WIL 40 AC 139 (1) WILLESDEN Borough of Willesden. 1944 THE 69th ANNUAL HEALTH REPORT GEORGE F. BUCHAN, M.D., F.R.C.P., D.P.H., Medical Officer of Health. London : WIGHTMAN & CO. LTD., 104, Regency Street, S.W.I. BOROUGH OF WILLESDEN Health Department, 54, Winchester Avenue, Kilburn, London, N.W.6. September, 1945. To the Corporation of Willesden. I beg to submit herewith the Annual Health Report for Willesden for the year 1944, in accordance with instructions received from the Ministry of Health and Ministry of Education that it should be a short report. VITAL STATISTICS. 2,697 live births were registered. 74 still births were registered. 1,735 deaths were registered. The infantile mortality rate for the year was 42, being the lowest on record. 114 children under 1 year of age died in 1944. CANCER. There were 319 deaths of Willesden residents from Cancer in 1944, as compared with 334 in 1943. The two Municipal Cancer Clinics were continued throughout the year. 1 new patient attended in 1944. She was referred to Hospital, where an operation was performed and a diagnosis of intra-canalicular fibro-adenoma of the breast was made. Her recovery was good. At the end of 1944, 6 patients remained under observation—1 who had had cancer of the breast was awaiting admission to hospital for an abdominal condition, 2 who had been treated for cancer of the breast were still under observation at hospital, 2 who had been treated for cancer of the uterus and 1 who had been treated for cancer of the bowel remained well and showed no signs of recurrence. 1 patient who had been treated for cancer of the breast did not desire further following up and was removed from observation. INFECTIOUS DISEASES. During the year 1944, 1,856 cases of infectious diseases were notified, as compared with 2,738 in the previous year. The following table gives the number of notifications of certain diseases included in the above total of 1,856 together with the corresponding figures for 1943:— Table No. 1. Number of Cases Notified. No. of Notified Cases Confirmed. 1943 1944 1944 Diphtheria 136 60 17 Scarlet Fever 557 402 376 Pneumonia 439 283 283 Whooping Cough 238 411 401 Erysipelas 32 49 46 Measles 882 250 248 Diphtheria Immunisation.— The number of children who have completed a full course of immunisation since 1941 under the Council's scheme is as follows :— Table No. 2. Children under 5 years. Children 5 years of age and over but under 15 years. Total. 1941 1,186 813 1,999 1942 1,833 2,660 4,493 1943 1,691 2,520 4,211 1944 1,193 338 1,531 The approximate estimated number of children in Willesden at 31st December, 1944, was 10,700 under 5 years of age and 13,530 between 5 and 15 years of age. It was estimated that 62 per cent. of those under 5 years and 54 per cent. of those between 5 and 15 years had been immunised at 31st December, 1944. 3 The Council first made arrangements for immunising Willesden children against diphtheria in May, 1927. Immunisation was carried out at the Kilburn Health Centre and the Municipal Hospital. More recently, when the number of applicants has been large enough, immunisation sessions have been arranged in the schools. Since November, 1942, sessions have also been held regularly at each of the Council's Health Centres. Pamphlets on diphtheria prevention and copies of the broadcast of the Chief Medical Officer of the Ministry of Health have been distributed in considerable quantities and notices and articles have been put in the Press. The most effective method, however, of ensuring the immunisation of the child population is the following :— When the Health Visitors visit children aged 9 months or over under the Maternity and Child Welfare Scheme they draw the attention of mothers to the facilities existing for immunisation against diphtheria in order that they may think the matter over and have their children immunised at about 1 year of age if they so desire. The Health Visitors have this question of diphtheria immunisation in mind at each subsequent visit until the child has been immunised. Leaflets concerning diphtheria prevention with form on the back for parents' signature agreeing to have their children immunised have been sent to head teachers for distribution to their scholars. A high percentage of these forms are returned, duly signed, to the teachers. When immunisation sessions are held at the schools the mothers frequently take the opportunity of bringing any younger children not yet. immunised and getting all their family dealt with at once. It is noteworthy that there were only 17 cases of Diphtheria in Willesden in 1944 and there were no deaths. Enteric Fever.—1 case was notified in 1944. This was admitted to the Municipal Hospital and diagnosed and notified again as Cerebro-spinal Fever. The patient recovered. Dysentery.—22 cases were notified as Dysentery in 1944. Malaria.—2 cases were notified in 1944. 1 case occurred in a man of 35 years and 1 in a man of 37 years. Both patients originally contracted the disease in Sicily in 1943. Infectious Diseases of the Central Nervous System.—Poliomyelitis and Polio-encephalitis, Cerebrospinal Fever and Encephalitis Lethargica.—16 cases of these diseases were notified in 1944, as against 20 in 1943, 35 in 1942, 29 in 1941, 38 in 1940,18 in 1939, 24 in 1938, 22 in 1937 and 14 in 1936. 1 proved fatal, giving a fatality rate of 6'25 per cent, of notified cases. 13 cases were notified as Cerebro-spinal Fever. Of these 13 cases 12 proved to be Cerebro-spinal Fever and 1 was found in hospital to be suffering from Erysipelas. In addition, 1 case notified as Poliomyelitis was subsequently diagnosed as Cerebro-spinal Fever. The ages of the 13 cases which proved to be Cerebro-spinal Fever were as follows :— Under 1 year of age 0 Between 10 and 15 years of age 0 Between 1 and 2 years of age 2 „ 15 ,, 20 ,, „ 1 „ 2 „ 3 „ „ 2 „ 20 „ 35 „ „ 1 . . . . ,, 3 ,, 4 ,, ,, 0 ,, 3d ,, 45 ,, ,, 3 „ 4 „ 5 „ ,, 3 ,, 45 ,, 65 ,, ,, 1 ,, 5 ,, 10 ,, „ 0 65 years of age and over 0 The months in which the 13 cases occurred were as follows :— January, 1944 4 May, 1944 1 September, 1944 0 February, 1944 1 June, 1944 0 October, 1944 0 March, 1944 3 July, 1944 1 November, 1944 0 April, 1944 1 August, 1944 0 December, 1944 2 1 of these 13 cases which proved to be Cerebro-spinal Fever died. This patient was aged 1 year 10 months. Three cases of Poliomyelitis were notified, two aged 2 years and one aged 25 years. The cases aged 2 years were diagnosed in hospital, 1 as Cerebro-spinal Fever and 1 as Abscess in Axilla. Both recovered. The case of Poliomyelitis, aged 25 years, was discharged from hospital and referred for further treatment at an orthopaedic hospital for Paralysis of left leg. Pneumonia and Influenza.—283 cases of Pneumonia were notified in 1944, as compared with 439 in 1943. Deaths from Broncho-Pneumonia, Lobar Pneumonia and Pneumonia (unspecified) numbered 86, as compared with 130 in 1943 and 87 in 1942, and deaths from Influenza 9, as compared with 30 in 1943 and 12 in 1942. Whooping Cough.—411 cases were notified in 1944, but a total of 709 cases coming to their knowledge were visited by the Health Visitors, 428 of which occurred in children under 5 years of age. There were 4 deaths from Whooping Cough in 1944. 1 of the children who died was under 1 year of age, 2 were between 1 and 5 years of age and 1 was between 5 and 10 years of age. Measles.—250 cases were notified in 1944, but a total of 897 cases were visited by the Health Visitors, 205 of which occurred in children under 5 years of age. There was no death from Measles in 1944. Tuberculosis.—The following table shows the number of cases of Tuberculosis on the register at the end of each year 1938-1944 4 Table No. 3. Number of Cases of Tuberculosis on Register at end of Year. Pulmonary. Non-Pulmonary. Male. Female. Male. Female. 1938 361 330 80 92 1939 373 305 77 89 1940 337 250 61 84 1941 325 250 58 58 1942 361 278 68 65 1943 422 312 72 78 1944 446 369 76 80 MOTHERS AND CHILDREN UNDER FIVE YEARS. Municipal Health Centres.— At the 3 Municipal Health Centres, expectant mothers attended the medical consultation and medical treatment Clinics on 16,762 occasions, nursing mothers 22,875, and children under 5 38,256, making a total at these clinics of 77,893 attendances in 1944. Out of the total number of 2,697 children registered as born alive in 1944, 1,975, or 73 per cent., subsequently attended the Municipal Health Centres. The following table shows the total attendances of Expectant and Nursing Mothers and Children under 5 years of age at the Municipal Health Centres since 1938 :— Table No. 4. Health Centre Attendances. Total attendances of Expectant and Nursing Mothers and Children under 5 years of age. Attendances of Expectant Mothers at Ante-Natal Clinics only. 1938 (3 Health Centres open) 158,893 15,351 1939 (3 Health Centres open 8 months, 2 Health Centres open 4 months) 153,810 14,305 1940 (2 Health Centres open) 127,781 15,335 1941 (2 Health Centres open) 113,863 13,949 1942 (2 Health Centres open 10½ months, 3 Health Centres open 1½ months) 138,189 19,157 1943 (3 Health Centres open) 146,071 18,142 1944 (3 Health Centres open) 117,731 16,680 Princess Road Voluntary Centre.— The Council took over the Princess Road Voluntary Infant Welfare Centre in Kilburn as from 1st April, 1942. Children under 5 years of age attended the Medical Consultations at this Centre on 1,379 occasions and nursing mothers on 1,025 occasions during 1944. Government Evacuation Scheme—Expectant Mothers.— The registration of expectant mothers for evacuation during the last month of pregnancy under the Government's Evacuation Scheme was carried out at the Health Centres in accordance with the Government plan. MATERNITY HOSPITAL. Bookings.—1,079 patients were booked during 1944 for confinement in the Willesden Maternity Hospital. The fees at which these 1,079 cases were booked varied from 41 at £15 to 218 free. The average fee per case was approximately £4 14s. 8d. During 1944, 355 applicants for confinement in the Willesden Maternity Hospital were unable to be booked for the reasons set out below :— Table No. 5.—Applications for Booking Refused. No beds available 346 Not resident in Willesden 9 355 Hospital Confinements.— During 1944, 1,010 women were confined in the Willesden Maternity Hospital. 479 births of Willesden residents were notified from outside Institutions—68 from St. Mary's Hospital, 31 from University College Hospital, 30 from Queen Charlotte's Hospital, 19 from Paddington Hospital, 11 from Middlesex Hospital, and smaller numbers from other hospitals, 57 from a Nursing Home, 49 from a Maternity Home in Cheltenham, and smaller numbers from other Nursing and Maternity Homes. These, together with some 453 in the Central Middlesex County Hospital, are approximately 70 per cent. of the births belonging to Willesden. 5 It is to be noted that in 1944 many mothers desiring institutional confinement were unable to obtain beds. 346 applicants for the Willesden Maternity Hospital alone had to be refused. Some of these obtained beds in other hospitals, some solved their difficulty by registering for evacuation in the last month of pregnancy, and some had to be confined at home. The following table shows the domiciliary and institutional confinements:— Table No. 6. Years. Domiciliary Births attended by Midwives. Domiciliary Births attended by Doctors. Births in Hospitals and Nursing Homes. Total Births notified. (Note—Notified not registered.) 1931 515 1,174 1,110 2,799 1932 457 997 1,220 2,674 1933 532 776 1,357 2,665 1934 610 680 1,436 2,726 1935 589 568 1,706 2,863 1936 646 516 1,745 2,907 1937 760 465 1,906 3,131 1938 710 394 1,974 3,078 1939 703 257 1,789 2,749 1940 521 129 1,640 2,290 1941 340 112 1,317 1,769 1942 663 163 1,788 2,614 1943 634 189 1,871 2,694 1944 653 166 1,905 2,724 The report on the Willesden Maternity Hospital by Mr. Arnold Walker, F.R.C.S., the Council's Consultant Obstetrician, appears later in this report. Ante-Natal Work for Institutions not under the Council.— Requests are received from the Middlesex County Council and from various London Hospitals for home visits to expectant mothers, and for special reports by the Council's Health Visitors in connection with women who are to be confined in these hospitals. 336 such reports were supplied in 1944. 291 Expectant Mothers booked for confinement in the Central Middlesex County Hospital were referred to the Willesden Health Centres for Ante-Natal care in 1944. Puerperal Pyrexia.—68 cases were notified in 1944. Maternal Mortality.— During 1944 there were 6 deaths classed to pregnancy and child-bearing—1 to Puerperal Sepsis, a self-induced abortion, and 5 to other puerperal causes. The puerperal mortality rate from Sepsis was therefore 036 per 1,000 registered total births. The total puerperal mortality rate was 2.17 per 1,000 registered total births. During 1944 there was, in addition, 1 maternal death from non-puerperal causes. The total maternal mortality from all causes, including criminal abortion, was 2.53 per 1,000 registered total births. Sterilised Accouchement Sets.— These sets are supplied in accordance with the arrangements stated in my Annual Report for 1930, p. 10. During 1944, 227 were supplied free, 199 at full cost and 313 at part cost—a total of 739. Specialist Help.— The Council accept responsibility for the payment of the fee of one of their specialists called in by a medical practitioner to assist him in connection with a difficult case of labour. No such consultations were paid for in 1944. The services of the Council's Consultant Obstetrician are also available in cases of Puerperal Fever and Puerperal Pyrexia when desired by the practitioner in attendance. Provision of Anaesthetist.— The Council further accept responsibility for the payment of a fee to an anaesthetist called in by a medical practitioner in connection with confinement cases. No such fees were paid in 1944. Home Helps.— The Council provided the services of home helps in connection with 72 confinement cases in 1944. Great difficulty was experienced in finding women willing to undertake this work and some mothers in need of home helps were unable to obtain them Maternal Mortality Investigations.— The Council have continued to take part in the investigation of deaths of mothers in childbirth for the Maternal Mortality Committee of the Ministry of Health. The investigations are carried out by the Council's Consultant Obstetrician. 5 cases were inquired into during 1944. 6 Hospital Treatment of Children under 5 Years of Age. Treatment for children suffering from Marasmus and the operative treatment of enlarged tonsils and adenoids continued to be available at the Willesden Municipal Hospital. 30 children were under treatment for Marasmus and 105 for enlarged tonsils and adenoids and mastoid disease. 4 of the children suffering from Marasmus died. Children were admitted to hospital to a limited extent for orthopaedic conditions. Ophthalmia Neonatorum.—The number of cases of this disease notified in 1944 was 8, this being the same figure as for 1943 and 1942. This gives a case rate of 2.97 per 1,000 registered live births. A district midwife attended the confinement in 2 cases, and 6 cases were born in hospital. Treatment was obtained at a hospital in 6 cases, and at the Municipal Health Centre in 2 cases. Complete recovery with unimpaired vision occurred in 7 cases. In 1 case the patient removed from the district and no further information was obtainable. Cases of inflammation of or discharge from the eyes of infants or of cases of ophthalmia neonatorum entering Willesden after notification elsewhere are also visited by the Health Nurses. Teaching of Mothercraft at the Centres. This important part of the work of each Health Centre had to be suspended on the outbreak of war. THE CARE OF PREMATURE INFANTS. The Ministry of Health issued Circular 20/44 on March 22nd, 1944, dealing with the Care of Premature Infants. Arrangements have been made for obtaining knowledge of all children whose weight at birth is 5½ lbs. or less. The services of a paediatrician are available if necessary. Midwives and Health Visitors give particular attention to these babies, and the services of home helps are provided if necessary and available. The proposals as to the provision of special staff and accommodation in the case of institutional treatment will be borne in mind by the Council when development of the Maternity Hospital is practicable. A paediatrician is attached to the Maternity Hospital. All discharges of such infants from the Willesden Maternity Hospital and Central Middlesex County Council are notified forthwith to the Health Department and followed up. In 1944, out of a total of 114 deaths of children under 1 year of age, 31 were due to premature birth. In 1943, out of a total of 155,25 were due to premature birth, and in 1942, out of a total of 130, 33 were due to premature birth. Taking only the deaths under 4 weeks of age in 1944, 30 out of a total of 70 were due to premature birth ; in 1943, 24 out of 61, r nd in 1942, 31 out of 61. CHILD LIFE PROTECTION. A number of foster children are still evacuated under the Government Scheme or privately with their Foster Mothers. At the end of 1944 there were 21 Foster Mothers and 37 Foster Children still in Willesden. There has been a great scarcity of Foster Mothers throughout the year. Women even when not otherwise occupied are unwilling to undertake the care of children in these difficult times and further they desire to be free whenever their husbands come home on leave. ADOPTION OF CHILDREN (REGULATION) ACT, 1939. This Act came into force on June 1st, 1943. It makes it unlawful for any body of persons to make any arrangements for the adoption of a child unless that body is a registered adoption society or a local authority. Adoption Societies have to be registered by the Councils of Counties or County Boroughs, and on September 8th, 1943, the Secretary of State issued the Adoption Societies Regulations, 1943, made under Section 4 of the Act. In carrying out the obligations placed upon them Adoption Societies make considerable demands on the services of Local Authorities' Officers. Section 7 of the Act is the section with which Willesden as the Welfare Authority is concerned. This section makes it the duty of any person, other than the child's parent or guardian or the person with whom the child is placed, who participates in the arrangements for the placing of the child, to notify in writing the Welfare Authority of the area in which the child is to be placed. It is illegal for the adopter or any other person concerned to give or receive any remuneration or reward. It is the duty of child protection visitors to visit and examine such children and the premises in which they are kept and further to seek out any children in respect of whom a notice should have been given. A child may be removed from the person with whom it is placed on the same grounds as a foster child. The provisions of Section 7 do not apply if the other person participating is a registered Adoption Society or a Local Authority or when the child is legally adopted or reaches 9 years of age. There are certain other exceptions. If a child is placed in the care and possession of another person by its parents without any other person in any way participating in the making of the arrangements it does not come within the provisions of Section 7 of the Act and the Health Visitor can then only exercise such supervision as is possible without compulsory power in the course of her maternity and child welfare work. 8 persons gave notice under Section 7 (3) in 1944 in respect of 9 children and, in addition, 1 child was found by a Health Visitor. There were no children under supervision at the end of the year, all having been legally adopted or moved out of Willesden. 7 THE CARE OF ILLEGITIMATE CHILDREN. The Ministry of Health issued Circular 2866 dealing with this matter on October 1st, 1943, and a revised edition on November 16th, 1943. A report on the subject appears in Appendix A. The Council consider that the establishment of a hostel is desirable and endeavours are being made to secure suitable' premises. NURSING HOMES. No new homes were registered in 1944. The total number of homes on the register at the end of 1944 was 6, providing accommodation for 4 maternity patients and 31 other patients. AGED AND INFIRM PERSONS. The suitable care of aged and infirm persons was reported on in last year's Annual Report. The problem continues to cause concern. A number of such persons have come to notice during the year and so far there is no satisfactory way of dealing with them. SOCIAL PROBLEMS GENERALLY. From year to year it becomes increasingly evident that associated with a Health Service the following provisions are required if it is to be really effective :— (1) Arrangements for a system of domestic help for those incapacitated or hard pressed. (2) Arrangements for a system of domestic help and personal care for the aged in their own homes. (3) Establishment of suitably-designed and fitted houses and flats where the aged could be accommodated if it were necessary to remove them from their own homes. (4) Establishment of homes or hostels for short whole-time stays of children in illness of mother and in the case of certain foster children, and for short or long stays of certain illegitimate children with or without their mothers. These might also be available for elderly people for short stays whilst their own homes are being cleaned or redecorated. (5) System of boarding children out with suitable foster mothers in certain cases. (6) Arrangements for sending certain children to permanent or long-stay homes. (7) The work of approving families who wish to adopt children and of supervising "adopted" children not legally adopted under the Adoption of Children Act, 1926, to be the duty of the Health Authority. (8) Arrangements for the suitable disposition of tuberculous patients. Infectious cases of tuberculosis should be in a suitable institution or colony. Non-infectious tuberculous patients and their families should be enabled to have suitable housing accommodation and living conditions, suitable work and working conditions, and extra domestic help as necessary. (9) Arrangements for providing or securing appropriate housing for various types of patients, such as heart cases or large families. (10) Provision of day nurseries where children under 3 years of age could be left for a few hours to enable their mothers to do their shopping or get some rest or recreation. Children 3 to 5 years should be provided for by the Education Department in nursery schools or classes. (11) Arrangements for securing suitable work and working conditions for certain cases. The Health Department should be in touch with choice of employment officers, labour exchanges and employers, and with industrial welfare officers. Applications for such help of the nature indicated above should be made to the Health Department, which should have a bureau in which all such organizations are listed. Although these organizations are numerous, it is sometimes difficult to secure the necessary help in a number of cases. The bureau would be the means by which the gaps in these social services are brought to light, and it should be a recognized duty of the health authority to see that complete provisions for social help are available. All cases requiring such help would be investigated and the appropriate action taken by the Health Department, so that overlapping and confusion would be avoided. Health Visitors are the most suitable officers for inquiries. It is through them that a large number of social difficulties are revealed. They visit the homes to see that the doctor's instructions are understood and are being carried out, they establish good relations with the families so that they come to be regarded as friends and receive the confidences of their people as to the social circumstances which may be militating against health. It is their duty to help and advise in any way they can. Reports on visits in connection with social circumstances would be referred to the bureau for action and to the family doctor for his information, so that in the light of the knowledge of the home conditions the doctor may be able to assess their influence on any deviations from health which the family may show. DOMESTIC HELP. On December 14th, 1944, the Ministry of Health issued Circular 179/44 relative to Domestic Help, enclosing therewith copy of a Defence Regulation which had been made to empower Local Authorities to provide domestic help where necessary and not only in maternity and child welfare cases as previously. Considerable publicity was given to this measure in the Press and on the wireless. As in the present circumstances there is no domestic help available, the only practical result has been that the Health Department has been inundated with applications for domestic staff, most of which would normally have been made to domestic agencies and Labour Exchanges. 8 THE SCHOOL MEDICAL SERVICE. On August 28th, 1942, the Board of Education issued Circular 1604, revising the arrangements to be made for the medical inspection of school children. Only 2 routine inspections are now required instead of 3—(i) on or as soon as possible after admission to school; (ii) in the last year of school life—but increased attention is required to be paid to the children by the School Nurses. These revised arrangements came into operation on the reopening of the Stonebridge Health Centre in November, 1942. During 1944, 2,487 children were medically inspected at routine inspections and 13,932 at special inspections and reinspections. Scabies.—See report on Uncleanliness and Scabies on pages 10 and 11. Uncleanliness.—(a) Willesden.—During 1944 cleanliness inspections were carried out in the schools on 437 occasions. The total number of examinations and re-examinations made during the year was 33,328. See report on Uncleanliness and Scabies on pages 10 and 11. (b) Reception Areas.—In the Annual Reports for 1940-1943 the results of cleanliness inspections made by the Willesden Council's Health Visitors in reception areas from April 20th, 1940, to end of 1943 were shown. The results of cleanliness inspections made by the Willesden Council's Health Visitors in reception areas during 1944 are as follows:— Table No. 7. Number Inspected. Number Nitty or Verminous. Percentage Nitty or Verminous. Willesden Evacuees 648 5 0.8% Other Evacuees 1,307 23 1.8% Natives 7,432 349 4.7% Medical Treatment in Willesden.— During the year 1944 school children were followed up by the Health Department on account of 9,526 medical defects and 3,695 dental defects. Of those defects found to require treatment, medical or dental treatment was obtained for 9,176 and domestic treatment was obtained for 1,377. 84 per cent. of the medical defects were treated, 69 per cent. receiving medical treatment and 15 per cent. domestic treatment; 76 per cent. of the dental defects followed up were treated. No record is available of defects requiring treatment which were not followed up. 95 per cent. of the total medical defects treated and 99 per cent. of the total dental defects treated were dealt with by the Education Committee. The remainder, or 5 per cent. of the medical defects and 1 per cent. of the dental defects treated, were dealt with by private practitioners, voluntary hospitals, or other charitable institutions, or Public Assistance. In connection with the defects treated, the children concerned made 41,006 attendances at the Health Centres. School Medical Service for Children Sent to Reception Areas.—3 of the School Nursing Staff were working in Reception Areas during 1944, until November 24th, when 1 obtained a post elsewhere and was not replaced. Medical Inspection of children for evacuation to Reception Area in 1944 was carried out in accordance with the requirements of Government Departments. HEALTH CENTRES. ATTENDANCES. Table No. 8. Medical and Dental Treatment—Attendances at Municipal Health Centres, 1944. Condition. Mothers, and Children under Five. Grand Total (Cols. 7 and 8). Expectant Mothers. Nursing Mothers. Children under Five. Total (Cols. 2—5). School Children. 0—1. 1—5. Total (Cols. 4 and 5). (1) (2) (3) (4) (5) (6) (7) (8) (9) 1. Cleansing — — 2 27 29 29 131 160 2. Throat, Nose and Ear Diseases — 1 12 449 461 462 3,229 3,691 3. Minor Ailments 22 61 466 2,643 3,109 3,192 19,550 22,742 4. Eye Diseases 4 5 200 494 694 703 3,225 3,928 5. Skin Diseases 29 17 206 208 414 460 378 838 6. Artificial Sunlight Treatment — — — — — — — — 7. Orthopaedics 27 95 346 697 1,043 1,165 2,116 3,281 8. Medical Consultations 16,680 22,696 23,415 9,091 32,506 71,882 — 71,882 9. Diphtheria Immunisations — — 21 2,103 2,124 2,124 168 2,292 10. Total (1—9) 16,762 22,875 24,668 15,712 40,380 80,017 28,797 108,814 11. Dental Consultations 2,945 627 — 732 732 4,304 7,582 11,886 12. Total (10—11) 19,707 23,502 24,668 16,444 41,112 84,321 36,379 120,700 13. School for Mothers — — — — — — — — 14. Nursery — — — — — — — — 15. Miscellaneous — — — — — 33,410 4,795 38,205 16. Grand Total (12—15) 19,707 23,502 24,668 16,444 41,112 117,731 41,174 158,905 9 (1) Kilburn Health Centre. Willesden Health Centre. Stonebridge Health Centre. Mothers and Children under Five. (2) School Children. (3) Total. (4) Mothers and Children under Five. (5) School Children. (6) Total. (7) Mothers and Children under Five. (8) School Children. (9) Total. (10) Grand Total. (11) 17. Medical Attendances 20,818 6,233 27,051 31,309 9,490 40,799 27,890 13,074 40,964 108,814 18. Dental Attendances 1,217 1,790 3,007 1,658 2,491 4,149 1,435 3,295 4,730 11,886 19. School for Mothers — — — — — — — — — — 20. Nursery Attendances — — — — — — — — — — 21. Miscellaneous 14,946 459 15,405 8,547 1,136 9,683 9,917 3,200 13,117 38,205 22. Total 36,981 8,482 45,463 41,514 13,117 54,631 39,242 19,569 58,811 *158,905 * In addition 3,136 attendances were made by Secondary and Technical School children and the following attendances by adults : Cleansing and Treatment of Scabies—1,021, Skin Diseases—45, Varicose Ulcers—511 and Orthopaedics under Section 181 of the Public Health Act, 1936—25, making a total of 4,738, which together with the 158,905 above makes a grand total of 163,643. In addition 5,672 attendances were made at the newly opened Scabies and Lice Treatment Clinic which in previous years would have been included in above Tables. Table No. 9. Showing Attendances at the Municipal Health Centres each year since 1913. Year. Mothers and Children under 5 years. School Children. Total. School for Mothers. Nursery. Miscellaneous. Grand Total. Medical. Dental. Total. Medical. Dental. Total. 1913 0 0 0 299 0 299 299 0 0 299 1914 0 0 0 2,517 0 2,517 2,517 0 0 2,517 1915 0 0 0 5,674 0 5,674 5,674 0 0 5,674 1916 389 0 389 9,593 0 9,593 9,982 0 0 9,982 1917 8,641 0 8,641 9,448 0 9,448 18,089 0 0 18,089 1918 32,169 1,165 33,334 15,811 2,403 18,214 51,548 44 220 51,812 1919 32,870 878 33,748 46,179 11,024 57,203 90,951 1,089 2,814 94,854 1920 51,468 1,823 53,291 64,588 10,670 75,258 128,549 2,354 3,452 134,355 1921 41,562 1,667 43,229 57,032 7,718 64,750 107,979 1,716 2,356 112,051 1922 27,505 894 28,399 39,989 7,025 47,014 75,413 1,616 2,190 79,219 1923 23,271 533 23,804 40,381 3,599 43,980 67,784 2,761 3,270 73,815 1924 17,082 520 17,602 34,845 2,460 37,305 54,907 2,896 2,808 60,611 1925 26,119 936 27,055 41,695 5,123 46,818 73,873 4,074 3,812 81,759 1926 39,084 1,491 40,575 47,786 5,909 53,695 94,270 4,126 3,645 102,041 1927 40,958 1,593 42,551 47,199 6,583 53,782 96,333 3,847 3,291 103,471 1928 40,787 1,733 42,520 43,956 6,484 50,440 92,960 4,485 3,355 100,800 1929 43,419 1,598 45,017 39,698 6,307 46,005 91,022 4,523 3,446 98,991 1930 59,372 2,341 61,713 49,610 10,537 60,147 121,860 5,958 5,371 133,189 1931 76,395 3,473 79,868 65,942 15,180 81,122 160,990 6,928 6,985 21,884 196,787 1932 84,342 4,385 88,727 67,964 16,094 84,058 172,785 6,536 6,227 28,817 214,365 1933 84,782 4,791 89,573 71,587 15,652 87,239 176,812 5,297 5,268 27,256 214,633 1934 88,472 5,036 93,508 62,212 13,095 75,307 168,815 5,337 4,726 30,139 209,017 1935 92,666 5,596 98,262 63,666 12,447 76,113 174,375 5,343 5,299 32,553 217,570 1936 96,728 5,752 102,480 67,736 12,325 80,061 182,541 5,198 4,985 38,440 231,164 1937 108,715 5,143 113,858 71,621 11,250 82,871 196,729 4,257 4,092 42,169 247,247 1938 114,769 5,265 120,034 67,811 11,541 79,352 199,386 4,877 4,387 47,312 255,962 1939 102,225 5,492 107,717 44,683 7,485 52,168 159,885 3,067 2,943 52,147 218,042 1940 79,306 5,000 84,306 16,017 4,117 20,134 104,440 — — 50,841 155,281 1941 71,557 4,445 76,002 22,576 3,585 26,161 102,163 — — 44,202 146,365 1942 88,644 5,839 94,483 37,974 5,474 43,448 137,931 - — 50,956 188,887 1943 96,737 4,948 101,685 40,314 7,575 47,889 149,574 - — 55,988 205,562 1944 80,017 4,304 84,321 28,797 7,582 36,379 120,700 - - 42,943* 163,643 * This includes the 3,136 attendances made by Secondary and Technical School children and the 1,602 by adults and others under Section 181 of the Public Health Act, 1936, which are shown in the footnote of Table No. 8. In addition 5,672 attendances were made at the newly opened Scabies and Lice Treatment Clinic which in previous years would have been included in above Tables. In 1944, 2 School Children and 4 Children under 5 years of age were treated under the Council's Scheme by X-rays for Ringworm of the Scalp. Table No. 10. Number of Individual Expectant and Nursing Mothers and Children who Attended the Municipal Health Centres in 1944. Public Elementary School Children 7,270 Children under 5 years of age 6,250 Expectant Mothers 3,544 Nursing Mothers 3,348 10 PRINCESS ROAD CENTRE. 1,147 attendances were made by Children under 1 year of age at the Medical Consultation Sessions in 194 I, 232 by Children 1-5 years of age and 1,025 by Nursing Mothers, or a total of 2,404. UNCLEANLINESS AND SCABIES. In last year's Annual Report a note was given of the various Government Circulars and Memoranda relative to uncleanliness and Scabies. Scabies had begun to increase slightly before the war, but during the war it has become very prevalent. In the early part of 1944 it showed some signs of decreasing, but in the last few months of 1941 and the early months of 1945 it again increased. The evacuation of children during the summer and autumn of 1944 and perhaps the absence of leave for Service men possibly contributed to the apparent decrease in these conditions. The number of adults with Scabies coming to knowledge was actually greater in 1944 than in 1943. The Council's new specially-built Scabies and Lice Treatment Clinic opened on March 16th, 1944. The following table shows the work done at the new Treatment Clinic and the 3 Health Centres in respect of Scabies and Lice in 1944. The cases were followed up in their homes by the Health Visitors and necessary action taken as to cleansing, disinfection, examination and treatment of contacts and education as to cleanliness. Steel nit combs are sold at the Health Centres. Certain publications relative to Lice and Scabies have been distributed. In the case of uncleanliness, especially of the aged, the Health Visitors work in conjunction with the Sanitary Inspectors, and if necessary and practicable, patients are admitted to hospital for a short period to enable the premises to be suitably cleansed. Table No. 11. Treatment of Scabies and Lice at the Treatment Clinic and Health Centres, 1944. No. of New Cases Treated. Total No. of Attendances Made. For Scabies. For Lice and Nits. Total. For Scabies. For Lice and Nits. Total. Children under 5 years 402 55 457 1,235† 58 1,293 Children 5-14 years 786 270 1,056 2,819* 286 3,105 Adults M. 274 M. 3 M. 277 2,683‡ 148 2,831 W. 822 W. 116 W. 938 Totals 2,284 444 2,728 6,737 492 7,229 † 59 of these attendances were made for the inspection of contacts who on inspection were found not to be suffering. Such contacts, nevertheless, usually receive treatment. * 73 of these attendances were made for the inspection of contacts who on inspection were found not to be suffering. Such contacts, nevertheless, usually receive treatment. ‡ 232 of these attendances were made for the inspection of contacts who on inspection were found not to be suffering. Such contacts, nevertheless, usually receive treatment. SCHOOL CHILDREN. Routine cleanliness inspections are held in each school department at least once a term and the Health Visitors have continued to visit their schools weekly to re-examine children found nitty or verminous and to see cases specially referred by the teachers. Every effort is made by home visitation to improve the standard of cleanliness of the family. Cases of Lice and Scabies are treated at the Treatment Clinic or Health Centres where they are under the care of a doctor and are referred to the Council's Skin Specialist as necessary. Table No. 12. Percentage of Children examined found Unclean at Routine Cleanliness Inspections. 1938 5.6 1940 5.5 1942 5.1 1939 5.0 1941 5.2 1943 6.1 1944 6.8 Table No. 13. Percentage of Individual Children examined found Unclean at Routine Cleanliness Inspections. 1938 3.8 1940 4.2 1942 4.2 1939 3.8 1941 4.2 1943 4.8 1944 5.2 Table No. 14. Total Number of Individual School Children Cleansed at the Authority's Clinics. 1940 476* 1941 219 1938 379 *Increase largely due to cleansing immediately prior to evacuation. 1942 189 1939 321 1943 348 1944 246 Table No. 15. Number of Cases of Scabies amongst School Children Treated at the Authority's Clinics. 1941 396 1942 725 1943 1,228 1944 786 11 CHILDREN UNDER 5 YEARS OF AGE. These generally come to light in connection with their elder brothers and sisters. In 1944, 402 were treated at the Centres for Scabies, making 1,235 attendances, and 55 were treated for Lice, making 58 attendances. The figures for 1942 were 363 treated for Scabies, making 977 attendances, and 34 treated for Lice, making 34 attendances, and for 1943, 834 treated for Scabies, making 2,014 attendances, and 73 treated for Lice, making 73 attendances. ADULTS. \ The figures below indicate that there is a considerable increase in Lice and Scabies amongst adults, or in any case that a greater number of adults suffering from these conditions are coming to the notice of the Health Department. These adults mainly come to the notice of the Health Department as contacts with known cases amongst • school children or as cases referred from hospitals or factories or by private doctors. Every effort has been made to secure the attendance of the men as well as the women in a family and the appointment of a suitably qualified male attendant at the new Treatment Clinic has greatly contributed to the success of this effort. Table No. 16. Attendances of Adults at the Authority's Clinics for Cleansing and Scabies. Number Treated. Attendances. Scabies. Lice and Nits. Total. Scabies. Lice and Nits. Total. Men. Women. Men. Women. 1938 - - - - - 104 1939 - - - - - 150 1940 - - - - - 556 1941 293 104 397 912 104 1,016 1942 568 88 656 2,287 88 2,375 1943 913 127 1,040 3,116 127 3,243 1944 274 822 3 116 1,096 119 1,215 2,683 148 2,831 SECONDARY AND JUNIOR TECHNICAL, ETC., SCHOOLS. The arrangement by which the Medical and Dental Staff of the Willesden Council carry out the inspection of pupils attending the Secondary and Junior Technical Schools in Willesden on behalf of the Middlesex County Council has been continued. The total number of pupils on the rolls of these Schools now included in this arrangement is approximately 3,000. In 1944, 808 routine medical inspections and 304 special and reinspections were carried out. 166 pupils seen at the routine inspections required treatment, including 74 on account of defective vision and 89 on account of deformities, mainly such as flat foot and postural curvature. The Middlesex County Council have arranged with the Willesden Council for pupils suffering from defective vision, orthopaedic defects and minor ailments to be treated at the Willesden Health Centres. 205 such defects were treated. 1,960 pupils were dentally inspected in 1944. 1,500 were found to require treatment and 590 were treated at the Willesden Council's Dental Clinics under the Middlesex County Council's Scheme. 3,136 attendances were made at the Clinics during the year for medical and dental treatment. REPORTS OF SPECIALISTS ATTACHED TO THE COUNCIL'S HEALTH CENTRES. Dermatological Department.—Report by H. Haldin-Davis, m.d., f.r.c.p., f.r.c.s. :—"There is not much to add to the report made for 1943, but two of the problems mentioned in that report have now been satisfactorily dealt with. The X-ray treatment of Ringworm which had previously given considerable difficulty, especially in cases below school age, has now been undertaken by the University College Hospital with very satisfactory results. As regards the treatment of Naevi or birthmarks now dealt with, by the Radium Institute, it should be mentioned that although this involves a journey to Northwood, which is quite an undertaking for the mothers of infants in war-time, this difficulty is now balanced by the fact that with modern X-ray technique a single treatment is usually sufficient to cure the case, whereas when these cases were treated with radium, although the results were very good, repeated attendances, extending over a number of months and sometimes for a year or two, were necessary in order to obtain a satisfactory result." Otherwise the work of the Dermatological Department has proceeded on normal lines throughout the year. Eye Department.—Mr. B. R. Medlycott, m.b., b.s., m.r.c.s., l.r.c.p., d.o.m.s., Ophthalmic Surgeon to the Council.—During 1944 Dr. Catherine Orr-Ewing and Mr. L. Mushin have carried on the work of this department in the absence of Mr. Medlycott, on War service. Dr. Orr-Ewing reports as follows :— " The outstanding feature of 1944 was the evacuation of children in the summer, which resulted in a reduction of attendances at Clinics. Many children returned in the autumn with the usual aftermath of evacuation—lost glasses, broken glasses and the freedom from parental control were used as an excuse by some 12 children to discard their glasses ! During the last 3 months of the year attendances were back to normal, and one outstanding and cheering fact was the co-operation of mothers of the ' under two year olds ' in following out treatment for squint, with the result that many of these toddlers were cured of their squints at that early age." Mr. L. Mushin reports as follows :— " Notes re Willesden Eye Clinic : (1) The increase in the number of attendances at the Eye Clinic continues, except for a short period in the summer, during the flying-bomb attacks, when there was some decline. (2) The very small number of cases of chronic blepharitis and phlyctenular conjunctivitis which are seen, indicates that the improvement in the general health of the school child is being maintained in the fifth year of war. These cases show a rapid response to treatment. (3) In most cases there is marked co-operation of the parents, who see that the children wear their spectacles regularly, and in the case of squinters, carry out the instructions of the ophthalmic surgeon as to the wearing of occluders, with consequent improvement in the vision of the amblyopic eye." Mental Health.—Dr. Reginald Lightwood, m.d., f.r.c.p., d.p.h., had to give up this work early in the year and has not yet been replaced. Orthopaedic Department.—Report by J. A. Cholmeley, f.r.c.s. :— "Although the number of attendances for examination and treatment at the Orthopaedic Clinic is still below the 1939 level, nevertheless the number attending is steadily increasing and this has occurred with only a monthly surgeon's visit, whereas before there was a weekly attendance. Unfortunately, at the present time, pressure of work is so great that a more frequent surgeon's attendance is impossible. Comparison of some of the clinic figures for 1939 and 1944 is interesting and the following 3 headings are worth noting :— No. referred in 1939. No. referred in 1944. As per cent. examined in 1939. in 1944. Rickets, 0-5 years 52 22 4.6 3.5 Flat Feet, 5-14 years 41 51, (60)* 3.6 8.2, (9.6)* Postural Defects of Spine, 514 years 33 47, (54)* 2.9 7.5, (8.7)* * Includes Secondary School Children. Thus the number of cases of Rickets in the age group 0-5 referred to the Orthopaedic Clinic is in 1944— the fifth year of the war—less than half the number referred in 1939, a great credit to the Medical and Nursing Staff of the Infant Welfare Centres. On the other hand, the number of cases of Flat Feet referred has increased considerably, and when considered as a per cent. of the cases attending for examination by the surgeon, this increase is over 100 per cent. There is no doubt that this increase is partly due to the poor quality and type of children's shoes which are generally available to the public. There has also been an increase in the number of children in the age group 5-14 (16)* referred on account of postural defects of the spine, this group includes the adolescents, on whom the strain of the war years cannot but leave a mark—a period of rapid growth and development when our rations may be inadequate, large school classes with overworked teaching staff, some of whom have had little training in physical culture, damaged schools leading to further overcrowding, at home, tired and overworked mothers, who expect help from the older members of the family, particularly the girls, and finally the shelter life with the disturbed nights. This brief and rough analysis for 1939 and 1944 of these 3 types of orthopaedic cases shows a most satisfactory fall in the incidence of Rachitic deformities ; in the Flat Foot class an unsatisfactory state of affairs due in no small part to the poor type of children's shoes, and finally the increase in postural defects of the spine, largely a social problem, at the present time almost unavoidable." Ear, Nose and Throat Department.—G. H. Livingstone, f.r.c.s.—Mr. A. L. Pereira, f.r.c.s., has carried on the work of this department in the absence of Mr. Livingstone. HOME NURSING SERVICE. The Home Nurse employed by the Council nursed 222 cases during 1944, and in connection with such cases paid 1,273 visits. Of the 222 Cases nursed during 1944, 217 were new cases. 212 of these 217 new cases were referred by the Health Department for nursing, 2 by private doctors and 3 by hospitals, associations or private persons. SANITARY SECTION. During the year the Deputy Chief Sanitary Inspector and 10 District Sanitary Inspectors were on the staff. The Deputy Chief Sanitary Inspector was appointed Acting Chief Sanitary Inspector in February, and during the year 4 of the District Sanitary Inspectors resigned on taking up other appointments. 5 District Sanitary Inspectors were appointed during December, 1944. The number of premises inspected on complaint was 2,887, and the total inspections and reinspections were 18,084. 13 271 verminous rooms were purified and measures were taken to combat infestation of beetles at Civil Defence Report Centres and Canteens, which entailed 45 treatments. Consequent upon the Council's acceptance of the powers delegated to them by the Middlesex County Council under the Rats and Mice (Destruction) Act, 1919, a Rodent Officer was appointed and commenced duties in March, and 2 operatives commenced duties in April. Inspections of 1,544 properties were made and disinfestation was carried out at 249 premises. In addition to ordinary sanitary work, the Sanitary Inspectors were engaged on Civil Defence duties, such as Control-room work, rehousing and billeting and food decontamination training. In this connection the Acting Chief Sanitary Inspector was responsible for the rehousing of all persons rendered homeless by enemy action, and 540 houses have been requisitioned and prepared under his supervision for this purpose. One District Sanitary Inspector has been seconded full time to this service. The following table shows the food certified as unfit for human consumption during the year :— Table No. 17. Table Showing Food Certified as Unfit for Human Consumption, 1944. Meat: Bread, Flour and Cereals, etc. 4,314 lbs. Bacon 906 lbs. Preserves (jars and tins) 920 Cooked 193 „ Cheese 278 lbs. Tinned 2,698 „ Butter and Fats 491 „ Raw 31,017 „ Eggs 1,879 Fish : Tinned Milk 3,606 tins Tinned 1,770 tins Soups 376 „ Raw 2,219 lbs. Miscellaneous : Vegetables : Sausage 1,145 lbs. Tinned 3,178 tins Tea 305½ „ Raw 836 lbs. Sugar 663 „ Fruit: Sweets and Chocolate 482 „ Tinned 374 tins Raw 346 lbs. In addition : 2 lorry loads of war-damaged assorted Groceries (individual items not identified) and assortment of Sauces, Puddings, Pickles, etc. PUBLIC MORTUARY. During 1944 bodies were deposited at the Mortuary as follows :— Table No. 18. From Willesden. From Acton. Total. Post-mortems 135 187 322 Post-mortems and Inquests 44 66 110 Adjourned Inquests 7 — 7 Accommodations 15 — 15 MUNICIPAL HOSPITAL. The 53rd Annual Report on the Municipal Hospital, written by Dr. Troup, appears later in this Report. Your obedient Servant, GEORGE F. BUCHAN, Medical Officer of Health. 14 THE FIFTY-THIRD ANNUAL REPORT on the MUNICIPAL HOSPITAL By ARTHUR G. TROUP, M.D., D.P.H., Medical Superintendent. The total number of patients admitted to Hospital during 1944 was 1,519, as compared with 1,985 in 1943. Cerebrospinal Fever. 9 cases of Cerebro-spinal Fever were admitted to Hospital during the year, and for the second successive year I have to record that no deaths occurred. Our statistics now show a mortality rate of 5.6 per cent. amongst the 71 cases treated with a sulphonamide drug during the past 6 years, as compared with a mortality rate of 40 per cent. for the 20 years, 1919-1938 inclusive, during which time serum therapy was employed. Diphtheria. Only 17 cases of authenticated Diphtheria were admitted during 1944, and of these 3 were Service sick and 1 from an outside area. 31 patients who were certified as suffering from this disease, and 15 others who were sent in for observation, were finally diagnosed as Tonsillitis 39, Laryngitis 4, Vincent's Angina 2, and Quinsy 1. The great majority of the Tonsillitis cases were due to a Haemolytic Streptococcal infection. The 17 Diphtheria cases were classified as 16 Faucial and 1 Naso-Pharyngeal. No deaths occurred. The following table compares the admissions during the past 25 years with the present year:— Total Admissions. Average Admissions per annum. Total Deaths. Average No. of Deaths per annum 1919-1939 7,636 363 375 18 1940-1943 (War years) 361 90 12 3 1944 17 — — — The peak year was 1922 with 673 cases and 56 deaths. Enteric Fever. The only case of Enteric Fever admitted was a Merchant Navy sailor, who was infected in North Africa. Puerperal Infections. The 18 Puerperal cases admitted to Hospital were diagnosed as follows :— Local Uterine Sepsis 2 Anaemia 1 Phlebitis 2 Septic Episiotomy Wound 1 Abortion 1 Mammary Abscess 7 Retained Placenta 1 Mastitis 3 No deaths occurred. Scarlet Fever. There was a decrease in the number of Scarlet Fever cases admitted during the year, 312, as compared with 45? for 1943. As mentioned in last year's report, it has been found possible to cut down the period of detention in Hospital for the majority of these cases to 21 days from the commencement of the illness. During 1943, 52 per cent, of the patients were discharged between the 21st and the 25th day. The corresponding figure for 1944 was 66 per cent. Other Diseases. Tonsillitis 44 Erythema 2 Rubella 27 Cellulitis 2 Enteritis 19 Herpes 2 Dysentery 12 Ophthalmia Neonatorum 2 Chicken-Pox 12 Quinsy 1 Bronchitis 10 Gingivitis 1 Mumps 5 Pleurisy 1 Influenza 4 Scurvy 1 Dermatitis 4 Haematuria 1 Adenitis 3 Cerebellar Abscess 1 Pneumonia 3 Glandular Fever 1 Laryngitis 3 Malignant Endocarditis 1 Impetigo 3 Acute Leukemia 1 Otitis Media 2 Myelitis 1 Vincent's Angina 2 Pemphigus Neonatorum 1 Tuberculous Meningitis 2 Negative Cases 4 Total Number : 178. 6 deaths occurred, 2 from Tuberculous Meningitis, 2 from Pneumonia, 1 from Acute Leukemia and 1 from Malignant Endocarditis. Marasmus Cases. 27 Marasmic infants were admitted during the year, and the total under treatment was 28. The former may be classified as follows :— Gastro-Enteritis 21 Malnutrition 6 6 deaths occurred. 15 Ear, Nose and Throat Cases. Under the Emergency Medical Service Scheme, children are admitted from the Middlesex Hospital and from the Harrow General Hospital for treatment, in addition to children resident in the Borough of Willesden. (1) Willesden : (a) Health Centre Cases— Removal of Tonsils and/or Adenoids 383 i Mastoidectomy 4 Miscellaneous 4 (b) Hospital Cases— Removal of Tonsils and/or Adenoids.. 6 Mastoidectomy 8 Miscellaneous 2 (2) Middlesex Hospital : Removal of Tonsils and/or Adenoids 74 Antrum Puncture 1 (3) Harrow General Hospital : Removal of Tonsils and/or Adenoids 146 Service Sick. Service Sick include men or women belonging to any of His Majesty's or Allied Forces, the Merchant Navy, Police, and Prisoners of War. 102 patients coming under this category were admitted during the year, the large majority of which were suffering from infectious diseases. Rubella 42 Jaundice 2 Chicken-Pox 14 Influenza 2 Mumps 10 Sub-Arachnoid Haemorrhage 2 Scarlet Fever 7 Cerebrospinal Fever 1 Measles 5 Malaria 1 Tonsillitis 7 Vincent's Angina 1 Diphtheria 3 Whooping Cough 1 Erysipelas 3 Negative Cases 1 Total number : 102. No deaths occurred. Civilian Sick. Civilian Sick patients are cases which have been transferred from another Sector Hospital on the authority of the Group Medical Officer. 118 such patients have been admitted to the Willesden Municipal Hospital during the year. These cases may be classified as follows :— General Medical Cases 63 General Surgical Cases 11 Cancer Cases 44 Air Raid Casualties. 16 Air Raid casualties were admitted, 14 of whom were from 1 incident in the neighbourhood of the Hospital. 4 cases were of a serious nature and the other 12 were suffering from minor injuries only. Cases Admitted from Other Authorities. During the year 1944, 54 cases were admitted from areas other than the Borough of Willesden. Treatment Centre. During March a Treatment Centre for Scabies and verminous conditions was opened at the Hospital. During the 10 months it has been operating, the following cases have been treated Scabies Cases and Contacts 1,726 Verminous conditions 187 Other 2 The total attendances have been 5,672. Schick Test and Active Immunisation against Diphtheria. Nursing Staff. During 1926 a commencement was made in Schick Testing the Nursing Staff and immunising those nurses who proved susceptible to Diphtheria. Since that date 18 cases of Diphtheria have occurred : 1 in 1927, 1 in 1928, 1 in 1929, 2 in 1930, none in 1931, 1 in 1932, none in 1933, 2 in 1934, 1 in 1935, 2 in 1936, 2 in 1937, 1 in 1938, 2 in 19.39, none in 1940, 1 in 1941, none in 1942, 1 in 1943, and none in 1944. (1) Number of cases of Diphtheria occurring amongst Probationer Nurses during the first 8 months of 1926 9 (Before immunisation was carried out.) (2) Incidence rate per annum 45% (Taking 30 as average number of Probationer Nurses.) (3) Number of cases of Diphtheria occurring amongst Probationer Nurses from 1927 to 1944 18 (After immunisation was carried out.) (4) Incidence rate per annum 3.5% (Taking 30 as average number of Probationer Nurses.) (5) Number of Nurses Schick Tested (1927-1944 inclusive) 472 (6) Number of Nurses giving a positive reaction 201 (7) Percentage of Nurses giving a positive reaction 42.5 16 Table No. 19. Diseases. No. in Hospital on 1-1-44. Admitted. Total under Treatment. Discharged Recovered, or Transferred. Died. Mortality per cent. Remaining in hospital on 31-12-44 Cerebro-spinal Fever — 8 8 7 — — 1 Diphtheria 12 14 26 23 — — 3 Enteric Fever — 1 1 1 — — — Erysipelas 3 25 28 27 1 3.6 — Measles — 43 43 30 1 2.3 12 Puerperal Infections — 18 18 17 — — 1 Scarlet Fever 30 312 342 328 — — 14 Whooping Cough 5 39 44 37 3 6.8 4 Mixed Infections — 9 9 9 — — — Other Diseases 5 178 183 167 6 — 10 Marasmus 1 27 28 18 6 21.4 4 Tonsil and Adenoid Cases (Willesden.) 10 391 401 401 — — — Tonsil and Adenoid Cases (Middx. and Harrow Hospitals.) — 221 221 221 — — — Civilian Sick 27 115 142 66 41 — 35 Service Sick 2 102 104 99 — — 5 Air Raid Casualties — 16 16 16 — — — Totals 95 1,519 1,614 1,467 58 — 89 Laboratory. Table No. 20. Nature of Examination. Positive Result. Negative Result. Total. 1 Swabs for C. diphtheriae 36 979 1,015 2 Typing of C. diphtheriae cultures — — 17 3 Sputum, etc., Direct examination for M. Tuberculosis 47 196 243 4 Blood—Widal 3 4 7 5 Blood—Cultures — — 9 6 Blood—Counts — — 70 7 Blood—Films — — 64 8 Blood—Chemical examinations — — 115 9 Urine—Chemical examinations — — 82 10 Urine—Microscopical examinations — — 79 11 Urine—Cultural examinations — — 31 12 Faeces—Chemical examinations — — 4 13 Faeces—Microscopical examinations — — 8 14 Faeces—Cultural examinations — — 120 15 Cerebro-spinal Fluid—Chemical examinations — — 12 16 Cerebro-spinal Fluid—Microscopical examinations — — 20 17 Swabs, etc.— Direct smears — — 124 18 Swabs, etc.— Cultures — — 314 19 Water—Presumptive B. coli test — — 48 20 Water—Enumeration of organisms — — 48 21 Salmonella serological identifications — — 19 22 Preparation of vaccines — — 1 Total 2,450 17 Table No. 21. Sources of Specimens Examined. Municipal Hospital 1,200 Private Practitioners 588 Health Centres 466 Middlesex County Council Dispensary 100 Engineer's Department 96 2,450 THE FOURTEENTH ANNUAL REPORT on the WILLESDEN MATERNITY HOSPITAL for the Year 1944. By ARNOLD WALKER, M.A., M.B., B.Ch., F.R.C.S., F.R.C.O.G. The most important feature of the year 1944 was the disorganization caused by flying-bomb and rocket attacks. A number of cases booked for confinement in the hospital failed to present themselves, and a number of cases booked for confinement in the Central Middlesex County Hospital were admitted during a period when the maternity department of that hospital was transferred to a safer area. The Willesden Maternity Hospital suffered no damage from this form of enemy activity. 1 patient died during the year from pulmonary embolism after a difficult labour. Table No. 22. Statistical Details of the 1,014 Cases dealt with during 1944. Cases completed 1,014 Eclampsia 1 A. Booked at the Health Centres 1,005 Organic Heart Disease 9 Discharged well 999 Puerperal Pyrexia 29 Transferred 1 Uterine Infection 9 Delivered elsewhere 3 Urinary Infection 9 Died 1 Breast Infection 3 Not pregnant 1 Thrombo-phlebitis 1 B. Admitted as Emergencies 9 Pulmonary Infection 2 Discharged well 9 No cause found 5 Of the 1,005 booked cases, 502 were primiparae and 503 were multiparae. Of the 9 emergency cases, 3 were primiparae and 6 were multiparae. Operations performed— Forceps delivery 32 The forceps rate was therefore 3.15 per cent. Presentations— Caesarean Section 11 Occipito Anterior 819 Previous Caesarean Section 5 Occipito Posterior 129 Elderly primigravida, breech presentation 1 Normal Breech 22 Abnormal Breech 4 Elderly primigravida, mental condition 1 Twins 15 Triplets 1 Impacted brow presentation 1 Face 3 Persistent oblique lie 1 Brow 1 Placenta Praevia 1 Shoulder 1 Rigid cervix 1 Miscarriages 14 Manual Removal of Placenta 12 Hydatidiform Mole 1 Induction of Premature Labour 4 Ante-partum Haemorrhage— Toxaemia of Pregnancy 3 Placenta Praevia 4 Vomiting 1 Accidental Haemorrhage 12 Transfusion 12 Prolapse of Cord 2 Blood.. 6 Toxaemia of Pregnancy admitted for treatment 21 Serum or Plasma 3 Blood and Serum or Plasma 3 1,012 viable children were born to 995 mothers. Of these, 38 were stillborn and 19 died. 18 THE FIFTEENTH ANNUAL REPORT on the SUPERVISION OF MIDWIVES for the Year 1944. 51 Midwives gave notice of their intention to practise in Willesden in 1944, 29 of these being in the Central Middlesex County Hospital. Midwives practising and living in Willesden attended 2,091 cases either in hospital or on the district as midwives or maternity nurses, as against 2,285 in 1943. In addition, 16 midwifery or maternity cases were attended in Willesden by midwives living outside Willesden. The 8 Municipal District Midwives attended 548 midwifery cases in 1944 and in addition answered 4 emergency calls and carried out ante-natal care of 106 cases which were subsequently confined elsewhere. Midwives attached to Queen Charlotte's Hospital District Home, Kilburn, attended 131 midwifery cases. 77 of these were Willesden residents attended on behalf of the Willesden Council with, in addition, 18 cases attended for ante-natal care only. 54 were cases attended outside Willesden. Midwives attached to the Willesden District Nursing Association attended 200 maternity cases on behalf of the Council. During the year 235 notifications were received from Midwives practising in Willesden in accordance with the rules of the Central Midwives' Board and of these, 198 notifications were in respect of medical aid, 162 in respect of the mother and 36 in respect of the child. The seventh year's working of the Domiciliary Midwifery Scheme and the Second Period Training School for pupil midwives has been very satisfactory. The number of whole-time Municipal Midwives is 7, and a full-time relief midwife. In addition, under arrangements made with the Willesden Borough Council, Queen Charlotte's Hospital District Home deals with midwifery cases in the area allotted to the Home, and the Willesden District Nursing Association deals with the Maternity Nursing throughout Willesden. The Watling and Willesden Training School for Second-period Pupil Midwives.—During the year 36 pupil midwives worked on the district. Of the 548 confinements dealt with by the Municipal Midwives, the pupil midwives attended 416 under the direct or indirect supervision of the midwives. The pupil midwives took responsibility for the ante-natal care, attended and took responsibility for the labours and nursed the mothers and their babies during the 14 days immediately following labour. In addition to the work shown above in respect of the Municipal Midwives cases in Willesden, the pupil midwives attended :— Ante-Natal Clinics 102 Maternity and Child Welfare Clinics for mothers and babies 87 The Lecture Courses. A Discussion Class, each week, taken by the Supervisor of Midwives at the Health Department. Of the 36 pupil midwives, 25 sat for their final midwifery examination, 23 passed, 2 failed, but passed at the next examination. TWENTY-SEVENTH ANNUAL REPORT for the YEAR 1944 on DENTAL WORK in connection with SCHOOL CHILDREN, EXPECTANT and NURSING MOTHERS and CHILDREN under 5 years. By E. A. JENNINGS, L.D.S., R.C.S.Eng. The renewal of hostile air activity and the consequent re-evacuation of residents and their families from the area has impeded the execution of the Council's Scheme of inspection and treatment. The Centre at Willesden Lane was rendered completely inoperative for 23 sessions. Treatment was carried on with difficulty and disjointedly for a considerably longer period while equipment was being repaired and materials restored. The Centres at Willesden Green and Stonebridge Park did not escape unscathed and interference with routine work was experienced there also. 19 In spite of these molestations the total treatment sessions at the centres numbered 1,430, while 137 were utilized at routine school inspections, 10 for administrative purposes and 11 for Civil Defence. 11,215 mothers, infants, elementary and secondary school children were inspected, 8,711 of these were defective and 4,313, or nearly 50 per cent., were treated at the centres. General Anaesthetics were administered to 2,393 patients during 130 sessions, which is an average of 18'4 per session. 13,628 attendances were recorded at the centres during the year. This work was carried'out by a staff of 3 dental surgeons and 3 nurses, and a part-time Anaesthetist. ELEMENTARY AND SPECIAL SCHOOLS. The total number of children on roll in December was 10,738, as compared with 13,963 in December, 1943. This figure represents about half the pre-war number attending Willesden schools. INSPECTION. Routine.—Inspections were suspended during the months of July, August and September, so that 111 visits only were made to the schools during the year, when 6,735 children were subject to an oral examination. Specials.—1,123 children attended the centres for inspection. Out of the total 7,858 inspected, 5,946, or nearly 75 per cent., were found to require treatment. 2,839, or approximately 48 per cent., were treated at the centres. TREATMENT. 4,878 teeth were filled, of which 1,371 were on the temporary dentition. 4,953 were extracted, which includes 892 permanent teeth either removed for excessive caries or for the relief of overcrowding. In addition, 1,181 sundry operations were performed, such as pulp removals and dressings to anterior teeth, the making and fitting of acrylic caps to fractured teeth, inlays, silver nitrate applications, gum treatment and so forth. It is estimated that 770 sessions were taken up in the performance of this work. WILLESDEN SECONDARY AND JUNIOR TECHNICAL, ETC., SCHOOLS. 26 visits were made to the schools, when 1,774 scholars were inspected. There were also 186 special inspections at the centres, making a total of 1,960 for the year. Of these, 1,500, or 77 per cent., required treatment, and 590, or 39 per cent., were treated at the centres. Treatment to some extent was frustrated by reasons already mentioned, and the number of scholars accepting treatment showed a decline from 754 to 590. 1,558 fillings were done, 193 teeth were extracted which, together with 626 sundry treatments, makes a total of 2,377 operations performed during 200 sessions. General anaesthetics were administered to 101 cases. Total attendances amounted to 1,742. MATERNITY AND CHILD WELFARE. 1,397 mothers and infants were inspected, of whom 1,247 needed treatment. 736 had their treatment completed and 148 partially completed at the centres. 2,122 teeth were removed, 1,733 teeth filled which, together with 1,413 sundry operations, make a total of 5,268 treatments for the year. 85 dentures were supplied and there were 2 dentures remade and 2 repaired during the year. Attendances totalled 4,304 and the estimated number of treatment sessions for this work was 460. - REPORT ON WAR-TIME NURSERIES, 1944-1945. At the beginning of April, 1944, there were 11 nurseries open in Willesden, accommodating 560 children, 0-5 years. 2 nurseries were under construction to take a further 100 children, and a site was under consideration to relieve the congestion in the Kilburn area. By June the flying-bomb raids put an end to any extension of the nursery scheme. Attendances.—The total attendances from April 1st, 1944, to April 1st, 1945, amounted to 108,097. The flying-bomb raids, with resulting evacuation, caused a 50 per cent. reduction in attendances during June, July and August, 1944. Medical Inspection.—Regular inspection of the children has been carried out by the Medical Officers from the various Health Centres. Immunisation against Diphtheria has been carried out in the nurseries. Toys.—The National Fire Service have presented toys to Chichester Road Nursery and Longstone Avenue Nursery. The toy situation in the nurseries is still difficult. Several matrons have raised money for toys by holding a jumble sale at the nursery. The Canadian Red Cross Society sent toys to Braintcroft Nursery. The Ministry of Health yearly allowance of 2s. 6d. per child is quite inadequate to meet the toy situation. Clothing. - The W.V.S. have been unable to give a great deal of help this year, owing to the needs of the Continent. Mrs. Baldwin has continued to give valuable help with marking and making of clothes. The Senior Girls' Schools knitted all the woollen garments for the new Gladstone Park Nursery. 20 Damage to Nurseries.— Wesley Road damaged by blast; closed for 2 days. Chichester Road damaged by blast; closed for 1 day, except for top floor, which was unsafe owing to ceiling damage. Repairs have now been carried out. Training of Students.—10 nurseries are affiliated to the National Society of Children's Nurseries. The students attend for lectures at Hendon Polytechnic and Hammersmith School for Women. 3 students entered for the Diploma in November ; 2 students obtained the Diploma, the third passing in the practical section only. Training of Nursery Assistants.—There are now 14 Nursery Assistants attending lectures in preparation for the Diploma; 1 candidate obtained the Diploma in May, 1944, and 7 are due to sit for the examination in May, 1945. REGISTERED DAILY GUARDIANS. The scheme of the Ministry of Labour and National Service for Registered Daily Guardians came into operation in Willesden in May, 1942, and is operated from the Health Centres. Suitable guardians are registered at the Health Centres and notified as to the number of daily children they may take and the Labour Exchange is informed. Mothers are put in touch with Guardians if necessary. The mother makes her own arrangements with the Guardian as regards the care and feeding of the children and the weekly sum payable. The Labour Exchange makes an additional payment to the Guardian of 4s. in respect of each child under 5 years cared for on 4 or more days a week and 2s. for 1 to 3 days per week. The Exchange looks into the question of whether the mother's employment is war work. The Council's Health Visitors supervise the Registered Daily Guardians and pay not less than monthly visits to them. At the end of 1944 57 Daily Guardians were registered to take 87 children. Of these 57 guardians, 36 actually had children in their care at the end of the year. These 36 had 43 children in their care, thereby releasing 40 mothers for work. The guardians were not women who would have been out at work even if they had not taken daily children. Their care of these children was therefore not detracting from the war effort. The objections to this scheme are that the 4s. is an inadequate contribution from the Government and the forms deter some people from making use of the scheme. If a mother can get her child into a War-time Nursery for Is. per day or 6s. per week she is not likely to show much enthusiasm for a scheme under which she has to pay the bulk of the daily guardian's fee. At a nursery all food is supplied and the full rations are still available for home use. This is not so in the case of Daily Registered Guardians. Certain clothing is also supplied in the nurseries which saves wear and tear of the children's own clothing and a considerable amount of laundry work is done for them at the nursery. APPENDIX A. THE CARE OF ILLEGITIMATE CHILDREN. Circular 2866 of the Ministry of Health. REPORT OF MEDICAL OFFICER OF HEALTH. Circular 2866, dated October 1st, 1943, has been issued by the Minister of Health and deals with the care of illegitimate children. The Minister asks that the welfare authority shall submit proposals to him within the next few months in accordance with Section 204 (1) of the Public Health Act, 1936, which is as follows :— " A welfare authority may, subject to the general approval of the Minister, make arrangements for the care of expectant and nursing mothers and of children who have not attained the age of 5 years and are not being educated in schools recognized by the Board of Education : Provided that nothing in this section shall authorize the establishment by such an authority of a general domiciliary service by medical practitioners." The following table shows in 5-yearly periods, beginning 1915, the total number of live births, the total number of illegitimate live births, and the illegitimate birth-rate per 1,000 total live births:— Period. Total Live Births. Illegitimate Live Births Illegitimate Birth-Rate per 1,000 Total Live Births. 5 years, 1915-1919 15,834 638 40.29 5 „ 1920-1924 16,762 491 29.29 5 „ 1925-1929 13,403 457 34.10 5 „ 1930-1934 13,866 490 35.34 5 „ 1935-1939 14,447 581 40.22 3 „ 1940-1942 6,623 255 38.50 21 No information is easily available as to the number of women who attend the maternity centres of the Authority on account of illegitimate pregnancies or births. No distinction is made in respect of such cases at these centres. Nevertheless, as expectant mothers, the general impression is that they attend much in the same proportion as other such mothers, namely, about 80 per cent. It should be appreciated that the women who so attend are not " bad " women and that few of them are cases of second or third pregnancies under similar conditions. It is generally only in the case of mentally defectives that such multiple pregnancies occur. The Minister suggests the consideration of this problem under the following headings (a), (b), (c), (d), (e), (f), (g) and (h):- (a) Wherever possible to persuade the girl to make known her circumstances to her parents and, if the home is likely to be a satisfactory one, to persuade the grandparents to make a home there for the little one. Inquiries are always directed by the Matrons of the Health Centre to ascertain what provision has been made for the child. (b) Advising the expectant mother on suitable accommodation before and immediately after confinement. Generally speaking, at the present time the expectant mother is in a position to remain in her lodgings or with her parents or friends until the confinement, which usually takes place in hospital. Usually these expectant mothers have in present circumstances sufficient money to enable them to remain where they are, but before the war the difficulty of lack of money did arise in a number of cases. Where accommodation has to be found for the expectant mother the Health Department may refer her to the Public Assistance Officer or get into touch with one or other of the following voluntary agencies or moral welfare workers attached to diocesan and other religious bodies working in Willesden :— Miss Southon, The London Diocesan Council for Moral Welfare (Protestant). Works in Willesden, chiefly Kilburn and neighbourhood, Hampstead and Hackney. Last year this body dealt with about 200 cases, of which approximately 50 were in Willesden. Miss Kitchen, The London Diocesan Council for Moral Welfare (Protestant). Works in Harlesden and Harrow. Miss Plater, of 59, Gloucester Place, the Roman Catholic Rescue Worker for the North-West area. After the confinement the foregoing agencies also assist the girl to find suitable accommodation and sometimes also suitable work. The Public Assistance Officer may also help her. (c) Assisting the girl to obtain an affiliation order or otherwise to secure assistance from the father of the child. The Health Department refers the mother to the Probation Officer of the Court, who advises the girl as to how to see this matter through. If she should come within one or other of the aforementioned voluntary agencies, the agency also impresses upon her the desirability of securing such an affiliation order and helps her towards this end. (d) Assisting the mother to find employment, preferably with her baby, in an institution or in private employment. The above-mentioned voluntary agencies assist the mother to find employment. The mother's difficulty is that she does not usually wish to have the baby with her and if relieved of the care of her baby she is usually able to return to her former employment. The existence of the baby, however, complicates her position and it is in such circumstances that the voluntary agencies are sometimes able to help. The Crusade of Rescue, Waifs and Strays, Dr. Barnado, etc., may take the children but not the mothers. (e) If a home cannot be found for the baby with the girl's relatives (see (a) above), finding lodgings for mother and baby when the mother desires non-resident work. This accommodation might be in a special hostel set up by a voluntary body or by the welfare authority itself. If in ordinary lodgings it would be necessary to arrange for the baby's care by day, e.g., in a war-time nursery. This is really the crux of the problem and if arrangements could be made whereby the child was taken care of there is little doubt that the mother would be able to look after herself. Hostels of the type referred to are few in number, limited in accommodation and serve a wide area. There is no such hostel in the Willesden area. (/) Finding a suitable foster mother if it is necessary for mother and baby to be separated. In such cases it may be desirable for the authority to guarantee payment to the foster mother, recovering from the mother. (This scheme works satisfactorily in Birmingham.) This work is usually done by the Health Department so far as Willesden foster mothers are concerned, but great difficulty exists at the present time in getting a foster mother. If foster mothers were available it would be necessary for the Authority to guarantee them payment if the child is going to have a more or less permanent home with such foster mother. (g) Arranging for places in a residential Nursery or Home, for babies whose mothers cannot look after them and for whom accommodation cannot be found by other means. In some cases arrangements are made by the Health Department through the Women's Voluntary Services for the evacuation of babies to the residential nurseries maintained by the Women's Voluntary Services. There is, however, great difficulty in securing places for babies. (h) In special cases, e.g., where the mother is very young or is the wife of a man not the father of the child, giving advice about legal adoption. The Health Visitor advises any mother wanting her child to be legally adopted to go to an Adoption Society or the Court Probation Officer if she has an adopter in view. 22 Hostel. Paragraphs (e), (f) and (g) can best be met by the institution of a hostel by the welfare authority. Such a hostel should be devised : (1) To accommodate the mother for a period before the birth of the child as may be necessary ; (2) To accommodate the mother and her child, if the mother does not desire to be separated from her baby and desires non-resident work—when the mother finds work, both she and the baby would probably leave the hostel ; (3) To accommodate the mother and her child until the mother finds work, that is, if she wishes to be separated from the child—the child in these circumstances would probably remain in the hostel ; (4) To accommodate the child only until the mother can make other arrangements, e.g., adoption, foster mother. In connection with such a hostel it would be necessary at some stage to place the children with suitable foster mothers approved and paid by the welfare authority. There are some 100 illegitimate babies born each year in Willesden, and a number of cases of such pregnancies and children with or without their mothers would require to be accommodated temporarily in the hostel as indicated above. It is difficult to say exactly the amount of accommodation which would be required in a hostel of this description. It is suggested that the St. Monica's Home Hospital, Brondesbury Park, would be suitable, provided there were a sufficient number of approved foster mothers for the care of the children at later stages. GEORGE F. BUCHAN, Medical Officer of Health. 1st March, 1944. APPENDIX B. COMPREHENSIVE HEALTH SERVICE. Summary of the Government's Proposals with Notes by the MEDICAL OFFICER OF HEALTH. 1. Scope of the New Service. (a) A National Health Service will be established. (b) There will be nothing to prevent those who prefer to make private arrangements for medical attention from doing so. But for all who wish to use the service it will provide a complete range of personal health care—general and specialist, at home, in the hospital and elsewhere. (c) The service will be free, apart from possible charges for certain appliances. 2. Structure of the Service. (a) Central. (1) Central responsibility to Parliament and the people will lie with the Minister of Health. (2) At the side of the Minister there will be a professional and expert advisory body to be called the Central Health Services Council. The Council will be a statutory body and its function will be to provide professional guidance on technical aspects of the Health Service. (b) Local. (1) Local responsibility will be based on the county and county borough councils, which are the major local government authorities now. They will administer the new service partly in their present separate capacities over their present areas, partly as the needs of the service require —by combined action in joint boards over larger areas. (2) Areas suitable for hospital organization will be designated by the Minister after consultation with local interests. (3) The county and county borough councils in each area will combine to form a joint authority to administer the hospital, consultant and allied services ; in the few cases where the area coincides with an existing county area the authority will be the county council of that area. (4) At the side of each new joint authority there will be a consultative body—professional and expert —to be called the Local Health Services Council. (5) Each joint authority will also prepare and submit for the Minister's approval an " area plan for securing a comprehensive Health Service for all kinds in its area. (6) Ccunty and county borough councils combining for these duties of the new joint authority will also severally be responsible for the local clinic and other services in accordance with the area plan. Responsibility for child welfare will be specially assigned in whatever way child education is assigned under the current Education Bill. 23 3. Hospital and Consultant Services. (a) It will be the duty of the joint authorities themselves to secure a complete hospital and consultant service for their area—including sanatoria, isolation, mental health services, and ambulance and ancillary services in accordance with the approved area plan. (b) The joint authorities will do this both by direct provision and by contractual arrangements with voluntary hospitals (or with,other joint authorities) as the approved area plan may indicate. (c) The powers of present local authorities in respect of these services and the ownership of their hospitals will pass to the joint authority. (d) Voluntary hospitals will participate, if willing to do so, as autonomous and contracting agencies ; if so, they will observe the approved area plan, and certain national conditions applying to all hospitals in the new service alike ; they will perform the services for which they contract under the plan, and receive various service payments from both central and local funds. (e) Special provision will be made for inspection of the hospital service through centrally selected expert personnel. (/) Consultant services will be made available to all, at the hospitals, local centres, or clinics, or in the home, as required ; they will be based on the hospital service, and arranged by the joint authority, either directly or by contract with voluntary hospitals under the approved area plan. (g) Measures for improving the distribution of consultants, dealing with methods of appointment and remuneration, and relating the consultant service to other branches of the new service generally, will be considered after the report of the Goodenough Committee. 4. General Medical Practice. (a) Everyone will be free, under the new Health Service, to choose a doctor—the freedom of choice being limited, as now, only by the number of doctors available and the amount of work which each doctor can properly undertake. (b) Medical practice in the new service will be a combination of grouped and separate practice. Grouped practice means practice by a group of doctors working in co-operation. Separate practice means practice by a doctor working on his own account—broadly similar to practice under the present National Health Insurance scheme, but with important changes. (c) Grouped practice will be conducted normally, though not exclusively, in specially equipped and publicly provided Health Centres. In England and Wales the Centres will be provided and maintained by county and county borough councils. (id) General practice in the National Health Service will be in the main organized centrally under the responsible Health Minister. All the main terms and conditions of the doctor's participation will be centrally settled, and much of the day-to-day administration will be the function of a Central Medical Board— largely professional in composition, and acting under the general direction of the Health Minister. (e) The main duties of the Board will be : (1) To act as the "employer" of the doctors engaged in the public service. Thus, the Board will be the body with whom every doctor will enter into contract. In the case of practice in Health Centres in England and Wales, however, there will be a three-party contract between the Board, the local authority and the doctor. (2) To ensure a proper distribution of doctors throughout the country. For this purpose the Board will have power to prevent the taking over of an existing public practice or the setting up of a new public practice in an area which is already " over-doctored." (/) It is not proposed that there should be a universal salaried system for doctors in the new service. Doctors engaged in Health Centres will be remunerated by salary or the equivalent ; doctors in separate practice normally by capitation fee. In some cases, e.g., grouped practice not based on a Health Centre, remuneration by salary or the equivalent could be arranged if the doctors concerned so desired. Rates of remuneration will be discussed with the medical profession. (g) It is not proposed to prohibit doctors in public practice from engaging also in private practice for any patients who still want this. Where a doctor undertakes private in addition to public practice, the number of patients he is permitted to take under the National Service, and consequently his remuneration, will be adjusted. (h) Young doctors entering individual practice in the public service for the first time will normally be required to serve for a period as assistants to more experienced practitioners, and the Board will be able to require them to give full time to the service if necessary. (j) Compensation will be paid to any doctor who loses the value of his practice, e.g., by entering a Health Centre or because he is prohibited from transferring the practice to another doctor on the ground that there are too many doctors in the area. Superannuation schemes will be provided for doctors in Health Centres and the possibility of providing them in other forms of practice will be discussed with the profession, and the practicability of abolishing the sale and purchase of public practices will be similarly discussed. (k) Arrangements for the supply of drugs and medical appliances will be considered and discussed with the appropriate bodies. 5. Clinics and Other Services. (a) It will be the duty of the joint authority to include in its area plan provision for all necessary clinics and other local services (e.g., child welfare, home nursing, health visiting, midwifery and others), and to provide for the co-ordination of these services with the other services in the plan. 24 (b) County and county borough councils will normally provide most of these local services. The exact allocation of responsibility between the joint authority and the individual county and county borough councils will be finally settled in each case in the approved area plan ; but the principle will be that services belonging to the hospital and consultant sphere will fall to the joint authority, while other local and clinic services will fall to the individual councils. (c) Child welfare duties will always fall to the authority responsible for child education under the new Education Bill. (d) New forms of service, e.g., for general dentistry and care of the eyes, will be considered with the professional and other interests concerned. In the case of dentistry the report of the Teviot Committee is awaited. Finance. The following table given in the White Paper shows the total cost of the scheme to public funds and the proportion to which that cost might be borne by ratepayers and central funds:— Service. Cost Met from Central Funds. Cost Falling on Ratepayers. Total Cost to Public Funds. (a) By Direct Grants or Payments. 0b) By Grants in Aid of Rates or Precepts. Total Cost from Central Funds. £m. £m. £m. £m. £m. Expenditure of new Joint Authorities 28.4 - 28.4 41.6 70 Exchequer Grant to Voluntary Hospitals 10 — 10 — 10 Expenditure of County and County Borough Councils 8 7.6 15.6 6.4 22 Fees to General Practitioners and Payments to Chemists 30 — 30 — 30 All Services 76.4 7.6 84.0 48.0 132.0 The White Paper goes on to state how far the central funds will consist of, or be assisted by, sums of money set aside out of contributions under a social insurance scheme will fall to be considered later. The Beveridge Report proposed that a sum of £40 millions per annum should be available for the new health service. Of this, £35*7 millions would be the share appropriate to England and Wales, and if this assistance is assumed, the proportions in which the total cost of the new service would fall on the social insurance scheme, the taxpayer and the ratepayer would be, on the foregoing estimates and ignoring the effect of the block grant under the Local Government Act, 1929 : Social Insurance Scheme ,£35*7 millions, or about 27*0 per cent. Taxpayer 18'3 millions, or about 36*6 per cent. Ratepayer 48'0 millions, or about 36'4 per cent. £132.0 millions. Again ignoring the effect of the block grant, the corresponding table for the incomplete services in 1938-39 would be approximately : £m. Contributions under N.H.I. Acts 11.2, or about 20 per cent. Taxpayer 3.0, or about 6 per cent. Ratepayer 40.3, or about 74 per cent. 54.5 NOTES BY MEDICAL OFFICER OF HEALTH. The foregoing summary of the proposals is culled from the abridged version of the National Health Service published by the Government. The following observations, however, are submitted :— Central Control.—All the medical and health services of Central Government will not be the function of one Ministry. The following, amongst others, appear to be excepted from the control of the Ministry of Health, namely, the Industrial Medical Services under the Factory Acts, the Ministry of Labour, the Ministry of Supply, the Ministry of Fuel and Power and certain features of the School Medical Service under the Board of Education. Local Control.—Here again a number of authorities are at work in an area. Firstly, the Joint Board which will itself provide hospitals and certain other forms of treatment and will plan what is to be provided by County Councils and County Borough Councils. The Welfare and Education Authority will also be involved in the local provision to be made and presumably their services will be a part of the plan to be devised by the Joint Board. Medical Personnel.—It should be observed that the employment of the doctor in general medical practice is under the Central Medical Board of the Ministry of Health and that only where he works in a Health Centre is the Local Authority a party to the contract. The distribution of doctors will be determined by the Central Medical Board and what powers of appointment of doctors, if any, the Local Authority concerned may have is not clear. 25 PROPOSALS AS THEY AFFECT WILLESDEN. It would appear that the Willesden Council will be affected in the following ways :— 1. The Willesden Municipal Hospital and the Willesden Maternity Hospital will pass to the Joint Board. 2. The Midwifery Service will revert to the County Council. 3. The position of Willesden as a Welfare Authority or as an Education Authority will be determined by the Education Bill. As the Bill now stands it would appear that these services will pass to the County Council and that there may be delegated powers to Willesden to carry them out in accordance with the County Council plan, or it may be in accordance with the Joint Board plan. 4. The control of Infectious Diseases is not definite in the White Paper and may or may not remain with the Willesden Borough Council. 5. Environmental Hygiene as now practised by the Sanitary Section of the Health Department will remain with the Willesden Borough Council. CERTAIN GENERAL PRINCIPLES OF A NATIONAL HEALTH SERVICE. Certain general principles should determine the structure of a National Health Service and guide its development. 1. There should be only one central Government Department dealing with medical care, personal and environmental hygiene, whether in the works, the office or the schools or the home, and the various social circumstances, other than moneys, which affect good health. 2. Locally there should be one authority sufficient in size and adequare in financial resources to deal with a comprehensive health service in its widest aspects. This authority should be the Local Authority for the area and the Health Services should be administered with the other services for which it may be responsible, many of which are necessarily allied to questions of health. It is stated in the White Paper that proposals for new local government areas have been rejected on the grounds of urgency, but it does not appear that in the present circumstances this plea holds good for the following reasons :— (1) Even if there were no war there is not sufficient medical personnel to man a complete service. (2) Immediately after the war only attenuated Health Services can possibly be available as medical personnel will not be released at once. (3) The Comprehensive Health Service as envisaged will probably take ten years at least after the war is over before it could be considered, as reasonably adequate. Private Practice.—It will be observed that although the service is comprehensive, private practice may be carried on by doctors in the service. This will obviously be difficult to arrange and some very clear thinking will have to be done in order that there is no conflict of opinion between the doctor and his patient as to whether he is being treated under the Public service or as a private patient. It should further be observed that the service includes provisions other than medical care, e.g., nursing, ambulance, etc., and it is not clear whether they too would be paid for privately. Health Centres.—Health Centres are indicated as subjects for trial, but they cannot be established in any local area unless the Joint Board include them in their plan after consultation with the Local Health Services Council and with the approval of the Minister. The Consultant Service to be provided is to be a part of the Hospital Service and the consultants required in clinics or at home will,it is presumed,be provided by the Hospitals. This arrangement is good, but it is unsatisfactory that the Hospital and Consultant Service is under the Joint Board and the Health Centre Service is under the County Council or County Borough Council or the Welfare and Education Authority, while the Domiciliary Medical Service appears to be under the Central Medical Board of the Ministry of Health. HEALTH. In the White Paper emphasis is put on the Hospital Service and the Treatment of Disease which, in my opinion, although important, should not be the main considerations of a Local Health Authority, whose aim should be to maintain and improve the health of the people. The maintenance of health is a complex process. It is the family doctor who should be in the front line in this matter. The maintenance of health implies not only a knowledge of the physical and mental state of the individual, but knowledge of the background, the environmental, industrial and social conditions under which he works and lives. If improvement in national health is to be achieved, the general practitioner and consultant must know these conditions and assess their influence on health and illness. Many of these environmental matters and social circumstances are brought to light by Sanitary Inspectors, Health Visitors, Hospital Almoners and members of Local Authorities themselves, and such information must be pooled with medical knowledge so that a complete picture may be presented to the authority in order that they may decide as to the best measures to be taken for the promotion of health. As the White Paper leaves severely alone the questions of environmental hygiene and social circumstances as they affect health, it does not appear that full use will be made of knowledge acquired in respect of these matters. The whole tendency of the White Paper is to make not only the doctor but the public hospital minded rather than health minded. 26 GENERAL. Generally speaking, the White Paper does not propose to simplify the administration of health services in Willesden or elsewhere. At present two authorities—the County Council and the Willesden Council—provide these services in Willesden. Under the proposals of the White Paper three authorities—the Joint Board, the County Council and the Willesden Borough Council—will all be concerned unless the Middlesex County Council by itself is constituted a joint board. It should also be noted that in a way the Central Medical Board is a fourth authority, as it would appear that Local Authorities will be unable to make such medical appointments as they desire, and the way in which they desire, except via this Board. An obscure paragraph headed "The Part of Medical Officers of Health and Others" in the White Paper is worthy of quotation as it is the only reference to Medical Officers of Health in the document :— "Whatever changes there may be in the scope of the health services locally provided and in the local organization for providing them, it is clear that there will be an even more important part in the future than there has been in the past for social medicine and the medical organization of public health. The new service will make great calls upon all those medical men and women already engaged in the work of local health authorities, and upon all those who assist in the ancillary services now; just as it will give new scope and better opportunity, not only to those already engaged, but to newcomers to this branch of professional life." GEORGE F. BUCHAN, Medical Officer of Health. 1st March, 1944.