organisms of the 49 confirmed cases were of the following types:- Salmonella typhimurium 24 indiana 4 st.paul 4 bredeney 3 enteritidis 3 agona 2 manhattan 1 newport 1 osis 1 Stanley 1 virchow 1 Clostridium welchii 4 The four cases of Clostridium welchii food poisoning occurred in an old people's luncheon club. Infected pork was found to be the cause and investigation revealed that all the persons who ate the pork developed similar symptoms. Unfortunately, one old lady died. Infective jaundice Thirty-five cases occurred during the year compared with 25 cases in 1971. 36 Leptospirosis Only one case was notified during the year, the patient being a bui Ider employed on drainage work. Malaria Four cases were notified all of which were contracted abroad. Measles For the second year running, the number of cases of measles notified was exceptionally low, 568 compared with 559 in 1971. There seems no doubt that measles vaccination, which was introduced in 1968, is potentially a most effective weapon in reducing the incidence of this disease. Ophthalmia neonatorum Four cases of ophthalmic infection in the newborn were reported and investigated, two being found to be gonococcal in origin. Poliomyelitis and smallpox No cases of these two serious diseases were notified in Wandsworth during the year. Scarlet fever There was a decrease in the number of cases reported which totalled 31 compared with 35 in 1971. Tuberculosis The number of new cases notified during the year was 136, the sources of information being as follows:- Primary notifications 111 Un-notified at death 4 Transfers from other areas 21 The number of deaths certified as due to various forms of tuberculosis was 23. Particulars of the primary notifications and deaths during the year, classified by sex and age, are given in the following table:- 37 TABLE 5 Age groups Primary notifications Deaths Pulmonary Nonpulmonary Pulmonary Nonpulmonary M. F. M. F. M. F. M. F. Under 1 year 1 — 1 — — — — — 1-4 — — — — — — — — 5-9 — — — — — — — — 10-14 — 1 — — — — — — 15-24 5 7 1 1 — — — — 25-44 16 14 2 8 — — 1 — 45-64 24 10 1 7 1 6 1 3 65 and over 8 3 1 — 6 2 2 1 Totals 54 35 6 16 7 8 4 4 Tuberculosis - epidemiological investigations During the year, investigations were undertaken at two educational establishments in Wandsworth, details of which will be found in the School Health Section of this Report. Typhoid fever During the year three cases were reported and investigated. The first case involved a woman aged 25 years who had been on holiday in Italy and who was taken ill two days after her return to this country. The second case occurred in an immigrant aged 25 who became ill whilst flying to this country from Pakistan and who was admitted to hospital two days after arrival. The third case - a 31 year old man - became ill four days after arriving home from a holiday in Morocco. Each of the patients involved was deemed to have been infected abroad and all made a full recovery. Whooping cough There was again a considerable decrease in the number of cases reported, 16 compared with 68 cases in 1971. 38 Bacteriological examinations Bacteriological examination of stools and other specimens in connection with food poisoning and infectious disease was carried out by the Joint Microbiology and Public Health Laboratory at St,George's Hospital, Tooting and 2,275 specimens were examined during the year- Stool and urine ,,, 2,265 Nose and throat swabs 10 International certificates of vaccination against smallpox and cholera Persons travelling abroad to certain specified countries are required to possess a certificate of vaccination bearing the authenticating stamp of the local authority of the area in which they were vaccinated, During the year, 12,551 such certificates of vaccination against smallpox, and 5,934 certificates in respect of cholera, were stamped, Smallpox - Surveillance Under the Public Health (Aircraft) Regulations, 1966 and the Public Health (Ships) Regulations, 1966, persons arriving in this country from areas abroad where smallpox is endemic and who are not in possession of a valid international certificate of vaccination against smallpox must be placed under surveillance for a specific period, During the year, 76 such persons who were proceeding to addresses in the Borough were kept under observation, Immigrants The number of immigrants reported as taking up residence in the Borough during the year was 1,446 of whom the public health inspectors were able to contact 874, who were advised regarding registration with a family doctor and the desirability of having a chest X-ray, TABLE 6 DISEASE NUMBER OF NOTIFIED CASES OF INFECTIOUS DISEASES IN AGE GROUPS  Under 1 year 1 2 3 4 5-9 10-14 15-24 25-44 45-65 Uver 65 Acute encephalitis 1 — — — — — — — — — — 1 10 Acute meningitis 3 — — — — 3 — 2 1 1 — Acute poliomyelitis — — — — — — — — — — — Anthrax — — — — — — — — — — — — Cholera — — — — — — — — — — — — Diphtheria — — — — — — — — — — — — Dysentery 3 7 9 12 9 52 10 7 26 7 — 142 Food poisoning 5 — 1 2 4 6 1 5 15 2 8 49 Infective jaundice — — 1 — 1 4 4 11 10 4 — 35 Leprosy — — — — — — — — — — — — Leptospirosis — — — — — — — — 1 — — 1 Malaria — — — — — — — 1 1 2 — 4 Measles 33 56 58 79 65 270 2 4 1 — — 568 Ophthalmia neonatorum 4 — — — — — — — — — — 4 Paratyphoid fever — — — — — — — — — — — — Plague — — — — — — — — — — — — Relapsing fever — — — — — — — — — — — — Scarlet fever — — 2 2 — 21 3 3 — — — 31 Smallpox — — — — — — — — — — — — Tetanus — — — — — — — — — — — — Tuberculosis — — — 2 — — 1 14 40 42 12 111 Typhoid fever — — — — — — — 1 2 — — 3 Typhus — — — — — — — — — — — — Whooping cough 2 1 4 2 2 5 — — — — — 1 6 Yellow fever — — — — — — — — — — — — Totals 51 64 75 99 81 361 21 48 97 58 20 975 39 TABLE 7 NUMBER OF NOTIFIED CASES OF INFECTIOUS DISEASES IN WARDS PUTNEY CENTRAL BATTERSEA DISEASE 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 s Acuie encephalitis — — — — — — — — — — — — — — — — — — 1 — 1 Acute meningitis — — 3 1 — — 1 — 1 — — — 1 — — 2 — 1 — — 10 Acute poliomyelitis — — — — — — — — — — — — — — — — — — — — — Anthrax — — — — — — — — — — — — — — — — — — — — — Cholera — — — — — — — — — — — — — — — — — — — — — Diphtheria — — — — — — — — — — — — — — — — — — — — — Dysentery — 1 4 95 7 4 7 1 3 1 3 — — 7 1 1 7 — — — 142 Food poisoning — — 4 5 3 5 6 1 — 4 2 — 7 4 2 5 — — — 1 49 Infective jaundice — 1 — 2 3 4 4 1 1 3 1 2 — — 1 — 2 3 — 7 35 Leprosy — — — — — — — — — — — — — — — — — — — — — Leptospirosis — — — — — — — — — — — — — — — — — — — — 1 Malaria — — 1 — — — — — — — 1 — — 1 — — — — 1 — 4 Measles 16 10 27 24 20 85 8 30 27 17 8 10 11 5 3 49 56 57 26 79 568 Ophthalmia neonatorum — — — — 1 1 — — — — — — — — — — — 1 — 1 4 Paratyphoid fever — — — — — — — — — — — — — — — — — — — — — Plague — — — — — — — — — — — — — — — — — — — — — Re0lapsing fever Scarlet fever — 1 9 5 — — — — 4 — 1 1 1 — — 1 1 4 2 1 31 Smallpox — — — — — — — — — — — — — — — — — — — — — Tetanus — — — — — — — — — — — — — — — — — — — — — Tuberculosis 1 3 3 12 2 10 2 3 1 1 5 10 1 5 13 6 5 6 B 3 2 111 Typhoid fever 2 1 3 Typhus Whooping cough — — — — 3 — 3 — — — 1 — 2 3 3 1 16 Yellow fever — — — — — — — — — — — — — — — — — — — — — Totals 17 16 51 146 40 110 28 36 50 30 26 14 26 30 13 65 75 77 33 92 975 40 41 PART 3 ENVIRONMENTAL HEALTH SERVICES K, J, Winton, M,A,P,H,I,, Chief Public Health Inspector The three divisions into which the Environmental Health Section was Organised in 1970 are now working very satisfactorily as individual units, However, owing to there being a 25 per cent, shortage in the qualified inspectorate during the year, the programmes of work which had been designed for the divisions have had to be shelved until such time as staff are available to implement them, It has become obvious that the use of technical assistants has come to stay and plans were commenced during the year for their training at Colleges of Further Education, The General Division carried on its usual but nonetheless essential day-to-day task of dealing with routine complaints and during the year a marked increase was noticed in the number of complaints concerning accumulations of refuse and rubbish dumped in alleyways and on vacant sites, Other complaints which were dealt with by this division related to gipsies, to mice and, in particular, to the smell from a glucose factory in York Road (locally referred to as the 'Battersea smell'), Much has been said and written about this factory, but, at the close of the year, it was obvious that all the publicity, via the media of the press and television, had achieved more than any statutory notices could have done in bringing the problem nearer to a final solution, The gipsies, however, are a different story, and although attempts were made to find a site, the one which was offered to them did not meet with their approval, and consequently the solution to this problem has been severely delayed, Complaints about mice also increased considerably and one of the worst problems was on the Doddington Road Estate, Following a detailed survey, the floors had to be taken up and pipe ducts sealed off in order to contain the mice and stop them travelling throughout the block, Once this work had been carried out, the rodent operatives were able to eradicate the infestation, During the year, this borough participated with other London Boroughs in a mouse survey which was conducted by the Ministry of Agriculture, Fisheries and Food, and much credit is due here to the rodent officers of the Health Department for their work in this respect, 42 The drainage section also bad a full year's work, the number of applications being received far exceeding that of any previous year, mainly due to the tremendous drive going on throughout the borough for house improvement, The Food Division, unfortunately, was hampered by lack of staff and the fact that, during the year, the divisional inspector obtained an appointment with another Authority, Consequently, until he was replaced by Mr,N,V,Saunders from Harrow, the division was running with two inspectors against the establishment of five, Very little routine revisiting was therefore carried out during the year, the inspectors being fully occupied in dealing with complaints and sampling duties, The Housing Division increased its success of the previous year and exceeded all expectations in the number of inspections made, They were also hampered by the lack of qualified technical staff and by the fact that technical assistants joining during the year had to be trained, In spite of this, the division virtually completed all the surveys in the slum clearance programme and made further inroads into properties in multiple occupation, Statistically, the year was very little different from any other, and although the enthusiasm of the younger inspectors still pervades, the shortage of staff and the concomitant increase of work inevitably puts more strain on those available, Tribute must be paid this year not only to the technical staff for their output despite staff shortages but also to the administrative staff for their support during this difficult period, Environmental pollution has, over the last few years, been afforded increased publicity nationally, The public, quite rightly, are becoming aware that chemical pollution of soil, water and air, by both industry and the essential services, together with noise from aircraft, are conditions which were accepted by our forbears as part of life but which now should no longer be tolerated, These expressions of concern by the public were borne home to the inspectors many times during the year when they gave lectures and informal talks to various local groups such as scouts, guides, schoolchildren and the staffs of hospitals and multiple stores, It is becoming obvious that the Environmental Health Section will have to widen its field of operation in the future with the individual divisions being broken down into specialist sections, The role which the public health inspector has played for the last 100 years of being a "Jack of all trades" is fast disappearing and taking on that of a specialist in one particular field, 43 PUBLIC HEALTH INSPECTION A summary of the inspections and visits carried out during the year by the staff of the Environmental Health Section is given in Table 8, TABLE 8 Primary Visits Revisits Totals To investigate complaints 8,185 7,242 15,427 Offices, Shops and Railway Premises Act 2,013 3,779 5,792 Infectious disease enquiries 700 142 842 Factories Act 963 381 1,344 Hairdressing establishments 22 175 197 Outworkers 123 — 123 Housing clearance area schemes 878 197 1,075 Individual unfit properties 112 296 408 Housing reports 299 — 299 Housing Act 1969 (Qualification Certificates) 480 1,016 1,496 Houses in multiple occupation 9,531 9,937 19,468 Improvement grants 1,488 27 1,515 Hotels 12 10 22 Housing Act 1957 (permitted numbers) 252 — 252 Housing Associations (conversions) 53 1 54 Long-stay immigrants 479 326 805 New drainage 1,092 11,868 12,960 Smoke control orders 11,235 1,260 12,495 Food premises 1,575 5,311 6,886 Markets, stalls and delivery vehicles 158 62 220 Food sampling 371 59 430 Pharmacy and Poisons Act 9 149 158 Caravan sites 19 107 126 Animal boarding establishments 2 — 2 Riding establishments 2 — 2 Pet shops 29 86 115 Rodent control 3,947 6,103 10,050 Oisinfestation 690 — 690 Disinfection 158 — 158 Incontinent laundry service 140 5,609 5,749 Others 12,184 672 12,856 Totals 57,201 54,815 112,016 Table 9 gives details of the sanitary operations carried out during the year, 44 TABLE 9 Putney Central Battersea Totals Premises cleansed and repaired 140 230 321 691 Drains tested 53 25 32 110 Drains cleansed or repaired 295 557 284 1,136 Water closets, cleansed, repaired or renewed 34 61 75 170 Soil pipes altered or repaired 4 11 10 25 Waste pipes provided, altered or repaired 6 23 43 72 Rainwater pipes repaired 6 13 20 39 Roofs and gucters repaired ,,, 88 101 194 383 Damp conditions otherwise remedied 81 140 208 429 Yards drained or paved 1 3 4 8 Dustbins provided 4 10 25 39 Water cisterns cleansed, covered or repaired 2 4 1 7 Water supply reinstated 60 69 70 199 Defective stoves and fireplaces remedied 1 — 5 6 Animals improperly kept 6 5 4 15 Accumulations of rubbish, etc,, removed 17 50 49 116 Smoke nuisances 11 18 12 41 Other nuisances 8 13 20 41 Totals 817 1,333 1,377 3,527 Number of preliminary notices served 173 325 312 810 Number of preliminary notices complied with 150 255 278 683 Number of abatement notices served 128 319 414 861 Number of abatement notices complied with 133 214 307 654 Legal proceedings During the year, legal proceedings were taken by the Council in 64 instances in connection with the abatement of nuisances, Drainage work Drainage work to new premises, reconstruction of drains to existing premises and drainage in connection with conversion schemes are carried out under the supervision of technical assistants of the department in co-ordination with the public health inspectors, Plans are required to be submitted to the Council for approval under the drainage by-laws and during the year 928 applications were received, 45 There were 3,634 tests made in connection with drainage installations and 54 connections made to the Council's sewers during the year, The clearance and maintenance of public sewers is the responsibility of the Council and maintenance costs are reclaimed from owners of properties connected to the public sewer, A close working liaison with the Technical Services Department implements the rapid clearance and repairs of public sewers, Sewerage and sewage disposal The trunk sewers and sewage disposal of London are the responsibility of the Greater London Council, and the local sewers which discharge into the trunk sewers are the responsibility of the Borough Councils, The Council's brick and pipe sewers are regularly cleansed and are reasonably adequate for their purpose, Water supply The bulk of the water supply in Wandsworth, as in other Inner London Boroughs, is obtained from the mains of the Metropolitan Water Board who are responsible for its purity, Water supplies from this and other sources proved satisfactory both in quality and quantity throughout the year, All new and repaired mains are disinfected with chlorine; after a predetermined period of contact the pipes are flushed out and refilled; samples of water are then collected from these treated mains, and the mains are returned to service only after the analytical results are found to be satisfactory, The quality control from the Metropolitan Water Board's laboratories is carried out by means of daily sampling from the sources of supply, from the treatment works or well stations, from the distribution system and through to the consumer, Any sign of contamination or any other abnormality is immediately investigated, All dwellings in the borough, numbering approximately 127,000 and catering for a resident population of 302,258, were supplied from the mains of the Metropolitan Water Board, No houses were permanently supplied by standpipe, 46 No artificial fluoride is added to the water supply by the Board and where the fluoride content is indicated in the analyses it represents the naturally occurring fluoride in the water, The natural fluoride content of the mains water was 0,20 parts per million, There has been no change in policy on the question of the general fluoridation of the water supply in Wandsworth, The Council has already made a decision in favour of fluoridation but the Metropolitan Water Board will take no action until all the authorities whose areas are served by the Board are similarly in favour, Nursing homes The Council controls the registration and supervision of all nursing homes within the Borough, and its powers in this connection are contained in the following Acts and Regulations:- Public Health Act, 1936, Nursing Homes Act, 1963, The Conduct of Nursing Homes Regulations, 1963, and, for mental nursing homes:- Mental Health Act, 1959, The Mental Health (Registration and Inspection of Mental Nursing Homes) Regulations, 1960, The Conduct of Mental Nursing Homes Regulations, 1962, Periodic visits are made to all the homes by the Department's medical and nursing officers and public health inspectors and, in addition to the supervision of the nursing care provided and of the sanitary arrangements in the homes, there is a close liaison between the Department's staff and that of the Superintending Architect of the Greater London Council and the London Fire Brigade's Fire Prevention Officers to ensure that fire precautions and means of escape in case of fire are at all times satisfactory, There were five nursing homes in the Borough at the end of the year, with a total of 203 beds, Their categories and accommodation are given below, together with the number of inspections made during the year- Mental nursing home (1) ,,, ,,, 117 beds Mother and baby home (1),,, ,,, 17 beds Other nursing homes (3) ,,, ,,, 69 beds Inspections by medical and nursing officers 8 Inspections by public health inspectors ,,, 6 47 Hairdressers and barbers The provisions made under Section 21 of the Greater London (General Powers) Act, 1967, state that no person may carry on a business as a hairdresser or barber at any premises unless he is registered in respect of those premises by the Borough Council; 235 such premises are registered with this Authority, A total of 197 visits were made by technical assistants during the year in connection with the work of registration and the enforcement of existing bye-laws which lay down standards of cleanliness in hairdressers' establishments, In view of the increase in the use of wigs, hairdressers and wigmakers were warned of the dangers of using benzine, cartx>n tetrachloride and trichloroethylene for cleaning wigs, except in the open air or in well-ventilated rooms, The 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 mice, These duties are carried out by the pest control officer assisted by four rodent operatives, All infestations coming to light, whether by complaint or otherwise, are systematically investigated and appropriate action taken, Where the cause of the trouble is obviously a defective drain or other structural defect 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, During the year, 3,947 complaints of infestation were received in respect of which a total of 10,050 visits were made by the staff, Again, more than two-thirds of these complaints related to the presence of mice, whereas those concerning rats have again decreased, The increase in mice complaints is disturbing and various methods, including the old-fashioned mouse trap, have been used, In addition to the work of rodent control, the pest control officer continued to carry out evening " forays" on pigeons roosting under railway bridges in the Borough, The bridges are a favourite breeding ground and by attacking the pigeons at their roosting sites profitable results have been obtained, over 1,000 birds and eggs being taken during the year, 48 Offensive trades There is one establishment in the Borough at which the scheduled offensive trade of fat-melting is carried on, The firm concerned has been established for many years and the trade is 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 1 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 in 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 128 persons registered under the Act, and 158 visits were made to the premises, Under the Poisons Rules (No,2) Order, 1968, the following fees to be paid by listed sellers of Part II poisons are authorised:- (a) for entry of name in the Corporation's list, £1,25, (b) for retention of name in the Corporation's list, 75p each year, Consumer Protection Act, 1961 The majority of the provisions of this Act and the Regulations made thereunder are enforced by the public health inspectors, Particular attention was given during the year to secure compliance with the Oil Heater Regulations at premises selling secondhand oil heaters and to ensure that unsafe heaters were not on sale, Reports were received from the Fire Authority during the year concerning fires, some of which were caused by oil heaters that did not comply with the Regulations, Retailers were 49 advised only to offer for sale oil heaters which bore a B,S,I, mark and specified warning notice, Attention was also paid to secondhand gas and electric fires on sale to ensure that they complied with the Fireguard Regulations, Noise Abatement Act, 1960 During the year, 119 complaints concerning noise were received and investigated by the public health inspectors, Many of these complaints were again concerning laundrettes, particularly self-operated laundrettes which are often open until a very late hour, The investigation by the inspectors in connection with these complaints has necessitated their visiting the premises in question often in the very early hours of the morning, during the evening and very late at night, This type of work outside normal working hours does put a considerable burden upon the inspectorate involved, In addition, one visit to these premises is by no means enough, and investigations are often very drawn out in trying to decide whether the best practicable means have been taken to reduce the noise, at least to a reasonable level, Noise other than industrial noise is very difficult to deal with, as it is often of an intermittent character, For example, the sounding of chimes by ice-cream vendors after hours is an offence, but unless an inspector or the police are on the spot at the time the offence is committed, no prosecution can be taken, The Act does provide, however, for any three persons aggrieved by a noise nuisance to initiate action by complaining to the Local Authority, I must again thank the Scientific Branch of the Greater London Council for the assistance which they have given to the inspectors during the past year in recording and making observations on various noise nuisances, Offices, Shops and Railway Premises Act, 1963 The work of administering the Offices, Shops and Railway Premises Act is the responsibility of the Council's Chief Public Health Inspector, specialist public health inspectors and tachnical assistants, Despite a shortage of specialist public health inspectors during the year under review, the inspection of premises registered under the Act has proceeded in a methodical manner, 50 Registration,— Registration of most premises is only effected after an initial visit by the inspectors and there is still ignorance by occupiers as to their duties in this respect, National publicity could be valuable as a means of reminding potential occupiers of their responsibilities in this direction, General,— Compliance with most parts of the Act continues to be satisfactory but many occupiers only take action to comply with all aspects of the Act following pressure from the Local Authority; thus systematic inspection still continues to be necessary, and without regular visits to premises standards would undoubtedly fall, Planning,- During the year, particular attention has been given to the examination of plans of proposed offices, shops and warehouses, and many observations have been made so that the building, or addition to the building, will comply with all relevant legislation from the moment of occupation, It is regretted that so much space is often devoted to the sales area of shops, and minimal consideration is given to staff needs, and inspectors find such conditions as assistants standing about in passages to get a few minutes morning or afternoon break, Most of the larger firms provide very satisfactory rest room facilities and it is to be hoped that future legislation will insist on at least a heated well-lit corner of the premises away from the public being reserved for staff rest periods, Hoists and Lifts Regulations,- Since the Regulations require an inspection of the lift to be made at six-monthly or yearly intervals by a competent person it would seem that, if the report on its condition is unsatisfactory, a certificate stating the required work had been completed should be sent to the Local Authority following a reinspection by the competent person, It is suggested that new proposed legislation should cover the submission of such a report, During the past year, the enforcement of the Act in this borough has proceeded purposefully and considerable improvement has again occurred in a wide variety of premises during 1972, The following table shows the classification and number of premises registered at the end of 1972, the number of persons employed and the number of inspections and other visits made during the year;- 51 TABLE 10 Class of premises Number registered Persons employed General inspections Revisits or other visits Offices 967 14,437 780 964 Retail shops 1,811 8,123 976 2,481 Wholesale shops, warehouses 113 1,179 54 92 Catering establishments open to the public, canteens 266 2,019 201 240 Fuel storage depots 2 43 2 2 Totals 3,159 25,801 2,013 3,779 Protection of Animals The Council has an agency arrangement with the City of London Corporation whereby that Authority's veterinary officer carries out inspections of premises in respect of which applications have been made for licences under the various Animal Protection Acts, The 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 being kept for sale, 28 licences were issued by the Council during 1972, Animal Boarding Establishments Act, 1953,— This Act provides that no person may keep a boarding establishment for animals (defined as cats or dogs) in the Borough except under licence, Two such licences were granted during the year, Riding Establishments Acts, 1964 and 1970,- These Acts provide 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 two riding establishments were granted, 52 Animals (Miscellaneous Provisions) Order 1957,- Under the terms of this Order, the following Orders of the Ministry of Agriculture, Fisheries and Food were advertised in the 'National Press':- Newcastle Disease (England and Wales) Order 1971, Brucellosis (Eradication Areas) Orders, Brucellosis (Area Eradication) Orders, Diseases of Animals (Approved Disinfectants)(Amendment) Order 1972, Tuberculosis (Compensation) Amendment Order 1972, Diseases of Animals (Miscellaneous Fees) Order 1972, Live Poultry (Restrictions) Amendment Order 1972, Foot and Mouth Disease (Infected Areas)(Vaccination) Order 1972, Land Charges Act, 1925 During the year, the'Department dealt with 9,652 enquiries relating to local land charges These enquiries necessitate a careful search of records and drainage plans, 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 development programmes or slum clearance areas, Common lodging houses There are no registered common lodging houses in the Borough, New legislation The following Regulations came into force during the current year- Poisons (Amendment) Rules 1971 (SI 1971 No,1835) on 1st January 1972, The Housing (Prescribed Forms) Regulations 1972 on 1st May 1972, Housing Finance Act 1972 on 27th July 1972, The Milk (Special Designations)(Amendment) Regulations 1972 on 1st October 1972, The Labelling of Food (Amendment) Regulations 1972 on 8th November 1972, The Gas Safety Regulations 1972 on 1st December 1972, 53 HOUSING Housing Aot, 1957 Clearance Areas,- Seventeen houses were represented under Section 157 of the Housing Act, 1957: 88 houses were demolished following declaration of Clearance Areas under Section 42 and a further 45 following compulsory acquisition under Section 43(2), Closing Orders,- Under Section 157 of the Act, five individual houses, five parts of houses and six basements were represented for closure; four Closing Orders were made under Section 17(1) and nine Closing Orders under Section 18, Under Section 27, Closing Orders were determined in respect of two houses, one part of a house and nine basements and permission was given for one house subject to a Closing Order to be used for storage purposes, Housing Acts, 1961-1969 Houses in multiple occupation 19,468 visits were made in this connection during the year, a total of 5,264 houses being visited for the first time of which 1,781 were found to be in multiple occupation, bringing the total of such houses on record to 8,985, An analysis shows the occupation of these houses to be as follows:- Occupancies: 2 3 45 6 78910 No, of houses: 5,298 1,918 745 402 278 163 78 53 50 The general practice is to try to get properties in multiple occupation brought up to a standard acceptable to the Corporation by informal action, and although a considerable amount of work is carried out by owners voluntarily, others have not been co-operative, and consequently it has been necessary to serve 185 notices under Section 16 of the Housing Act 1961, requiring the provision of means of escape in case of fire, and 63 notices under Section 15 of the Act requiring the provision of additional facilities within the premises, In three instances the owners failed to comply with these notices and the work was carried out in default, 54 The work carried out by owners, both voluntarily and following the service of notices, resulted in 361 houses being brought up to standard, In 596 instances, owners who had received either formal or informal notification that work was required reduced the number of lettings in their premises and in these circumstances no further action was taken, In some cases houses are over-occupied and the most satisfactory method of dealing with them is by making an Order under Section 19 of the Housing Act 1961 which imposes a limit of persons and households, 65 such Orders were made during the year and a further 11 notices of intention to make Orders were served, One existing order was varied to a higher number following improvements to the property and one order was determined, leaving a total of 153 Orders in force, In 9 instances where squalor existed, Management Orders were made, bringing the total number in force to 29; these Orders require the person managing the premises to ensure the cleanliness, repair and maintenance of all the parts of the property in common use, Maintaining the vigorous action in tackling multiple occupation is having the desired effect of controlling the problem, Housing Act, 1969/Housing Finance Act, 1972 Qualification Certificates,- Minor changes in procedure and the removal of anomalies were brought about by the Housing Finance Act, and the phasing out of controlled rents will have the effect of gradually making this qualification procedure obsolete, The following is a summary of applications received and action taken during the year:- 55 TABLE 1 1 Section 29(1)—Where a dwelling does not have all the standard amenities Applications received 149 Applications withdrawn 19 Certificates of Provisional Approval issued 91 Qualification Certificates issued 98 Applications under consideration 163 Section 28(1)—Where a dwelling already satisfies the conditions Applications received ,,, 211 Applications withdrawn 36 Notices of Refusal to issue Qualification Certificates 69 Qualification Certificates issued 254 Applications under consideration 662 Caravan Sites and Control of Development Act, 1960 There are five licensed caravan sites containing a total of 21 dwellings in the Borough, Rent Act, 1968 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, Under the provisions of the Housing Fi nance Act 1972 this procedure is being phased out over a number of years, The following is a summary of action taken in this connection during the year:- TABLE 12 Applications for certificates of disrepair received 6 Certificates of disrepair issued 4 Undertakings received from landlords 1 Applications for cancellation of certificates of disrepair received Nil 56 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, 1,673 applications were considered for eligibility for additional points on health grounds in accordance with the Council's points scheme, A further 2,078 recommendations were made in respect of Council tenants who requested transfer to more suitable alternative accommodation on health grounds, In my last Report I referred to the new procedure whereby applicants for rehousing could state on their application forms any medical reasons which might warrant priority in rehousing and could give authority for an approach to the family doctor for detailed information, The new system has now been in operation for over sixteen months and has proved successful in reducing the number of requests to general practitioners for medical certificates in support of rehousing, 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 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 the public health inspectors in the Food Division, Samples of food and drugs for analysis by the Public Analyst are obtained by the public health inspectors of this division and a detailed account of this work appears later in this section of the report, The total number of food premises of all kinds on the register in the Borough is 2,281 and during 1972 they were visited on 7,694 occasions, Details of the various types of food premises will be found in Table 13 which follows, 57 Food Hygiene (General) Regulations, 1970 These Regulations consolidate and amend the Food Hygiene (General) Regulations 1960 and 1962, the principal changes in requirements being:- (i) raw food which has to be milled or refined to make it fit for human consumption is no longer outside the scope of the regulations (definition of "food", Regulation 2(1)); (ii) before food is offered for sale it must be separated from any food which is unfit for human consumption (Regulation 9 fbj); (iii) animal feed must not be kept in a food room unless it is in a closed container that eliminates the risk of contamination (Regulation 9(e)): (iv) any person handling open food (food not adequately protected by wrappings, etc,) must wear clean and washable overclothing, except in specified cases (Regulation 11); (v) the business of packing or storing eggs, fruit or vegetables on farm premises is made subject to certain requirements (Regulation 33), The separate categories of trade carried on in food premises which are subject to these Regulations are shown in Table 13 which also indicates the number of premises which comply with Regulation 18 relating to the provision of washing facilities for food handlers and Regulation 21 which requires the provision of facilities for washing food and equipment, Table 14 summarises the visits paid to food premises during the year and Table 15 shows the work carried out to comply with statutory requirements, i Legal proceedings,— Four summonses were issued under the above Regulations as follows:- (a) against two partners of a bakery in respect of the condition of the premises, The court imposed a total fine of £300 for the ten offences and a sum of £50 for costs was awarded to the Council; (b) against a bakery proprietor in respect of the condition of the premises, The court imposed a total fine of £200 for the eight offences and a sum of £20 for costs was awarded to the Council; 58 (c) against a bakery proprietor in respect of the condition of the premises. The court imposed a total fine of £250 for the seven offences and a sum of £20 for costs was awarded to the Council; (d) against a grocer in respect of his omission to provide a wash-hand basin, or a hot water supply to the sink, as well as the insanitary condition of the premises. The court imposed a total fine of £90 for the three offences. TABLE 13 PREMISES WHERE FOOD IS SOLD. STORED OR PREPARED Number No. fitted to comply with Regn. 18 No. to which Regn. 21 applies No. fitted to comply with Regn. 21 Bakehouses 27 27 27 27 Bakers 67 62 67 63 Butchers 153 153 153 153 Cafes and restaurants 274 274 274 274 Canteens 113 113 113 113 Chemists 39 39 39 39 Clubs 59 59 59 59 Confectioners 336 329 285 198 Dairies and milk depots 7 7 7 7 Dining centres 24 24 24 24 Fish friers 57 57 57 57 Fishmongers 28 28 28 28 Food factories 16 16 16 16 Greengrocers 164 164 164 152 Grocers 402 402 402 395 Hostels and homes 28 28 28 28 Ice-cream manufacturers 14 14 14 14 Market stalls 158 — — — Off-licences 130 126 31 31 Public houses 160 157 160 160 Take away food shops 25 25 25 25 Totals 2.281 2.104 1.973 1,863 59 TABLE 14 VISITS TO FOOD PREMISES Bakehouses 134 Bakers and confectioners 694 Butchers' shops 779 Cafes and restaurants 1.276 Chemists' shops 76 Dairies and milk depots 10 Dining centres 45 Fried-fish shops 197 Fishmongers' shops 74 Food factories 52 Greengrocers' shops 303 Grocers' shops 1.221 Ice-cream premises 840 Markets, stalls and delivery vehicles 220 Pharmacy and poisons 158 Public houses 263 Take-away food shops 107 Others 1,145 Total 7.694 TABLE 15 WORK COMPLETED TO COMPLY WITH STATUTORY REQUIREMENTS Wash-hand basins provided 20 Sinks provided 10 Provision of hot and cold water over sink and wash-hand basin 38 Accommodation for clothing provided 6 Premises repaired and redecorated 176 Dustbins provided 14 Soap, towels and nailbrushes provided 36 Floors and floor covering repaired 90 Ventilation and ventilated lobbies provided 8 Dirty equipment cleansed 53 Artificial lighting provided 8 Refuse cleared 19 Wash-hand notices provided 25 Water closet accommodation provided 2 Infestation of rodents cleared 16 Yard surfaces cleansed or repaired 9 Trapped sink waste pipes provided 18 Dirty working surfaces cleansed 8 Screening of food provided 6 60 Food Hygiene (Markets, Stalls and Delivery Vehicles) Regulations, 1966 These Regulations lay down requirements as to food hygiene in respect of markets, stalls and delivery vehicles. The principal requirements relate to:- Cleanliness of stalls and delivery vehicles. Cleanliness of persons engaged in the handling of food and of their clothing. Hygienic handling of food. Provision of water supply and washing facilities. Proper disposal of waste material. Granting of certificates of exemption from certain requirements. 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 158 food stalls in the Borough and 190 inspections were made during the year; 30 inspections were also carried out on delivery vehicles under the above Regulations. The principal difficulty in securing stallholders' compliance with the Regulations related to proper screening to prevent contamination of food. 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 29 applications for registration under the provisions of Section 16(1)(a) and 10 applications for registration under the provisions of Section 16(1 )(b) were submitted to the Council. In all cases the premises were found to be satisfactory and registration was granted. During the year 220 food complaints were received from members of the public and appropriate action was taken in every case. 61 Legal proceedings — Food and Drugs Act, 1955 Summonses were issued against traders for offences under this Act and the reasons for prosecution and the Court's findings are given below:- Subject of complaint Fine Foreign matter in bridge roll £25 Mouldy apple turnover £25 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 26 applications were received from persons to be registered as distributors of milk. In each case a certificate of registration was granted. Eleven notices of cancellation of registration were received. At the end of the year there were 226 persons and one dairy on the register. Food and Drugs Act. 1955 During the year, 100 samples of milk were submitted for analysis to which reference is made towards the end of this section of the report. 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 1972 is given below:- Special designation Number of licences issued "Pasteurised" 32 "Sterilised" 18 Milk (Special Designation) (Amendment) Regulations, 1965 These Regulations provide for the issue of Dealers (Prepacked Milk) Licences under the special designation "Ultra-Heat Treated" and 21 applications for such licences were received during the year. 62 Butchers' shops There are 153 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 779. Slaughter of animals There are no licensed slaughterhouses in the Borough. Poultry processing There is one establishment in the Borough at which the preparation of poultry for sale is carried out on a comparatively large scale. The birds are received from the proprietor's own farms where they have been bred, killed and de-feathered and at this stage the carcasses are subject to a preliminary inspection. On arrival at the premises in this Borough, the carcasses are eviscerated and dressed, following which a further inspection is made. The majority of these birds go to hotels and cafes and some for retail sale. Thirty-six visits were made to the above premises during the year, the number of birds processed being approximately 100,000, made up of broilers, hens, ducks, pheasants, turkeys and capons. The weight of poultry condemned as unfit amounted to 577 lb. The very small percentage of birds rejected as unfit for human consumption is by reason of the fact that the birds have already been inspected at the farms where they are killed. 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 85 such shops in the Borough and 271 inspections were made during the year. Catering establishments All restaurants, cafes, canteens, clubs, dining centres, hostels, community homes and nursing homes were regularly inspected throughout the year. There are 498 such premises on the register and 1,321 inspections were made. 63 Bakehouses There are 27 bakehouses in the Borough and during the year 134 visits by the food inspectors were made to these premises. Five 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 Four hundred and ninety food samples were examined bacteriologically at the Public Health Laboratory during the year and details are given below:- MiIk 9 Ice-cream 52 Shell-fish 387 Fish 22 Eels 10 Miscellaneous 10 Total 490 Milk The nine samples of sterilised milk submitted to the turbidity test were reported to be satisfactory. Ice-cream The 52 samples of ice-cream were examined at the Public Health Laboratory by 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. The following table gives a summary of the results:- Grade Number of samples 1 29 2 3 3 5 4 15 Total 52 64 In every case where the sample was considered to be unsatisfactory, the manufacturer was approached with a satisfactory outcome as shown by subsequent sampling. Shell-fish, fish and eels 419 samples of shell-fish, fish and eels were examined and two consignments were found to be unsatisfactory. M iscellaneous items Ten samples were submitted and all were found to be satisfactory. Imported Food Regulations 1968 There is one cold storage depot in the Borough to which 92 visits were made in connection with the above Regulations. In addition 20 consignments of food were inspected by the Public Health Inspectors at various other premises in the Borough. Food surrendered or condemned tons cwts Meat (carcase) 2 6 Canned meat 1 — Other canned food — 12 Fish — 12 Frozen foods 5 8 Other foods 1 5 Total weight 11 3 The visits to premises in this connection numbered 249. 65 REPORT OF THE WORK OF THE PUBLIC ANALYST FOR 1972 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. During the year 1,000 samples of food and drugs were submitted foranalysis;100 samples of milk, 865 other foodstuffs and 35 drugs. Of these 2 were submitted as formal samples, while 998 were purchased informally. One of the formal samples and 103 of the informal samples were found to be adulterated or below standard, representing 10.4 per cent, of the total samples submitted. The samples submitted for analysis comprised the following substances:- Beers, wines and spirits 13 Beverages (cocoa, coffee, tea, etc.) 16 Cereal preparations 8 Cheese products 27 Confectionery 130 Cream 8 Fats (butter, margarine, etc.) 14 Fish (canned, etc.) 57 Fruit (canned and dried) 71 Ice-cream 11 Meat products (including sausages) 145 Milk 100 Milk products 60 Pickles and condiments (including spices) 91 Preserves 32 Soft drinks 78 Soups 32 Vegetables 72 Drugs 35 TABLE 16 SAMPLES FOUND TO BE ADULTERATED OR BELOW STANDARD Sample No. Nature of Sample Report Formal 229 Ground Haldi Contained excess lead Informal 6490 Almond marzipan Slight deficiency of almond 66 Sample No. Nature of Sample Report 6512 Fried chips Incipient rancidity of fat 6521 Evaporated fruit salad Labelling irregularity: ingredients listed in wrong order 6525 Almond marzipan Slight deficiency of almond 6527 Almond marzipan icing Slight deficiency of almond 6534* Sterilised milk Consisted of 10% milk with extraneous water 6553* Jam Sponge Found to contain mouse excreta 6556 Prime beef steak in rich gravy, canned Deficient in meat content 6560 Spiced mixed vegetables Labelling irregularity: ingredients listed in wrong order 6567 Condensed full cream milk, sweetened Deficiency in total milk solids 6568 Casserole meat with vegetables and gravy, canned Deficient in meat content 6571 Milk Contained extraneous water 6573* Baked beans Mould growth found 6590 Sliced beef in jelly Deficient in meat content 6594* Calpol elixir Found to contain splinter of wood 6595* Demerara sugar Found to contain rodent excrement 6596 Milk food with nonmilk fat Deficiency of fat 6597 Chunky steak with carrots in rich gravy Deficient in meat content 6609* Apple turnover Found to contain the vertebra of a bird 6629 Steak and kidney pudding Deficient in kidney 6632* Bottle of milk Found to contain the larvae of fruit flies 6652* Chocolate mousse Found to contain a piece of plastic wrapping 6653* Fresh cream chocolate eclairs Sourness of cream confirmed 6665 Truffled pork liver pate Deficient in meat content 6666 Evaporated fruit salad Labelling irregularity: ingredients listed in wrong order 6667 Almond marzipan Slight deficiency of almond 6687* White bread Found to contain brown dough infested with insect larvae 6708* Currant bun Found to contain mouse excreta 6726* White bread Contained dark patches made up of dirt and grease from machinery 6730 Ice-cream Deficient in milk solids 6738 Cod roes Contained foreign matter including a small fly 6767 Crabeye beans Insect infestation 6777 Ice-cream Deficient in milk solids not fat 67 Sample No. Nature of Sample Report 6778 Ice-cream Deficient in milk solids not fat 6780 Fresh cream slices Contained fat other than milk fat in the cream 6794 "Cheese'n shrimp" Cheese element deficient in butter fat 6825 "Orange" Labelling irregularity: contained added sugar 6826 Pineapple juice Deficient in pineapple 6827 Grapefruit juice Labelling irregularity: contained added sugar, possibly deficient in fruit content 6842 Peppermint liqueur Labelling irregularity: no declaration of spirit strength on label 6863* Bottle of milk Contained vegetable debris from flowers 6886 Ground Haldi Excess lead present (45 parts per million) 6902 Dried instant grapefruit drink This was a dry "mix", not a dried drink 6903 Raspberry buttermilk Labelling irregularity: had been "cultured and sugar added" 6921 Tomato ketchup flavoured critps Incipient rancidity of fat 6945 Sheep tongues, canned Contained jelly, wrongly designated 6972 New potatoes, canned Labelling irregularity: carrying liquor not mentioned in the title 6999 Apple juice Deficient in fruit 7005 Condensed cream of mushroom soup, canned Deficient in fat 7006 Pilchards in tomato sauce. Canned Labelling irregularity: no list of ingredients 7009 Unsweetened lemon juice Deficient in fruit 7013 Fresh milk concentrate Failed to comply with the Condensed Milk Regulations 1959 7015* Bread Dirty dough containing iron, grease, etc. 7021 Fruit salad, canned Labelling irregularity: ingredients listed in wrong order 7023 Fruit cocktail in syrup, canned Labelling irregularity: ingredients listed in wrong order 7028 Strawberries in syrup, canned Deficient in sucrose 7029 Double concentrated tomato paste Corroded can. Contained lead in an amount equal to permitted limit and an excess of tin. 7033 Halloumi cheese Labelling irregularity: not labelled in accordance with the Cheese Regulations 68 Sample No. Nature of Sample Report 7049 Mackerel in natural oil Labelling irregularity: oil not mentioned in list of ingredients 7056 Ground Haldi Contained 50 parts per million of lead 7068 Butter beans, canned Labelling irregularity: carrying fluid not mentioned in designation 7073 Fillets of anchovies Labelling irregularity: no list of ingredients 7081 Brinjal pickle Labelling irregularity: ingredients listed in wrong order 7089 Beans sprouts Labelling irregularity: carrying fluid not mentioned in designation 7095* Vermouth Carbon deposit in bottle 7096 Rose geranium jelly Labelling irregularity: bore no list of ingredients 7097 Spiced grape jelly Labelling irregularity, bore no list of ingredients 7098 Tarragon jelly Labelling irregularity: bore no list of ingredients 7099 Margarine Excess moisture 7105 Butter beans, canned Labelling irregularity: carrying fluid not mentioned in designation 7113* Bottle of milk Exhibited brown stains due to mould 7124 "Outline" low fat spread Appears to fall within the category of margarine but does not comply with the Margarine Regulations 7137 Steak and kidney pudding, canned Deficient in kidney 7171* Milk bottle Dried film of charred organic matter 7174 Orange drink Contained excess saccharine 7196 Herring in natural oil Labelling irregularity: bore no list of ingredients 7197 Herring in tomato sauce Labelling irregularity: bore no list of ingredients 7201 Cinnamon Deficient in volatile oil 7207 Smoked herring fillets Labelling irregularity: bore no list of ingredients 7216 Steak and kidney pudding, canned Deficient in kidney 7230 Butterscotch dessert topping Labelling irregularity: misleading in respect of type and position of title 7236 Soft cheese Excess water: label incorrect in two respects 7247 i Fruit salad in heavy syrup Labelling irregularity: ingredients not listed in correct order 69 Sample No. Nature of Sample Report 7277 Shandy Deficient in alcohol 7278 Pineapple juice Labelling irregularity: should be 7279 Orange juice designated "sweetened fruit 7280 Grapefruit juice juice" 7285* Milk Contained iron and rust from disintegrated wire wool 7316 Fruit salad in syrup Labelling irregularity; ingredients listed in wrong order 7330 Steak and kidney pudding, uncooked Deficient in kidney 7350 Baby herrings, canned Labelling irregularity: no list of ingredients 7351 Fillets of anchovies, canned Labelling irregularity: no list of ingredients 7352 Sild. canned Labelling irregularity: no list of ingredients 7359 Roast chicken and sausage with stuffing and gravy Labelling irregularity: ingredients listed in wrong order 7378 Cheese spread Labelling irregularity: cheese incorrectly described 7389* Canned macaroni pudding Contained carbonised matter, possibly from over cooking 7429 Chocolate syrup Contained dye not listed among ingredients 7435 Chicken curry Deficient in meat; no list of ingredients 7438* Sliced bread Contained starter switch from fluorescent lighting tube 7448 Baby clams: canned Labelling irregularity: no list of ingredients 7460* Sterilised milk: insoluble matter Mixed with dried milk 7461* Sterilised milk: insoluble matter Mixed with dried milk 7489 Dried instant lemon drink Labelling irregularity: wrongly described The 22 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 six complaint samples were submitted but, following analysis, it was considered that the complaints were not justified. Details of these cases are given below:- 70 TABLE 17 Sample No. Nature of Complaint Report 6572 Meat extract: unpleasant taste No contamination found: unusual taste probably due to variation in ingredient quality 6670 Bread roll: foreign body Dried fruit 6790 Corned beef, canned; black discolouration Dried blood 7016 Pork sausages: deficiency of meat content Contained 70% of meat 7151 National dried milk: foreign matter Charred milk particles 7152 Sun-tan cream: caused irritation No irritant material found Milk samples During the year, 100 samples of milk were submitted for analysis (87 ordinary milk, 12 Channel Islands or South Devon milk, and one separated milk). Of these, one sample of ordinary milk was found to be below the minimum standard and appropriate action was taken. The minimum legal standards relating to the composition of milk are as follows Ordinarymilk 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% Pesticide Residues in Foodstuffs During the year, sixteen samples of food were taken by the Corporation for examination by the Public Analyst for pesticide residues, and the results are shown below. The types of food were selected by the Association of Public Analysts under the scheme initiated by the Association of Municipal Corporations to ascertain the extent, if any, of contamination of foodstuffs by toxic chemicals. For the purposes of the scheme it was decided that amounts of these compounds below certain limits (depending on both the type of pesticide and the type of food) should be considered insignificant. 71 TABLE 18 Sample Remarks Full fat soft cheese .. Contained traces of BHC; Heptachlorepoxide and DDE. All "below the reporting limits". Mercury 47.5. PP 109. Butter Contained traces of Heptachlorepoxide and DDT, both "below the reporting limits". Beef dripping Contained traces of Heptachlorepoxide and DDE. both "below the reporting limits". Corned beef Contained a minute trace of BHC. "below the reporting limit". Spare rib lamb Contained a minute trace of BHC, "below the reporting limit". Organo phosphorus residues, none detected. Milk (Pasteurised Homogenized) Organo-chlorine residues, none detected. Baby foods Contained a trace of BHC, "below the reporting limit". White loaf Contained a very small trace of BHC, "below the reporting limit". Plaice fillets ... Contained traces of BHC: DDE; TDE; DDT, all "below the reporting limits". Mercury 82.5 P.P. 109. Apples Organo-chlorine residues, none detected. Organo phosphorus residues, none detected. Thio-carbamates—trace, "below the reporting limit". Mercury 15 P.P. 109. Pears Traces of DDE; DDT. "below the reporting limits". Organo phosphorus pesticide, none detected. Thio-carbamates—trace. "below the reporting limit". Mercury 10 P.P. 109. Grapefruit Organo chlorine residues, none detected. Organo phosphorus residues, none detected. Mushrooms ... Traces of DDE; DDT, both "below the reporting limits". Thio carbamates—trace, "below the reporting limits". Lettuce Traces of BHC. "below the reporting limit". Organo phosphorus residues, none detected. Thio-carbamates, trace "below the reporting limit". Beef suet Heptachlorepoxide 12 P.P. 109. Mussels BHC 23 P.P. 109. Traces of DDE; TDE. DDT; all "below the reporting limit". Mercury 245 P.P. 109. 72 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 Secretary of State for Employment and Productivity:- Factories Act (Part I) Table 19 (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 53 75 1 - (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 963 1.232 59 - (iii) Other premises in which Section 7 is enforced by the Local Authority (excluding outworkers' premises) 14 37 - — Totals 1.030 1.344 60 — PLATE A DODDINGTON CHILD HEALTH CENTRE - A foot clinic in progress (see pages 3, 9 and 110) PLATE B DODDINGTON CHILD HEALTH CENTRE - The staff common room (see pages 3, 9 and 110) PLATE C CERVICAL CYTOLOGY - The mobile cytology unit (see page 94) PLATE D CERVICAL CYTOLOGY - The interior of the mobile cytology unit (see page 94) PLATE E PLATE F DENTAL HEALTH EDUCATION - School children watching a puppet show depicting "Mr. Toothbrush" defending "Peter Molar" against "Jimmy Germ". (see pages 116 and 1 38) 73 TABLE 20 (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 Sanitary conveniences: (a) insufficient 3 3 — 2 — (b) unsuitable or defective 103 103 — 2 — (c) not separate for sexes ... — — — — — Other offences against the Act (not includ ing offences relating to outwork) 1 1 — — — Totals 107 107 — 4 — Factories Act (Part VIII) Table 21 OUTWORK (SECTIONS 133 AND 134) Nature of work Section 1 33 Section 134 No. of outworkers in August list required by Section 133(1) (c) No. of cases of default in sending lists to the Council No. of prosecutions for failure to supply lists No. of instances of work in unwhole some premises Notices served Prosecutions Wearing apparel— making, etc. 64 - - - - - Household linen 4 — - — - — Curtains and furniture hangings 7 - - - - - Artificial flowers 4 - - - - - Lampshades 2 - - - - - Total 81 - - - - - 74 ATMOSPHERIC POLLUTION Clean Air Acts, 1956 and 1968 Smoke Control Orders The implementation of the Council's smoke control programme requires the making of seven Smoke Control Orders. The Council's fourth Smoke Control Order became operative on 1st July 1972, and the fifth on 1st November 1972. The sixth Smoke Control Order was made on 16th October 1972, and will become operative on 1st November 1973. A map showing the existing and proposed Smoke Control Orders is shown in this section of the report. Smoke, dust and grit nuisances and observations During the year, 138 complaints were made alleging nuisances from smoke, dust, grit, etc., emitted from premises in the Borough. All received careful and sometimes prolonged investigation. Observations are also kept upon the chimneys of industrial premises in the Borough and, when necessary, appropriate action is taken. During 1972, 121 such observations were made. Installation of furnaces Notification is required, under Section 3 of the Clean Air Act, 1956, of any proposal to install a furnace with a heating capacity 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, as far as is practicable, capable of being operated continuously without emitting smoke. Five such notifications were received during the year. Measurement of atmospheric pollution Daily readings of the concentration of smoke and sulphur dioxide(SO2) in the atmosphere were continued during the year at the three stations in the Borough where recording apparatus is maintained. Readings at the Tooting Library station were discontinued from September 1972 by agreement with the Map of London Borough of Wandsworth showing Wards and Smoke Control Areas 75 merit of Trade and Industry. A record of these readings in microgrammes per cubic metre for the year under review is given in Table 22 below. The readings are taken by members of the staff of the department and the information is passed to the Department of Trade and Industry for collation with data received from authorities all over the country. TABLE 22 Station Roof— Municipal Buildings 207 Lavender Hill Battersea Tooting Library Month—1972 Smoke SO2 Smoke SO2 Smoke SO2 January 55 136 76 220 58 200 February 54 156 69 230 51 172 March 132 109 91 196 74 160 April 69 138 61 168 50 157 May 48 140 46 182 45 148 June 38 132 44 137 32 116 July 21 142 49 122 26 120 August 22 60 44 114 30 102 September 45 200 61 158 — — October 40 174 70 142 — — November 46 212 78 181 — — December 52 247 90 219 — — Averages 52 154 65 172 46 147 76 MISCELLANEOUS MATTERS Swimming baths The Corporation has three public baths which have indoor swimming pools, at Putney, Balham and Battersea, and two openair pools, at King George's Park and Tooting Bec. All Corporation baths are supplied from the mains of the Metropolitan Water Board. The water is chlorinated and circulates continuously through a filtration plant. Samples of water are taken at regular intervals and are submitted to the Public Health Laboratory at County Hall for bacteriological examination. During the year, 86 samples were submitted for examination. Satisfactory results were obtained in 84 instances, with slight deviations in two samples; further tests proved satisfactory. There are open-air swimming pools at two of the Corporation's children's homes, one of which is situated at Banstead in Surrey. Satisfactory samples were taken by Banstead Urban District Council in respect of the home in their area. Several Inner London Education Authority's schools in the Borough have swimming baths, and during the year 100 reports were received from the Scientific Branch of the Greater London Council in respect of 13 of these baths. Satisfactory results were obtained in 95 instances; in the remaining samples there were slight deviations from normal but further tests proved satisfactory in all cases. Examination of water from artesian wells and taps Thirty samples were submitted for examination at the Public Health Laboratory and found to be 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. 77 Bedding and clothing are collected and steam-treated at the Disinfecting Station. 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. During the year 158 disinfections were carried out. 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. In 1972, 690 premises were disinfested for vermin. Control of insect pests: The construction in large blocks of flats, of covered ducts for hot water, plumbing and drainage pipes has sometimes been a cause 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 Two hundred and seventy five treatments were given during the year at the two personal cleansing stations to persons suffering from scabies, 114 to schoolchildren, 125 to adults and 36 to children under school age. In addition, 1,319 treatments for verminous conditions were given, 1,013 to schoolchildren, 179 to adults and 127 to children under school age. These figures include the following treatments carried out under arrangements made with the London Borough of Lambeth relating to their residents and children attending schools in Lambeth Adults and pre-school School children children Total Scabies 30 22 52 Vermin 18 52 70 78 Laundry service for incontinent persons During the year 5,749 bags each containing about 10 lb. of soiled linen were collected and the contents laundered and returned to the owners. This valuable service continues to be in great demand by old and inform persons. Coroner's Court and Mortuary Details of post-mortem examinations and inquests held at the Coroner's Court, and of bodies received into the mortuary during 1972, are set out in the following table:- TABLE 23 Details of bodies received Usual place of residence Totals Wandsworth Merton Elsewhere Unknown Post-mortem only 669 324 161 45 1,199 Post-mortem and inquest 79 34 45 7 165 Total post-mortems 748 358 206 52 1,364 Inquest only — — — — — Total inquests 79 34 45 7 165 Total bodies received 748 358 206 52 1,364 Verdicts at Inquests held— Accidental/misadventure 36 17 33 2 88 Alcoholism 4 — — — 4 Natural causes 3 — 2 — 5 Open verdict — 1 3 — 4 Suicide 34 13 5 3 55 Homicide 2 3 2 — 7 Drug addiction — — — 2 2 Totals 79 34 45 7 165 In addition to the above, a further 75 inquests were held at the Coroner's Court although the bodies were not required to be received in the mortuary. 79 Transportation of bodies abroad The bodies of persons dying in this country who are normally resident abroad are sometimes transported overseas for burial. This cannot be done without a certificate from the Medical Officer of Health of the district in which the death has taken place to the effect that the death was not due to infectious or contagious disease, and that no recent epidemic of such disease had occurred in the district. No certificates were issued during the year. Cremation Regulations, 1930 Under these regulations, 2,210 cremations were authorised during 1972. STAFF TRAINING Public Health Inspectors. Technical Assistants and other staff The Council provides facilities for public health inspectors, technical assistants and other staff to undertake refresher courses and to attend conferences and courses relevant to their work. In 1972 the following courses were attended:- A fire prevention course by one public health inspector and six technical assistants. A course on the Hoists and Lifts Regulations by two public health inspectors. A two-day symposium on clean food by two public health inspectors. A one-day symposium on aircraft noise by the Chief Public Health Inspector. A one-day course on insect pests in stored food products organised by the Ministry of Agriculture, Fisheries and Food by two public health inspectors. A noise prevention course by one public health inspector. A one-day course on problems with the administration of the Offices, Shops and Railway Premises (Lifts and Hoists) Regulations by six public health inspectors. 80 A civil defence course for public health inspectors by one public health inspector. A weekend school by two public health inspectors. A one-day course on the control of rodents in sewers by two rodent operatives and one student. A rodent control course organised by the Ministry of Agriculture, Fisheries and Food by two rodent operatives. A two-day symposium on odour control by the Deputy Chief Public Health Inspector. In addition, the Annual Conference of the Association of Public Health Inspectors at Blackpool was attended by a divisional public health inspector and the Annual Conference of the National Society for Clean Air at Scarborough by the Chief Public Health Inspector. Student Public Health Inspectors Under the limits imposed by the Public Health Inspectors' Education Board, six students are allowed to undertake training within the department. They attend day release courses at the South-East London Day College and the Tottenham Technical College combined with a full programme of visits and practical training with a qualified inspector. Four students were in training in the department at the close of the year. PART 4 PERSONAL HEALTH SERVICES 81 These services are provided by the Council, in its capacity as local health authority, under those sections of the National Health Service Acts and the Health Services and Public Health Act, 1968, which are designed to safeguard the health of the individual and to provide care and attention should ill-health occur. Comprehensive health centres The policy of development of new health centres to serve areas of need, and to replace old adapted premises, first approved by the Health Committee in May 1967, was pursued throughout 1972. In addition to the three health centres already in an advanced planning stage, namely Bridge Lane, S.W.11 , Brocklebank, S.W.18, and Larch Road, S.W.12, together with a fourth centre at Burtop Road, S.W.17, (still in an early planning stage) preliminary discussions took place with representatives of St.George's Hospital, Tooting, local general practitioners, and the two Executive Councils concerned, to consider the provision of a fifth centre to be included within the development area of the Hospital. At the end of 1972 the programming of the centres remained as for 1971, since provisional completion dates had not been decided for the Burtop Road and St.George's Hospital Centres. Community nursing service Co-ordination and co-operation were the watch words of the community nursing service during the year. While welcoming the the introduction in October 1971 of the Mayston Structure of Management, the matter of implementation occupied us for the greater part of 1972. We intended that the structure of management and its implementation would, wherever possible, engender a high degree of job satisfaction and recognition for individual effort within a team of people working together; and that each member of staff be afforded respect for his contribution and to experience his value as a team member. To facilitate a team approach the two nursing officers working within each geographical area were based at the same centre within their area, and all staff coming under their span of control were allocated bases within that 82 area. Such an arrangement encouraged the team to be mutually supportive, mutually critical and to clarify and change their thinking concerning the variations in the role of the four arms of the service. As a result of a number of meetings between the staff of Queen Mary's Hospital, Roehampton, and the community nursing staff, a liaison scheme commenced in January. The scheme involves the planned early discharge of surgical patients, and ensures that admission and discharges are planned with full knowledge of the patients' clinical and social conditions and of the support that can be provided by the community services. The practice of "attaching" community nursing staff to groups of general practitioners continues to grow and at the end of the year nine members of staff were working in "attachment" and two in liaison schemes. Health visiting service At the beginning of the year one health visitor was working in an "attachment" scheme. During the course of the year attachment schemes involving three health visitors started and in addition two health visitors commenced working in liaison schemes. The continuing process of attachment of health visiting staff to general practice has played an important part in increasing the general practitioners' and the public's awareness of the role of the health visitor. The demand for health visiting has increased and the type of service demanded has also changed; so the health visitors have had to adjust to changes in the character and needs of the people served, new ways of carrying out the service, changes within the organisation and the considerable changes in the total resources available. The improvement in the social and economic state of the community no longer requires the health visitors to be totally committed to mothers and young children, but demands that the service be extended to the whole family. The work of the health visitor consists of advising, teaching, counselling, identifying needs and linking with medical, para medical, and social work agencies. Continued contact with families gives the health visitors detailed knowledge of the community with an identifiable service to contact when in need. The number of first visits made during the year to children under five years of age was:- 83 TABLE 24 Children born in 1972 4,187 Children born in 1971 3,252 Children born in 1967-1970 9,913 Total visits of all kinds paid by health visitors during the year: Effective visits 45,801 Unsuccessful visits 15,403 Total visits to the elderly 3,880 Domiciliary midwifery service The number of home confinements attended by the domiciliary midwives continues to decline. There were 252 home confinements this year as against 347 in 1971, but the number of patients delivered by the domiciliary midwives in the general practitioner obstetric unit at the Weir Hospital has increased from 87 in 1971 to 92 in 1972. The early discharge scheme has continued; all hospitals offering maternity service to the residents of Wandsworth now use this service and all mothers attending the maternity departments of hospitals are made aware of this service. A total of 834 patients have been nursed in their own homes following hospital confinements and it says much for the reputation of the domiciliary midwives that the majority of mothers using the early discharge scheme have elected to do so. The close co-operation with St.George's Hospital, Tooting, has continued. In April it was arranged with St.James' Hospital, Balham, that a midwife would attend the two ante-natal clinics held each week to be available for consultation with the staff of the clinic and those patients requesting early discharge after confinement. This close co-operation between the hospital and the community staff ensures a full exchange of information and continuity in the care of the patient. The midwives have taken 924 blood specimens for the Guthrie test. Mothers attended in their own homes during the year were as follows:- 84 TABLE 25 Home confinements 252 Booked early discharges 450 Unbooked early discharges 384 This total of 1,086 was eleven fewer than in the previous year. The number of home nurses working in partnership with general practitioners has increased from three to six. Discussions are taking place with other general practitioners and it is anticipated that more "attachment" schemes will be introduced in the coming year. A most encouraging aspect of group attachment is the increasing support given to the elderly sick and the handicapped in the community. Over 70 per cent of all cases requiring nursing care at home are 65 years of age or over, and the number steadily increases year by year. Regular consultation with the general practitioner and improved communication between hospital and community staff has resulted in the home nurse not only giving skilled nursing care, but assisting in the rehabilitation of the elderly. Immobility and incontinence are commonly found in this age group of patients and the increase in the number of nursing auxiliaries and the in-service training now provided, has led not only to an increased number of visits, but also ensured an improved quality of care. After discussion with the staff of Queen Mary's Hospital, Roehampton, a liaison scheme involving both hospital and the community nursing staff commenced in January This scheme, called the Planned Early Discharge of Surgical Patients, enabled the admission and discharge of selected surgical patients to be arranged with the full knowledge of the patient's clinical and social conditions and the support that can be provided by the community services. The provision of home nursing service commences on the actual day of discharge, the nurse acting as communicator with the general practitioner, the hospital and the community services. The following table shows the total number of persons nursed and the visits paid during the yean- Home nursing service 85 TABLE 26 Age First visits Revisits Totals Under 5 years 34 334 368 5-64 years 831 21,689 22,520 65 years and over 2.169 100.039 102,208 All ages 3,034 122,062 125,096 Home bathing service This is an integrated part of the home nursing service which is undertaken by nursing auxiliaries who, although not qualified nurses, are trained to undertake many tasks for patients who do not need full nursing care. All patients receiving home bathing service are visited at least monthly by a trained nurse. Loan of equipment To ensure the efficient nursing of patients in their own homes the Council operates a scheme for lending, without charge, equip ment as distinct from those items which can be prescribed by general practitioners. To avoid duplication of function by the Health Department and the Social Services Department, arrangements were made for the latter department to control all issues of equipment normally provided to handicapped persons. The number of occasions on which articles were issued on loan by the Health Department during the year is shown below:- Beds (hospital or cot) 8 Hoists 25 Mattresses 4 Ripple beds 100 Rubber and plastic sheeting 184 The Council's provision of home nursing equipment is supplemented by the British Red Cross Society, which provides commodes and wheelchairs and smaller items of equipment such as air rings, bed pans, urine bottles and crutches. The Council is continuing to make a grant to the Society to assist in maintaining stocks of equipment. Incontinence pads service The issue of incontinence pads, which are of great assistance in the nursing of incontinent persons in their own homes, continues and 185,900 pads were issued during the year. In addition, 56,200 86 interliners were issued for use in special protective pants provided by the Council. Protective pants and interliners are of particular value for ambulant patients, including subnormal and handicapped children. Most households make their own arrangements for disposal of incontinence pads and interliners, but in some cases it is necessary to arrange collection and disposal by incineration. Home dialysis The programme of home dialysis conversions continued during 1972, when requests for help were received on eight occasions, the majority emanating from Fulham Hospital as in the previous year. Good working relations were maintained with all the hospitals concerned. During the year two patients on home dialysis received kidney transplants, one of whom sadly died. The prolonged period during which there were power cuts due to industrial disputes caused serious concern for the welfare of home dialysis patients, some of whom might have been on dialysis when the power was cut. However, thanks to good liaison with the Electricity Boards, this problem was overcome by patients being taken into the hospitals' own dialysis units where necessary. The table below gives details of the cases dealt with in 1972. TABLE 27 Hospital Date of completion of adaptations Cost Lambeth January, 1972 £982.72 St. Helier April, 1972 £567.00 Fulham July, 1972 £976.00 Fulham September, 1972 (portable unit provided) £1,689.00 Fulham October, 1972 £951.00 Fulham Not completed at end of year £1.350.00 (estimated) In addition to the cases shown above, one other patient was referred in 1972, but the adaptations to his premises were not completed as the patient received a kidney transplant. 87 Family planning This key service continued to develop steadily in 1972 and Wandsworth remains one of the leading local health authorities in this field. Throughout the year excellent communications have been enjoyed with hospital consultants, general practitioners and the neighbouring boroughs of Merton, Richmond and Lambeth. As in previous years, the South-West London Sranch of the Family Planning Association has acted as the agent of the Council in operating the clinics held in our maternal and child health centres and on hospital premises. There is no charge for consultation or medical supplies for patients recommended on medical grounds and patients referred on social grounds pay only for supplies although in cases of economic difficulty supplies may be given free of charge. The further expansion of the service in 1972 comprised three new weekly sessions, namely, at the Stormont and Doddington Child Health Centres and - a particularly welcome development at St.George's Hospital, Tooting. These augmented the eighteen sessions already held each week in Wandsworth - thirteen at our maternal and child health centres and five in a hospital setting (at StJames', Balham, and Queen Mary's, Roehampton). Oral contraceptives remain the most popular form of birth control prescribed. In addition, during the summer, the Council decided to meet on the basis already mentioned in relation to the Family Planning Association the charges for Wandsworth residents who attended Brook Advisory Centres (all located outside the Borough) to obtain advice on birth control. Accordingly per capita payments were made in relation to the 246 patients who in the last half of 1972 attended these centres, which cater particularly for young people. So far as the service within the Borough was concerned, 4,109 new patients were seen in the course of the year, a very appreciable increase on the comparable figure in 1971 (3,336). The total attendances increased similarly from 20,318 in 1971 to 23,935 in 1972. The increase in the number of new domiciliary patients from 154 to 192 was equally impressive; at the end of the year 424 patients were receiving service at home compared with 374 twelve months previously. This indispensable domiciliary family planning service is fully comprehensive, free of 88 charge, and easily available - any doctor, health visitor, social worker or probation officer can recommend that it be given and every case receives prompt attention. The popularity of the family planning clinics reflects the high quality of service rendered by the members of this service. In this regard our special thanks are due to Dr.Edge, the Chairman, Mrs.Crampton-Smith, the Organising Secretary, Dr.Duncan-Whyte and her medical colleagues, and all the nurses and clerical staff of the Family Planning Association. Looking to the future, in February the Health Committee considered the desirability of abolishing all charges which the Council made for family planning services but, in the absence of any concrete evidence of a financial deterrent in the existing arrangements, decided to launch a major publicity campaign with the object of comparing subsequent attendances at the clinics in Wandsworth with those in an adjoining borough where a completely free service was scheduled to be introduced the following April. An intensive publicity drive was accordingly launched in the spring. In November the Health Committee reconsidered the question of charges in the light of the 67% increase in the attendance of new patients experienced during the first three months, in the context of a completely free service, in the London Borough of Lambeth compared with an increase of 27% in Wandsworth during the same period, and the Council subsequently accepted a recommendation to abolish all charges in relation to the attendance of residents of the Borough at Family Planning Association Clinics within or without Wandsworth, and at Brook Advisory Centres, with effect from the beginning of 1973. In addition this free service would be available to non-residents working in the Borough who attend local clinics. Finally, the possibility of establishing "walk-in" centres where young people would receive in informal surroundings advice regarding not only birth control but also allied emotional problems was being actively explored at the end of the year. The statistical analysis which follows (Tables 28 and 29) gives details of the patients who were helped during the course of the year. 89 TABLE 28 New patients seen: 1972 1971 Medical 711 220 Social 3,398 3,116 Totals 4,109 3,336 Contraceptive methods advised: Sheath 160 66 Oral contraceptive 2,429 2,074 Diaphragm 377 493 Intra uterine device 494 519 Other methods 323 52 No method advised 326 132 Established patients attending for first time during the year 6,273 4,909 Number of attendances (including new patients) 23,935 20,318 Number of premises in use as family planning clinics at end of year 11 8 Number of sessions held 1,383 1,162 90 TABLE 29 FAMILY PLANNING DOMICILIARY SERVICE 1972 1971 1972 1971 New cases Pregnant on referral (advised or for advice after delivery) 16 14 Medical 15 14 Social 177 140 Totals 192 154 Termination of pregnancy 8 4 Number of children on referral Cervical smears taken 58 50 0 2 — First method chosen: 1 25 13 Intra-uterine device 63 57 2 39 31 Oral contraceptive 85 60 3 34 40 Cap 11 5 4 37 23 Sheath, etc. 9 10 5 24 16 Advice 24 22 6 15 13 Total visits made by doctors 720 857 7+ 16 18 Age of mother on referral Total visits made by nurses 1,856 1,832 Under 16 4 — Total number of patients seen by doctors 409 407 16-20 37 29 21-24 67 33 25-29 37 44 30-35 34 25 Over 35 13 23 Unplanned pregnancies Intra uterine device 2 5 Oral contraceptive 12 8 Cap 3 1 Sheath, etc. 7 6 24 20 Withdrawn from domiciliary service: 1972 1971 Transferred to local clinics 87 55 Left district, transferred where possible 26 40 Transferred to other domiciliary services 6 26 Discharged (e.g. to care of G.P.. gynaecologist, etc.) 22 11 Refused advice 1 1 Termination and sterilisation 7 8 Sterilisation—female 18 20 Vasectomy 8 3 Totals 175 164 Total number of patients referred since April. 1967—1,065. Number of patients being advised at 31st December. 1972—424. 91 Cervical cytology The outstanding features of 1972 were the introduction at the beginning of the year of the National Recall Scheme for Routine Cervical Cytology; the commencement in February of two early evening clinics for the general public; and the use in the autumn of a mobile cervical cytology unit kindly loaned by the Women's National Cancer Control Campaign. Exactly five years after a nation-wide cervical cytological screening service was introduced in this country, a centrally based recall system was launched whereby women aged 35 and over whose previous test had been negative would be invited to have a further test 5 years after their last examination. Under this scheme, recall is initiated by the National Health Service Central Register at Southport for those women in relation to whom it received a copy of the form used when they were previously examined. The names concerned are forwarded to the appropriate Executive Council which transmits them to the corresponding local health authority after consulting the patients' general practitioners; this procedure enables the family doctor to advise against the recall where this is contra-indicated on medical grounds. The local health authority then writes to each patient concerned inviting her to be screened again either by her own doctor or at a local clinic. Where for any reason the patient fails to respond to the initial invitation a further letter is sent after an interval of six weeks. In Wandsworth where routine testing is repeated every three years irrespective of age a copy of the laboratory form is automatically sent to Southport in relation to every woman screened so that the local and national routine recall schemes are married effectively. Arrangements for recall, both locally and centrally, proceeded smoothly in 1972 and a grand total of 792 such routine examinations was performed in our clinics. Another welcome innovation was the establishment in February of fortnightly evening clinics at the Tooting and Victoria Drive Centres which were open between 6 and 8 p.m.; judging from the public response these meet a very real need in an age when more and more women are out at work during the day. For the same reason arrangements were made for a weekly screening clinic to be held in a factory employing a large number of women and offering adequate facilities for medical examination purposes. 71 women, of whom one was found to have a positive cervical smear, were examined in the course of this useful project. 92 Regrettably it proved necessary to end the regular screening clinic at the William Harvey Centre owing to the poor attendances, in part at least attributable to the difficult geographical location, but this setback was offset by the inclusion of a weekly session in the programme of the new Doddington Child Health Centre which opened early in the year. Although the number of women screened at our regular centres fell slightly - 2,409 examinations undertaken compared with 2,533 the previous year - the clinics continued to be well attended. The average number of seven patients seen at each session gave the doctor sufficient time for obtaining a good history of previous health, and carrying out a full gynaecological and breast examination. It also allowed for general health counselling. Some general practitioners in the borough prefer to provide a cervical cytology service themselves, but the majority advise and encourage their patients to attend the Council's clinics. During the year, approximately four women in every thousand screened were found to have a positive cervical smear. Once again the detection of minor but nonetheless frequently troublesome infections or abnormalities proved an important by-product of cervical cytological screening, such conditions being present in nearly one-third of the women who attended the clinics in 1972. Although no case of malignancy was detected, the discovery of less serious abnormalities in 32 women underlined the value of routine palpation of the breast as part of the overall screening examination conducted in the cervical cytology clinics. In addition much anxiety regarding the possible presence of a malignant growth is relieved, particularly in those women who have a family history of breast cancer. Detailed statistical information for 1972 (including the factory screening results) is given in the following table:- TABLE 30 Number of sessions held each week 7 Total number of women examined 2,409 Total number of sessions held 323 Average number of women examined at each session 7 Total number of cases cytologically and clinically negative (healthy women) 1,687 Total number of cases with morbid conditions 722 93 Morbid conditions found: (i) positive malignant smears 10 (ii) dyskaryosis (abnormal cells present in smear) 1 (iii) cervical erosion 86 (iv) cervicitis 34 (v) cervical polyp 56 (vi) ovarian cyst 4 (vii) uterine fibroids 28 (viii) all degrees of prolapse 33 (ix) breast abnormalities 32 (x) vulvovaginitis: (a) monilia 44 (b) trichomoniasis 96 (c) non-specific 85 (d) senile 33 (e) other 41 (xi) miscellaneous abnormalities 11 (xii) other conditions 146 Total morbid conditions 740 * Some patients had more than one condition. The use of a Mobile Cervical Cytology Unit Continuing publicity is essential if full advantage is to be taken of the cervical screening facilities available to the general public through the family doctor and the local health authority well-woman clinic. Hence the intensive publicity drive undertaken throughout the Borough in the spring. The knowledge that probably well under half the women in the most vulnerable groups are screened regularly also prompted the acceptance of the offer of a leading voluntary organization in this field, the Women's National Cancer Control Campaign, to lend a mobile unit to the Borough free of charge for a period of four weeks in September. 94 The primary purpose of the visit of the mobile unit, with its attendant publicity, was therefore to encourage more women to take the "smear" test to detect pre-cancerous conditions of the neck of the womb. It was hoped that by taking the mobile unit into areas where women live and work, there would be an easing of the communication and commitment barrier which militates against women first attending formal, static clinics and that, after initial attendance at the mobile unit, they would be more favourably disposed to attending permanent clinics for future examinations. It was also hoped that the mobile unit would be of particular value in attracting the especially vulnerable groups, namely women over 35 years of age and/or mothers of several children and particularly those in the lower socio-economic groups. To this end the mobile unit was used at the following five locations:- (i) Forecourt of Battersea Training Centre, Thessaly Road, S.W.8. - 4/5th September; (ii) Chatham Hall Child Health Centre, Northcote Road, S.W.11. 6/8th September; (iii) Site adjoining Meyrick Arms Public House, Falcon Road, S.W.11. - 11/15th September; (iv) Forecourt of Roehampton Training Centre, Roehampton Lane. S.W.15. - 18/22nd September; (v) Forecourt of Putney Swimming Baths, Dryburgh Road, S.W.15. — 25/29th September. In selecting the sites, the general principle adopted was that they should not be immediately adjacent to existing cytology clinics but that they should be within reasonable distance of such clinics for subsequent recall and follow-up. A considerable amount of preparatory administrative and clerical work was necessary over a period of four months before the arrival of the Unit. These preparations entailed close consultation with the Women's National Cancer Control Campaign, water, gas and electricity authorities, the Metropolitan Police, other Departments of the Council, the voluntary helpers who assisted in the preparation and distribution of leaflets, and with hospital laboratories who were to undertake examination of the smears. 95 So far as local publicity was concerned this was prepared in collaboration with the Council's Press and Information Officer and comprised press releases, posters to be displayed on site and about 18,000 individual leaflets to be distributed either on a door-to-door basis or handed out in the street. The decision as to the method of distributing leaflets was based on the nature of the locality, with door-to-door distribution being used in the predominantly residential areas of Thessaly Road and Roehampton Lane and street hand-outs being used in the other three areas, namely Northcote Road, Falcon Road and Dryburgh Road where there were more commercial and public recreational activities. Valuable assistance in distributing the leaflets was provided by members of Scouts Groups and the Alton Youth Club in relation to door-to-door delivery and by voluntary helpers organised by the Women's National Cancer Control Campaign in relation to street handouts. A visit to the Unit by The Worshipful the Mayor was greatly appreciated. To provide a further means of monitoring and evaluating the performance of the mobile unit, a concurrent publicity campaign was arranged in two control areas which were not to be visited by the unit and where there were well-established static clinics. The two control areas selected were Balham - where leaflets were distributed on a door-to-door basis within a half-mile radius of the Balham Child Health Centre, Bedford Hill - and Tooting Broadway, where leaflets were handed out in the street. During the four-week period a total of 374 women attended the mobile unit. A detailed analysis of those attending by age, marital status and source of referral is given in the following tables:- TABLE 31 ANALYSIS OF WOMEN ATTENDING BY AGE-GROUP AND MARITAL STATUS Age-group Married Totals % Single Totals % Separated or divorced Totals % Widowed Totals % TOTALS Under 25 7 1.9 4 1.1 1 0.3 – – 12 25-34 54 14.5 8 2.1 4 1.0 1 0.3 67 35-44 79 21.1 5 1.4 5 1.3 5 1.3 94 45-54 94 25.1 3 0 8 5 1.3 6 1.6 108 55 64 48 12.8 8 2.1 2 0.6 7 1.9 65 65-74 11 2.9 – – – – 16 4.3 27 Over 74 – – – – – – 1 0.3 1 TOTAL 293 78.3 28 7.5 17 4.5 36 9.7 374 Table 31 shows that the majority of women attending were married, and that nearly 80% of all who attended were 35 years of age or over. 96 TABLE 32 SOURCES OF REFERRALS TO MOBILE UNIT Source of Referral No. % Leaflet, door-to-door 50 13 Leaflet, street handout 123 33 Local notice or poster 65 17 Local newspaper 24 6 Saw mobile unit on site 52 14 Referred by community nurse 5 2 Referred by General Practitioner 5 2 Told by a friend 50 13 Total 374 100 TABLE 33 DETAILS OF MORBID CONDITIONS DETECTED Morbid Conditions Malignancy Ovarian Cyst Fibroids Breast lump Trichomonas Vaginalis Monilia Nonspecific infection Atrophic Vaginitis Polypi 44 1 1 1 2 5 14 18 2 TABLE 34 RATE OF DETECTION OF MORBID CONDITIONS IN THE MOBILE UNIT COMPARED WITH STATIC CLINICS Malignancy Other Morbidity Mobile Clinic Ordinary Clinic Mobile Clinic Ordinary Clinic 1 : 354 1 : 235 1 : 9 1 : 3 One positive smear was detected in a middle aged woman with several children and the diagnosis of carcinoma of the cervix was subsequently confirmed following hospital investigation. In addition, another 34 women were found to be suffering from less serious conditions requiring treatment or further investigation. These detection rates undoubtedly are low in comparison with detection rates at permanent clinics and the reason for this lies in the fact that 62% of women seen at permanent clinics are referred by family doctors and in the majority of cases come to the family doctor with gynaecological symptoms. This high 97 proportion of referrals through the family doctor where the permanent clinics are concerned is in sharp contrast to the very small percentage (2%) of referrals from this source to the mobile unit. Of the women attending the mobile unit, some 83% said that their visit was the result of seeing a leaflet, reading a press item, or seeing the unit on site. 46% gave leaflets as their main reason for coming and it would appear that the street handout (33%) was more successful than the door-to-door distribution (13%). Looking at the attendance rate it can be said that for each hundred leaflets distributed, one person attended the unit and similar results were achieved at the static clinics in the control areas. The original estimate of the cost of the campaign was £1,700 but in fact the expenditure proved to be in the region of £1,000, giving a cost per woman examined of about £2.70. The comparable cost of each examination in one of our regular clinics during the first half of the 1972/73 financial year was £1.70. Looking at the overall results of the mobile campaign, it must be stated that attendances at the mobile unit were lower than had been hoped - and hence the higher cost of the mobile unit examination - and there appear to have been two main reasons for this. In the first place, adverse weather conditions were experienced on several days. Secondly, and more importantly, it was found that the attendances were low when the mobile unit first started operation at each location and tended to increase during the period of each visit. This indicates that a period longer than one week in a particular location probably is necessary before the unit becomes fully effective. The long-term effect that the mobile unit will have upon attendances at permanent clinics cannot be judged until a reasonable period of time has elapsed. In the period of four months during and since the visit of the mobile unit, the average number of women attending permanent clinics has been 50 a week, as compared with an average weekly attendance of 43 in the three months preceding the visit. The effect at this stage can only be described as marginal and this is borne out by the experience of other London Boroughs where the unit has been used. Undoubtedly the exercise has been valuable in highlighting the need to concentrate publicity efforts in relation to the waiting room of the family doctor where posters can be exhibited and leaflets displayed; and to reinforce the efforts of general 98 practitioners by ensuring that health visitors and home nurses, whether attached to general practices or operating from child health centres, lose no opportunity of encouraging women to be screened regularly. Similarly, regular advertisement in the local press of the services available is an effective adjunct to this person-to-person publicity. In conclusion, there can be no doubt that the visit of the mobile unit and the attendant greatly appreciated voluntary effort has served a valuable purpose in crystallising firm impressions concerning the effectiveness of the various publicity media available. The experience gained as a result of this venture will be put to good use in furthering the sustained effort which alone can persuade women as a whole to recognise the important new frontier of preventive medicine which screening for pre-symptomatic disease at an early, eminently curable, stage represents. Ante-natal and post-natal care The midwives work in close co-operation with the general practitioners and five midwives attend ante-natal clinics in doctors' surgeries. Weekly ante-natal clinics are held by the midwives at seven of the centres, a doctor being in attendance once a month at each of the clinics to take blood samples. The patients delivered in hospital usually return to that hospital for post-natal examinations, or, if preferred, attend their general practitioners. Those patients delivered at home or in the General Practitioner Obstetric Unit of the Weir Maternity Hospital are examined by their general practitioner. It is the responsibility of the health visitor, visiting the mother following confinement, to ensure that the mother is aware of the importance of receiving post-natal care, and to encourage her to accept the post-confinement medical examination and advice on family planning. TABLE 35 Number of sessions attended by doctors 38 Number of sessions attended by midwives only 488 Number of women attending for ante-natal care 2,379 Number of women attending for post-natal care 2 Total attendances 2,762 99 Premature infants During the year there were 4,551 births, 386 (nearly 8%) fewer than during 1971. The proportion of live premature births to the total live births increased slightly from 7.8% in 1971 to 8.4% in 1972, there having been 375 live premature births in 1972 and 383 in 1971. There was a considerable change in the number of premature stillbirths, which increased from 28 in 1971 to 46 in 1972. The following table gives details of the 1972 premature births in Wandsworth:- TABLE 36 Live births Died under one month Stillbirths 2lb. 3oz. or less 13 10 12 Over 2lb. 3oz. up to and including 31b. 4oz 21 5 10 Over 31b. 4oz. up to and including 41b. 6oz 64 8 15 Over 41b. 6oz. up to and including 41b. 15oz. 103 1 2 Over 4lb. 15oz. up to and including 5lb. 8oz. 174 4 7 375 28 46 Mothercraft and relaxation classes Relaxation classes and talks on mothercraft are held at nine centres. Ante-natal education has, in the past, concentrated largely on preparing the expectant mother for labour and more recently for the responsibilities of parenthood. At present more and more emphasis is put on involving the fathers in the process taking place, enabling them to accept their parental responsibility together. The classes are extremely popular and for this reason the number of classes has been increased this year. The health visitors in the Roehampton area hold a relaxation class in Queen Mary's Hospital, Roehampton and this is proving to be very successful. table 37 Sessions held during the year 120 First attendances of mothers 462 Total attendances 1,319 Average attendance at each session 11 100 Child health centres The Doddington Child Health Centre, 311 Battersea Park Road, S.W.11 , opened on 1st February. This is a purpose-built centre within the Doddington Estate housing complex and, in addition to providing a wide range of health services for residents of all ages, it serves as a base from which health visitors, school nurses and clinic nurses work. Home nurses working in the area use the centre as a daily meeting place. All sessions formerly held at Welcome Hall Centre nearby were transferred to the new centre and the former health visitors' office at 10 Cambridge Road was closed. The new premises are also used by the Social Services Department, the League of Friends of the future Bridge Lane Health Centre, and by the Wandsworth Council for Community Relations. To improve and extend the service, investigations were undertaken during the year to assess the feasibility of extending the accommodation at Tooting and Chatham Hall Child Health Centres. Evening child health sessions are held at Balham and Tooting Child Health Centres and have proved very successful. Discussions are now taking place concerning the provision of evening clinics at other centres as the number of women in fulltime employment continues to increase steadily. In addition, consideration is being given to the possibility of holding relaxation and mothercraft classes in the evenings. TABLE 38 Number of sessions held during the year 1,760 Number of children attending: Born 1972 3,759 Born 1971 3,664 Born 1967-70 5,814 Total number of children attending 13,237 Total attendances 39,469 Average attendance per session 22,3 Occasional creches The occasional creches continue to be exceedingly popular, and the demand for admission is very heavy. As the provision of playgroups increases in the borough to cater for all children needing such facilities, so will the creches be used more selectively in relation to the activities of the clinics. The recruitment of staff continues to be a problem and it is of much concern that, in employing trained playgroup personnel, we may be depriving playgroups who serve a greater number of children of valuable staff members. 101 LINKS WITH PAEDIATRIC DEPARTMENTS Developmental Screening and the Assessment of Handicapped Children The concept of early identification of handicap by periodic developmental screening of all young children has its logical counterpart in the provision of special clinics where further investigation, treatment and comprehensive care can be initiated. The exact localisation of assessment clinics, that is whether they should be attached to a hospital, a special school or run by the local authority is immaterial - such divisions are artificial. What is essential is that hospital specialists, family doctors and those working in community paediatrics, teachers working in special schools and therapists in specialised departments should combine in their efforts to see the child as a whole, for only then is it possible to offer constructive advice to the parents and plan realistically for the child's future. With this in mind during 1972, closer links have been established with the Paediatric Departments of the hospitals associated with Wandsworth. Senior doctors from the hospitals are now undertaking clinical sessions at the child health centres whilst local authority doctors experienced in developmental paediatrics, have become part of the team helping to assess handicapped children either in hospital or in special sessions held in local authority clinics. At present the following arrangements are in existence:- Queen Mary's Hospital - A Principal Medical Officer holds Roehampton. an Assessment Clinic weekly at (Westminster Hospital the Eileen Lecky Clinic. Group) - Once a month a Paediatrician from the Hospital attends this Clinic. - A clinical medical officer attends the Paediatric Department twice weekly, to help in the assessment of children attending the Prosthetic Unit. 102 - A Paediatric Registrar undertakes two weekly clinical sessions in local authority centres. St.James' Hospital Balham. - A clinical medical officer attends the Paediatric Department weekly to help in the assessment of children. A Day Observation Unit is being run in association with the Paediatric Department, Wandsworth Health Department, Wandsworth Social Services Department and the Inner London Education Authority (see under Day Observation Unit, Blackshaw Road). St.Thomas's Hospital - A Senior Registrar from the Paediatric Department attends the Doddington Child Health Centre twice a month to help in the assessment of children in association with a clinical medical officer. - This Senior Registrar also attends the Doddington Child Health Centre weekly to undertake a clinical session. St.George's Hospital Tooting A Principal Medical Officer attends the Assessment Clinic which is held twice a week. On two occasions in the month, the clinic is mobile and held either at the Braidwood Audiology Unit or at the Tooting Child Health Centre. A second doctor, a clinical medical officer, has been appointed as a clinical assistant to attend the Assessment Clinic on three days in each month. 103 A Day Observation Unit is being run in association with the Paediatric Department, Wandsworth Health Department, Wandsworth Social Services Department and the Inner London Education Authority. (See under Day Observation Unit, Blackshaw Road). A Paediatric Registrar undertakes a weekly clinical session in the Tooting Child Health Centre. A Physiotherapist from the Paediatric Department attends the Special Care Unit attached to the Summerley Day Nursery. Further association with the Paediatric Departments of these hospitals is in the planning stage. The recognition that the assessment of a handicapped child is but the beginning of an on-going process of planning for his follow-up, both immediate and long-term and requiring the specialist knowledge of the hospital paediatrician and the doctor familiar with the facilities in the community, is one of the most important facets of child care today. Medical students, hospital nurses and administrative staff continue to attend the local authority clinics and schools to gain experience of the facilities which cater for all children who live in the community. Day Observation Unit, Blackshaw Road, S.W.17. A new day unit for the informal assessment of handicapped children was opened in May 1972 at 177 Blackshaw Road. Preschool children are accepted who require observation for a period lasting from a few weeks to six months in a nursery setting before their physical, intellectual or psychological problems can be evaluated. The unit, which is for eight children, is attached to a children's residential home and is a combined project run by the Social Services Department, the Hospital Service, Wandsworth Health Department and the I.L.E.A. Recommendation for admission can, therefore, come from a number of sources but the unit is under the 104 medical supervision of the paediatricians of St.George's and St. James' Hospitals and is an extension of the assessment facilities of the hospitals. Whilst in the unit, a multi-disciplinary team consisting of a paediatrician, local authority doctor, psychologist, audiologist, speech thereapist and physiotherapist combine to provide effective diagnosis and treatment and formulate a programme for the child's care and management. Close liaison with the hospitals concerned enables full use to be made of other specialists. Day-to-day medical problems are the responsibility of the Health Department whilst the necessary support for the handicapped family and the administrative matters, including transport, are dealt with by the Social Services Department. The parents play an important part in the unit and it is envisaged that it will provide an educational setting for parents and staff alike. An occupational therapist is in charge of the unit and three nursery nurses assist her. The I.L.E.A. have agreed to provide a nursery teacher to assist in the assessment of the educational needs of each child in this age group. Provision of Physiotherapy at Summerley Special Care Unit Following discussion between the Health Department and St. George's Hospital, Tooting, it was agreed that a physiotherapist from the Paediatric Department should continue to attend the Special Care Unit at Summerley Day Nursery on a weekly basis. The Unit admits up to eight children at a time, most of whom are severely physically handicapped and require physiotherapy. In addition to carrying out actual treatment, the physiotherapist was able to advise nursery staff on how to handle the children in order to prevent or mitigate the appearance of secondary handicaps. Attention was drawn to means whereby opportunity could be provided to enable the children to achieve their maximum potential and numerous practical improvements such as the provision of suitable chairs, tables, toilet fittings and toys were introduced. The association has been of the greatest possible benefit and has provided a very practical link between the hospital and the local authority. It has demonstrated beyond doubt that there is a need for an extension of the service to other handicapped children in the community. This is now under consideration. 105 Handicap and Observation Register For the past seven years, a comprehensive register of handicapped children and of children at risk of developing a handicap has been kept in the Health Department. It has proved a most useful statistical guide but, more important, it has continued to alert us to the value of the early detection and treatment of defects. In 1972, 1,456 children under the age of five were included in the register out of a total pre-school population of about 25,000. All children on the register are examined regularly for defects and developmental screening tests are undertaken. The completeness of the register depends on co-operative effort and, throughout the year, the collaboration of all concerned, that is, clinic doctors, hospital specialists, general practitioners, health visitors and others, has been excellent. The Chronically Sick and Disabled Persons Act 1970 enabled greatly increased provision to be made for the welfare of handicapped people and has stressed even further the necessity for close association with the Social Services Department when dealing with the handicapped child. Much practical effort has gone into meeting the needs of any child or his family who can derive benefit from the additional facilities which may now be provided under the Act. The following tables set out the statistics relating to handicapped children under five years of age:- TABLE 39 CHILDREN ON HANDICAP REGISTER Visual 24 Auditory 22 Language and speech 21 Epilepsy 36 Cerebral palsy 37 Spina bifida/hydrocephalus 28 Muscular dystrophy and other neuromuscular diseases... 5 Metabolic and endocrine disorders 16 Alimentary disorders 8 Cardiovascular disease 35 Respiratory disease 10 Genital and urinary disorders 9 E.S.N 18 E.S.N, (severe) 61 106 CHILDREN ON HANDICAP REGISTER - cont'd Maladjusted, autistic and psychotic 5 Battered babies 9 Blood disease 15 Limb and skeletal abnormalities 27 Chronic illness (neoplastic) 1 Skin conditions 4 Other conditions 13 Total number of handicaps 404 Total number of handicapped children 289 Number of children with multiple handicaps 84 Number of children with chromosomal abnormalities (including Down's syndrome) 22 TABLE 40 CHILDREN ON OBSERVATION REGISTER Under 2 years 729 2 and under 3 years 192 3 and under 4 years 148 4 and under 5 years 98 Total 1,167 Immunisation and vaccination An important change took place during the year when it was decided to introduce a new schedule of routine immunisation in childhood. For many years children had started their primary courses of prophylaxis at three months, receiving protection against diphtheria, tetanus, whooping cough and poliomyelitis; these courses were completed at five months, and reinforcing doses were given at 15 months. Under the new arrangements the first doses are given at six months and the second and third at eight and fourteen months respectively. No reinforcing dose is necessary. This new schedule is in accordance with that recommended by the Department of Health and Social Security as providing the maximum antigenic response. One result of the change is that the figures of completed primary courses are necessarily lower than those for 1971, as no child who started a primary course on the new schedule in 1972 could have completed it by the end of the year. Even allowing for this fact, however, it appears that there has been a general reduction in 107 primary and reinforcing courses. This is particularly disappointing where measles and rubella are concerned, the numbers having dropped considerably. It is interesting to note that the smaller numbers attending Council clinics or immunised in school are paralleled by the smaller numbers going to their family doctors. The ending of the routine vaccination against smallpox of babies, which occurred in 1971, is reflected in the very low figures of primary vaccinations in 1972. Revaccinations are mainly of people travelling abroad and are likely to stay constant for some years to come. TABLE 41 IMMUNISATION AND VACCINATION STATISTICS FOR CHILDREN UNDER 16 YEARS NUMBER OF COMPLETED CASES (Note—Although diphtheria, whooping cough and tetanus are shown separately. most children receive combined antigens which enable protection against two or three diseases to be given in only three injections.) 1972 1971 Smallpox vaccination— Primary vaccinations: Council clinics 181 1,340 General practitioners 169 587 350 1,927 Re-vaccinations: Council clinics 50 43 General practitioners 291 370 341 413 Diphtheria immunisation— Primary courses: Council clinics and schools 1,522 3,537 General practitioners 596 1,029 2,118 4,566 Reinforcing injections: Council clinics and schools 3,834 4,903 General practitioners 921 1,492 4,755 6,395 Whooping-cough immunisation— Primary courses: Council clinics and schools 1,307 3,253 General practitioners 539 950 1,846 4,203 Reinforcing injections: Council clinics and schools 1,672 1,992 General practitioners 453 701 2,125 2,693 Tetanus immunisation— Primary courses: Council clinics and schools 1,547 3,618 General practitioners 646 1,104 2,193 4,722 108 Reinforcing injections: Council clinics and schools 3,871 4,883 General practitioners 1,002 1,565 4,873 6,448 Poliomyelitis vaccination— Primarv courses: Council clinics and schools 1,473 3,515 General practitioners 606 915 2,079 4,430 Reinforcing doses: Council clinics and schools 3,819 4,958 General practitioners 857 1,362 4,676 6,320 Measles vaccination— Council clinics and schools 1,646 2,503 General practitioners 358 648 2,004 3,151 Rubella vaccination— Council clinics and schools 1,468 3,760 General practitioners 20 58 1,488 3,818 Mother and Child Health Dental Service Dental services for expectant and nursing mothers and for preschool children are provided in conjunction with the school dental service at the various treatment centres in the Borough. During the year there were 27 attendances by mothers and 1,219 by pre-school children to whom 22 and 994 fillings were provided respectively. This represents an overall expansion of the service in excess of 40% over the previous year. An experimental scheme was instituted at St.Christopher's Treatment Centre wherein the mothers at the toddlers clinics are asked by the attendant doctor if they would like to discuss the care of teeth in small children with the dental staff on duty. This is arranged on the spot and the mothers are seen by the dental staff in between their regular appointments. In this way the child is introduced to a dental environment and, by an informal discussion, ensures that the mother is well-informed about the care of teeth in young children and of the necessity of routine visits to the dentist. 109 Chiropody Report by A.E.Trenter, M.Ch.S., S.R.Ch., M.R.S.H. — Chief Chiropodist Chiropody services are available to expectant and nursing mothers, schoolchildren, the physically handicapped and persons of pensionable age. The appointment during the year of additional full-time and sessional staff enabled the chiropody service to reach its full establishment for the first time. At the end of the year the staff comprised five senior chiropodists and twenty sessional chiropodists working under the supervision of the Chief Chiropodist. Treatment is available in twelve clinics in various parts of the Borough. The service is also available in nine old people's homes run by the Council, eight homes run by voluntary organisations, three private homes, one nursing home and one convent. Treatment is also given in the private surgeries of chiropodists acting on behalf of the Council and there is an extensive domiciliary service for those patients who are housebound. In cases where patients are able to walk but are unable to reach the clinic unaided, transport is provided. At the beginning of the year, the Doddington Child Health Centre was opened. This building in Battersea Park Road incorporates a well-equipped, purpose-built chiropody surgery and, in addition to its excellent treatment facilities, provision has been made for the making of foot appliances. During the year, a pilot survey of children's feet and footwear was carried out in various schools in the Borough. The findings of this survey clearly indicate that the health of schoolchildren's feet deteriorates progressively during school life and that their footwear is frequently unsatisfactory. Many children's shoes are bought in shops where little attempt is made by the retailer to ensure good fitting. Some parents buy shoes for their children without the child being present at all. It is not surprising therefore that many children's feet are being unnecessarily deformed. The chiropody service plays a major role in maintaining the mobility and independence of the elderly. If we are to ensure that future generations of elderly people are to escape the chronic foot troubles that have affected the elderly of recent generations, the chiropodist's skills must be utilised to the full, especially in the preventive field of foot-health, 110 Statistics for the year 1972 are as follows:- TABLE 42 Number of sessions held: at clinics 3,350 at homes for old people 494 Number of patients seen for the first time in 1972: at clinics and homes for old people 4,970 at private surgeries 625 in their own homes 1,854 Number of treatments: at clinics 22,939 at homes for old people 3,903 at private surgeries 4,311 in patients' own homes 12,047 Adoption and boarding-out Throughout the year, the advice of the medical staff continued to be available to social workers of the Social Services Department about adoptive children and the parents who hoped to adopt them. This frequently involved making medical enquiries concerning the health of both children and parents. Occasionally, potential educational difficulties were investigated and a clinical assessment of the child was carried out. During the year, numerous cases were considered and advice was given both formally (when special investigations were carried out) and informally during case conferences or at personal interviews with the social workers. Close liaison with the Social Services Department continued to operate in connection with children who needed to be boarded out. Venereal diseases At a time when the most serious infectious diseases have either nearly disappeared or are well under control, the pattern of the sexually transmitted diseases stands out in contrast. The figures for Wandsworth, shown below and in graph form, are typical for London which accounts for nearly half of the national total of cases. The important features of the current trends are their occurrence in the absence of the major upheavals of war when similar rates were last recorded, and their persistence in the face of antibiotic treatments on which so much hope was placed in the early 1950's. 111 TABLE 43 Year All conditions Syphilis Gonorrhoea Other genital infections Other conditions Primary and secondary Other 1967 2,855 25 47 509 2,274 – 1968 3,387 23 63 604 2,697 – 1969 3,858 29 48 640 3,141 – 1970 4,200 34 40 755 3,371 – 1971 5,173 34 61 817 2,938 1,323 1972 5,466 33 47 845 3,059 1,482 Syphilis, although the most serious of these diseases, fortunately remains at a low rate. On the other hand, gonorrhoea has again increased but to a lesser degree than in the previous four years. It must be realised that these figures refer to the number of positive cases of each condition and not to the number of patients involved. For instance, one patient may have several complaints or may return several times in the same year due to reinfection. It has been estimated that about 20% of patients with gonorrhoea become reinfected within a year. The group of other genital infections includes a wide range of conditions, fungal, parasitic and bacterial, which are passed on by intimate sexual contact; these are:- Chancroid Lymphogranuloma venereum Granuloma inguinale Non-specific genital infection Non-specific genital infection with arthritis Trichomoniasis Candidiasis Scabies Pubic lice Herpes simplex Warts (condylomata acuminata) Molluscum contagiosum Of these, non-specific genital infections, most commonly diagnosed in men, is the most important since it accounts for as many patients as gonorrhoea, but the cause is not yet clearly known; furthermore, the incubation period is much longer, the treatment is less effective and recurrences are possible months or years later, without re-infection. 112 Concern about the local situation was expressed in Council and in January 1972 I submitted a report supporting the further development of the role of the Council in the campaign against venereal disease. There are in fact no venereal disease clinics in Wandsworth and, in consequence, the tracing of contacts is mainly undertaken by staff employed by the London Borough of Lambeth, the cost of which is reimbursed by this Borough for the important follow-up work undertaken in relation to Wandsworth residents. In practice, more than 70% of Wandsworth patients attend the Lydia Clinic at St.Thomas's Hospital in Lambeth. From early 1972 the Borough co-operated with the Health Education Council in a project concerning the control of sexually transmitted diseases in conjunction with the London Borough of Lambeth. This has involved participation in the activities of the Steering Committee, co-operation with the Research Division of the Health Education Council and three Research Welfare Officers, and the use of specially designed illuminated display units. These units, which warn against the risk of catching gonorrhoea were sited for two-week periods in three colleges of education and in the Arndale Centre, and subsequently for a month at a time in the public libraries in Wandsworth. The illuminated sequence lasted about one minute and was well accepted at all display sites. An open-line recorded message of VD information by telephone was one of the suggestions of the Steering Committee and this has been made available for the whole of London 01-246 8072 - by the Department of Health and Social Security, and all clinics are listed in the telephone directory. This confidential telephone service was introduced in December and more than 74,000 calls were made in that month! 113 Yearly Numbers of Reported Venereal Diseases from Wandsworth NUMBER OF CASES OF VENEREAL DISEASE REPORTED DURING THE YEAR 114 Health education General Health education forms an integral part of all the services provided by the Health Department in relation to communication and persuasion. The aims of the Health Education Service are to foster, encourage and support these activities, in the most appropriate way for the service in question. Without doubt the main means of health education is the person-to-person contact between health staff and the public. This involves those in the field, such as health visitors, home nurses, midwives and public health inspectors and also those who face the public at reception desks or answer their calls, when seeking appointments or making general enquiries. The service of the health department is judged largely by the experience that people have when coming in contact with it, so what is needed is for all personnel to be made aware of the potential of their own role in health education, however small it may seem. The more obvious health education activities continue, such as the Mothers' Clubs, run by health visitors, or mothercraft lectures by midwives. Displays are put up in the child health centres and supplies of leaflets and other literature are made available. Health inspectors give lectures to various groups in response to invitations. All of these activities are supported by the provision of appropriate audio-visual aids. The health education service increased its resources with the much needed addition of a new 16 m.m. sound projector, a slide projector and a daylight screen. A big improvement was made to the storage of leaflets and posters in appropriate filing systems. Despite the very limited space, room was found for a hanging-type poster cabinet, making it much easier to examine specimens of available posters. In order to make plans, discuss new ideas, review new materials and facilitate their application, a Health Education Panel was started in the latter part of the year, with regular participation of medical, nursing and administrative staff. Dental health education The first school dental surgery commenced operating in Wandsworth in 1912. A photograph taken at that time and which was published in my Annual Report for 1970 shows group instruction in oral hygiene. Even before then, and ever since, group and individual instruction have been given. Exhibitions 115 have been mounted, posters fixed on walls, and leaflets distributed in an effort to stem the increase in dental disease, all to no avail. These efforts have been sporadic, and there has been no measurable change in attitude by the public to the care of their mouths. Indeed the increase in the quantity and variety of refined foods combined with the general lack of mouth care has resulted in virtually the total population being affected by dental disease. As this disease is largely preventable, a new approach is necessary for public health authorities to bring about the change in attitude necessary to at least limit dental disease, as a prelude to full scale prevention. The most effective feasible public health measure on record, fluoridation of the water supplies, is still not available even though it would reduce dental decay by at least 50%. Thus instead of an automatic, low cost method of control, we must resort to a health education programme, staffed by expensive personnel who are in short supply, extending over at least two generations in order to ensure sufficient change in attitude to enable us to begin to control dental disease. During 1972 a scheme was introduced which will be expanded so that it eventually gives continuous coverage to all primary school children, with constant reinforcement. It is based on the full, annual school dental inspection programme which is a constant reminder to parents and children that disease needs constant care. It works in two phases. A puppet show designed for infant school children illustrates the evils of "Jimmy Germ" and extol Is the virtues of a healthy mouth resulting from the combined attention of the toothbrush, the dentist and elementary diet control (see photographs, centre pages). The show was performed 51 times to an average audience of about 120 children. This paves the way for the second phase aimed at junior school children. Groups of 10 to 12 children are asked to use a disclosing medium to stain the debris (plaque) on teeth which causes both tooth decay and gum disease. They are then asked to remove the stain with toothbrush and toothpaste. The use of a mirror during this process vividly illustrates the problem and the method of control. At the same time faults in toothbrushing technique and diet in relation to mouth disease are discussed. 151 sessions of this practical health education were given in 1972 by Miss E.Mutter, the Dental Auxiliary, who suggested this method. Third year students from the Royal Dental Hospital participated in some of 116 these sessions under Miss Mutter's direction. It is hoped that dental students will become more involved in this procsss as time goes by, as it will benefit both students and the community, and prove to be of great value to our staff. 1972 is only the beginning. Another Dental Auxiliary is to be added to the staff and suitable Dental Surgery Assistants will be trained for this role so that within two years all infant and junior schoolchildren will be covered by this programme. The infants are a little immature for the supervised disclosing and brushing, but are very susceptible to the puppet show. It will also enable Dental Officers to concentrate on operative repair and prevention and to avoid, to a large extent, the constant effort to present health education to individual patients who, due to a high level of disease, are in a stress situation. Such situations are far from conducive to good reception of such an important philosophy, whereas the relaxed happy atmosphere and familiar surroundings of a school are a distinct advantage. As stated earlier in this Report, an experimental scheme was instituted at St.Christopher's Treatment Centre wherein the mothers at toddlers clinics are asked by the attendant doctor if they would like to discuss the care of teeth in small children with the dental staff on duty. This is being done on an informal basis, between patients, with, if possible, a quick look at the child's teeth. In due course this will be assessed to see if it should be expanded to other centres. Meanwhile the basic dental health education given at the chairside will support this programme where it is considered necessary. Health Education through general publicity Family Planning and Cervical Cytology were the two services for which general publicity was mounted during the year. In support of the material produced and distributed by the Family Planning Association a poster and a leaflet were published under the title: "Plan for your family" in which general information and encouragement were given as well as a list of clinics. The posters were widely distributed throughout the Borough by post and by personal delivery to Council clinics. General Practitioner surgeries, hospitals, libraries, chemists, laundrettes, the Director of Social Services and various voluntary organisations. The leaflets were similarly distributed with the exception of chemists and laundrettes. It should be noted that family doctors continue to make about 25% of the effective referrals to the family planning clinics. This publicity was part of the general expansion of the family planning services which continued the trend of the previous year and overall there was an increase of 20% in the total number of patients seen. 117 For Cervical Cytology a leaflet was produced with the heading: "Important to all women". It contained a simple explanation of the test and the need for it and, again, a list of the available clinics. The distribution was the same as for the Family Planning material and there was also a poster with the slogan and telephone number and for the convenience of health visitors and doctors small cards were produced, of suitable size for the pocket or handbag and intended to support personal commendation. As a means of evaluation, the booking clerk asked each enquirer about the source of referral and this revealed that the family doctor accounted for the large majority of new cases. Two special projects intended to boost the uptake of the cervical cytology service were a series of clinics held in a local factory in the early part of the year and the use of a Mobile Unit during the month of September. Both were supported by publicity. The approach to the factory was made following a trial at another factory in 1971. In order to achieve an even uptake of the service, all the women in the factory were sent in their paypackets a letter of invitation to the clinic, department by department, and the factory nurse added her personal commendation. In all 71 women were seen, but many reported to the nurse that they had been tested elsewhere. This uptake represented about 18% of the 400 women employed, which is comparable to the 20% seen at the other factory in 1971. As these are the two largest employers of women in Wandsworth it was not considered appropriate to plan similar services in respect of other smaller factories in the Borough. One of the main hopes pinned on the Mobile Cytology Unit was that the general publicity and interest generated by having it in the Borough for a month would increase the uptake at the regular clinics, but there was no significant change in this direction. During the visit of the mobile unit volunteers distributed about 18,000 leaflets and it was of particular interest that the street hand-outs were much more successful at persuading women to attend than was the door-to-door distribution. Overall it took the distribution of one hundred leaflets to persuade one women to attend. Health Exhibition at Gamett College There was an exhibition at Gamett College during March on similar lines to that of 1971. Again the nursing staff from the Health Department prepared and manned an exhibit about the services and functions of the Health Department in the community, and this was much appreciated. 118 Health education in schools At the invitation of Head Teachers, health visitors continued to give talks in a number of schools throughout the year. Similarly, doctors were asked to speak, in some instances to the schoolchildren and in others to Parent-Teacher Associations. Health education in schools takes many different forms according to the particular curricular policy of the school. A number of schools invite the health education team from the I.L.E.A., who have numerous prepared illustrated talks, suitable for different age-groups, on a wide range of health subjects. During 1972 the Divisional Education Officer was approached to see what further assistance the health education services of the Health Department could give to the schools in the Borough and the position was being examined in detail at the end of the year. The Health Education Council's project on the control of Venereal Disease in the Community The Borough co-operated in this project, in which Wandsworth and Lambeth are the two trial areas, both by representation on the Steering Committee and by receiving publicity material on test. An illuminated box display unit was tried out in three colleges of education, in the Arndale shopping arcade and in the Council's libraries. Care of old people Old people, despite all the services available, often do not avail themselves until they become very ill. The health visitor has a unique opportunity to reach old people and discover needs before they become too serious. The link between the health visitor, the home nurse and the family doctor is obviously essential for the effective care of old people in their homes and the system of attachment of community nursing staff to general practitioners does much to ensure continuity of care. Besides health visiting and home nursing the Health Department also provides home bathing services and chiropody for old people. Family casework and problem families At the beginning of the year four problem families were being given support by the Social Workers (Health Services) who are attached to the Health Department by the Inner London Education Authority. In May, responsibility for the supervision of one of 119 these families was assumed by the Social Services Department, and the remaining three families continued to be visited by the Health Department Social Workers. Chest Clinics There are in the Borough three Chest Clinics; Wandsworth, in the Municipal Buildings; Battersea, in St.John's Hospital, St. John's Hill; and Balham, in the Department of Thoracic Medicine at St.James' Hospital, St.James's Drive. The first two clinics draw their patients mainly from the Borough but the last-named draws patients also from the adjoining London Borough of Lambeth. Close liaison continues between the staffs of the Chest Clinics and the Health Department and there is active co-operation on all aspects of the work. I am grateful to the Chest Physicians 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 guidance. The Annual Report of the Battersea Chest Clinic Care Committee follows. Unfortunately, owing to the protracted illness of the Secretary to the Wandsworth Tuberculosis Care Committee, the Annual Report on the work of that Committee was not available at the time of publication of this report. I should like to thank both Care Committees for the excellent work they have carried out during the year in helping patients suffering from diseases of the chest. Statistics relating to tuberculosis will be found in Part 2 of this report. Dr.P.C.Anderson, the Consultant Chest Physician at the Balham Chest Clinic, retired in March after many years of distinguished service to which appropriate tributes were paid by both the Health Committee and the Council. He has been succeeded by Dr.F.J.C. Millard to whom a warm welcome is extended. 120 BATTERSEA CHEST CLINIC CARE COMMITTEE ANNUAL REPORT The Battersea Chest Clinic Care Committee has pleasure in presenting the Annual Report for 1972. The Committee has continued to meet'at monthly intervals during the year and we are grateful to the Westminster Hospital Board of Governors for providing us with every facility. The Committee's work during the year under review has been varied, grants being made in many different circumstances. Our funds have proved immensely valuable in providing the assistance required, and thus relieving anxiety and difficulties. Help is frequently needed with clothing and footwear, and we have been greatly assisted once again by a parcel from the Queen Mary's London Needlework Guild. Many of our older patients found it a major problem to pay for adequate heating and we were able to provide grants in a number of these cases. At Christmas it was agreed that funds allocated for gifts to patients shouid be on a more generous scale than usual. £200 was distributed to out-patients and those spending Christmas in the Chest Ward at St.John's Hospital. From the letters received it was obvious that these gifts were greatly appreciated, and helped to provide a little extra cheer. Of our fund raising activities the most important were the two Old Tyme Dances at the Battersea Town Hall. Once again Mr.Tom Collyer undertook the organisation of these events which were highly successful, as well as being most enjoyable. We are indeed grateful to Mr.Collyer for the time and effort so freely given on our behalf. We include too, a special 'thank you' to the ladies of the W.R.V.S., for all their hard work in providing refreshments and donating the profits to our funds. Our thanks also go to the Wandsworth Borough Council for allowing us the free use of the hall and amenities, and to the following firms for donations and raffle prizes:- Messrs.Dawson & Co.,Ltd. Decca Radio and Television Messrs.J.Lyons & Co..Ltd. Prices Patent Candle Co.,Ltd. 121 In October it was decided to hold a Wine and Cheese Party, and this new venture afforded our many friends a most pleasant evening and added considerably to our funds. For the first time members of the newly formed Battersea Rotoract Group (Junior Rotary) offered to organise a sponsored walk from Brighton to Battersea, in aid of our funds. In spite of bad weather this noble effort resulted in £53 being added to our funds, and we are most grateful for this. We wish to record our great appreciation of the financial help given by the Rotary Club of Battersea Park, the Morganite Carbon Company and other friends. We have maintained our close co-operation with the various voluntary and statutory bodies who help with the welfare of our patients. In conclusion, we wish to express our thanks to Miss Greenaway, Social Worker, and Mrs.FaithfulI, Secretary, for the work carried out on behalf of the Committee. N.F. CLARK-LAWRENCE (Miss), Chairman. STAFF TRAINING AND STUDENT TRAINING Management training, with a view to the reorganisation of the National Health Service in 1974, was to the fore during the year. The Deputy Chief Nursing Officer attended a four week senior management course held at the University of Birmingham. A Principal Nursing Officer and a Nursing Officer attended a middle and lower Management course respectively, at Chiswick Polytechnic, both of four weeks duration. The five health visitor students appointed in 1971 were successful in their examinations and joined the staff in September. Eight health visitor students were sponsored for training commencing in September. District midwifery training was provided by the domiciliary midwifery service for twenty-one pupil midwives and a one day observation visit of the domiciliary midwifery service was arranged for one hundred and twenty-two nurses taking the obstetric nurse course. 122 There was a steady increase in post graduate training during the year. Three health visitors and two home nurses were successful in completing their fieldwork practical work instructors course, as were the twelve home nurses who undertook the district nurses training. Seven health visitors were sponsored to attend a visual aids/projectionist course at Wandsworth Technical College on a half day release for twelve weeks basis and six were successful in the examination. Refresher courses arranged by the Health Visitors' Association and the Royal College of Midwives were attended by four health visitors, one school nurse and three midwives. Forty-two student nurses from St.George's Hospital were each placed with members of the community nursing service for six weeks, and a further one hundred and sixty three students and pupil nurses were given the opportunity to observe the work of the community nursing service and to be involved in the delivery of the personal health services to the community. Finally, full advantage continued to be taken of the excellent facilities provided by the London Boroughs Training Committee in the form of courses, seminars, study days and discussion meetings for staff working in the health and social services. Warm thanks are due to the Director, Miss Margery Taylor, and her staff for their invaluable and every-ready help and advice. MEDICAL EXAMINATION OF STAFF The medical examination of existing and prospective staff is undertaken in the Health Department on behalf of all departments of the Council. Before appointment, every prospective new entrant to the service is requested to complete a medical questionnaire for scrutiny by a medical officer and 1,107 questionnaires were scrutinised in the year. 194 prospective entrants were subsequently called for a physical examination either because of their age, the nature of the employment they were taking, or because of their medical history. In addition to its work in relation to new entrants to the service, the Health Department carried out 36 special medical examinations of existing staff at the request of the Council's Establishment Officer, arising from extended sick leave or other medical reasons, and 79 examinations related to employment with the Council, including drivers of heavy goods vehicles. 123 LONDON BOROUGH OF WANDSWORTH PART 5 SCHOOL HEALTH SERVICE ANNUAL REPORT OF THE PRINCIPAL SCHOOL MEDICAL OFFICER FOR THE YEAR 1972 CONTENTS Introduction Special Schools Pupils on School Rolls Audiology and Audiometry Medical Inspection of Special Investigation Clinics Schoolchi Idren Tuberculosis—Epidemiological Vision Investigations Personal Hygiene B.C.G. Vaccination of Infectious Illness reported Schoolchildren from Schools School Dental Service Medical Treatment of Free School Milk Schoolchildren Health Education in Schools Handicapped Pupils Sanitary Conditions in Schools Introduction I have the honour to present the eighth annual report on the School Health Service of the London Borough of Wandsworth for the year ended 31st December 1972. As described in earlier Reports, the Inner London Education Authority is responsible for the School Health Service but, by virtue of an agreement under Section 32 of the London Government Act, 1963, there is joint use by the Authority and the Borough of profession staff, premises and equipment. The Medical Officer of Health is the Principal School Medical Officer of the Inner London Education Authority for the area and is responsible to that Authority for the day-to-day running of the Service. 124 It is not possible in these brief introductory comments to highlight all the varied activities of the school health service but, before mentioning some features of especial interest in 1972, a restatement of the basic enduring objectives of the service may not be inappropriate in an era when change follows change in rapid succession. These aims can be summarised, I believe, as the regular medical supervision of all school pupils entailing a comprehensive examination at the time of school entry (which sets the seal on periodic developmental assessment throughout the early years of life) and at least once during the secondary school stage as well as at any other time on the request of teacher, nurse or parent; the detection, assessment and close observation of all handicapped children; the maintenance of a satisfactory state of immunization against serious infectious diseases; the fostering of a high standard of hygiene and of a healthy physical environment; the provision of individual health counselling for older school children and of health education for all pupils; and the encouragement of a sense of full partnership in all concerned with the health and education of the child in the setting of both school and home. Hence it is axiomatic that, potentially, the parent has a key part to play. Equally clearly these objectives cannot be achieved unless the necessary time is made available to enable justice to be done to the medical examinations, nursing surveys and multidisciplinary consultations which are of the very essence of the service. To this end the future pattern of school medical examinations in Wandsworth is being actively explored with the Inner London Education Authority and this review inevitably embraces the role of the school nurse vis-a-vis both school doctor and health visitor. Collaboration with teachers, education welfare officers and social workers is another vital facet meriting the closest attention if health and education are to thrive in the widest sense. Turning now to the well nigh 50,000 pupils on the rolls of schools in Wandsworth it is heartening to report that the general physique of all but a minute percentage of the 16,356 children examined routinely during 1972 was found to be satisfactory. This healthy testimony to improved nutritional standards in recent decades was reinforced by the small number of children in junior schools who were considered to need free milk on medical grounds under the Education (Milk) Act, 1971. It is hardly necessary to add that these satisfactory clinical physical impressions in no way detract from the overall excellence of milk as a nutrient in childhood. 125 Less satisfactory is the continuing increase in head lice infestations detected amongst school children and, although increasing attention was paid to treating the affected families as a whole in 1972, there is clearly a need for an even greater effort in the year ahead. In this context, it cannot be stressed too strongly that infestation can affect children whose standard of hygiene is perfectly satisfactory and this needs to be explained to parents if their co-operation is to be obtained. Parental attendance at school medical examinations enables such essential health information to be imparted and it is therefore a matter for particular regret that parents were present at only 52.4% of the routine general medical examinations of Wandsworth pupils undertaken in 1972. Such personal contact between doctor and parent in the school setting ought to be given a high priority notwithstanding the difficulties inherent in an age when more and more mothers are engaged in full-time employment. Happily, in contrast to the rise in verminous conditions detected, the number of cases of scabies treated at the cleansing centres fell from 106 to 45. Once again it is good to record that the incidence of infectious illness reported from schools generally remained at a low level although the number of cases of mumps rose spectacularly (from 21 to 704) and, disappointingly, those of measles virtually doubled - 351 compared with 182 in the previous year. A modest increase in the number of german measles infections was also reported. These adverse figures in relation to measles and rubeila - there is as yet no vaccine against mumps generally available - lend strong support to the need to intensify the immunization campaigns which have been launched in recent years to reduce drastically the incidence of these diseases, in the interests respectively of children born and unborn from whom they can exact a heavy price. Two accounts in the text of epidemiological investigation in relation to tuberculous infection at educational establishments in the Borough highlight the invaluable help rendered in this still important field of tuberculosis control by the staff of the local Chest Clinics and of the South-West London Mass X-Ray Service. It is a pleasure to place on record my warm thanks to Dr.Anderson (who retired during the course of the year), Dr. Citron, Dr.Millard, Dr.Nash and their colleagues for their unstinting help during 1972. The assistance of the schools in relation to routine Mantoux or Heaf testing, and where necessary BCG vaccination, and rubella immunization activities is also greatly appreciated. Maintaining a high state of immunity against these diseases in an extremely mobile population is a constant challenge. 126 In spite of changes of staff - inevitable with the reorganization of the National Health Service looming ever larger on the horizon the school dental service continued to maintain a very satisfactory output. A heartening report was received from the Department of Education and Science following the visit of a Dental Inspector at the beginning of March, reflecting great credit on the staff in general and on the Principal School Dental Officer, Mr.Weedon, in particular. Two further dental surgeries were opened in secondary schools - making three in all - and the health education activities of the dental service expanded dramatically. All in all a most impressive record to which the statistics in the body of the Report testify eloquently. The administrative unification of the child health service in 1971 has proved to be most rewarding and full details of the activities undertaken in the setting of ordinary school, special school, audiology and special investigation clinics will be found in Part 5 of this Annual Report in which advances in the field of health education are also outlined. In conclusion I am indeed glad to have the opportunity to thank all members of the staff of the school health service for their cheerful efficiency throughout the year, and to express to Mr.Kingdom, the Divisional Education Officer, and to the Heads of schools in Wandsworth my warm appreciation of their continued help and support which I deeply value. The Medical Adviser to the Inner London Education Authority, Dr.Stewart, and his colleagues have again given me constant encouragement and invaluable advice for which I am especially grateful. Pupils on school rolls In May, 1972 there were 49,425 pupils on the rolls of schools in Wandsworth, including primary and secondary day schools together with special day and boarding schools and classes for handicapped pupils. Medical inspection of schoolchildren Routine medical examinations are performed by medical officers working in either a full-time or part-time capacity. Whenever the necessity arises the family doctor is consulted about the results of the examination, and parents are invited to attend, so that any matters relating to the child's health may be discussed 127 out delay. Much valuable information is also obtained from the school nurses, the staff of the Education Welfare Service and the teaching staff. Immunisation records receive special scrutiny and, if indicated, the attention of the parents is directed towards completing the immunisation schedule, particularly with regard to the prevention of diphtheria, poliomyelitis, tetanus and tuberculosis. Nowadays, attention is also paid to measles and rubella prophylaxis, where appropriate. Control of infection and infestation is facilitated by means of the medical inspections and the health surveys made by the school nurses. In this respect, examination of children before a school journey is of proven value. Relatively frequent medical examinations take place at the schools for the handicapped. Specially approved medical officers examine educationally subnormal children. Although the emphasis rests upon the educational status of these children,any physical abnormality is carefully assessed, for the successful treatment of a physical defect may well enhance the child's prospects of securing gainful employment after leaving school. Behaviour problems in children of all ages continue to present difficulties. To solve a behaviour problem is often an exacting task, demanding intensive application of medical and educational resources. Routine general medical inspections during 1972 totalled 16,356 compared with 17,713 in 1971. Of those children inspected 18.4% were referred for treatment of defects, 8.2% being referred for treatment of defects other than vision. The corresponding percentages for 1971 were respectively 15.8 and 7.1. The following table (Table44)shows the number of children referred for treatment or observation of the defects listed at routine general medical inspections during 1972, expressed as a rate per 1,000 children inspected, together with the corresponding rates for 1971. 128 TABLE 44 Number examined 1972 1971 16,356 17,713 Defects Rate per thousand Treatment Observation Treatment Observation Skin 9.17 5.81 10.22 4.80 Eye—vision 109.01 50.56 94.45 41.55 Squint 6.97 5.69 6.83 3.84 Other 0.98 0.67 3.02 1.02 Ear—Hearing 9.11 9.23 7.62 9.26 Otitis media 2.57 1.83 1.98 3.16 Other 1.83 0.79 0.96 0.73 Nose and throat 5.56 11.74 3.39 16.03 Speech 5.38 6.79 4.16 6.61 Lymphatic glands 0.86 1.47 0.45 3.78 Heart—Congenital 1.71 4.28 1.24 5.98 Acquired 0.79 3.48 0.28 2.54 Lung—Bronchitis 1.83 1.90 1.35 2.60 Asthma 4.59 3.97 3.22 3.50 Other 0.75 0.86 1.13 1.52 Developmental—Hernia 1.10 1.41 0.90 1.24 Other 1.28 3.91 1.52 3.50 Orthopaedic—Posture 1.22 2.08 1.24 3.73 Feet 5.93 3.00 5.76 4.91 Other 2.32 1.28 2.43 2.09 Nervous-—Epilepsy 1.16 0.86 1.52 0.73 Other 3.22 1.04 0.79 1.02 Psycho—Development 2.75 5.81 2.03 4.74 Stability 4.65 11.43 3.67 8.36 Abdomen 0.55 1.71 0.45 1.13 Other—Debility 0.37 2.26 0.56 1.35 Enuresis 11.49 12.47 9.09 12.82 Obesity 6.65 5.38 5.36 6.38 Other 9.42 4.83 5.14 3.33 Details of non-routine medical inspections carried out in 1971 and 1972 are as follows:- TABLE 45 1972 1971 Re-inspection 8,722 7,895 Other non-routine inspections (see table below) 4.742 5,346 7-plus experimental scheme inspection 109 120 Totals 13,573 13,361 Total routine and non-routine inspections 29,929 31,124 129 TABLE 46 ANALYSIS OF NON ROUTINE MEDICAL INSPECTIONS Nature of inspection Number inspected 1972 1971 Bathing centre inspection: Scabies 2 2 Employment certificates 239 425 Theatre children 7 60 School journeys 2,883 2,946 Recuperative holidays—before departure 64 59 Recuperative holidays—on return — — Secondary school annual surveys 100 50 Candidates for higher awards — — Nautical school entrants — — Outward-Bound courses 1 14 Infectious disease investigation — 4 T.B. contacts — — Boarding schools for the delicate—before departure 22 13 Boarding schools for the delicate—on return — — Handicapped pupils—statutory examination 108 114 Handicapped pupils—periodic special defect examination 621 724 Research investigation and enquiries — 2 Special examinations at request of— Head teacher—child's name entered in special book 72 114 Head teacher—others 179 273 School nurse—following health survey 29 13 School nurse—other 118 78 Divisional Officer (Education) 45 61 Education Welfare Officer or Care Committee 40 29 Parent 100 100 School Medical Officer 44 25 Others— Accident on school premises 1 — Boxing—reference from school A B A. or similar association 10 — For free travel — 2 Reference: (i) connected with remedial exercises foot classes — — (ii) by gymnast or physiotherapist — — Referred by hospital — — Referred by speech therapist — — Referred by general practitioner — Miscellaneous (including inspections specifically for provision of free milk) 51 288 Re-inspections 8,722 7,895 TABLE 47 PHYSICAL CONDITION OF PUPILS 1972 1971 Proportion satisfactory and unsatisfactory— Satisfactory 99.25% 99.06% Unsatisfactory 0.75% 0.94% 130 TABLE 48 ATTENDANCE OF PARENTS AND CARE COMMITTEE REPRESENTATIVES 1972 1971 Number of pupils inspected 16,356 17,713 Parents present 52.4% 50.0% Care Committee representatives present 61.4% 63.9% Vision All children entering school are given a vision test at their first routine medical examination and further tests are carried out at each successive routine medical examination throughout the child's school life. Should concern be felt as a result of the school vision tests, the child will be referred either to his doctor or to the ophthalmologist. Visual acuity standards expressed as percentages of the numbers of children whose eyes were tested are set out in the following table:- TABLE 49 Not wearing spectacles Wearing spectacles 6/6 6/9 6/12 or worse Referred for treatment 6/9 6/6 6/12 or worse Referred for treatment 1972 Boys 81.5 6.5 5.7 6.4 3.6 1.5 1.2 4.0 Girls 78.7 7.7 6.7 7.5 3.3 1.8 1.8 5.5 1971 Boys 82.3 6.2 5.6 5.4 3.2 1.5 1.3 3.3 Girls 79.3 7.0 6.9 7.5 3.5 1.6 1.8 4.1 Personal hygiene TABLE 50 Year Number examined Number found verminous Pupils found to be verminous % of number examined Annual comprehensive health surveys 1972 26,445 336 1.27 1971 19.211 175 0.91 Additional health surveys 1972 13,295 415 3.12 1971 15.918 336 2.11 131 During both types of survey, vermin were found on 751 occasions, representing 1.89% of the total number of examinations. The number of individual pupils found to be verminous was 603 or 1.22% of the school roll of 49,425. On 588 occasions the parents or children, or both, were advised about treatment and in many cases were given Lorexane shampoo for home treatment. On the further 163 occasions pupils were referred to bathing centres for appropriate treatment. The work done at the two bathing centres in the Borough in connection with vermin, scabies and impetigo is shown in the following table. 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). These figures include not only schoolchildren referred after a health survey but also those attending on their own initiative. TABLE 51 1972 1971 Vermin Cases treated 603 425 Total attendances 1.013 557 Scabies Cases treated 45 106 Total attendances 92 228 Impetigo Cases treated Nil Nil Infectious illness reported from schools TABLE 52 1972 1971 Chicken-pox 493 329 Dysentery, diarrhoea or enteritis 76 78 Food poisoning — 2 German measles 159 124 Glandular fever 2 2 Impetigo 29 20 Influenza 6 4 Jaundice 1 4 Measles 351 182 Mumps 704 21 Ophthalmia and conjunctivitis 11 19 Pneumonia — 1 132 Ringworm (body) 13 24 Ringworm (scalp) 6 6 Scabies 13 23 Scarlet fever 20 29 Sore throat 23 2 Tonsillitis 39 29 Whooping cough 4 24 A close watch is maintained on the incidence of infectious disease in schools and in this context I am indebted to the teaching staff 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. Medical treatment of schoolchildren The number of sessions, new cases and total attendances at school treatment centres during 1972 were as follows:- TABLE 53 Type of clinic Sessions New cases Attendances Minor ailments 620 546 7,648 Special investigation (i.e. enuresis, obesity and behaviour problems) 213 182 1,331 Dental 4.588 5.251 17,678 Vision 287 935 3,897 Orthoptic 155 90 331 Audiology 41 44 254 More detailed information about some of these clinics will be found later in this report. Handicapped pupils Handicapped pupils who may need special educational treatment are referred from many sources. In some cases (e.g. delicate children or those with physical handicaps) 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. children who are 133 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. Children who are recommended for admission to Paddock School (formerly a junior training centre for subnormal children) will have been examined under Section 34 of the Education Act and will be considered either Educationally Subnormal (Severe) or Educationally Subnormal (Special Care), depending upon the degree of handicap present. Parents have the right to appeal in those cases where they indicate that they do not accept the recommendation and advice will then be sought from the Medical Adviser of the Inner London Education Authority. Special schools There are twelve schools in Wandsworth providing special educational treatment. Not all the pupils at these schools reside in Wandsworth and some children who live in the Borough attend special schools in other areas. At the end of 1972 the number of children receiving special education at schools in Wandsworth was as follows:- TABLE 54 Type of handicap Day Residential Blind 9 81 Deaf 29 29 Delicate 113 — Educationally subnormal 834 — Maladjusted 63 72 Physically handicapped 60 — The importance of social training is emphasized at these special schools. The scope of education has been broadened to stimulate and maintain the children's interest in the daily activities of the community and to prepare them to take their place as citizens and find employment appropriate to their abilities when the time comes for them to leave school. Social workers are attached to the Greenmead School for Physically Handicapped Children, Chartfield Open-Air School and Oak Lodge School for Deaf Children. In addition, a social worker visits the Partially-Hearing Unit at Sellincourt School. 134 Audiology and audiometry Loss of hearing constitutes so great a handicap for a child in the learning situation that continued vigilance must be kept for its detection. Throughout the pre-school period, screening tests are undertaken by the clinical medical officers and special observation is made on children who are at risk of being deaf. At the time of school entry, each child is tested by means of sweep audiometry and if a hearing loss is found, or if deafness is suspected by the school medical officer, teacher, nurse or parent, further investigation is undertaken. Referral is made either to a hospital otologist or to the audiologist appointed by the Inner London Education Authority who attends the three audiology clinics in the Borough located at the Eileen Lecky, Doddington and Tooting Child Health Centres. The child's general practitioner is kept informed. During 1972 increasing use was made of the Braidwood Audiology Unit at Tulse Hill (Lambeth) where children can be given a comprehensive assessment. The specialists of the Unit contact the schools to give advice on children with poor hearing. A peripatetic teacher of the deaf visits pre-school children in their homes as well as children with a hearing loss who attend ordinary schools. The numbers of children given audiometer tests during 1972 are as follows:- Pupils given screening tests 7,203 Pupils given pure tone tests after failing screening test 722 Pupils referred to otologist 117 Special investigation clinics There are six special investigation clinics in the Borough, which are run jointly with the Inner London Education Authori'ty. Children are treated fo.r enuresis, obesity, and behaviour problems, or a combination of these difficulties. Most cases are referred following medical inspection in school, but a few come from private doctors and the parents themselves. 135 The doctors are assisted in the clinics by a school nurse and a social worker; the latter provides information about the social background of the patients, visits the homes, and maintains contact with the Education Welfare Service. During the year 182 new cases were dealt with and the total attendances numbered 1,331. Tuberculosis - epidemiological investigations Two epidemiological investigations were carried out during the year at educational establishments where it was thought possible that staff or children had been exposed to tuberculous infection. A full-time student at a college of education died ten days after admission to hospital with tubercular meningitis. Postmortem examination showed evidence of active pulmonary tuberculosis. A Mass X-ray Unit visited the college and X-rayed all students and staff; letters were sent to all authorities covering the areas in which past students who were possible contacts were living or working. No further cases were discovered. The student, a woman aged 37, was in the third year of her studies. She had been medically examined at the start and had been graded A1; her chest X-ray at that time showed no apparent disorder. I am grateful for the co-operation received from the South-West London Mass X-ray Service and the many medical officers of health involved in this country and the Irish Republic. A 16-year-old schoolgirl was found to be suffering from pulmonary tuberculosis. Investigations were carried out among the 404 child contacts and the 50 members of the staff. All but 18 of the children and all but one of the staff were found to be normal; the remaining nineteen did not attend for examination. I wish to thank the South-West London Mass X-ray Unit and Dr. Millard of the Balham Chest Clinic for their help. B.C.G. vaccination of schoolchildren The vaccination of children against tuberculosis is normally carried out in the autumn and spring terms and is at present offered to all eligible children aged 13 years. The decision has been made to reduce this age to 11 years, and during 1973 136 children aged 13 and 12 will be vaccinated. The change will be completed in 1974 when 11-year-olds and 12-year-olds will receive protection. Children whose skin tests show negative results and who have not been subject to tuberculous infection are vaccinated; children with positive results are referred to the Chest Physicians for X-ray and any further necessary investigation and treatment. The following table summarises the results: TABLE 55 (a) Number of eligible children 4,083 (b) Number of consents received 3,384 (c) Number of consents received for alleged contacts of known cases of tuberculosis (included in (b)) 11 (d) Number of children skin-tested and read 2,980 (e) Number of positive reactors among (d) not previously vaccinated 392 (13%) (f) Number of positive reactors among (d) known to have been previously vaccinated 340 (11%) (g) Number of negative reactors among (d) 2,248 (76%) (h) Number of children skin-tested but not read (absentees) 228 (i) Number of children vaccinated 2,248 Vaccination against tuberculosis is also available to students in colleges. Of 93 students skin-tested, four were vaccinated. School dental service The pattern of the re-organisation of the National Health Service began to take shape. Although some doubts were eliminated, it was a year of question as to the future of the school dental service, and unfortunately the end of the year saw the answer to this question only in outline. These doubts may be reflected in the greatly increased turnover in staff, for it was the first in the five year tenure of the Principal School Dental Officer in which staff changes have been appreciable. Mrs.D.Knight resigned her senior dental officer post after having a baby, but one full time and four sessional dental officers resigned during the course of the year. This situation was exacerbated by the absence of a part-time dental officer through a prolonged illness. 137 Illness also affected the dental surgery assistant staff in that one full time dental surgery assistant has been away for a considerable period. Here again resignations occurred, two attributable to impending motherhood and a third through change of employment. Fortunately, replacement of staff was achieved reasonably promptly, but this, and the internal movement of staff to cover temporary vacancies did impose some strain on the service. A one day in-service training course was held in February for dental auxiliaries. This was done on behalf of the Inner London Education Authority at the Eileen Lecky Treatment Centre, for those auxiliaries working for the Authority. Invitations were extended to auxiliaries working in Outer London Boroughs. Twenty-six attended for the following programme:- "Local Anaesthetics and their reactions". "Extraction of deciduous teeth". "Is our dietary advice too sloppy?" and "Dental health education; does it need re-assessment?" The latter two subjects were combined for an afternoon seminar, which had to be curtailed when time ran out on a very successful day. The first I.L.E.A. in-service training course for Dental Officers was held during the year and Miss A.Stockel was fortunate in obtaining a place on it. Mr.A.D.Valentine is attending the Diploma in Dental Public Health course run by the Royal College of Surgeons. This occupies one academic year of intensive study. In the health education field, Miss E.Mutter our Dental Auxiliary, has steadily expanded her work during the year. In conjunction with the I.L.E.A. Health Educators, the I.L.E.A. puppet show presented the evils of Jimmy Germ to primary school children during a six weeks tour of the Borough. It proved to be very popular with both children and staff. Its reception paved the way for "brush-ins" in the primary schools. These are a group activity during which some 10 to 12 children stain their teeth to see how much debris there is on them. They are then asked to remove the stain by using a tooth brush, which teaches the children just how difficult and time consuming it is to clean teeth properly. During this procedure faulty brushing habits are corrected and the reasons and times for cleaning teeth are discussed. 138 The I.L.E.A. mobile dental surgeries were again used at Oak Lodge, Linden Lodge, Chartfield and Paddock Schools. An additional commitment was made for its use in the latter part of the year. At the request of the I.L.E.A. one was used at Hatchford Park residential school for the physically handicapped at Cobham. Basically the mobile surgery is used twice a year for two weeks at each school for treatment and preventive therapy. A dental inspector from the Department of Education and Science makes a visit every second year to inspect the dental services. Subsequently a report on them is sent to the Department of Health and Social Security, the Education Authority, and to the Local Authority. Such a visit was made on 1.3.72 and the dental services were examined in relation to the 1971 statistics. Overall the result was good because in general the output was above the national average. However, the inspector recommended that the dental services could be improved, particularly in two areas. Further effort should be made to expand the Mother and Child Health service and orthodontic cases should be screened more ca'refully. It was pointed out that the number of discontinued cases was considered to be too high. He agreed with the Principal School Dental Officer that the combination of pressure on existing treatment centres, and the difficulty of access to them, required treatment facilities in the St.Mary's Park/Queenstown area. Active consideration is being given to this problem. Two further surgeries have been installed in secondary schools making a total of three. Further expansion of treatment facilities will take place with the building of Larch Road and Brocklebank Health Centres. Both projects are scheduled to commence early in 1973. A fire in the boiler room at Victoria Drive Centre put the surgery there out of action for a considerable period until a new dental unit could be installed. Statistics relating to the year's work are as follows:- TABLE 56 Sessions Number of inspection sessions in schools 310 Number of ordinary treatment sessions 3,657 Number of health education sessions 182 Number of orthodontic sessions 439 Number of general anaesthetic sessions 1 4.589 139 Inspections Number of first inspections in schools 31,538 Number of first inspections in clinics 6,375 Total 37,913 Percentage requiring treatment 52.6 Re-inspections at schools or clinics 2,059 Percentage requiring treatment 51.5 Attendances First visits 5.251 Subsequent visits 12,427 Total 17,678 Treatments Courses of treatment completed 5,415 Fillings done 18,391 Other operations, including crowns, inlays, X-rays, etc. 11,528 Free milk for schoolchildren All children attending special schools are entitled to free milk, but authority for the provision of free milk to pupils attending ordinary schools is restricted by the Education (Milk) Act 1971 to pupils aged seven years and under. Under Education Act powers, children over seven years of age in junior schools can receive free milk only when so recommended by the Principal School Medical Officer on health grounds. In September 1971, the Council invoked its powers under the Local Government (Financial Provisions) Act, 1963 to provide free milk for all children in junior schools not otherwise entitled to daily milk. At the beginning of 1972, 313 children in junior schools were receiving free milk on medical recommendation. A further 227 children were similarly recommended during the year, whilst 31 children were removed from this category, so that by the end of the year the number of pupils receiving milk on medical recommendation was 509. Health education in schools At the invitation of Head Teachers, health visitors continued to give talks in a number of schools throughout the year. Similarly, doctors were asked to speak, in some instances to the schoolchildren and in others to Parent-Teacher Associations. 140 Health education in schools takes many different forms according to the particular curricular policy of the school. A number of schools invite the health education team from the I.L.E.A. who have numerous prepared illustrated talks, suitable for different age-groups, on a wide range of health subjects. During 1972 the Divisional Education Officer was approached to see what further assistance the health education services of the Health Department could give to the schools in the Borough and the position was being examined in detail at the end of the year. Other references to health education will be found in Part 4 of this Report. Sanitary conditions in schools All school premises are inspected annually by the school medical officers, and when necessary by public health inspectors, who offer advice on the sanitary conditions and standards of hygiene. Any matters calling for attention are passed to the Divisional Officer of the Inner London Education Authority. 141 INDEX Accidents 2, 78 Acute encephalitis 34 Acute meningitis 34 Acute respiratory infection 1 Adoption 110 Aged persons 10, 11, 84, 118 Alcoholism 2, 4, 78 Analysis of food and drugs 65 Animal Boarding Establishments Act, 1963 51 Animals, protection of 51 Ante-natal care 9, 98 Area comparability factors 28 Atmospheric pollution 6, 7, 16, 74 Attachment schemes 9, 10, 11, 82, 84 Audiology 132, 134 Audiometry 134 Bacteriological examinations 5, 38,63, 76 Bakehouses 63 Barbers 47 Bathing centres 77, 131 Baths, home 11, 85 " personal cleansing station 77, 131 " swimming 76 Battersea Chest Clinic Care Committee Report 120 B.C.G. vaccination of schoolchildren 5, 127, 135 Birth control 3, 7, 9, 87, 116 Births 1, 28, 29, 30 Blackshaw Road Day Observation Unit 9, 12, 103 Blind and partially-sighted children 133 Boarding-out 110 Braidwood Audiology Unit 134 Bridge Lane Health Centre 12, 81 Brocklebank Health Centre 12, 81, 138 Bronchitis 2 Burtop Road Health Centre 12, 81 Butchers shops 62 Cancer 2, 8, 29, 91, 92 Caravans 55 Care of old people 10, 11, 84, 118 Catering establishments 62 Cervical cytology 3, 8, 9, 91, 116 Chest clinics 5, 119 Child health centres 100 Chiropody 9, 11, 109, 118 Cholera 6, 34, 38 Chronically Sick and Disabled Persons Act, 1970 12, 105 142 Cigarette smoking 2, 4 Clean Air 6, 7, 74 Cleansing station 77, 125, 131 Clearance areas 53 Closing Orders 53 Common lodging houses 52 Communicable diseases 2, 4, 34, 39, 40 Community Nursing Service 81 Comprehensive health centres 12,81,138 Comprehensive health surveys (schoolchildren) 130 Consumer Protection16, 48 Coroner's Court 7, 78 Creches 100 Cremation Regulations, 1930 79 Day nursery, special unit 9, 104 Deaf children 9, 133, 134 Death, causes of 1, 32, 33 " rates 1, 29, 30 Deaths, cancer 29 " heart disease 30, 31 " infant 1. 29, 31 " maternal 1, 29, 31 " tuberculosis 29, 36 Delicate children 132 Dental service, mothers and young children 10, 108, 116, 138 " " schoolchildren 3, 1 14, 126, 132, 136 Developmental paediatrics 5, 9, 10, 101 Diphtheria 106, 127 Disinfection and disinfestation 4, 76 Doddington Child Health Centre 3, 9, 109 Domiciliary midwifery service 8, 83 Drainage 6, 42, 44 Drugs, misuse of 4 Dysentery 4, 34 Early discharge schemes 9, 11, 83, 84 Education (Milk) Act, 1971 124, 139 Education Welfare Service 127, 135 Educationally subnormal children 127, 133 Enuresis 132, 134 Environmental health services 6, 15, 41 Environmental pollution 6, 7, 16, 42, 74 Epidemiological investigations 16, 37, 125, 135 Factories Act, 1961 72 Family casework 118 Family planning 3,7,9,87,116 Fireguards 49 Fish shops 62 Fluoridation of water supply 16. 46, 115 Food and Drugs Acts 56, 60, 61 Food hygiene 5, 57, 60 143 Food poisoning 4, 35 Food premises 6, 56 Food sampling 42, 56 , 61, 63, 65, 70 Food stalls 60 Food, unsound 61 Foot clinics 9, 11, 109, 118 Free school milk 124,139 Furnaces, installation of 74 German measles, vaccination 6, 107, 125, 127 Gipsies 6, 41 Guthrie test 9, 83 Hairdressers 47 Handicap and observation register 9, 105 Handicapped children 9,101,105,132 Head infestation 125 Health centres 11,12,81 Health Committee 25 Health education and publicity 3, 9, 114, 116, 118, 137, 139 Health surveys 8, 11, 109 Health visiting service 82 Heart disease 30,31 Home bathing service 11, 85, 118 Home dialysis 11, 86 Home nursing equipment, loan of 85 Home nursing service 11,84,118 Home tuition 133 Houses in multiple occupation 6, 42, 53 Housing 6, 42, 53 Housing accommodation applications 56 Housing Finance Act, 1972 54 , 55 Hunter Report 13,20 Hygiene inspections of schoolchildren 130 Ice-cream sampling 63 Illegitimate children 2,29,30 Immigrants 5, 6, 38 Immunisation and vaccination 5, 106, 125, 127 Imported Food Regulations 1968 64 Incontinence pads service 11, 85 Incontinent persons, laundry service 7, 78 Infant mortality 1, 29, 31 Infectious diseases 2, 4, 34, 39, 40 Infectious illness in schools 125, 131 Infective jaundice 35 Influenze 1,2 Inquests 78 International vaccination certificates 38 Laboratory facilities, bacteriological 5, 38, 63, 76 Land Charges Acts, 1 925 52 Larch Road Health Centre 12, 81, 138 144 Laundry services 7, 78 Legal proceedings 44, 57, 61 Leptospirosis 36 Liaison with other services 3, 9, 10, 12, 83, 84, 101, 104, 119, 122, 124 Loan of home nursing equipment 85 London Boroughs' Training Committee 14, 122 Lung cancer 2 Maladjusted children 133 Malaria 4, 36 Maternal mortality 1, 29, 31 Mayston Report 11, 81 Measles 4, 36, 125 " vaccination 6, 36, 107, 127 Medical examination of staff 122 Medical inspection of schoolchildren 126,128,129 Medical treatment of schoolchildren 132 Mental health 2, 10 Midwifery service 83 Milk, provision for schoolchildren 124, 139 Milk sampling 61,63,70 Milk supply 61 Minor ailments 132 Mortality, infant 1,29,31 " maternal 1,29,31 Mortuary 7, 78 Mother and baby homes 46 Mothercraft classes 9, 99 Mumps 125 National Health Service, re-organisation 13 Neo-natal mortality 1, 29 Noise 6, 7, 49 Noise Abatement Act, 1960 49 Nursing auxiliaries 11,85 Nirsing homes 46 Obesity 2, 132, 134 Occasional creches 100 Offensive trades 48 Offices, Shops and Railway Premises Act, 1963 49 Oil heaters 48 Old people, care of 10, 11, 84, 118 Ophthalmia neonatorum 36 Orthodontics 138 Orthoptics 9, 132 Outworkers 73 Partially-hearing children 133,134 Perinatal mortality 1,29 Personal cleansing station 77, 125, 131 Personal health services 81 Personal hygiene 125, 130 Pest control 6, 47, 77 145 Pesticide residues in foodstuffs 6, 70 Pet Animals Act, 1951 51 Pharmacy and Poisons Act, 1933 48 Physically handicapped children 132,133 Pigeon control 47 Pneumonia 1, 2 Poliomyelitis 36 Poliomyelitis vaccination 106, 127 Pollution 6, 7, 16, 42, 74 Population 1, 7, 28 Post-mortem examinations 78 Post-natal care 98 Poultry processing 62 Premature infants 31, 99 Premises 26 Prevention of Damage by Pests Act, 1949 47 Problem famiIies 118 Prophylaxis 5, 106, 125, 127 Prosecutions 44, 57, 61 Public Analyst, report on work of 65 Public Health Laboratory 5, 38, 63, 76 Pupils on school rolls 126 Relaxation classes 9, 99 Renal dialysis 11, 86 Rent Act, 1968 55 Riding Establishments Acts, 1964 and 1970 51 Rodent control 41, 47 Rubella vaccination 6, 107, 125, 127 St. George's Hospital Health Centre 12, 81 Samples, adulterated 60, 65 " fish and eels 63 " food and drugs 56, 61, 65 " ice-cream 63 " milk 61, 63, 70 " shell-fish 63 " water 76 Sanitary conditions in schools 140 Scabies 77, 125, 131 Scarlet fever 36 School dental service 3, 114, 126, 136 School health service 10, 17, 123 " " " health education 3, 114, 118, 137, 139 Sewage disposal 45 Sewerage 45 Sexually transmitted diseases 3,4,110,118 Shell-fish sampling 63 Slaughter of animals 62 Smallpox 5, 36, 38 Smallpox, international vaccination certificates 38 vaccination 5, 107 146 Smoke control 6, 7, 74 " " measuring stations 74 Smoking 2, 4 Special educational treatment 9, 132 Special investigation clinics 132, 134 Special schools 126, 133 Special unit, day nursery 9, 104 Staff 16, 25 Staff, medical examination 122 Staff training 14, 80, 121, 137 Statistics, dental 138 " immunisation and vaccination 107 " vital 1, 28, 29 Stillbirths 1, 29, 30 Students, training of 80, 121 Suicide 2, 78 Surveys 8, 11, 109 Swimming baths 76 Tetanus immunisation 106, 127 Training of staff 14, 79, 121, 137 Training of students 80, 121 Transportation of bodies abroad 79 Tuberculosis 2, 4, 5, 36 " deaths 29, 36 epidemiological investigations 16, 37, 125, 135 notifications 36 Typhoid fever 4, 37 Unsound food 60, 61 Vaccination and immunisation 5, 106, 125, 127 Vaccination, international certificates 38 Venereal diseases 3, 4, 110, 118 Vermin 77, 125, 130, 131 Vision testing 9, 130, 132 Vital statistics 1, 28, 29 Walk-in Centres 88 Wandsworth Tuberculosis Care Committee 119 Water sampling 76 Water supply 16, 45 " " fluoridation of 16, 46, 115 Whooping cough 4, 37, 106