library f THE HEALTH of NORTHAMPTONSHIRE in 1963 PART 1 Report of the County Medical Officer of Health NORTHAMPTONSHIRE MENTAL HEALTH PROJECT An interview during studies of public opinion (see p. 84) (Photograph by courtesy of the Northampton “ Chronicle and Echo ”) THE TOLL OF LUNG SMOKING (see pages 3 and 37) THE HEALTH of NORTHAMPTONSHIRE in 1963 PART I Report of the County Medical Officer of Health TABLE OF CONTENTS Page Introduction ... ... ... ... ... ... 3 Staff ... ... ... ... ... ... ... 7 Vital Statistics ... ... ... ... ... ... 10 Care of Mothers ... ... ... ... ... 14 Care of Young Children ... ... ... ... ... 17 Midwifery ... ... ... ... ... ... 24 Home Nursing ... ... ... ... ... ... 27 Health Visiting ... ... ... ... ... 31 Health Education ... ... ... ... ... 35 Prevention of Illness, Care and After-Care ... ... ... 39 Home Help Service ... ... ... ... ... 42 Mental Health ... ... ... ... ... ... 45 Ambulance Service ... ... ... ... ... 53 Infectious Diseases ... ... ... ... ... 58 Liaison Arrangements ... ... ... ... ... 68 Research, Publications and Post Graduate Visitors ... ... 70 Food and Drugs ... ... ... ... ... 71 Enviromental Hygiene ... ... ... ... ... 77 Appendix—Mental Health Project ... ... ... 84 A detailed index is to be found on pages 107 and 108 NORTHAMPTONSHIRE COUNTY COUNCIL. October, 1964 To the Chairman and Members of the Northamptonshire County Council. Mr. Chairman, My Lords, Ladies and Gentlemen, I have the honour to present my second Annual Report, which is the sixty-seventh such report of the County Medical Officer of Health. Introduction This is the second issue of the Annual Report in its new form. The general reaction to the changed layout has been favourable and it is hoped to continue it, emphasis being placed on different aspects of the work of the County Health Department in successive years. Copies of the previous report were sent to a wide variety of interested organisations and individuals, and amongst the latter were included all general practitioners working in the county. It was encouraging to find that, of the 175 family doctors who received them, approximately half indicated that they would like to continue to do so in the future. Health of the County The general health of the county has remained satisfactory, with a birth rate somewhat higher than that for England and Wales and an infant mortality appreciably below the national average. The population had, by the middle of the year, reached 305,740, which is an increase of 4,780 over the previous year’s figure. On turning to deaths, diseases of the cardiovascular system accounted for approximately half the total, with cancer and other forms of malignant disease being responsible for a further 17% and respiratory diseases for 12%. Attempts at prevention must be increasingly concentrated on these three major causes of death and, although the scope is at present limited, it is at least more than fully established that smoking, particularly of cigarettes, plays a substantial role in deaths from diseases of the heart and lungs. This is especially true of lung cancer, deaths from which advanced by about 1,000 compared with 1962, to reach the new record British total of some 27,000, or one death every 20 minutes. The facts are known and the public must decide whether they are to continue their self-destruction at this steadily increasing rate. Parents have a particular responsibility here, as it is clear that it is their smoking habits which largely determine those of their children. Two final points must be made about smoking. The first is that, contrary to statements which from time to time appear in the press, there is no low level of consumption at which smoking becomes safe, for the chances of developing lung cancer are increased even for light smokers, and become progressively higher in proportion to the number of cigarettes consumed. Recently published figures have shown that the smoker of 1-14 per day increases his chances of dying of lung cancer more than eightfold, whilst the smoker of 35 or more per day increases his danger no less than 45 times compared with a non-smoker. The second fact is that, for the average young or middle-aged man or woman, there is much to be gained by stopping smoking, as the chances of dying from lung cancer diminish to about half their former levels after five years of abstinence ; to about one third after 10 years ; and by 20 years to only 15% of the death rate of those who continue to smoke. It is therefore untrue to offer the excuse that the damage is already done—much of it can be undone by giving up the smoking of cigarettes, or possibly by changing to the relatively safer pipe or cigar. Ten-year Plan From time to time during the year, public criticisms have been made in various parts of the country of the whole concept of ten-year plans for the development of local health authority services, and it has been suggested that these plans represent no more than a mass of statistical good intentions. I remain a confirmed enthusiast for the principle of the ten-year plan, giving as it does an opportunity to look ahead and, as far as Northamptonshire is concerned, I believe that we are already beginning to reap the benefits of this type of planning. It has likewise been argued that there should be uniformity in the provision of health services throughout the country, for ten-year plans showed highly variable provisions in different areas. It must be admitted that some local health authorities appear to have made more generous provision for their services than have others, but it is likely that, from their studies of the national figures, my colleagues will recommend their authorities to adjust the original plans where these appear to be inadequate and, over a period of years, I hope that a general levelling- up of standards will take place. The strongest arguments in favour of local health authorities are surely that they can design their services expressly to meet local demands, and that the more progressive can go ahead and pioneer projects in a way which would be much less likely if they were centrally controlled. The original development plan for Northamptonshire was revised and extended during the year, and it has so far proved possible to implement the great majority of its initial proposals within the envisaged times. Mental Health Project An outstanding event of 1963 was the initiation and carrying through of the Mental Health Project. This was an imaginative approach to a vast problem, and credit must be given to a wide variety of organisations which took part, as well as to a large number of individuals. We have heard a lot about community care of the mentally disordered in recent times and it should be emphasised that, before this can be effective, we must establish a community which, in fact, cares. The Northamptonshire Mental Health Project brought together representatives of the local health authority, of the hospital service, of general practitioners, and of voluntary agencies and, whilst it is always invidious to mention particular names, great credit must go to the Deputy County Medical Officer. The Project began with an attempt to measure public attitudes to mental health and mental disorder ; it then sought to influence these attitudes ; and it was concluded in 1964 by a further endeavour to measure public attitudes and, through this, to estimate the effects of the health education campaign. All these activities represented extra work for everyone concerned and there were times when the pressure of this work was even in danger of creating the very types of mental stress amongst those taking part which the Project was seeking to diminish in the public at large ! I am sure that the venture was well worthwhile and I hope that everyone will read the preliminary report on the Project which appears as an appendix (p. 84). I also hope that the Project has shown that it is possible for a medium-sized local health authority to participate in an ambitious piece of work over and above the bare statutory essentials of everyday preventive and social medicine. Co-ordination of Social Work Another notable event was the initiation of a co-ordinated scheme of social work for the care and after-care of the mentally disordered in Northamptonshire (p. 47). This arrangement between the County Council and St. Crispin Hospital is unique of its kind and is designed to overcome the difficulties which can arise if two separate social work staffs, one based on the hospital and the other on the community, are trying to meet the same human needs. The larger combined staff increases the opportunities for seconding social workers for professional training and, as the scheme evolves, it is confidently anticipated that the whole standard of psychiatric social work will be raised. Achieving co-ordination between the three branches of the National Health Service and the welfare and voluntary services is of the utmost importance, and a further step in this direction was taken with the establishment of the joint sub-committee of the County Health and Welfare Committees. The work of these two committees is complementary and the new sub-committee should help to ensure that common policies are achieved for the benefit of the community. Fluoridation In my report for 1962 I dealt extensively with this subject and was pleased to record that the Health Committee’s welcome of the report on the fluoridation studies in this country and its advocacy of fluoridation as a valuable and safe contribution to the prevention of dental caries had been endorsed by the County Council. The County Council forwarded this resolution to the County Councils Association, a deputation from which met the Minister of Health in November 1962 to urge the immediate adoption of fluoridation as a national policy. The Ministry subsequently issued a circular to local health authorities permitting them to make arrangements with water undertakers for the addition of fluoride to those water supplies which are naturally deficient in it. The Health Committee authorised discussions with the various water undertakers supplying the county, but these proved abortive because, in the meantime, the county borough of Northampton rejected the policy of fluoridation and, as it has a water supply which is shared with a large area of the county, progress was blocked. The position was further complicated by the fact that the Bucks Water Board, which serves part of the south of Northamptonshire, also serves five other counties ; the Mid-Northamptonshire Water Board serves two other counties ; the Higham Ferrers and Rushden Water Board serves part of Bedfordshire ; and the Nene and Ouse Water Board extends into part of Huntingdonshire. For that reason the Health Committee felt that the County Councils Association should be asked to pursue with the Minister of Health means whereby a uniform national policy for fluoridation of water supplies can be achieved. A resolution to this effect was put to the County Council on 9th March, 1963, and led to a spirited debate on the question of dental health and fluoridation, at the end of which the Health Committee’s resolution was passed by 58 votes to twelve. It only remains for me to say that I hope that the County Councils Association will be successful in its discussions with the Minister, as otherwise the problems so often inherent in the differing geographical areas of water boards and local health authorities are such that achieving widespread fluoridation will be extremely difficult. It is only where a local authority has its own exclusive water source that fluoridation can readily be implemented—as has recently happened in Birmingham—and I am sure that the best solution lies in national legislation rather than in years of complicated negotiations at local level. Staff Good progress was made in staffing. The first post of Assistant County Medical Officer of Health with participation in the assisted Diploma in Public Health scheme was advertised and attracted several good candidates, the successful one commencing his studies at London University in October. The health visiting service has been fully staffed throughout the year and the recruitment states of the midwifery and home nursing services have remained satisfactory, as indeed have all other sections of the County Health Department. Unfortunately the year was marred by two deaths. Miss W. M. Williams died in August after a prolonged illness. She came to Northamptonshire in 1944 and, on the inception of the National Health Service in 1948, became the County Council’s first Superintendent Nursing Officer. Her work in maintaining and developing that service was well known to the Health Committee and, in addition, she played a prominent role in the work of many voluntary organisations, having a particular interest in those concerned with the welfare of old people. Miss Williams was a respected and popular member of the staff and the work which she did in the county will remain as a monument to her nineteen years of service in Northamptonshire. Equally tragic was the death in April of Dr. H. R. Simpson who had been appointed as Senior Assistant Medical Officer, with special responsibility for mental health, only the previous summer. He had commenced his medical studies after serving in the army, and consequently brought to his work a mature outlook. He rose to a senior post in the public health service of the State of Victoria, Australia, and Northamptonshire was fortunate in obtaining his services when he returned to this country. His clinical work was of a high order and, in addition, he had a particularly attractive personality. His death, at the age of 39, was a sad loss both to his family and to his profession. Acknowledgments The achievements of the Health Department during 1963 have been the result of team work, for which I am grateful to all members of the staff. During the more hectic periods of the Mental Health Project, many members of the health visiting, nursing, medical and clerical staff worked particularly long hours and did so without hesitation or complaint. I am likewise very appreciative of the kindness shown to me and my staff by the chairmen and members of the committees which we serve. They gave patient and generous consideration to the many matters which were brought before them, and it was most encouraging to have their continued support in the various endeavours of 1963. I have the honour to be, Your obedient servant, J. J. A. REID, County Medical Officer of Health. STAFF County Medical Officer of Health and Principal School Medical Officer: J. J. A. Reid, T.D., M.D., Ch.B., B.Sc., D.P.H. Deputy County Medical Officer of Health and Deputy Principal School Medical Officer: A. Gatherer, M.D., Ch.B., D.P.H., D.I.H. Senior Medical Officer: H. R. Simpson, M.B., Ch.B., D.P.H., D.C.H., D.Obst., R.C.O.G. (died 30th April) W. J. McQuillan, M.B., B.Ch., L.M., D.P.H., D.C.H. (from 1st October) Assistant Medical Officers: Mrs. M. H. Ballantyne, M.B., Ch.B. (part-time). P. C. Barry, L.R.C.P., L.R.C.S. (to 30th April). P. X. Bermingham, M.B., B.Ch., D.P.H. (also District Medical Officer of Health). Mrs. M. V. Capon, M.B., B.S. Mrs. C. Collins, M.B., B.Ch., D.P.H., D.C.H. (from Is/ September) (part-time). Miss J. F. Croll, M.B., Ch.B. Mrs. J. M. St. V. Dawkins, M.B., B.S., D.P.H., D.C.H. (also District Medical Officer of Health). Miss M. G. H. Dickson, M.R.C.S., L.R.C.P., D.P.H. (to 30th September) (part-time). Mrs. L. M. Egdell, M.B., Ch.B. (from Is/ October) (part-time). J. V. L. Farquhar, M.A., M.R.C.S., L.R.C.P., D.P.H. (also District Medical Officer of Health). Miss M. C. Goodchild, M.R.C.S., L.R.C.P., D.C.H. M. P. Howell, L.M.S.S.A., D.P.H. (from 10th fune) A. Lucas, L.R.C.P., L.R.C.S., L.R.F.P.S., D.P.H. (also District Medical Officer of Health). F. R. N. Lynch, M.B., Ch.B., D.P.H. (also District Medical Officer of Health). Mrs. M. Reid, M.B., Ch.B. (part-time). Mrs. M. W. Scott Clarke, M.B., Ch.B., D.P.H. (part-time). Mrs. M. B. Smith, M.B., Ch.B., D.P.H. (part-time). Mrs. E. A. Ward, M.B., B.S. (part-time). Chief Dental Officer: P. W. Gibson, L.D.S. Dental Officers: J. Aaron, M.B., B.S. M.R.C.S., L.R.C.P., L.D.S., (part-time). Miss M. Brown, L.D.S., (to 9th January). Mrs. F. Campbell, L.D.S. (part-time). R. J. H. Corfe, L.D.S. M. E. Eagland, B.Ch.D., L.D.S. (part-time). W. R. Hannah, B.D.S. (from Is/ October). R. D. Hopkinson, L.D.S. Mrs. F. M. Jones, L.D.S. C. M. Perry, L.D.S. Dental Auxiliary: Miss D. M. Marshall (from 9th September). Superintendent Nursing Officer: Miss W. M. Williams, S.R.N., S.C.M., H.V.Cert., Q.N. (died 19th August). Miss N. Taylorson, S.R.N., S.C.M., M.T.D., H.V.Cert., Q.N. [from 1st October). Deputy Superintendent Nursing Officers: Miss N. Taylorson, S.R.N., S.C.M., M.T.D., H.V.Cert., Q.N. {to 30th September). Miss L. Bogle, S.R.N., S.C.M., H.V.Cert., Q.N. (from Is/ December). Assistant Superintendent Nursing Officers: Miss L. Bogle, S.R.N., S.C.M., H.V.Cert., Q.N. [to 30th November). Miss F. I. Taylor, S.R.N., S.C.M., H.V.Cert., Dip. Soc. Sc., Q.N. {from Is/ February). Superintendent Health Visitor: Miss S. H. Buchanan, S.R.N., S.C.M., H.V.Cert. Health Education Organiser: Miss J. A. Forester, S.R.N., S.C.M., D.H.Ed., H.V.Cert., P.H. Tutor’s Cert., Q.N. Chief Clerk: R. J. Bruce County Ambulance Officer: P. H. J. Wilkinson Deputy County Ambulance Officer: W. C. Collett {from Is/ August). Senior Mental Welfare Officer: E. Towning, R.M.P.A. Mental Welfare Officers: Miss E. M. Bliss, S.R.N. S. A. Crouch. K. Greenwood, S.R.N., R.M.N., Dip. Social Studies. B. F. Norman. Mrs. A. Pebody, M.A., Dip. Soc. Sc. Miss O. Towning, Dip. Social Studies {to Is/ September). Mrs. J. Woodford, M.A.O.T. {from 11th November). Mental Welfare Officers/Craft Instructors {Occupational Therapists): Mrs. A. M. Jobbins, M.A.O.T. Mrs. K. Kench, M.A.O.T. {from 22>rd September). Miss C. M. Mulhearn, M.A.O.T. {to 31s/ August). Welfare Assistant: N. J. Lock {from 2nd December) Training Centre Supervisors: Corby—Mrs. E. Cocker* Henley Industrial Unit, Kettering—Miss F. L. Caswell* Mr. W. Lewis* Henley School, Kettering—Miss H. E. Griffin* Northampton—Mrs. M. B. Redley* Wellingborough—Miss B. V. Miller* * Diploma for teachers of the Mentally Handicapped. Henley Hostel: N. L. Laffan, R.M.N. (Warden) (from 16th September) Mrs. M. Laffan (Matron) (from 16th September) Senior Speech Therapist: Mrs. M. G. Cunningham, L.C.S.T. Speech Therapists: Miss S. A. R. Bruce, L.C.S.T. Miss J. A. French, L.C.S.T. Mrs. L. Gilby, L.C.S.T. (part-time to 19th December) Mrs. G. Wilson, L.C.S.T. (part-time) Home Help Organiser: Miss E. Newell Assistant Home Help Organisers: Miss S. Collier [from 13th May) Mrs. M. Hager (from 13th May) VITAL STATISTICS Area of the Administrative County . 578,947 acres Population (Census 1961) . 292,771 ,, 1963, Mid-year estimate. 305,740 Structurally separate dwellings occupied (Census 1961) . 96,552 Private households (Census 1961) . 93,649 Rateable Value (April 1st, 1963) . £10,480,549 Actual product of a penny rate (1962-63) . £15,276 Live births. Live birth rate per 1,000 population. Illegitimate live births per cent of total live births. Stillbirths . Stillbirth rate per 1,000 live and stillbirths ... Total live and stillbirths. Infant deaths. Infant mortality rate : Total (per 1,000 live births) . 17.92 Legitimate (per 1,000 legitimate live births) . 17.83 Illegitimate (per 1,000 illegitimate live births) . 19.48 Neonatal (first four weeks) mortality rate per 1,000 live births. 12.30 Early neonatal (under 1 week) mortality rate per 1,000 live births . 11.07 Perinatal (stillbirths and deaths under 1 week combined) mortality rate per 1,000 live and stillbirths . 26.46 Maternal deaths (including abortion) . 1 Maternal mortality rate per 1,000 live and stillbirths . 0.17 Northamptonshire Male Female Total 2,917 2,775 5,692 18.62 5.41 41 49 90 15.57 2,958 2,824 5,782 69 33 102 England & Wales 18.2 17.3 20.9 14.2 0.28 1. Population. The Registrar General estimated the resident mid-year population for 1963 to have been 305,740 compared with 300,960 in 1962. The estimated populations for the urban and rural areas were 169,570 and 136,170 respectively. The natural increase in population, i.e. the excess of births over deaths, totalled 2,266. The estimated increase in population was 4,780. 2. Deaths. The total number of deaths after adjusting for outward and inward transferable deaths, was 3,426, compared with 3,333 in 1962. The crude death-rate based on the mid-year estimated population was 11.21, compared with 11.07 in 1962. Cardiovascular disease accounted for 1,846 deaths (53.88% of the total), malignant disease for 583 (17.02%) and respiratory diseases for 416 (12.14%). There were 2,845 deaths in these three groups, which is 83.04% of the total deaths. Lists of the causes of deaths, classified under the thirty-six headings of the International Statistical Classification of Diseases, Injuries and Causes of Death, 1948, are given in Tables VI and VII (pages 80 to 83), whilst the history of the rate, together with other vital statistics for 1912-1963, are shown in graph form on page 12. Comparability factors for each urban and rural district, Tables Nos. VI (a) and VI (b) (pages 80 and 81), have been provided by the Registrar General for adjusting the local birth and death rates. The comparability factors make allowance for differences in age and sex distribution, and when multiplied by the crude birth and death rates of an area, make them comparable with the rates of other areas similarly adjusted. 3. Births. The number of live births assigned to the County was 5,692 (2,917 males and 2,775 females), compared with 5,528 in 1962, giving a birth rate of 18.62 per 1,000 population, compared with 18.2 for England and Wales. 4. Stillbirths. The number of stillbirths registered was 90 compared with 83 in the previous year. The rate per 1,000 total births was 15.57 compared with 14.79 for 1962, and with 17.3 for England and Wales. 5. Infant Mortality. The number of infants who died before attaining their first birthday was 102 (69 males and 33 females), compared with 108 in 1962. Of these, 6 were illegitimate. The rate per 1,000 related live births was thus 17.92 compared with 20.9 for England and Wales. The history of the rate for the past fourteen years is shown in graph form on page 13. An analysis of the apparent causes in 104 cases is given in Table II (page 21), although the Registrar General has only ascribed 102 deaths to this County. 6. Neonatal Mortality. This sub-division of the infant mortality comprises all infant deaths within twenty-eight days of birth, and of the 102 infant deaths, 70 were classed as neonatal. The rate per 1,000 live births was 12.30 compared with 13.75 for 1962, and with 14.2 for England and Wales. The majority (63) of the 70 neonatal deaths were in the first week of life, the main causal factor being prematurity. 7. Perinatal Mortality. There was a total of 153 cases (90 stillbirths and 63 deaths under one week) in this category, the mortality rate being 26.46 per 1,000 live and stillbirths. 8. Maternal Mortality. One woman died from causes associated with childbirth compared with four women for the previous year, giving a maternal mortality rate of 0.17 per 1,000 live and stillbirths. VITAL STATISTICS CARE OF MOTHERS (Section 22—National Health Service Act, 1946) 1. Notification of Births The number of births notified, after adjustment for transferred notifications, was : Live Births Stillbirths Total Domiciliary . . 1,516 8 1,524 (26.7%) Hospital . . 4,125 55 4,180 (73.3%) Total . . 5,641 63 5,704 Details of all notifications are transmitted to the health visitors, who begin visiting immediately after the tenth day. 2. Premature Infants (5|lb. or less at birth, irrespective of the period of gestation) There were 183 premature live births and 30 stillbirths in hospital, and 42 live and one stillbirth at home. The total survival rate has averaged 93.8% over the past five years, and this satisfactory record reflects the professional skill and facilities which are nowadays available for the care of premature babies. 3. Deaths Ascribed to Pregnancy or Childbirth The Registrar General reported one maternal death. The cause of death was pulmonary oedema, myocardial degeneration and anaemia of pregnancy, and it is most unfortunate that the anaemia was not detected and corrected earlier in pregnancy. The death occurred in hospital. The maternal death rate per 1,000 live and still births was 0.17 compared with a rate for England and Wales of 0.28. 4. Relaxation and Parentcraft Classes Details of these classes are given in the section on Health Education (page 36). * 5. Maternity Accommodation At the request of the hospital authorities, the booking of cases on social grounds continued to be carried out by the County Health Department, as district midwives are well acquainted with the domestic circumstances of each case. The arrangements have worked reasonably well, but it is impossible to accommodate every mother who would prefer to be confined in hospital. The numbers of cases booked each month were : Barratt Maternity Home, Northampton . 32-40 St. Mary’s Hospital, Kettering . 26 Corby Maternity Unit . 60 Park Hospital, Wellingborough . 64 6. Care of Unmarried Mothers The County Council assisted forty-three unmarried mothers by accepting financial responsibility for their stay in St. Saviour’s Diocesan Maternity Home, Northampton, and at similar homes elsewhere, each girl being required to pay 54/- per week towards the cost, if she was receiving the full maternity allowance. Contributions received from other sources were also deducted from the final account. The Peterborough Diocesan Family and Social Welfare Council received a grant of £1,200 from the County Council for their work in the community. Of the 308 illegitimate births in the county, 124 were helped by social workers, 108 of these being first pregnancies. The ages of the mothers ranged from 14 to over 30 years. The age group 14-21 years accounted for 98 of the 124 cases. Enquiries made amongst the mothers six months after confinement revealed that so far thirty-seven of the babies had been adopted. The record of illegitimacy in the county over the past 25 years is given in the graph (p. 16). This shows that, since the wartime increase, the figure has varied between 4 and 5.5 per cent of all births. 7. Family Planning Clinics There was an increased demand for such services. Thirty women attended the Northampton Women’s Welfare Association Clinic, and 13 attended the Rugby Family Planning Clinic. Sessions at the County Council’s own clinics at Corby and Kettering are held twice monthly. At Kettering, 240 women made a total of 421 attendances, and at Corby, 144 women made a total of 212 attendances. STATISTICS OF ILLEGITIMACY m V0 o vO o O v0 O ON LO On nO to On On ON ON ON $ On LO 5 * On ro On On ON ? On On m On 00 ro On <N CARE OF YOUNG CHILDREN (Section 22—National Health Service Act, 1946) 1. Child Welfare Centres There are 60 fixed child welfare centres, four being held in purpose-built premises (Corby (Pen Green Lane), Kettering, Rushden and Wellingborough), two in places adapted for the purpose (Corby (Beanfield) and Desborough) and 54 in hired premises. To serve rural districts where the child population is too small to justify the opening of a fixed centre, a mobile health clinic was introduced in November, 1962, and has provided a very useful service. The itinerary of the clinic takes in 35 villages and mothers and children from a further 37 villages are conveyed to it by the estate car which tows the caravan. The towing vehicle is also used for general transport purposes of the Health Department and the caravan for school health work where adequate medical inspection rooms are not available. The number of children born in 1963 attending all child welfare centres for the first time was 3,459, representing 61% of the total registered live births. The total number of attendances by children under one year of age was 38,026, an increase of 5,481 (17%) over 1962. Attendances of children between the ages of one and five years was 21,303, compared with 21,310 in 1962. The substantial increase in the attendances of children under one year of age is due not only to the increasing popularity of child welfare centres but to the success of the mobile health clinic. A total of 216 children born in 1963 and 515 children born during the period 1958 to 1962 attended this clinic for the first time during the year, and 2,693 attendances were made. In addition to the mobile clinic, free bus facilities are supplied to serve 22 centres in rural areas, 253 journeys being made to convey 2,751 mothers and 3,649 children. For the first time, the work of the child welfare centres was continued throughout the month of August, sessions being held at the normal times as far as the staffing position would allow. It was found that this was an arrangement which was greatly appreciated by many mothers. 2. Mothers’ Clubs The formation of mothers’ clubs in association with child welfare centres has been a welcome development in recent years. These clubs are socially enjoyable and also play an important role in giving mothers opportunities of learning more about infant care and other aspects of mothercraft. In addition to those previously established at Corby (New Town) ; Corby (Bean- field) ; Corby (Rockingham Road Estate) ; Daventry ; Kettering ; Wellingborough (Health Clinic) and Wellingborough (St. Andrew’s), further clubs have now been established at Bug- brooke ; Wellingborough (Thursday Club) and Rushden. 3. Play Centres Play centres, organised by the local mothers’ clubs, are held at the Health Clinic, Oxford Street, Wellingborough, and the Beanfield Health Clinic, Corby. At Wellingborough the centre caters for up to 25 children from 9.30-11.30 a.m. on one morning each week. Similar facilities are offered at Corby, where two weekly sessions are held. A rota of helpers is organised, five or six attending each session. Activities include music and movement, road drill, story reading and educational games. The Health Visiting staff are keenly interested in these projects, which give mothers the opportunity of a free morning, knowing that their children are well cared for. The play centres are also valuable from the children’s point of view, serving as a useful preparation for entry to school. 4. Child Guidance This service, which is available to pre-school children where necessary, is dealt with in Part II of “ The Health of Northamptonshire in 1963 ”. 5. Speech Therapy This is likewise considered in Part II. 6. Nurseries and Child-Minders Regulation Act, 1948 There was a substantial increase in applications for registration during the year and, at 31st December, the premises registered under the Act were : “ Oakroyd ” Day Nursery, Finedon Road, Wellingborough Parish Hall, Weston Favell, Northampton Memorial Hall, Old Stratford 25 Back Lane, Hardingstone 4 East Street, Long Buckby 4 Selsey Road, Corby ... “ Queen Anne’s ”, Oundle “ Wychwood ”, Draysons Lane, Crick “ Avonhurst,” and “ Miles Well House ”, Lumbertubs Lane, Boothville, Northampton ... 7 School Lane, Harpole 46 Hall Avenue, Rushden 18 children 16 children 12 children 6 children 16 children 7 children 12 children 12 children 14 children 8 children 6 children In all cases, applicants for registration and their assistants are required to have a chest X-ray examination. The potential importance of this is shown by the case of one of the applicants whose husband made arrangements for her chest X-ray and decided to be examined at the same time. As a result, he was found to have active tuberculosis and was subsequently admitted to hospital. The applicant and her children were examined and fortunately were found to be clear. 7. Distribution of Welfare Foods Centres for the distribution of national dried milk, cod liver oil, vitamin tablets and orange juice are located wherever there is a demand. There is a full-time centre in the Health Department in Northampton and part-time centres manned by County Council staff at Kettering, Corby, Wellingborough, Rushden and Daventry, as well as that provided by the mobile clinic. The remaining centres are manned by unpaid voluntary helpers who sell the foods from their homes, from shops, and at child welfare centres. The total number of centres at the end of the year was 152. Of these, 145 were voluntary, 30 being at child welfare centres. The number of items distributed during the year was : National Dried Milk (full cream and half cream) ... ... 78,701 Cod liver oil ... ... ... ... ... 6,371 Vitamin A and D Tablets ... ... ... ... 6,444 Orange juice ... ... ... ... ... 67,560 Total ... ... 159,076 There was no change in the price of welfare foods and the total number of items distributed during the year was some 17,000 more than in 1962, thus regaining some of the ground lost following the imposition of increased charges for vitamin preparations in June, 1961. 8. Dental Care Report by the Chief Dental Officer Dental inspection and treatment was provided for the priority classes of patients (expectant and nursing mothers and pre-school children) as the availability of staff allowed and, following the trend of recent years, the number of attendances made by children under five years of age increased again (922 in 1963 ; compared with 825 in 1962 ; 745 in 1961 and 523 in 1960). The 1963 figure is almost double the 1960 one, despite the fact that the number of staff available did not appreciably increase until the last quarter of 1963. Dental caries is clearly established now as a disease of the very young child and regretfully it must be reported that the youngest patient for whom conservative treatment was successfully carried out last year was only 18 months old ! On the other hand, the early incidence of decay in the child’s life gives rise to a golden opportunity to win the confidence of the very young patient. The average child coming to the surgery for the first time at the age of 2\-3>\ years proves to be a highly co-operative patient, as yet unworried by the careless talk and frightening inflections of their elders, and once the little one knows by virtue of his own experience how easy and uncomplicated conservative dental treatment can be, no amount of hostile external influence affects him in any way. Most dental surgeons would agree that the child who does not attend a dental surgery before starting school, proves more often than not less co-operative than a younger patient coming for first treatment at around the age of three. Opportunity for treating expectant and nursing mothers became ever more remote with the cessation of county council ante-natal clinics and the provisions of the National Health Service Act, 1961, which made free dentures available to these patients through National Health Service practices. Eighty mothers made 283 attendances in 1963 as against 107 making 389 attendances in 1962. It can be safely assumed that, as more and more mothers obtain their dental treatment through National Health Service practices, an increasing number of very young children must also be treated in the same way, as it is natural that mothers should tend to take their children with them to their own practitioners. The main function of local authority dental services towards expectant and nursing mothers would now seems to be an educational and preventive one, with welfare and baby clinics, mothers’ clubs and other groups providing the means of contact for the dental surgeon with significant numbers of women. With the appointment of one dental auxiliary in 1963 and the promise of another in late 1964, greater opportunity for reaching these groups will become possible from now on. Despite the yearly increase in the amount of treatment given to very young children and the very high standards of living and of health generally enjoyed by them to-day, one regrets the continued high incidence of dental caries, and in the absence of progress on the question of fluoridation of water supplies, there is no doubt that our youngsters will continue to be plagued by the effects of dental disease despite increasing attempts at health education directed towards sensible eating habits and oral hygiene. TABLE I. (a) Numbers provided with dental care : Commenced Made Examined Treatment Dentally Fit Expectant and Nursing Mothers ... 80 77 74 Children under five ... 456 551 509 (b) Forms of dental treatment provided : tions General Anaesthetics Crowns and Inlays Fillings Scalings and gum treatment Silver Nitrate treatment Radio- graphs Dentures provided Complete Partial Expectant and Nursing Mothers 237 29 1 78 30 2 12 15 21 Children under five 300 142 — 238 4 171 4 — — 9. “At Risk ” Register On 1st October a register was started of children considered to be at risk of developing any physical or mental handicap. Broadly, the categories in which they are placed on the register fall into the following groups : (1) Significant family history of disease. (2) History of antenatal or perinatal disease or injury. (3) Postnatal disease or injury. (4) Developmental defect. A child is registered if there is any adverse condition likely to affect him physically or mentally, and it is primarily the responsibility of the health visitor to decide whether a child should be registered. When the child is between the age of six weeks and three months the health visitor’s record card is sent to the office as a routine measure and, in cases where the special “ at risk ” section has been completed, the child concerned is placed on the register and a special tag is fixed to the health visitor’s card, thus enabling her to know that the child has been placed on the central register. Information concerning an antenatal or perinatal disorder is obtained direct from the maternity hospital, family doctor or midwife by means of the birth notification card, which has been redesigned to include any such information. In many cases, children are known to be at risk within 36-48 hours of birth, and are therefore registered, this information being available to the health visitor prior to her first visit to the child. Children will remain on the register for at least two years, and health visitors will make more frequent but, it is hoped, unobtrusive visits, thus allowing greater opportunity for detecting any handicap at an early stage, which in turn should enable prompt steps to be taken for it to be remedied. When the child is two years of age, the health visitor will make a special visit to review the case. If she is satisfied that no risk remains, the child will then be removed from the register, but if, on the other hand, the risk remains, the mother will be invited to take the child to the clinic to be seen by a doctor. A similar examination will take place at four years, and the health visitor will then assess the child’s fitness for school and, if she considers that special schooling may be necessary, the School Health Service will be notified. In cases where a child is regularly being seen by a paediatrician or general practitioner, the mother will be encouraged to keep her appointments, and will not be asked to attend the local authority doctor for a special examination of her child. The scheme was operative for only the last three months of 1963 and a total of 378 children were registered. It is hoped that, in time, this system of registration will provide a rational system for the early detection of handicaps, while in the meantime providing some basis for a more selective approach to health visiting. 10. Causes of deaths of children under one year Details of these deaths are given in Table II, from which it will be seen that prematurity is substantially the largest problem, accounting for over one-third of the deaths. Congenital malformations come second, with respiratory diseases and birth injuries third and fourth respectively. Progress is being made in overcoming the problem of prematurity, and the 1963 figures show an improvement in that respect over those for 1962, when 51 infants died primarily from this cause. TABLE II Cause of Death Age in Weeks Total -1 -2 -3 -4 4-52 Prematurity 38 — 1 — — 39 Congenital malformations ... 5 — — 3 10 18 Respiratory diseases 3 — — 1 12 16 Birth Injury 8 1 — — — 9 Asphyxia and atelectasis 6 — — — — 6 Infections (other than lung and gut)... — — — — 4 4 Accidents — — — — 2 2 Enteritis and Diarrhoea — — — — 1 1 Haemolytic Disease 1 — — — — 1 Other Causes 2 — — — 6 8 Totals 63 1 1 4 35 104 These figures have been prepared from an analysis of death returns received from the local Registrars, and differ slightly from those quoted by the Registrar General. According to the latter there were 32 children who died in the period 29 days to one year. It must be emphasised that this table is based only on the information contained in death certificates, and that practitioners vary in the way they complete these. For example, the death of a premature baby who died from asphyxia or from cerebral haemorrhage might be ascribed to either of the latter without the fact that it was premature being noted. If, however, prematurity was mentioned on the certificate, the death would be classified under this heading. CHILD WELFARE CENTRES Name of Centre Barton Seagrave Boothville Boughton Bozeat ... Brackley Brigstock Brixworth Broughton Burton Latimer Cold Ashby and Welford Collyweston Corby (Pen Green Lane) Corby (Beanfield) Corby (Diagnostic Centre) Corby (Elizabeth Street) Daventry Deanshanger Desborough Doddington, Great Duston (Congregational Church) Duston (Rifle Butt) Earls Barton Finedon ... Geddington Gretton Hackleton Hardingstone ... Helmdon ... . Higham Ferrers Irchester Irthlingborough (St. Peter’s Hall) Irthlingborough (Community Centre Kettering (School Lane) Kettering (St. John) ... Kings Cliffe Kings Sutton . Kislingbury Long Buckby ... Middleton Cheney Moulton Oundle Potterspury Raunds Roade ... Rothwell Rushden... Silverstone . Spratton... Thrapston Towcester . Weedon ... Weldon ... ... . Wellingborough (Oxford Street) Wellingborough (St. Andrew’s) West Haddon ... Weston Favell ... Wollaston Woodford Woodford Halse . Yardley Hastings Mobile Clinic Average No. Sessions held !ending Session By Doctor By Health 48 20 2 47 24 — 37 12 — 23 12 — 60 12 — 30 12 — 21 12 — 41 12 — 44 12 12 42 11 — 42 12 — 36 51 — 52 47 17 67 51 — 58 47 2 26 24 — 51 12 — 67 11 12 30 12 — 43 21 — 82 24 — 37 12 12 33 12 10 36 12 — 23 12 — 19 12 — 24 12 12 37 11 — 52 24 — 52 12 12 44 11 — 35 12 — 36 147 2 25 12 12 6 11 — 50 12 — 60 11 — 26 13 — 49 12 — 39 24 — 28 12 — 26 12 — 27 12 — 36 12 — 41 12 12 80 51 — 41 12 — 18 11 — 14 12 — 28 12 — 23 12 — 28 12 — 71 62 — 45 24 — 43 12 — 31 24 23 33 13 10 23 12 — 27 12 — 42 12 7* 377f — * Average attendance per village t Visits to villages MIDWIFERY (Section 23—National Health Service Act, 1946) 1. Statistics The following table shows the number of cases attended by midwives in the past eleven years. Year Doctor not booked Doctor booked Total Doctor present at time of delivery of child Doctor not present at time of delivery of child Doctor present at time of delivery of child (either the booked doctor or another) Doctor not present at time of delivery of child 1953 ... 15 454 531 769 1769 1954 ... 12 682 445 540 1679 1955 ... 16 555 425 696 1692 1956 ... 42 582 424 621 1669 1957 ... 54 513 408 719 1694 1958 ... 44 598 340 808 1790 1959 ... 74 525 326 896 1820 1960 ... 54 528 298 991 1871 1961 ... 51 436 293 950 1730 1962 ... 12 89 348 1088 1537 1963 ... 8 47 338 1130 1656 There was an increase of 119 births over 1962 and it is pleasing to note a further decline in the number of cases for whom no doctor was booked. 2. Midwives The number who notified their intention to practise was 119. Of these 75 were employed by the Council (including relief mid wives), 39 by Hospital Management Committees, and five were independent mid wives. 3. Co-operation with General Practitioners This has continued throughout the year. One general practitioner conducts his ante-natal clinic in County Council premises, with midwives attending weekly on a rota system. Several other midwives attend general practitioners’ ante-natal clinics held in their own premises, and one midwife holds a small clinic in her district room with the general practitioner attending. In the rural areas, most midwives meet the general practitioners at the patients’ own homes for routine examinations in the last weeks of pregnancy. 4. Midwife Teachers There was an increase of four and there are now fourteen teaching midwives. This facilitates the placement of pupils where there are more domiciliary confinements, and gives the teaching midwives occasional respites from the arduous task of training pupils. 5. Midwifery Pupils More pupils have been received from Horton General Hospital, Banbury, owing to the fact that one of their districts did not have a sufficient number of cases for pupil training. Tutorials for these pupils were given by the county administrative nursing staff, and public health lectures by the Deputy County Medical Officer of Health. The pupils also attended a number of relaxation and parentcraft classes, as this is an important part of the preparation for their future work. A full quota of pupil midwives came from St. Mary’s Hospital, Kettering as usual and, from the two hospitals, a total of 29 pupils received training during the year, while one Australian midwife came for one month’s district training for admission to the English roll. 6. Post-Graduate Courses Midwives attended courses arranged by the health education section during the year and 18 attended courses approved by the Central Midwives Board. 7. Relaxation and Mothercraft Classes This valuable work continued in close liaison with the health visitors. The numbers of classes and attendances are contained in the health education section of this report (p. 36). 8. Maternity Outfits 1,752 outfits were made available free of charge for use in home confinements. 9. Sparklet Oxygen Apparatus These small machines have proved their value during the year for babies suffering from asphyxia at birth and may well have played their part in reducing the peri-natal mortality. 10. Disposable Equipment There has been an increase in the use of " disposables ” this year, caps, masks, enemas and syringes now being used. This is of tremendous help to the midwife in terms of time saved in sterilisation and laundry. 11. Off Duty An off-duty rota system was offered to midwives during the year, but they unanimously elected to work a five-day week and have two rest days as they prefer to deliver their own patients if possible, and believe that the patients themselves like to know who will be present at confinement. 12. Visits of Observation Student nurses from Northampton General Hospital, Kettering General Hospital, St. Crispin Hospital, and the Leicester Queen’s Institute District Training School, have visited in order to have days on the district with the county midwives. 13. Cars Cars are authorised for use in all districts, both urban and rural, and the trend towards the use of privately-owned cars instead of County vehicles was continued. The number of cars in use at 31st December by district nurse/midwives, health visitors, occupational therapists and speech therapists was 172. (a) Provided by County ... ... ... 77 (b) Privately owned ... ... ... ... 95 The 77 cars provided by the County were distributed as follows : 57 District Nurse/Mid wives 12 Health Visitors 1 Home Help Organiser 1 Audiometrician 2 Occupational Therapists 3 Speech Therapists 1 Mental Welfare Officer During the year the type of car was changed from the Ford Popular to the Anglia. Fifteen were purchased and distributed as follows : 13 for district nurses. 1 for health visitor. 1 for speech therapist. 14. Houses At 31st December, 16 houses and 3 cottages were owned by the County Council. Nineteen houses were rented by the County Council from District Councils and one from another source. HOME NURSING (Section 25—National Health Service Act, 1946) 1. Staff With the untimely death of Miss W. M. Williams, to which reference is made in the introductory letter to this report, Miss N. Taylorson was promoted from the post of deputy to that of Superintendent Nursing Officer and, at the same time, the opportunity was taken of separating this post from that of Superintendent Health Visitor, as the work of these two departments had become so extensive that it was desirable to have them under separate administrative heads. The home nursing supervisory staff now consists of a Superintendent Nursing Officer, a deputy, and two assistants. During the year Miss Taylorson was awarded a Council of Europe Fellowship to enable her to spend two months on a study tour of Sweden, Denmark, and the Netherlands. This tour covered all aspects of nurse and midwifery training and practice, and Miss Taylorson was received with notable hospitality wherever she went. As well as carrying out their customary duties the supervisory staff took a prominent part in the mental health education project and gave lectures both in the course of this and in the syllabus of nurse training at Northampton General Hospital. The number of staff employed at the end of 1963 was : Full-time district nurses ... ... ... ... 16 Part-time district nurses ... ... ... ... 14 Full-time district nurse midwives ... ... ... 55 Part-time district nurse midwives ... ... ... 5 Full-time health visitor, district nurse midwives ... 13 Total ... 103 2. Cases The numbers of patients attended were as follows : Total number of persons nursed ... ... ... ... 6,940 Number of children under 5 years of age at first visit ... ... 405 Number of persons over 65 years of age at first visit ... ... 3,638 A study has been made of trends in district nursing over the period 1953-1963, the results of this being given in the table opposite. It will be seen that the number of patients receiving home nursing reached its peak of 11,731 in 1957, since when it has gradually declined to the present total of 6,940. It is clear that the pattern of the district nurse’s work is changing and that more effective therapy and the greater emphasis on rehabilitation have resulted in fewer bedridden patients, except in the terminal stages of their illnesses. DISTRICT NURSING STATISTICS 1953-1963 Patients Medical Surgical Infectious Diseases Tuberculosis Maternal Complications Others Total At time of ls2 visit Total Visits Aged 65 or over Under 5 1953 4,861 2,946 306 90 373 635 9,211 3,459 984 163,588 1954 5,140 2,701 110 136 440 675 9,202 3,510 866 170,969 1955 5,791 2,520 127 87 347 709 9,581 4,256 892 172,357 1956 6,298 2,104 30 78 200 1,734 10,444 4,725 791 171,857 1957 6,309 1,881 90 118 179 3,154 11,731 4,504 796 169,250 1958 6,259 1,928 30 90 185 3,227 11,719 4,213 706 165,155 1959 6,012 1,757 4 76 115 1,633 9,597 3,712 659 155,206 1960 5,133 1,581 10 61 147 495 7,427 3,420 583 138,875 1961 5,148 1,563 41 33 142 610 7,537 3,452 500 143,552 1962 4,845 1,509 50 30 120 487 7,041 3,581 384 142,750 1963 Inform ation clas sified dif ferently 6,940 3,638 403 139,589 On analysing the figures for different groups the following tentative conclusions were reached : Medical. There was a decrease between 1957 and 1962 and it is probable that a substantial part of this was due to the introduction of oral forms of treatment for diabetes mellitus, which used to be the largest single reason for district nurse visits when many elderly diabetics had to receive daily injections of insulin. Surgical. The drop in surgical cases was progressive from 1953 and may be the result of improved surgical techniques in hospital, plus the use of antibiotics, in addition to which the number of minor operations carried out at home by general practitioners has almost certainly declined over the 10-year period. It will be interesting to see whether the falling trend in surgical cases is reversed as hospitals initiate policies of early discharge or of out-patient surgery. Infectious Diseases. The improvement in preventive measures plus health education, and again, the use of antibiotics, have all contributed to the fall between 1953 and 1962. The seriously ill child with the complications of measles or with severe whooping cough are virtually things of the past. Tuberculosis. The improvement here was to be expected as a result of earlier detection through mass radiography and more effective treatment. Maternal Complications. The substantially improved position reflects the improving standard of antenatal care and midwifery, plus the value of antibiotics in combating maternal infections. Those over 65. There was a gradual rise from 1953 to 1956, then a fall until 1960, followed by a further rise to 1963. The fall between 1956 and 1960, despite the increasing number of old people in the community, is probably partly due to the availability of oral treatments for diabetes, to which reference has already been made, as this form of therapy applies particularly to older people who have, in the past, required insulin. The upward trend since 1960 is likely to be maintained. In 1963 the system of record keeping was simplified as certain of the former groups, such as tuberculosis and infectious diseases had become too small to justify their being recorded separately, and in future the information which is gathered will relate solely to age, with particular reference to the elderly and the young. The falling trend in home nursing is not a phenomenon peculiar to Northamptonshire as is shown in annual reports of the Ministry of Health which record that the national total of nursing visits has been decreasing since 1958, while the number of patients receiving home nursing has been declining since 1954. These changes do not mean that district nurses will have less work to do in the future, as an increasing proportion of their time is already being taken up with the elderly, where both nursing and rehabilitation require relatively long periods of work with any given patient. 3. Equipment Increasing use has been made of disposable equipment. Disposable syringes and needles are invariably used, and plastic sheeting, absorbent pads and pre-packed enemas are in regular use. It is hoped to provide further similar facilities, as this will reduce the amount of work for the individual nurse, thus enabling her to give more time to the personal problems of her patients. In the case of syringes and needles the high standard of safety as far as any possibility of infection is concerned must also be taken into account. 4. Non-nursing visits In addition to the visits which have already been described, nurses paid a total of 11,735 non-nursing visits, this being a reduction of 1,012 from the figure for 1962, and representing the first sign of the improvement caused by the setting up of a comprehensive county Home Help Service with its own organiser and assistants. Future years should see a further substantial reduction in these non-nursing visits. There were also 8,027 non-nursing visits to those over the age of 65, and this represented an increase of almost 1,000 over 1962. This work is of substantial benefit to old people and, during the extremely hard winter of 1963, the nursing staff kept a very careful eye on many of the elderly living in their districts. 5. Training The customary in-service lectures were held during the year as reported in the section on health education (p. 35). The nursing staff also continued to spend two-week periods in Northampton General Hospital for refresher courses, and these facilities were greatly appreciated. The County Nursing Service has received its usual visits from nurses undergoing training at Northampton and Kettering General Hospitals, St. Crispin Hospital, and the Queen’s Institute Training Centre at Leicester. 6. Reorganisation Towards the end of the year a start was made on the reorganisation of the district nursing areas and, in carrying this out, the following factors are being studied : (a) the population of the areas ; (b) their geography ; (c) the case loads of nurses ; (d) the type of cases nursed, with particular reference to the numbers of midwifery and of general nursing cases. It is hoped, in accordance with the provisions of the 10-year plan, to reduce the case load of combined district nurse/midwife/health visitors to a figure in the region of 1,800, which will allow them sufficient time to carry out all aspects of their duties. Attempts will also be made to introduce nursing teams wherever possible so as to allow limited specialisation and, in particular, to ensure that those nurses who practise midwifery obtain a sufficient number of cases during the year in order to keep their skills up to date. This reorganisation will take time and must largely be achieved as retirals take place or as the growth of population in any given area necessitates an increase in staff. 7. Nursing Homes The only home on the register at the end of the year was Townsend Nursing Home, Upper Benefield. 8. Cars This subject is dealt with in the Midwifery Section of the report. 9. Houses This subject is dealt with in the Midwifery Section of the report. HEALTH VISITING (Section 24—National Health Service Act, 1946) 1. General As has already been explained in dealing with district nursing, a change in administrative arrangements came about in the autumn with the promotion of the Deputy Superintendent Nursing Officer in charge of Health Visitors to the newly-created post of Superintendent Health Visitor. Miss S. H. Buchanan, the Superintendent Health Visitor, was invited by the Minister of Health to serve on the Oxford Area Nurse Training Committee. The establishment of health visitors was increased by four and these vacancies were all filled so that, by the end of December, there was the equivalent of 46£ health visitors on the county staff, this figure including one who had recently qualified and who was being held supernumerary to the establishment. One retirement took place and the vacancy was filled by a student who had trained under the county scheme. Details of visits carried out are as follows : Infants 1963 ... 50,532 1962 48,478 Children—one to five years ... • • • ... 44,635 48,408 Tuberculosis 1,116 1,314 Mentally subnormal • . . . . . 1,058 938 Infectious diseases and other visits ... ... ... 10,200 9,936 The following attendances were made by health visitors : 1963 Child welfare centres ... ... 1,879 107,541 1962 1,701 109,074 Mobile welfare centre ... 375 59 Chest clinics ... 326 329 Immunisation clinics ... 153 207 Vision clinics 137 98 Family planning clinics 74 59 Enuresis clinics 23 14 Venereal diseases clinic 39 — Diabetic clinic 24 — These figures give some impression of the work carried out by health visitors, but it is important not to confuse quantity of visits with quality, and an increasingly selective approach to health visiting has allowed more time to be spent with those clients who require substantial amounts of help with their problems. It should also be noted that the decrease of some 1,500 in the number of individual visits was balanced by the substantially increased number of attendances at child welfare centres and other forms of clinics. 2. Training There were two students in training during the year and one of these completed her studies and obtained her certificate in December. Two health visitors took the four months part-time group adviser course with a view to preparing themselves for such posts in the county. There appeared to be no doubt about the value of these courses, nor about the need to provide some form of special training for those who are to lead groups of health visitors. Five health visitors attended post-certificate courses arranged by the Health Visitors Association in Cambridge, Leicester and London, and four were trained to carry out hearing screening tests at a two-day course at Leicester. The subject of general in-service training is dealt with in the section on health education (page 35) but several additional programmes were arranged for health visitors. The consultant psychiatrist and team of the child guidance clinic held three discussion meetings for health visitors ; area meetings were held to permit the audiometric nurse to discuss her work with the health visiting staff; and the secretary of the Peterborough Diocesan Family and Social Welfare Council similarly attended meetings in order to discuss problems of mutual interest. 3. Health Education The health visitors were actively concerned in the Mental Health Project and carried out the major part of the surveys of public opinion at the beginning and end of the programme. In addition, groups of health visitors attended all the study days arranged for special groups during the Project, and some organised special meetings in their own areas at which they either spoke themselves or arranged for outside speakers to attend. As is explained in the section on health education the programme of health teaching in schools is continuing to develop. In one of the secondary schools, Her Majesty’s Inspector attended a class being taken by the health visitor and his subsequent report commented most favourably on the work which he had seen. Antenatal classes are well attended and health visitors enjoy the opportunity of getting to know the mothers in advance of their first calls. The development of mothers’ clubs, which is remarked upon elsewhere in this report, has also been in no small measure due to the work of the health visiting staff, who have likewise taken a keen interest in play centres. 4. Detection of Phenylketonuria The pilot scheme started in Kettering in 1962 proved satisfactory and administratively convenient, so it was extended to cover the entire county during 1963. Although no cases of phenylketonuria were detected it was considered desirable to continue these efforts to find one of the few preventable causes of mental subnormality, and the work did not, in fact, throw a substantial additional load on the health visiting staff. It may well be that, in the future, other diseases of a similar nature will be detectable by means of a urine test, in which case the experience gained in the present search for phenylketonuria will prove valuable. 5. Tuberculosis At the end of 1962 an attempt was made in the Corby area to see if the home supervision of tuberculous patients could be put on a more selective basis. This proved highly successful from the point of view of the patients themselves as well as of the consultant chest physicians and the health visitors, and a similar selective process was extended to all parts of the county during 1963. 6. Liaison with General Practitioners Planning was continued’with the view to initiating experimental schemes of direct attachment of health visitors to general practices in Northamptonshire in the course of 1964. In the meantime, however, the services of health visitors have been made available to two family doctors who conduct their own child welfare clinics. 7. Specialised Health Visiting In general it is desirable that the same health visitor should deal with the entire needs of any given family and this is the policy which has been pursued throughout the county. During 1963, two special after-care schemes were started to cover certain aspects of diabetes mellitus, and of venereal disease in the county. The health visitor undertaking this work was given a small rural area on which she could spend approximately half her time, the other five half-day sessions each week being fully occupied with after-care work based on two out-patient clinics at Northampton General Hospital. (a) Diabetes Mellitus. There is probably no other disease in which it is so important that the social aspects should be fully considered and in which the patient has to play so active a r61e in his or her own treatment. All diabetics have to observe certain dietary restrictions and, particularly if they are elderly when the disease first develops, this may represent a substantial change in their way of life. It is one thing to prescribe a diet in the hospital diabetic clinic and quite another for an elderly diabetic patient to understand its details in her own home. In the case of the minority who require to give themselves insulin, much has again to be learned, and both in this case, and even more so in dietary training, the health visitor has an important role to play. The specialised health visitor attends the diabetic clinic at Northampton General Hospital and deals with any medico-social problems which present themselves, as well as being able to continue the teaching about diet and other subjects in the patients’ own homes. In this work she maintains liaison with her colleagues and also with the district nurse who may be involved in teaching insulin injection techniques. In inaugurating this scheme, help was received from the diabetic clinics at Cardiff and Leicester, where this type of after-care by means of health visitors has been in existence for many years, and valuable assistance was also received from the British Diabetic Association. The diabetic population of this country is increasing, partly as a result of greater longevity, partly because young diabetics now survive to have increasing numbers of children, and partly because of the higher rate of detection amongst the general public. Only by the provision of health visitor assistance in the work of after-care will it be possible for the diabetic clinics and family doctors of this country to cope with the situation during the next decade, and the follow-up scheme which has been initiated in the county should form a basis on which to develop this work locally. (b) Venereal Disease. Whilst venereal disease is not a substantial problem in Northamptonshire compared with certain other parts of the country, there can be no doubting the large number of social factors which must be taken into account in its treatment. There are particular problems of ensuring that patients who commence treatment in fact continue it until it has been completed and there is also the task of contact tracing. This type of work is ideally suited to the training and skills of a health visitor and arrangements have been made for such services to be made available to the venereal disease clinic at Northampton General Hospital. Health visitors also have regular links with Kettering General Hospital and Northampton General Hospital in connection with other medical matters, particularly where these concern young children or old people, and it is anticipated that the demand for their services will increase. 8. Family care The main work of the health visitor continues to be centred on the family, as has always been the case, and her interest covers the grandparents as much as the infants. It is customary to give one or two examples of the varied work of health visitors and the following are amongst the incidents which took place during 1963 : The health visitors do not give up their interest in their families when these move out of the area, particularly when they go abroad. One such family are at present being helped by remote control. A first baby arrived in the home of a couple where the husband was in the foreign service. For the first few months the parents needed a lot of support and advice, then they were posted abroad, but the health visitor still carries on a monthly advice service by correspondence. She is also commissioned to buy all the child’s clothing in this country and send it to the family. The benefits have not been all on one side, as the health visitor has spent a holiday with the family. This is not the first occasion a health visitor has advised a mother living overseas, by correspondence. Many of the family problems are social rather than health problems and the health visitors find it an advantage to be able to interview their clients at their offices or clinics when this is the case. A health visitor received a telephone call from a factory in the next village, the caller being a Mr. X. who said he had a serious problem and would like an appointment to see her as soon as possible. He came to the clinic in his lunch break, and told the health visitor his wife had left him and their four children, ranging in age from 17 to 9 years. She was staying with a friend and there seemed to be no question of another man. Mr. X. said he and his wife had not always been happy and he admitted that he wasn’t blameless, but said that his wife was a poor manager with money and this caused arguments. The situation had deteriorated since his sister-in-law and her two illegitimate boys had come to stay with the family in their three-bedroomed council house. The health visitor said she would see what could be done and that she would first try to see Mrs. X. Two days later the sister-in-law was admitted to hospital after an overdose of sleeping tablets. She had become aware that she was a cause of friction between Mr. and Mrs. X, and the health visitor was able to arrange with the almoner for her to stay in hospital for a few days while she and the District Welfare Officer found some suitable lodgings for the woman and her sons. A friend was found who offered to give them a home, and the National Assistance Board Officer guaranteed the rent. The health visitor then saw Mrs. X, who agreed to return home. The health visitor discussed their mutual problems with them and urged Mr. X not to leave all decisions to his wife, but to take his share of responsibility for the welfare of the family. She suggested he should make himself responsible for paying the rent, and that they should plan their budget together. They were willing to make an effort to do better and, so far, have succeeded in doing so. HEALTH EDUCATION 1. Introduction “ The health of the people is really the foundation upon which all their happiness and all their powers as a State depend.” This remark, made by Disraeli nearly a century ago, is still apt. A variety of methods and media, teachers and agencies, are all concerned nowadays with the promotion of health and the prevention of disease but, without the active co-operation of the individual and the community in which he lives, no positive results can be achieved. Health education is concerned with the whole way of life. Habits and attitudes—intangible and often difficult to comprehend—must be studied, understood and, if necessary, changed. This is a lengthy process, but one which has proved its worth during the last two decades. The initial elimination of diphtheria and of poliomyelitis is the result of medical advance working hand in hand with health education of the public, for there would have been little point in developing potent vaccines if the public had not been persuaded of their value. Harder tasks lie ahead in trying to influence people’s attitudes towards such matters as smoking, nutrition, and mental illness, for much more is required of each individual than the mere acceptance of an injection. It is encouraging to find that there is an increasing demand from the public for knowledge about health matters and, just as a commercial undertaking would try to expand its facilities to meet its customers’ requirements, so health education facilities need to be reviewed both nationally and locally in order to ensure that their development is keeping pace with public needs. In Northamptonshire, the past year has seen substantial advances in the field of health education. 2. Organisation As the work of the health education section has become more widely known and the use of visual aids in all forms of teaching more fully appreciated, the demands on the section have increased and, in order to cope with the greater amount of work, a clerk and a visual aids assistant were appointed in April. To avoid wastage by holding large supplies of leaflets and posters which rapidly become outdated, a new selective system has been introduced whereby most publications are obtained direct from the publishers as and when required. A further eight flannelgraphs were specially made for members of the staff. Flannel- graphs, demonstration material, filmstrips and the sound film projector have all been used to a much greater extent, as will be seen by the following comparative table. USE OF VISUAL AIDS Type of A id 1963 1962 Flannelgraphs 178 96 Demonstration Aids 93 69 Filmstrips 789 598 Cine Projector 153 53 Clinic Displays 26 12 The photographic side of the work developed during the year and the cine camera was used to take several hundred feet of film dealing with various aspects of mental disorder. It is hoped to produce an edited version of this as an aid to teaching. The 35 mm. camera was also extensively used and a selection of photographs dealing with the care of the mentally ill and mentally subnormal are being made into a filmstrip. Photographs were also taken of the opening of the Henley School and Industrial Centre at Kettering, of the mental health exhibition, of the health education feature at the County Show, and of all displays produced in the section. 3. In-Service Training The courses which were run during the year included the following : (a) In January, a two-day study course on human relations was arranged by the Central Council for Health Education at Knuston Hall. (b) Three classes on relaxation exercises were given by a senior physiotherapist from Northampton General Hospital to new members of the staff and any others needing a refresher course. (c) Four training classes on the methods and techniques of interviewing were held for health visitors and nurses taking part in the Mental Health Project survey. (d) General staff meetings were held on four occasions, the subjects for discussion being : “ Why community care ? ” ; “ Recent advances in human genetics " ; " Congenital abnormalities ” ; and “ Hypnosis in childbirth ”. (e) Three health visitors have each spent two days a week for three months in the health education section in order to gain a wider knowledge of methods and media, and to prepare themselves for teaching in schools. In addition to such in-service training, various groups of staff attended refresher courses outwith the county. 4. Relaxation and Parentcraft Classes These classes are still very well attended. 2,007 mothers made 10,132 attendances at 1,383 sessions. The film, “ To Janet a Son,” is now shown at most centres at the conclusion of the course, and expectant fathers are invited as well as expectant mothers. This has proved a great attraction and over 200 fathers have attended and helped to produce some lively and interesting discussions. 5. Clinic Displays Over twice the number of displays was made, with such varying themes as Mental Health ; Speech Therapy ; Kill That Fly ; To Smoke or not to Smoke ? ; and Care of the Feet. A monthly rota in all the permanent clinics has helped to stimulate the interest of mothers and has ensured that their attention is focussed on single subjects instead of being divided amongst a heterogeneous collection of posters. Portable display boards are being made by the Henley Industrial Unit to enable health visitors to have easily assembled visual aids in any type of hall. 6. Schools There is a continued demand for health teaching in the schools and arrangements with head teachers for implementation of the standard syllabus are made by the health education section, which also produces sets of visual aids for each health visitor taking part in the scheme. During the past few months much publicity has been given both in the national and professional press to the increased incidence of venereal disease, especially amongst young people. It was felt that this subject should not be approached in isolation but rather tackled in association with other related biological and social facts, so the main teaching in schools has been given with the framework of the “ Growing Up ” syllabus. A further account of this work will be found in Part II of “ The Health of Northamptonshire in 1963 ” (p. 12). 7. External Activities (a) A health education marquee is now an accepted part of the county agricultural show, and the theme of “ Mental health and community care ” was used for the displays at Overstone, the British Timken Show, and the British Red Cross Society’s Gymkhana. (b) Details of the staff of the County Health Department and a diagramatic display of their work formed the basis for an exhibit in the local government exhibition at Kettering. (c) Two exhibitions were staged at Brackley. One of these was on home safety and incorporated displays by the local schools, a silver cup being presented to the winner. Later in the year an exhibition on mental health and an evening film show attracted a good audience. (d) A new venture was the “ Focus on the hurt mind ” exhibition at Northampton Town Hall for one week in October. This was staged with the help of the staff of St. Crispin Hospital, and under the sub-title, " Hospital to Community,” it emphasised the rehabilitation and community care of the mentally sick. A total of 945 members of the public visited the exhibition and, on the day set aside for schools, over 150 children showed an active interest. In addition, film shows were held each evening, and meetings were arranged for interested groups—such as the Society for Mentally Handicapped Children, and the local Association for Mental Health. (e) Help was given with the special open days held at each of the centres for the mentally handicapped. Photographic displays were arranged and film shows for the public proved so popular that, on two occasions, half the audience had to be entertained with slides showing the work of the centres whilst they awaited their turns for the film shows. 8. Smoking and Health During the year the committee set up by the Surgeon General of the United States Public Health Service added its authority to the list of those who have unequivocally confirmed the relationship between smoking and lung cancer, chronic bronchitis, and a variety of other ailments. Earlier statements in Britain from the Medical Research Council, the Royal College of Physicians, the Ministry of Health, and other authoritative bodies, have each apparently produced only a temporary effect on the cigarette consumption, and it is clear that every available means of health education must be applied to discourage children from starting to smoke and to help adults to rid themselves of the addiction. During the first three months of 1963 it was decided not to over-emphasise the teaching of the danger of cigarette smoking because the mobile unit from the Central Council for Health Education had been booked for the beginning of April, and it was felt that a concentrated, combined effort directed towards all sections of the community at the same time would be more penetrating and effective. However, routine requests for talks on the subject continued to be met by the health education section. At the end of March, every health visitor and district nurse was given a supply of antismoking leaflets and posters with instructions to display them prominently on the day the campaign was to be launched. New displays portraying by diagram and caption the pros and cons of smoking were prepared by the health education section and set up in the four main clinics in the county, together with a large, well-lit display in a central position at County Hall. An adequate supply of leaflets was at hand at each centre and the exhibitions were emphasised by the use of posters both inside and outside the clinics. The campaign itself was launched at Rushden clinic in the presence of representatives of the County Council, other public bodies, and the staff of the Health Department. Mr. M. Donaldson, F.R.C.S., F.R.C.O.G., introduced the campaign, and a demonstration was given by the mobile team of the Central Council for Health Education. During the anti-smoking week the programme of the mobile unit was mainly concentrated on the schools, but other organisations such as the British Red Cross Society, the St. John Ambulance Brigade, Women’s Voluntary Services, and a youth club, also provided large and interested audiences. The press was very co-operative and good coverage was given to all the activities. This led to further requests for talks and information from mothers’ clubs, Rotary clubs, and youth groups. The staff of the Health Department are very alive to the need for the continuation of this teaching, and every opportunity is taken to bring the knowledge home to the individual and to groups whenever an occasion arises. Use has been made of filmstrips and flannelgraphs, but requests for the film, “ Smoking and You,” has not always been met, as the demand seems to be far greater than the supply. It was interesting to note that the leaflets dealing with the subject in question and answer form were twice as popular as the pictorial ones. As in all health education projects, evaluation is extremely difficult. Following discussions with members of the staff of the Health Department, two main points have emerged; namely that there is now a substantially greater awareness of the danger of smoking amongst the general public ; and that people in authority or in a position to exert an influence on children and youth are nowadays much more inclined to curb their desire to smoke during times when their example might be followed by the children, even if they are not willing to stop smoking completely. Reference to work amongst schoolchildren will be found in Part II of this report (p. 12). 9. The Mental Health Project This was an exciting new venture in health education and was the first time in Great Britain that such a large-scale effort had been launched with the express aim of spreading knowledge and understanding about mental disorders amongst the population of a county. The amount of work which fell upon the health education section was substantial, especially when it is remembered that this had to be done while at the same time keeping all the other routine tasks going. A preliminary account of the project will be found in the appendix to this report (p. 84). 10. Mass Media During the year, articles about the work of the Health Department have appeared much more frequently in the local press, and a good working relationship has been established between members of staff and the reporters. Topical items have also been presented on radio and television by the County Medical Officer of Health and his Deputy. PREVENTION OF ILLNESS, CARE AND AFTERCARE (Section 28-National Health Service Act, 1946) 1. General A wide variety of services is supplied under Section 28 of the Act, and most of these are described elsewhere in this report. A brief description will now be given of several which are not covered elsewhere. 2. Provision of nursing equipment Throughout the year this service has grown substantially. An additional 20 commodes, 20 walking aids and 15 wheel chairs have been purchased and there have been increases in stocks of all the smaller items—bed pans, aerated rubber rings, urinals, backrests and bedcradles—in order to cope with the needs of the increasingly early discharge of patients from hospital to their own homes. Two new hydraulic hoists were also purchased, making a total of 14, all of which are out on loan. These hoists make it possible for patients who might otherwise require longterm or permanent hospital care to be nursed at home. Most of the larger pieces of nursing equipment are kept and lent out centrally by the County Health Department, but district nurses also maintain small loan cupboards of their own. The service is augmented by the medical comforts depots of the Northamptonshire branches of the British Red Cross Society and the St. John Ambulance Brigade, the County Council meeting 90% of the cost of approved replacements. 3. Convalescent home treatment Convalescent treatment is provided for patients who do not require extensive medical or nursing care. Thirty-five adults and nine children were sent for treatment on the recommendations of family doctors, health visitors, welfare workers and almoners. Vacancies were found at suitable convalescent homes, mainly on the south coast, and if patients were unable to travel alone, escorts were arranged by the British Red Cross Society. 4. Chiropody service The arrangements for providing a chiropody service for old people are made through voluntary organisations. Under the scheme such organisations can reclaim 75% of their net expenditure, based on the Whitley Council scales after the patient’s contribution of 2/6 has been deducted. In January, the fees for sessional treatments were revised and chiropodists with less than three years’ experience since qualification now receive £1/15/-, whilst chiropodists with longer experience receive £2/5/-, against the previous general fee of £1/17/6 for a three-hour session. In July, the Whitley Council rates of 7/6d. for surgery treatments and 12/6d. for domiciliary treatments were increased to 9/- and 15/- respectively. As more and more old people are taking advantage of this scheme and the chiropodists’ fees have increased considerably, the demand on the voluntary organisations’ funds (i.e. 25% of the approved expenditure after deducting the patients’ contribution) has also increased. Many organisations are finding that this cost is more than they can afford and have only been able to pay their way by increasing the charge to the patients. This means that although, in theory, the elderly should be able to get treatment for 2/6d., in practice they sometimes have to pay larger sums. One hundred and seventy-four claims for grants were received from 64 organisations. The number of treatments given was approximately 17,500, and the total amount of grants paid was £3,266 compared with £2,290 in 1962. (Note : From 1st April, 1964, the County Council grant has been increased to 80%.) 5. Occupational Therapy (i) Staff During the summer Miss C. Mulhearn left to return to Liverpool, and Mrs. K. M. Kench joined the staff from Northampton General Hospital, where she had been working for three years. (ii) Mental Subnormality The occupational therapists continue to visit the only two children who do not attend training centres. Sixteen older subnormal males and females are also being visited at home. Close liaison exists with the training centres, especially the Henley Industrial Unit, and the occupational therapists and the supervisors have been able to arrange more work from firms to be done partly by the trainees at the Unit and partly by housebound patients, to their mutual advantage. (iii) Mental Illness At the end of the year, 41 patients in this category were either being visited at home or were attending social clubs or occupational therapy classes, this being a substantial increase over the figure of 28 for the previous year. The following are examples of the type of help given by the occupational therapists :— (a) A woman, aged 63 years, was discharged from St. Crispin Hospital after a stay of three months and treatment for involutional depression, after which she was visited by a mental welfare officer at home and also attended out-patient clinics. Gradually her drugs were discontinued and she was invited to attend the occupational therapy class at Desborough. She welcomes the weekly outing as she lives alone, and she has become a very keen and helpful member of the class, and can always be relied upon to assist physically disabled patients. (b) A man, aged 37 years, received psychiatric hospital treatment for pains in his side and back. On being discharged three months later he was very reluctant to go back to work and, every time it was mentioned, went to great lengths to explain about his pains. Occupational therapy was suggested, and over a period of months he has shown gradual improvement, although he is not yet back at work and still requires substantial medication. (iv) Other Patients This group includes patients suffering from tuberculosis (only six now remain on the occupational therapy register) and from a variety of other physical illnesses or injuries. Examples of such patients are : (a) A man, aged 72 and suffering from heart failure, was referred by the district nurse. He had previously had his own business of making jewellery cases and similar products in wood and leather, and seemed'interested in making the jewellery itself. This he has since done, and has been able to make some extra pocket money, the occupational therapist helping with the selling, as the patient lives in a village. (b) A man, aged 53, suffering from active pulmonary tuberculosis, has been an in-patient at a sanatorium several times during the past 20 years, the last time being two years ago. Since then he has occupied his time with various handicrafts taught by the occupational therapist. He has also done some factory outwork. He relies very much on the visits from the occupational therapist as, owing to his disease, few people go to see him. (v) Red Cross Clubs for the Disabled The St. Giles’ Club at Kettering and the Disabled Club at Corby continue to flourish. Numbers have increased, and members of the clubs have participated in outings, parties and bazaars. A new occasion at Kettering has been a church service for disabled people, at which many members in wheelchairs sat in the aisle. (vi) Occupational Therapy Classes The classes at Desborough and Thrapston continue with about the same numbers as the previous year. Permission was granted for the Women’s Voluntary Service to transport patients to classes and this has proved an invaluable help to the occupational therapist, who is now able to spend more time with the patients. The Thrapston Care Committee has continued to provide support both by way of transport and a bazaar. (vii) Holidays for Disabled People Apart from the patients referred by the County Health Department, the occupational therapists also visit about 150 substantially and permanently physically handicapped patients registered with the Welfare Department. In May, some of these patients went on a holiday, organised by the Welfare Department, to a holiday camp near Lowestoft, and two occupational therapists went as helpers. The holiday was a great success and is to be repeated in 1964. HOME HELP SERVICE (Section 29—National Health Service Act, 1946) 1. Administration The year saw the beginning of the reorganisation of the Home Help Service. This was necessary because of the very substantial amount of district nursing time being spent on purely administrative matters connected with the service, and because there had never previously been a County Home Help Organiser with a staff of assistants to help her in her work. A County Organiser was appointed on 1st April and her first two assistants were in office the following month. The populous eastern industrial belt of the county was selected for the initial transfer of field administration from district nurses to assistant home help organisers, one of whom was stationed at Kettering and the other at Wellingborough. A small part of the southern and western areas of the county was looked after by the County Organiser herself pending the appointment of a third assistant in 1964. These areas have worked satisfactorily, the population of the area controlled by the Kettering assistant organiser being rather over 100,000, with 336 patients receiving help from a total of 225 home helps. The Wellingborough assistant is responsible for a population of about 78,000, with 226 patients and 141 home helps, while the County Organiser managed to exercise personal surveillance over a population of 22,000 involving 75 patients and 65 home helps. The newly-appointed assistants spent a period of five months working under the supervision of the County Organiser, while individual towns and villages within their districts were assimilated one at a time. As each area was transferred the home helps in that particular district were visited by appointment in their own homes and the new organisation was discussed with them. By the end of September the new administration was in operation and each assistant organiser was working under her own initiative with a full case load and fully capable of dealing with new applications, assessing their requirements in the light of their particular needs. Considerable gratitude is due to the nursing staff, who spared no effort in co-operating to make the transfer of the administration in their districts a smooth and successful process. In several instances, nurses gave up their rest days in order to accompany the organiser on her visits to the home helps, and this provided a very pleasant gesture of introduction. 2. Statistics The statistics for the year have been collected in a different way from that which previously applied, so direct comparisons are difficult. The following table shows how the work was apportioned between different types of patients. Type of Case No. of Cases Percentage 1. Elderly (aged 65 or over) 1,227 84.7 2. Chronic Sick and Tuberculous 118 8.1 3. Maternity 38 2.6 4. Mentally disordered 3 0.2 5. Others 64 4.4 Total : 1,450 100% The total number of households receiving home helps showed an increase of 124 over 1962, most of this being due to the larger number of elderly people being assisted, although there was also a small rise in the number of domiciliary confinements in which the services of a home help were required. The cost of the service per 1,000 population was £140 during the financial year ended 31st March, 1963, the cost per case being £38. This is not an inexpensive service, but it must be borne in mind that, by the provision of home helps, it is often possible to avoid the substantially greater expenditure and inconvenience of admission to hospital. In the case of the elderly, the availability of home helps may make all the difference between continuing independence in their own homes and admission to residential care. 3. Visits During the year the County Home Help Organiser and her assistants made a total of 3,303 visits. The number of such visits bears no relation to the time needed in each case for, in some instances, an hour, or even longer, is necessary with a particular patient before being able adequately to assess the situation and complete the necessary formalities. 4. Training Courses Owing to the reorganisation, no training courses were held during the year. 5. General The work of the home help is to carry out ordinary household tasks, and individual instruction on the needs of each patient is given by the organiser in charge of the case. Apart from these duties the regular visits of the home help do much to give the patient a feeling of security and of not being forgotten. The hazards of the severe winter proved the value of the service and a tribute is due to home helps for continuing to carry out their duties so readily and reliably in spite of the intense cold and the difficulties this brought. From the statistics it can be seen that the proportion of home helps employed, in relation to the number of cases, tends to be high, and this involves a considerable amount of supervision. In the larger industrial urban areas this might be overcome by employing only women willing to work over ten, or possibly fifteen, hours per week. This arrangement, however, could not be applied to the rural areas, where the home help who can spare only three or four hours a week is more useful. The service will develop further in 1964, when a third assistant organiser is due to be appointed, by which time most of the work will have been taken from the district nurses, leaving them free to concentrate on their professional duties. MENTAL HEALTH 1. Introduction The year saw substantial developments in the field of mental health, the three outstanding events being the Northamptonshire Mental Health Project ; the opening of the Henley Unit at Kettering ; and the inauguration of a joint social work scheme with St. Crispin Hospital. Reference will be made to the second and third of these in this section and a full account of the Mental Health Project will be found as an appendix (p. 84). Local health authorities have from time to time been accused of dragging their feet in matters of mental health. Critics of the speed of this progress should realise that obtaining staff of the right calibre for the various posts in community care of the mentally disordered is not easy ; and that the process of providing training and residential facilities calls for the selection of suitable sites and the negotiations for their purchase before the first bricks can be laid. In Northamptonshire, 1963 was the first of a triennium which will see substantial developments in the provision of facilities for the mentally ill and mentally subnormal in the community. 2. Administration (a) Committee The membership of the Mental Health Sub-Committee remained as outlined in the report for 1962. (b) Co-ordination with other Health Services Here again there has been no substantial change since 1962, and a very satisfactory working relationship exists between the staff of the County Health Department, St. Crispin Hospital, Pewsey Hospital, and local family doctors. The new co-ordinated social work scheme is dealt with below. 3. Staff (a) Medical Dr. H. R. Simpson, who took over as Senior Assistant Medical Officer in August 1962, died in April, and reference has been made to the loss in the introductory letter to this report. The vacant post was redesignated Senior Medical Officer and was filled by Dr. W. J. McQuillan, who joined the staff on 1st October. (b) Mental Welfare Officers The approved establishment was increased by four to a total of eleven, three of the increase being a result of the co-ordinated social work scheme. At the end of the year there were three vacancies. During the summer Miss O. Towning, Dip. Soc. Studies, left to get married, and was replaced by Mrs. J. Woodford, M.A.O.T., and in December Mr. N. J. Locke joined the staff as a welfare assistant. (c) Staff Training Two mental welfare officers continued on the course at the Lanchester College of Technology, Coventry, leading to the external Diploma in Social Science of London University. Mrs. E. E. Cocker, Supervisor of the Corby Junior Training Centre, gained the Diploma for Teachers of the Mentally Handicapped, and in the autumn Mr. D. Beale, Assistant Supervisor of the male section of the Henley Industrial Unit, Kettering, commenced the course. The Supervisors at all junior and adult centres are now qualified. 4. Care of the Mentally Ill A search for a site on which to build a hostel for elderly mentally disordered patients was unsuccessful, but towards the end of the year a large detached house standing in considerable grounds near St. Crispin Hospital came on to the market and negotiations were commenced with a view to its purchase. The figures in Table III give some indication of the work of the Department in the care of the mentally ill. During 1963 the total number of cases dealt with increased by 33 and it will be seen that, with the exception of those who were admitted informally, mental welfare officers were involved in the arrangements for admission to hospital in the great majority of cases. It is also interesting to note that only eleven patients had to be admitted through the emergency procedure under Section 29 of the Mental Health Act, 1959. TABLE III 1. Number of patients notified to County Health Department : (a) Subnormal and severely subnormal (b) Mentally ill and psychopathic 2. Action Taken : Domiciliary supervision or care Admitted to hospital : (a) informally (b) under Section 25 (observation) ... (c) under Section 26 (treatment) (d) under Section 29 (emergency) (e) under section 40 (detention whilst in hospital) (f) under Section 41 (transfer) (g) under Section 60 (Court Order) (h) under Section 71 (Hospital Order) (i) under Section 72 (transfer) (j) short-term care Action pending or no action under Mental Health Act 3. Patients on leave from hospital ... Patients discharged from hospital care Patients discharged from supervision or care Died or removed from area 1963 1962 110 96 840 821 950 917 370 367 104 117 206 182 35 20 11 28 — 1 — 1 7 1 — 1 24 19 193 180 950 917 18 15 689 677 321 171 153 122 1181 985 4. Total number of admissions (including those not dealt with by County Health Department) : (a) informally ... ... ... ... ... ... ... 618 586 (b) for observation ... ... ... ... ... ... ... 214 211 (c) for treatment ... ... ... ... ... ... ... 42 23 874 820 5. Joint social work scheme with St. Crispin Hospital In November a co-ordinated social work scheme between St. Crispin Hospital and Northamptonshire County Council came into being. The hospital is a large psychiatric one of some 1,100 beds which serves the major part of the county, and negotiations were begun in 1962 with a view to providing joint social work arrangements to cover both the hospital and the county of Northamptonshire. The factors involved in deciding to establish this scheme are contained in a report which was accepted by the St. Crispin Hospital Management Committee and by Northamptonshire County Council. This reads as follows : “ (a) Introduction In the spring of 1962 a tentative scheme for co-ordinating the social work of St. Crispin Hospital and the mental health section of the Northamptonshire County Council was formulated and submitted to the medical staff of the hospital for their consideration. After discussion, substantial agreement was reached, and the matter was then placed before the Hospital Management Committee, when it was again accepted that the subject should be further explored with a view to implementing the scheme. On the County Council side, the scheme was included in the Ten-year Plan for the Development of Northamptonshire’s Health Services, and was approved in principle by the Mental Health Sub-Committee, the Health Committee and the County Council. (b) Essential Features These may be summarised as follows : (i) An adequate background of social work is essential to a psychiatric hospital. At St. Crispin Hospital this object is not at present attained because of the complete absence of social workers, for whom there are three vacancies on the establishment. (ii) The modern emphasis on community care makes similar social work facilities important to the County Council. At present there are seven mental welfare officers and authority has been obtained to appoint an eighth in the current financial year. The background of these officers is variable : one is a registered mental nurse ; one is a registered general and mental nurse, and is at present undertaking training for an external Diploma in Social Science ; two have received University social work training ; one is a State Registered Nurse ; and two are clerical, one of whom is at present undertaking the course leading to an external Diploma in Social Science, while the other, it is hoped, will in due course be accepted for the one-year Younghusband type of training. (iii) This question of training is important for the future of both the hospital and the community services. In an area such as Northamptonshire, which is a substantial distance from a University, it is particularly important to be able to send mental health staff for training, and it is therefore essential to have a staff which is large enough to permit this without crippling the service. (iv) These considerations lead to the question of whether one service designed to cover both the hospital and the community would not be better than the present two separate services, one of which is at least temporarily defunct. It seems pointless to have hospital workers spending part of their time in the community, and the community workers spending part of their time in the hospital when amalgamation is possible and would have several advantages, namely : 1. It would terminate the present artificial distinction between different types of social workers ; 2. it would give a larger staff, which should make recruitment easier, and should also facilitate sending individual members for professional training ; 3. it would provide a better service for patients and should also add interest to the work of the staff concerned by giving them equal rights in the hospital and in the community ; 4. at a later stage it should be possible to include the social work staff of the proposed hospital for the subnormal at Upton, and also social workers from the Child Guidance Clinic, thus again broadening the scope of the service. (v) For these reasons an amalgamation of services was proposed which would give a total of 11 social workers to serve the needs of St. Crispin Hospital and of the County Health Department. (c) Official Attitude Community care for all those for whom it is appropriate, is the official policy of the Ministry of Health, and co-operation between the three branches of the National Health Service is likewise constantly being stressed. Ministry of Health circular 9/59, para. 23, makes specific reference to the possible sharing of psychiatric social workers, while circular H.M. (59) 46, para. 4, similarly commends a joint arrangement. (d) Suggested Arrangements (i) Staff. At the inception of the scheme these will be 11 in number, consisting of eight at present employed by the County Council and three on the establishment of the hospital. In the light of population growth, increasing demands for services will arise in the future, and either of these last two figures may have to be increased, but this will make no difference to the scheme. Once the scheme is in operation, the combined staff will work both in the community and in the hospital. Whilst they are in the community their work will be primarily on behalf of the County Council, and whilst they are in hospital, primarily on behalf of the Hospital Management Committee, although such distinctions are, in fact, rather artificial. In the course of their hospital work, certain of the staff may have to undertake social work or to liaise with the social workers of local authorities other than Northamptonshire County Council, but this need present no problems as, in doing so, they will, in fact, be representing the interests of the hospital rather than of a local authority. (ii) Future recruitment. All new recruits must at least have University entrance qualifications. If graduates can be obtained so much the better, and in such cases the appointing committee should be authorised to consider whether they might be started with an appropriate number of increments on the approved scale. Such graduates might be attracted by the prospect of being offered psychiatric social work training, as will be described overleaf. (iii) Employing authority. The combined staff would be on the strength of the establishment of the County Medical Officer of Health. This is a logical step because the majority are already on his staff, because social work is essentially a community activity, and not least because there are certain pay advantages for social workers employed by a local health authority as distinct from a hospital. This last factor should help recruitment. The establishment of the County Health Department would therefore have to be varied by the addition of one post on APT IV* and two on the special grade for mental welfare officers. The entire cost of these last three appointments would be refunded to the County Council by St. Crispin Hospital Management Committee, and would come to between £3,760 and £4,580. (iv) Appointment of new staff. All future staff would be selected by a committee consisting of one member of the Hospital Management Committee, one member of the Mental Health Sub-Committee of the County Health Committee, the County Medical Officer of Health or his Deputy, and the Physician Superintendent of St. Crispin Hospital or his Deputy. The decision to make an appointment should be unanimous as this would prevent the appointment of any officer who is unacceptable to either side. (v) Grading of staff. The present eight County Council appointments consist of one senior mental welfare officer on grade APT IV*, and seven on the special grade. The three hospital posts should consist of one senior psychiatric social worker on APT IV* and two on the local authority special grade. A senior psychiatric social worker is particularly desirable from the point of view of in-service training for staff. The grading would require to be adjusted as and when other social work staff become fully qualified psychiatric social workers. (vi) Staff training. All members of staff would be encouraged to undertake training leading to the psychiatric social worker qualification, to the Younghusband qualification, or to some other suitable professional qualification. The staff would be large enough not to require additional expenditure on locum appointments during such training. The cost of training would be borne by the employing authorities in exchange for the usual agreement to remain in the service for at least two years after qualifying, the actual expenditure to be shared between the Hospital Management Committee and the County Council in proportion to the establishment included in the scheme from either side. Thus, initially, there would be three from the hospital establishment and eight from the County Council establishment, which would mean that for training purposes the Hospital Management Committee would pay three-elevenths of the cost and the County Council would pay eight- elevenths. This would not, in fact, involve a substantial increase in expenditure, as the main part of the training is the officer’s salary during the period in question. Note : At present two members of the County Council staff are undergoing training for the external Diploma in Social Science and the cost of this would be excluded from the scheme, as the County Council has already accepted this commitment. (vii) Duties. These would consist of social work in the hospital and in the community. Some or all of the staff would be rotated through different duties and hospital departments at a rate to be determined by the Physician Superintendent and his consultant staff. All their duties would be determined by the Consultant Psychiatrists in consultation with the County Medical Officer of Health in so far as they relate to social work. Duties as mental welfare officers would be under the direction of the County Medical Officer, and all staff should be designated as mental welfare officers. (viii) Committee. It is suggested that a joint social work committee should be established, consisting of three members of the Mental Health Sub-Committee of the County Health Committee and three members of St. Crispin Hospital Management Committee. This committee would deal with any matters arising out of the initial scheme and would present reports to its parent bodies. All day-to-day administrative matters would be dealt with by the County Medical Officer of Health and the Physician Superintendent, or by their representatives. (ix) Premises. The County Council and the hospital would each provide the appropriate offices and other accommodation without any cross-charge to the other. *(Note : The posts on APT IV were subsequently upgraded to Grade ‘ A ’.) (x) Secretarial facilities. Here again each authority would accept direct financial responsibility. Adequate secretarial facilities are essential both in St. Crispin Hospital and in the County Health Department, and arrangements would have to be made for a system of joint social case-records. (xi) Introduction of scheme. The scheme will be introduced as soon as it has been ratified by the County Council and the Hospital Management Committee, with any financial or other approval necessary from the Regional Hospital Board or the Ministry of Health. It is desirable that the first advertisements for posts under this scheme should appear, if possible, by June 1963. In that connection, the County Council have one vacancy in their present establishment which, it is suggested, should not be filled until the joint scheme can proceed.” The proposals for the joint scheme were subsequently submitted to the Ministry of Health and, after hearing their views on the subject, it was agreed that the financial basis of the agreement should be that the St. Crispin Hospital Management Committee would be responsible for refunding three-elevenths of the total salary bill of the whole staff. As has been stated, the joint scheme came into operation on 1st November, 1963, although it had not, by that time, proved possible to recruit the full staff and, in particular, the services of a senior psychiatric social worker did not, in fact, become available until 1964. It is confidently hoped that this new pattern of social work will provide a higher standard of care for those members of the community who require it than could ever be possible with the hospital and the local health authority, relying upon their own independent staffs. 6. Care of the Mentally Subnormal (a) Cases A total of 110 new patients were referred to the Department and of these, 74 were accepted for supervision. Forty names were removed from the list of those under care, 10 because they no longer required supervision, 10 because of death, and 20 on account of having left the area. The total number receiving help was approximately 550, and these were visited by mental welfare officers where particular difficulties had to be solved, and in other cases by health visitors, who paid a total of 1,058 calls. (b) Hospital Care Thirty-seven patients were admitted to psychiatric hospitals for the subnormal, 34 entering informally, and three by order of a court. Twenty-four of these patients were admitted for temporary periods, usually in order to provide a break for their parents. At the end of the year the waiting list for admission to hospital was as follows : Males Females Total Under 16 Over 16 Under 16 Over 16 Urgent 2 1 1 3 7 Non-urgent ... 5 4 2 « 3 14 Totals : 7 5 3 6 21 The total number is the same as in 1962 and it will be very pleasant when the new hospital for the subnormal at Upton is available, thereby helping with the waiting list, as well as saving relatives from the present long journey to Pewsey Hospital in Wiltshire, where most patients from Northamptonshire at present have to be accommodated. (c) Voluntary Bodies Once again the centres received generous help from the local branches of the National Society for Mentally Handicapped Children, and the continued work of local members gave much encouragement to the staff and the parents of children. (d) Training Centres The total number attending the Training Centres in December was 228, an increase of 25 from last year (see Table IV). The year’s work in all the centres was extremely satisfactory, despite the inadequacy of the accommodation except at the purpose-built premises at Kettering. In the latter part of the year tenders were invited for new centres at Corby and Northampton, and it is hoped that these buildings will be finished in time for the start of the 1964 autumn term. Negotiations for a site at Wellingborough continued satisfactorily and there is every hope that the centre and hostel will be completed during 1965. The opening of the Henley Centre at Kettering was an exciting event. This is the first purpose-built centre, with separate accommodation for subnormal children and adults, to be opened in this county. It comprises the Henley School (junior training centre) for 45 children, the Henley Industrial Unit (adult training centre) for 70 adults, and the Henley Hostel (a residential unit) for 15 male adults. The Unit is named after the late Lord Henley who was for many years chairman of the County Council and of its Health Committee. Permission to use his name was obtained from Lady Henley, who very graciously attended, with other members of her family, the opening ceremony performed by Lord Newton, Joint Parliamentary Secretary to the Ministry of Health, on 15th November. The Henley School is attractive, bright and comfortable. There is a large hall which the children use as a dining-room or as a playroom in bad weather. The Industrial Unit is built on modern factory lines and is well fitted out, with emphasis on wood-working machinery and printing on the male side. The latter industry is developing rapidly into one of the busiest sections, and the Unit now has some long-term contracts. The women are trained in domestic and laundry work and some are proving adept at garment making. Both men and women collectively carry out assembly work on plastics, although it has so far proved difficult to get a constant supply of this. Owing to initial troubles in staffing, only seven out of the fifteen beds in the hostel were occupied, but these residents have settled down well and mostly work in the Henley Industrial Unit, although one boy has secured a post in a shoe factory whilst continuing to reside in the Hostel. TABLE IV Numbers attending Training Centres Under 16 Over 16 Total Henley Industrial Unit, Males 1 30 31 Kettering Females 1 25 26 2 55 57 Henley School, Males 17 _ 17 Kettering Females 17 — 17 34 — 34 Wellingborough Junior Training Centre : Males 26 — 26 Females 11 3 14 37 3 40 Corby Junior Training Centre : Males 21 3 24 Females 18 3 21 39 6 45 Northampton Junior Training Centre : Males 25 — 25 Females : 10 7 17 35 7 42 Banbury Training Centre : Males 5 2 7 Females 1 1 2 6 3 9 Rugby Training Centre : Female 1 — 1 Total under Training : 154 74 228 (e) Industrial Advisory Board A meeting was held in October between members of the Vocational Services Committees of the Rotary Clubs from Rushden, Kettering, Wellingborough and Corby, and representatives of the County Health Department, to consider ways and means of helping the Henley Industrial Unit. On 18th November an exploratory meeting to consider the setting up of an Industrial Advisory Board was held between the Chairman of the Mental Health Sub-Committee, eight representatives of Rotary Clubs, the Supervisors of the Unit, the Deputy County Medical Officer of Health, and the Senior Medical Officer, when it was suggested that Rotary Club members could provide useful advice : (a) on suitable jobs for selected trainees ; (b) on new lines of work and methods of obtaining orders; (c) on industrial methods suitable for use in the Unit. The meeting agreed to the formation of the Henley Industrial Advisory Board which promises to be of great value in the further development of Adult Centres. LADY HENLEY, LORD NEWTON AND THE MAYOR OF KETTERING AT THE OPENING OF THE HENLEY INDUSTRIAL UNIT (see page 51) HENLEY SCHOOL (see page 51) THE HEHLEY CENTRE - KETTERING A. N. Harris, F.R.I.B.A., County Architect A CLASSROOM t BATHROOM B STORES i BEDROOM C GENERAL PURPOSE HALL K LIVING ROOM D KITCHEN L SICKROOM CHILDRENS UNIT HOSTEL HELICOPTER LANDING AT CREATON HOSPITAL (see page 57) (Photograph by courtesy of Mr. J. Dinning. Northampton) NEW ESTATE-CAR DUAL PURPOSE AMBULANCE (see page 53) AMBULANCE SERVICE (Section 27—National Health Service Act, 1946) 1. Work Undertaken The following table summarises the work of the year, and the graph (p. 56) shows the trends since the commencement of the service in 1948 : No. of patients carried Mileage A ccidents or County Council Service emergency 7,583 Others 77,642 Total 85,225 612,589 Agency services equipped with radio- telephony 1,346 15,690 17,036 152,191 Other agency services 303 194 497 7,212 Supplementary services : Hospital Car Service ... 17 2,435 2,452 56,577 Taxis 58 1,793 1,851 26,404 Total ... 9,307 97,754 107,061 854,973 Rail journeys—273 patients were conveyed by rail, involving a mileage of 21,203. It will be seen that accidents and emergencies account for only 8.6% of all patients carried, the bulk of the work being the conveyance of persons to and from out-patient departments and clinics. The number of patients carried increased by 5,989 over the 1962 figure and this is mainly due to larger numbers attending out-patient departments, and to the tendency towards earlier discharge of hospital in-patients. The need for a continued increase in the establishment of vehicles and staff is ever apparent* With present road and traffic conditions, together with the increased demands on the service* there are inevitably delays in returning morning clinic patients to their homes, and thus the vehicles involved are rarely available for use with patients on afternoon appointments. Tribute must be paid to the St. John Ambulance Brigade and the British Red Cross Society who provide escorts, often at short notice, for patients travelling by rail, and to the Women’s Voluntary Service for having maintained the hospital car service during the year. 2. Vehicles Under the ten-year development plan it was envisaged that the establishment of vehicles would need to be considerably expanded to cope with the present and anticipated future demands upon the service. Consequently it was decided to increase the fleet initially during 1963/64 by six new vehicles, of which one was to be a conventional vehicle, and the remaining five were to be of a type not previously used within the service, namely small dual-purpose vehicles of the estate- car type capable of carrying four or five sitting cases or one patient on a stretcher. These provide more comfortable transport for sitting cases, besides being fast and economical. The cars are Austin A.60 Countrymen specially converted for stretcher use and, as the photograph opposite shows, the result has been attractive as well as efficient. 3. Staff The Ambulance Sub-Committee decided that a Deputy County Ambulance Officer should be appointed in 1963, not only to take charge in the absence of the County Ambulance Officer, but also to assist him in the supervision of the routine work of the service and in maintaining the close liaison with hospitals which is so essential for efficient operation. ’ Mr. W. C. Collett, previously a Superintendent with the Wiltshire Ambulance Service, was appointed to the post on 1st July. It was also found that there was need for an intermediate rank between driver and station officer, and accordingly one leading driver was appointed for each of the main stations. The establishment of driver/attendants was increased to enable a 24-hour service to be introduced at the Kettering and Northampton stations, and to commence the implementation of the policy of providing at least one fully-manned conventional ambulance for every main station. 4. Agency Services The Brackley St. John Ambulance Brigade informed the County Council that they were unable to continue to operate the service in that area after 31st March and there was thus no option but for the Council to assume direct responsibility from that date. The Brigade ambulance was purchased by the Council and their premises leased until a new station, scheduled for 1964, could be erected. Two additional driver/attendants were appointed to man the ambulance and the Brackley station is now a sub-station of Towcester, where the agency service was taken over on 1st October. The vehicles at Towcester are garaged in ex-fire service premises as a temporary measure until such time as a new depot can be built, probably in 1965/66. The establishment of vehicles at Towcester was increased from two to three, and a station officer and four driver/attendants were appointed. The main agency services at Daventry and Islip continued to give sterling service and are fully committed every day, but the agreement with the Weldon Motor Ambulance Committee was terminated on 31st March, since the work previously undertaken by this organisation had gradually been taken over by the Council’s full-time station at Corby. The remaining smaller agency services, namely, Desborough, Irthlingborough, Raunds and Rothwell, continued to give assistance but, since they rely on volunteers to staff their ambulances, they are, in the main, able to operate only at nights and week-ends. In fact, only 497 patients were carried by these four agencies during the year, involving a mileage of 7,212. 5. Establishment The establishment and distribution of staff and vehicles is as follows : (a) Headquarters County Ambulance Officer Deputy County Ambulance Officer 2 Control Officers 3 Assistant Controllers 1 Telephonist/Clerk (b) County Council Service STAFF Station Vehicles Station Officer Leading Drivers Drivers Brackley 2 — 1 2 Corby 5 1 1 6 Kettering 5 1 1 10 Northampton 5 1 1 9 Oundle ... 2 — — 2 Rushden 3 1 — 3 Towcester 3 1 — 4 Wellingborough 4 1 1 6 Reserve vehicles 2 — — — 31 6 5 42 (c) Agency services (equipped with radio-telephony) Station Vehicles Staff Daventry 3 4 full-time drivers and volunteers Islip 1 4 Part-time and volunteers Agency services (not equipped with radio-telephony) Station Vehicles Staff Desborough 1 Volunteers Irthlingborough 1 Volunteers Raunds ... 1 Volunteers Rothwell 1 Volunteers 4 These services are supplemented by the Hospital Car Service of the Women’s Voluntary Services and by the hiring of taxis in the Brackley and Daventry areas. 6. Radio-Telephony From 1st June, 1964, all radio-telephony equipment in use must conform to the new 25 kcs. channelling requirements of the Post Office and new frequency modulation equipment was purchased and installed at a cost of approximately £7,000. 7. Annual Competition For the first time an inter-station competition was held in May. The Chairman of the Ambulance Sub-Committee presented a shield, which will be competed for annually, and the winning team came from the Wellingborough station. This team was then entered in the national competition organised annually by the National Association of Ambulance Officers, but was not successful in the regional eliminating competition, being placed fourth out of five entrants. Nevertheless considerable experience was gained, and it is hoped to achieve a higher place in future years. AMBULANCE SERVICE 8. Use of Helicopter Service During the severe weather at the beginning of the year, a request was received from a local doctor for a seriously ill patient, who lived in a remote farm in the south of the county, to be taken to hospital. The farm had been cut off by snow drifts and all attempts to reach the patient by Land Rover with the aid of a snow plough were unsuccessful. An approach was made to the Rescue Co-ordination Centre, Royal Air Force, Plymouth, and a helicopter was promptly supplied, successfully transferring the patient to hospital (see photograph at beginning of section.) INFECTIOUS DISEASES 1. Notifications The following are the diseases notified during the year, with the corresponding figures l962 for comparison. Further details are given in Table V, page 59. 1963 1962 Dysentery—Bacillary 177 72 Erysipelas ... 12 10 Food Poisoning 19 20 Infective Hepatitis 74 88 Measles 4,183 2,033 Meningococcal Infection 5 3 Ophthalmia Neonatorum — 1 Paratyphoid Fever 4 — Pneumonia 101 106 Puerperal Pyrexia 37 6 Scarlet Fever 115 161 Tuberculosis—respiratory 69 74 —other ... 14 14 Whooping Cough 274 43 Comments : Apart from a moderate incidence of measles there was no outbreak of infectious disease worthy of note. The beneficial effects of immunisation were shown by the absence of diphtheria (seventh successive year) and poliomyelitis (second successive year). 2. Vaccination and Immunisation (a) General Protection against smallpox, poliomyelitis, diphtheria, whooping cough and tetanus is available to appropriate groups of the population at the County Council clinics or through the General Practitioner Service. In addition, B.C.G. vaccination against tuberculosis is offered to all children at the age of 13 years, irrespective of whether they are attending local authority or private schools (see Part II, p. 21). Yellow fever vaccination is also available for those who require it in connection with their travel abroad, but for this service a charge is made. (b) Triple Immunisation Triple vaccine protects against diphtheria, whooping cough and tetanus, and is in use in all County Council clinics, as well as at the surgeries of the vast majority of general practitioners. The alternative use of separate vaccine against the three diseases is immunologically more desirable, but convenience of triple vaccine has made it the method of choice. A total of 3,767 children received full primary courses in the year, while the number of boosters administered was 3,213. The table on page 60 shows the number of children born at any time since 1st January, 1949 who, by 31st December, 1963, had completed a course of immunisation against diphtheria. CASES OF INFECTIOUS DISEASES TABLE V. [Final numbers after correction.) 59 Xjuno3 aAfjejjsiiniupv Jo; sp^oi 115 274 4183 177 5 101 1 III *22£ 1 05 HJ* © rH 1 Tf 1 5084 spujsia IHJinM pauiqui03 joj s[e;ox 37 182 2431 1 O CO CO 1 in co 1 1 1 I™* 1 1 t>» CO rH 1 rH 2788 1 qSnojoqSuiip^w CM l> 211 1 ” l Tf 1 1 1 1 1 1 1 II " 1 1 1 228 I C/3 H u J3^S9DMOX 14 109 453 M | 00 1 1 1 1 Nw 1 1 " 1 1 1 595 5 H C/3 a uojsdBjqx PQB 9|puno CO T* 218 iw i Tf 1 1 1 1 1 N 1 CM | 1 1 233 uojduieq}.iO{^ iO Tp tH 700 1 00 T-H 1 TH © 1 1 1 N01 II 1 CO TH 1 m 757 1 RURAI Suuaigayj 1 ^ 1 1 °° 1 1 TP 1 1 1 CO 1 MINIM CM th 1 CM r-H © XJ4U3ABQ co o CM 1 1 0 1 1 o CO 1 2 | CM 1 II 1 M~1 1 10 1 1 - 05 «*• CO q^JOAvxug C''- 05 tH 342 CldCl 1 1 1 1 1 1 CM th 1 1 o 00 CO co © 159 1 M 1 - 1 1 1 II 1 II 1 1 1 1 05 I S8I spfjqsia ueqjg pauiqiuo^ io; siejox GO CM 05 1752 1 t'- CM 00 cm %o rH 1 1 1 1 MSS I CM rH IO rH 1 in © 05 CM CM q8nojoqSui[i9j\\ t"* Tf CM 733 12 1 Tf CM 1 1111 1 O CM 1 m in CM 00 uopqsn>£ t-h in GO I 1 1 1 - 1 1 1 1 1- 1 1 1 CO TH 1 CM 120 IpMq:>og cm cm 1 1" 1 1 1 - 1 1 1 II II 1 1 1 1 1 - 00 rH C/D spune^j th CO cm 1 IS 1 1 1 1 1 II II II II CM | 1 1 in 00 H U 5 3IPunO r 1 I00 1 1 1 i 1 II II II II 1 1 1 1 05 H C/2 5 q3nojoq3uqqpi i i 1 IS 1 1 1 rH 1 II II II II ~ 1 1 1 05 CM rH URBAN qSnojoqsag iO th i r 1 ~ 1 1 1 1 1 1 1 II II 1 1 CM © f-H Xqjog CO 05 CM 263 | m th 00 1 III lrt9H 1 co »n 1 O rH 345 I J9uii^Bq uo;jng 1 1 1 1 1 1 TH 1 1 1 00 1 II 1 1 1 Ml - 1 1 1 © CM (q3nojog) Suijags>j 05 TP cm 235 IS 1 OJ rH 1 III lNMS 1 in co 1 Tf 434 1 (,oaog) sjajjag uiBqSig l l 1 12 I ~ l « 1 MIMIII Tp | 1 1 05 rH (qSnojog) Xj;uaA-Bg 00 m TH 158 1 2 1 CO 1 1 II 1 N 1 1 rl l 1 1 205 (qSnoaog) Aaijpejg CM th 1 1 M 1 1 <M 1 M CM 1 1 II N N 1 ~ l 1 CO CO in © DISEASES Scarlet Fever Whooping Cough... Acute Poliomyelitis Paralytic Non-Paralytic Measles Diphtheria Dysentery (Bacillary) Meningococcal Infection Pneumonia Smallpox Acute Encephalitis Infectious Post Infectious Enteric or Typhoid Fever Paratyphoid Fever Erysipelas... Food Poisoning Puerperal Pyrexia Ophthalmia Neonatorum Tuberculosis of the Res- piratory System Other forms of Tuberculosis Malaria Infective Hepatitis Totals Age on 31/12/1963 (i.e., born in year) Under 1 1963 1-4 1959-1962 5-9 1954-1958 10-14 1949-1953 Under 15 Total Number immunised ... 1,414 14,852 17,397 15,409 49,072 Estimated mid-year child population . 5,450 20,650 V-V-' 46,500 72,600 Estimated percentage immunised 62% 70% 67% The overall figure is 1% better than in 1962 and just over two out of every three children have been immunised against diphtheria. As has been pointed out in the past, it must be remembered that these figures are only approximations and are likely to be underestimates because some family doctors do not send in their immunisation records as they are completed, preferring to keep them until a substantial number are ready for dispatch and, furthermore, not all children born in 1963 were old enough for immunisation before the end of the year. It is still important for parents to realise the desirability of having their infants immunised. Inevitably, the very success of the immunisation campaign, which was begun in 1941, has resulted in such a dramatic drop in the number of cases that the majority of young parents have never heard of a child suffering from diphtheria. The result is that they do not appreciate the importance of having their own infants immunised and, unless they can be persuaded of the importance of immunisation, there will inevitably be a decline in the general immunity of the young population which, in turn, will lead to a recrudescence of diphtheria. (c) Smallpox As was reported in the Annual Report for 1962 the Standing Medical Advisory Committee advised the Minister of Health that routine vaccination against smallpox should preferably be carried out during the second year of life. This advice came towards the end of 1962 and the present Report deals with the first year in which the new policy was pursued. The inevitable result was that only 630 children under one year were vaccinated compared with 3,180 in 1962. In the 1-4 years age group the numbers fell to 585 in 1963 from 2,198 in 1962, the corresponding figures for the 5-15 group being 257 and 8,493. The ages of those vaccinated and the type of vaccination performed are as follows : Primary Revaccination Under 1 year 630 — 1-4 years 557 28 5-14 years 146 111 Over 15 years 547 563 Totals 1,880 702 Grand Total ... 2,582 The grand total of vaccinations performed, namely 2,582, is extremely small compared with the 33,420 of 1962, but it is important to remember that in the earlier year there had been cases of smallpox in England with an enormous demand for vaccination. It seems clear that the majority of children who attained the new recommended age for vaccination during 1963 had, in fact, been vaccinated under the earlier policy during the previous year when the percentage of infants vaccinated reached the highest level (60%) since the introduction of the National Health Service. It will therefore be at least 1964 before the position becomes stabilised with vaccination in the second year of life as the standard procedure. (d) Poliomyelitis It is now clear that vaccination against this disease has resulted in a definite fall in its incidence. During the past five years (1959-1963) there were only two cases in Northamptonshire, compared with 106 in the previous similar period (1954-1958). The progress since the commencement of the immunisation campaign can be seen from the following table : Age Under 5 5 to 9 10 to 14 15 or over Total Grand Total 1956 409 688 — — 1,097 1957 1,114 4,769 1,374 — 7,257 1958 11,667 10,407 13,348 4,775 40,197 1959 5,131 2,758 2,844 16,079 26,812 120,433* 1960 3,957 632 628 18,891 24,108 1961 3,867 972 804 5,383 11,026 1962 3,046(2,217) 251(142) 185(70) 1,456(548) 4,938(2,977) 1963 4,237(4,024) 194(185) 79(74) 488(454) 4,998(4,737) * Of this total 108,846 persons who originally received two injections have received further doses to ensure an adequate level of protection, and 29,625 children who were under 12 years of age have received booster doses. The figures in brackets show the number of persons who received oral (Sabin) vaccine, and it will be observed that, in 1963, this almost completely replaced the injected (Salic) variety. (e) Tetanus Apart from the importance of protecting children, and hence ultimately the entire population, against tetanus by means of triple antigen, there is another aspect of this mattei which should be placed on record. Casualties, and particularly road casualties, who are taken to hospital have, in the past, usually been given an injection of anti-tetanic serum. This is made from the blood of a horse which has a high immunity to tetanus, and the injection provides a temporary protection for the patient into whom it is injected. The snag about this procedure is that some people are sensitive to horse serum and may sustain severe reactions, particularly if they are subjected to repeated injections of anti-tetanic serum. At Kettering General Hospital it was decided as a matter of policy that, where a patient had required an injection of anti-tetanus serum, he should immediately be effectively immunised against tetanus by means of tetanus toxoid, which is not prepared from horse serum, and which is most unlikely to produce adverse reactions. Having been protected by means of tetanus toxoid there would be no question of his having to receive anti-tetanic serum if he were involved in any future accident. In addition the Casualty Department of Kettering General Hospital initiates the immunisation of certain casualties with tetanus toxoid even if they have not been given anti-tetanus serum. To ensure an adequate level of immunisation, patients who have received tetanus toxoid are asked to return to the hospital after six weeks for a second injection, and arrangements have now been made with the County Health Department for the follow-up of all those who fail to report back for this. During the seven months the scheme was in operation, some 1,127 persons were given two injections at the hospital, and health visitors were asked to visit a further 346 who had failed to turn up for their second injections, although it was found that 121 of them had in fact already had the injection at the hospital or from their family doctor by the time the health visitors called. This scheme is a useful combined hospital and local authority approach to a medical problem. (f) Yellow Fever Vaccination was performed on 315 persons. Of these 254 were civilians who were travelling abroad to yellow fever areas, and a fee of one guinea was charged for each vaccination. The remaining 61 were military personnel. 3. Tuberculosis (a) Incidence and Mortality At the end of the year 1,041 cases of respiratory tuberculosis and 326 cases of non-respiratory tuberculosis remained on the registers, these figures being 148 and 22 respectively lower than in 1962. There were 69 primary notifications of respiratory and 14 of non-respiratory disease. Twenty-five new cases were transferred from other areas. Two notifications were posthumous. Table V, page 59, shows the number of cases notified in each district. Deaths from respiratory tuberculosis numbered 10, and from non-respiratory disease, two. There were thus 12 deaths from all forms of tuberculosis, compared with 15 in 1962. The mortality rate was 3.9 per 100,000, the rate for the combined urban districts being 2.4, and for the combined rural districts 5.9. The annual tuberculosis mortality rates from 1912 are shown in graph form on page 66. (b) Mass Radiography The No. 1 Mass Radiography Unit of the Oxford Regional Hospital Board undertook its customary surveys throughout the county, and a total of 14,069 persons were X-rayed. Of these, only 16 had newly-discovered significant pulmonary tuberculosis, giving a rate of 1.1 per 1,000 examinations. (c) B.C.G. Vaccination of Schoolchildren This subject is dealt with in Part II (page 21). (d) Extra Nourishment Grants Grants of free milk varying from one to three pints per day were made to 12 patients, most of whom lived in areas not covered by Voluntary Care Committees. Such grants are given on the recommendation of the Chest Physician without regard to the family income. (e) Reports of Chest Physicians The following comments are based on the annual report on the chest service of the Kettering Hospital Management Committee area prepared by Dr. O. E. Fisher, consultant chest physician. Despite the fact that the reorganisation of the chest service two years ago reduced the population served by about 50,000, admissions to hospitals have continued to rise, and 286 patients were admitted compared with 261 in 1962. Almost three-quarters of the patients have been male and, in the past 10 years, admissions have increased from 150 to 286, whilst the proportion of tuberculosis admissions has declined from 80% to only 22%. There was a total of 62 tuberculous admissions compared with 65 in 1962 and, of the former number, 52 were cases of respiratory disease. Forty-nine new cases of lung cancer were admitted compared with 53 in 1962 and, for the first time, chronic bronchitis has become the commonest cause of admission, accounting for 64 cases compared with 43 the previous year. Chest Clinic statistics Total attendances ... ... ... ... ... ... ... ... 4,807 New cases (excluding contacts) ... ... ... ... ... ... ... 1,555 Active respiratory tuberculosis, new cases ... ... ... ... ... 53 Active non-respiratory tuberculosis, new cases ... ... ... ... ... 14 Inactive respiratory tuberculosis, new cases ... ... ... ... ... 349 Active respiratory tuberculosis relapses ... ... ... ... ... ... 6 Contacts examined for first time ... ... ... ... ... ... ... 537 Contacts diagnosed as suffering from respiratory tuberculosis ... ... ... ... 4 Contacts diagnosed as suffering from non-respiratory tuberculosis ... ... ... Nil Classification of 57 new cases of respiratory tuberculosis (a) Tubercle bacilli not isolated ... ... ... ... 21 (b) Tubercle bacilli isolated ... ... ... ... 36 Number marked off clinic register as recovered (respiratory and non-respiratory) ... 149 Total number of cases on tuberculosis clinic register at 31/12/63 ... ... ... 498 Number of cases of positive sputum during the year, excluding new cases ... ... 17 The steady decline in new cases of respiratory tuberculosis continues and notifications have fallen from 150 in 1954 to 57 in 1963. New cases of non-respiratory tuberculosis referred to the clinics show no reduction, but this is probably because consultants in other specialties, with the exception of orthopaedics, now refer all non-respiratory cases to the chest department for treatment. The total number of new cases of tuberculosis diagnosed at chest clinics remained the same as in the previous year and the progressive decline which has taken place during the past 10 years is shown in the following table. New cases of tuberculosis diagnosed at chest clinic (Kettering Hospital Management Committee)—10-y ear-period, 1954-1963 Respiratory Tuberculosis Non - Respi ratory T uberculosis Total 1954 150 3 153 1955 101 15 116 1956 95 13 108 1957 118 12 130 1958 102 16 118 1959 lb 16 91 1960 78 22 100 1961 51 15 66 1962 63 8 71 1963 57 14 71 Deaths Deaths from tuberculosis have now reached very small proportions and have long since ceased to be a useful index of the amount of tuberculosis in the community. During the year the names of 16 patients, 15 respiratory and 1 non-respiratory, were removed from the clinic register on account of death. On examining these deaths more closely the precise causes were as follows : Cardiovascular disease ... ... ... ... 7 Pneumonia ... ... ... ... ... 1 Cancer of bronchus ... ... ... ... ... 1 Haematemesis ... ... ... ... ... 1 Senile degeneration ... ... ... ... ... 1 Suicide ... ... ... ... ... ... 1 Cause unknown ... ... ... ... ... 1 Pulmonary thrombosis and respiratory tuberculosis ... 1 Constrictive pericarditis and tuberculous empyema ... 1 Uraemia, diabetes, and respiratory tuberculosis ... 1 Thus out of a population of 200,000 the number of deaths amongst notified cases in which active tuberculosis was still present reached the very low level of 3, and in only one case was the cause of death primarily attributable to tuberculosis. Contact examination and B.C.G. vaccination All known contacts are asked to attend chest clinics or the 100 mm. mobile unit for chest X-ray, and for tuberculin testing in persons under the age of 35 years. Tuberculin negative reactors are given B.C.G. The extent of this work is as follows : Respiratory Non-Respiratory Cases on Tuberculosis Tuberculosis Register Contacts B.C.G. Contacts Contacts at end of Year Examined Vaccinations Total only Total only Year 1958 851 411 102 8 16 Nil 905 1959 773 396 75 4 16 1 867 1960 722 477 78 3 22 1 833 1961 709 507 51 4 15 1 704 1962 580 355 63 12 8 Nil 662 1963 537 395 57 4 14 Nil 498 In addition the following factory and school contacts were examined by the mobile X-ray unit : Number examined Respiratory tuberculosis Factory contacts 740 1 School contacts 161 Nil Mass Radiography The No. 1 (Northants) Mass Radiography Unit operates two 100 mm. units, one to carry out routine community surveys, whilst the second carries out a regular weekly programme examining general practitioner referrals as well as special request surveys such as factory contacts and positive tuberculin reactors in school children. The following table gives the number of persons examined and the number of cases of tuberculosis so far discovered by the two units. Community G.P. Referrals and Surveys Special Groups Persons X-rayed 9,750 4,319 Referred to Chest Clinics 53 166 Diagnosed active respiratory tuberculosis ... 4 12 Not yet diagnosed 10 11 Active respiratory tuberculosis rate per 1,000 0.41 2.78 It is noteworthy that the pick-up rate for abnormalities is almost seven times greater from the general practitioner referral unit than from the conventional unit. These figures confirm the trend of falling yields from conventional mass radiography noted in last year’s report, the pick-up rate for active tuberculosis having declined from 5.11 per 1,000 examined in 1946 to 0.44 per 1,000 in 1962. In fact, repeat community surveys in Northamptonshire now produce such low yields that it has been decided in future to concentrate all the mass radiography services on more selective methods of case finding. Non-Tuberculosis Chest Disease The majority of the work carried out by the chest service continues to be concerned with the investigation and treatment of non-tuberculosis respiratory disease. The following table illustrates the varied conditions which are now being dealt with : Bronchial cancer ... ... ... ... ... 54 Other malignant neoplasms... ... ... ... 7 Simple tumours and cysts ... ... ... 4 Chronic bronchitis and emphysema including cor pulmonale 155 Acute respiratory infections, including pneumonia ... 180 Asthma ... ... ... ... ... ... 24 Spontaneous pneumothorax ... ... ... 6 Non-tuberculous effusions, including empyema ... 14 Bronchiectasis ... ... ... ... ... 40 Sarcoidosis ... ... ... ... ... 5 Pneumoconiosis ... ... ... ... ... 4 Haemoptysis (unexplained) ... ... ... 7 Congenital heart disease ... ... ... ... 5 Acquired heart disease ... ... ... ... 31 Miscellaneous ... ... ... ... ... 90 No abnormality detected ... ... ... ... 1,029 As in the previous year’s report chronic bronchitis and lung cancer figure prominently in the work of chest clinics and, as treatment has little to offer in either condition, the only solution lies in prevention both of cigarette smoking and of atmospheric pollution. The following report is based on notes which have been supplied by Dr. N. O’Leary on her work in the south-west part of the county. There are 208 names on the tuberculosis registers of the chest clinics of Daventry, Northampton and Creaton Hospital. These patients live in the rural and urban areas of Daventry, Northampton, Towcester and Brixworth. Of the patients 114 are men, 93 women, and one is a child. There are five patients with non-respiratory tuberculosis, all of whom are women, and appear to be quiescent. Of the 208 patients on the registers, 32 men and 27 women are under close supervision, being seen every three months or oftener. Practically all the remainder are seen either once or twice a year. There were nine new cases of pulmonary tuberculosis during the year, comprising five men and four women. Of these, all the men and two of the women had positive sputums and all nine were admitted to hospital for assessment and treatment. Two men died in hospital ; one man and two women were still in hospital at the end of the year ; and two men and two women were discharged to continue treatment at home. Apart from new cases there were five patients with intermittently positive sputum. Of these, three harbour organisms resistant to one or more of the major anti-tuberculous drugs and one man and one woman have fully sensitive organisms, but owing to toxic effect TUBERCULOSIS MORTALITY RATES PER 100,000 POPULATION cannot tolerate anti-tuberculous drugs. Because of accompanying respiratory disability which limits their activities, it is not considered that these cases constitute serious threats to their environment. There were 213 new contacts examined during the year but no case of tuberculosis was found amongst them and there was a total of 1,986 attendances at the clinics. The picture of tuberculosis in this area is of a still declining disease, affecting chiefly the middle aged and elderly. 4. Venereal Disease Clinics for the diagnosis and treatment of venereal diseases are held as follows : Kettering, St. Mary’s Hospital Females Tuesday 5.30-6.30 p.m. Males Tuesday 6.30-7.30 p.m. Northampton General Hospital Females Monday 5.00-6.30 p.m. Friday 2.30-4.00 p.m. Males Wednesday 2.00-3.00 p.m. Friday 5.00-6.30 p.m. Peterborough Memorial Hospital Females Tuesday 10.30-12 noon Thursday 4.30-6.30 p.m. Males Monday 4.30-6.00 p.m. Wednesday 5.30-7.00 p.m. The numbers of county patients attending for the first time were : Other Syphilis Gonorrhoea Conditions St. Mary’s Hospital, Kettering . 2 6 41 Northampton General Hospital. 6 13 65 Peterborough Memorial Hospital . 1 6 Total . 8 20 112 These figures are somewhat higher than were those for 1962, when a total of 99 new cases attended clinics. As is explained in the section on health visiting (page 31), arrangements were made during the year for the part-time attachment of a health visitor to the venereal disease clinic at Northampton General Hospital in order to carry out after-care work, and a successful beginning was made on this task. LIAISON ARRANGEMENTS The importance of adequate linkage between the three branches of the National Health Service cannot be emphasised too strongly and it is one of the prime duties of the public health service to foster such co-operation. A brief account will be given of some of this liaison work, not only with the hospital and general practitioner services, but also with voluntary bodies and with other departments of the County Council. 1. Hospitals The County Medical Officer of Health continues as a member of the Management Committees of the St. Crispin and Northampton General Hospitals, as well as being a Governor of the United Oxford Hospitals. Further co-ordination is secured through the Medical Officers of Health Liaison Committee, at which representatives of the local health authorities in the Oxford Hospital Region meet with the senior staff of the Regional Hospital Board and a representative of the Ministry of Health in order to discuss matters of common interest. In addition to these formal arrangements, a wide variety of members of the staff of the County Health Department come into contact with hospital staff in the course of their duties and references to some of these contacts wall be found throughout this report. 2. General Practitioners A wide range of the staff are in regular touch with family doctors throughout the county and the County Medical Officer of Health is a member of the Local Medical Committee through which there is most useful liaison with representatives of the general practitioners. In March, an informal tea party was arranged at Corby to which were invited all local general practitioners, midwives, nurses, and health visitors. This occasion provided a useful opportunity for discussions on matters of common interest. A start was made on the preparation of a booklet describing the range of services provided by the County Health Department, as well as by several other organisations, with a view to its publication in 1964. A further step designed to foster closer understanding between the County Health Department and general practitioners was the distribution of “ The Health of Northamptonshire in 1962 ” to all family doctors. A card was sent with each copy asking if the doctor would like to receive further issues and, of the 175 which were sent, 58 were returned with an affirmative reply. As some of these related to doctors in partnership, it would appear that at least half the general practitioners in the county found the reports to be of interest. 3. Voluntary Organisations Individual members of the Health Department staff serve on the committees of a wide variety of voluntary organisations and, indeed, it is only through the help of some of these that it is possible to carry out all the statutory duties which are placed upon the Health Committee. Once again reference to certain of the organisations concerned has been made throughout the text of this report. 4. Other Departments of the County Council In “ The Health of Northamptonshire in 1962 ” a description was given of some of the work carried out by the County Health Department on behalf of or in conjunction with the Children’s ; Licensing ; Civil Defence ; and County Planning Departments, as well as of the arrangements for assisting in maintaining the health and welfare of the County Council staff. The outstanding new development of 1963 was in connection with the liaison arrangements between the County Health and Welfare Departments. Joint Sub-Committee of the County Health and Welfare Committees This sub-committee met for the first time in September, 1963. It arose from various considerations which were put forward in the 10-year plan for the development of the county’s health services, when it was pointed out that, as far as those suffering from physical handicap ; blindness ; partial blindness ; and deafness were concerned, both the Health and Welfare Departments were involved, the dividing line between their responsibilities being frequently vague or, indeed, non-existent. It was also indicated that one of the biggest health problems of the next decade would be the provision of adequate care for the elderly, and that in this field there was again a great overlap of interest between the two Departments. When the mentally disordered come to be considered there is an even more complex situation, as responsibility is split between general practitioners and the hospitals on the one hand and the County Health and Welfare Departments on the other. There are also matters of common interest concerning the staffs of both Departments, as the employment of professionally trained social workers becomes commoner in both. There is already a co-operative scheme involving the Health Department’s two occupational therapists, who are employed as Mental Welfare Officer/Craft Instructors, and the Welfare Department’s two Welfare Officer/Craft Instructors, and this has proved beneficial alike to patients and to the County Health and Welfare Committees. It was in the light of these and other considerations that it was suggested that a Joint Sub-Committee of the Health and Welfare Committees should be established to consider all matters of common interest. Some idea of the scope of the suggestions considered by the new Sub-Committee may be obtained from the items on its first agenda which included, arrangements for the discharge of patients from hospital to community care ; welfare arrangements for the elderly ; the training of social work staff; the future provision of sheltered workshops ; the co-ordination of certain case records ; the arrangement of contracts for the supply of provisions to the Henley Hostel; and several other matters. RESEARCH, PUBLICATIONS AND POSTGRADUATE VISITORS 1. Research The major item of research during the year was the survey of public attitudes to mental health which was undertaken as a preliminary to the Mental Health Project (see appendix p. 84). A further similar study was carried out in 1964 at the conclusion of the health education part of the Project and it is hoped that the results of these two studies will prove interesting once they have been analysed. In that connection it is worthy of note that the analysis is being undertaken with the assistance of the staff of the County Treasurer’s Department, using the electronic computer which is available there. This may well be a prelude to the further use of data processing equipment by the Health Department. 2. Publications The following publications appeared during the year : “ Diabetic clinics and the general practitioner ”—Reid, J. J. A., and Redhead, I. H. (1963), Lancet, 1 ; 159. “ Some public health aspects of diabetes mellitus ”—Reid, J. J. A. (1963), Public Health, 77; 145. “ Diabetes : A community health problem. Future policy and the local health authority ” —Reid, J. J. A. (1963). Proceedings of the Royal Society for the Promotion of Health, 1963 Congress. “ Diabetic schoolchildren ”—Reid, J. J. A. (1963), Balance, 10 ; 372. “ Mental health education—the Northamptonshire Project, 1963 ”—Gatherer, A. (1963), District Nursing, 6 ; 148. 3. Post-graduate Visitors A group of three doctors studying for the post-graduate Diploma in Public Health at the London School of Hygiene and Tropical Medicine visited the Department for a week’s intensive study of field work in March. Two of these visitors were from Norway and one was from a neighbouring county where he was participating in a sponsored D.P.H. course similar to that provided by Northamptonshire County Council. Amongst a wide variety of other visitors were doctors and public health workers from Korea, Ghana, Japan, Argentina, and the West Indies. Such visitors are particularly welcome as they act as a stimulus to the County Health Department staff, as well as providing a valuable source of critical evaluation of various aspects of the Department’s routine work. FOOD AND DRUGS The report of the Chief Inspector of Food and Drugs (F. J. Evans, D.P.A., M.I.W.M.A.) on the work done under the Food and Drugs Act, 1955, the Labelling of Food Order, 1953, and related legislation, for the year ended 31st December, 1963. 1. Summary of Samples Total Number taken Examined in Department Sent to Public Analyst Reported Against Milk 928 610 318 14 Channel Island Milk 95 — 95 1 Condensed Milk 2 — 2 — Evaporated Milk 1 — 1 — Cream 21 1 20 2 Ice Cream 25 — 25 Butter 21 — 21 — Margarine 13 — 13 — Lard, Dripping and Oil 17 5 12 — Cheese and Cheese Spread 19 2 17 — Soup 11 2 9 2 Fish Products 33 15 18 2 Meat Products 64 13 51 1 Sausages and Sausagemeat 67 1 66 — Potatoes 7 — 7 — Fruit and Vegetables ... 67 27 40 2 Flour Confectionery 53 18 35 1 Jam, Marmalade, etc. ... 26 2 24 2 Soft Drinks ... 54 2 52 5 Beverages 10 3 7 — Wines and Spirits, etc. 92 30 62 6 Meat and Fish Pastes ... 16 — 16 — Sweets and Chocolate ... 23 6 17 — Medicines 15 — 15 — Condiments, etc. 13 4 9 — Pork Pies, Pasties, etc. 64 55 9 — Bread and Butter 3 — 3 — Suet 3 — 3 — Vinegar 4 — 4 — Table Jelly 8 3 5 — Yoghourt 1 — 1 — Potato Crisps 9 2 7 1 Ground Almonds 1 — 1 — Totals ... 1,786 801 985 39 (For the year 1962 the total number of samples was 1,742) 985 samples were submitted to the Public Analyst during the year and although this figure showed a slight decrease compared with that for the previous year (1,032) an increase in the number of samples examined in the department brought the total number of samples dealt with to a new record. Only 39 samples were reported against, which represents a proportion of 4.0 percent. For comparison, the' percentage of unsatisfactory samples for the previous five years was as follows : ^ 1958 1959 1960 1961 1962 1963 5.2% 4.5% 4.8% 3.5% 4.1% 4.0% 2. Milk The Public Analyst (E. Voelcker, A.R.C.S., F.R.I.C.) reported that of the 413 samples of milk which were submitted to him for analysis, 15 were either adulterated or below standard. As was the case for last year, only two of the samples were adulterated with water and, to repeat last year’s statement, this is one of the lowest figures in the records of the department. The first of the samples containing added water was taken informally during routine sampling at the premises of a large dairy. It was sent to the Public Analyst for a freezing point test when it was found to contain a proportion of solids-not-fat below the normal standard. Although formal samples were taken the next day from the farm of the producer, and although samples have been taken at regular intervals since, no trace of water has been found, and its introduction into the original sample must have been due to an unrepeated accident. The second sample reported to contain added water was also an informal one, taken from a cafe at a newly- opened youth centre where milk was heated by steam injection in ignorance of the fact that the condensing steam added water to the milk. A formal warning was given and an undertaking was received that milk would not be heated in this manner in future. There is no doubt that the decrease in the number of samples reported to be below standard in fat, or in solids-not-fat, is due to the modern trend towards fewer and bigger herds and to fewer and bigger dairies. There is shown in the Milk Marketing Board records for Northamptonshire, for example, an annual decrease in the number of registered milk producers of the order of 8%, although the estimated total of sales of milk off farms for 1963 showed very little change when compared with the total for 1962. The steady decrease in the number of producer- retailers results in an increasing concentration of milk handling and distribution in the hands of the few large dairies. Thirteen samples were found to be below standard in fat, and two of these were also deficient in solids-not-fat, but these, on the freezing point test, were found to be free from added water. Where necessary, follow-up samples were taken, and in all cases the producers were advised of samples found to be below standard, and they agreed to take whatever action was recommended to improve the methods used in the handling of the milk and, where helpful, offered to seek advice with regard to improving the quality. It is convenient to assess the standard of the milk on sale in the County by averaging the results of the samples taken during the year. These figures show a remarkable consistency over the years and the table below gives the percentages for this year compared with the preceding four years. Milk Channel Island Milk Fat Solids-not-Fat Fat Solids-not-F at 1963 ... 3.59 8.90 4.56 9.22 1962 ... 3.58 8.93 4.52 9.23 1961 ... 3.58 8.92 4.55 9.25 1960 ... 3.53 8.89 4.48 9.27 1959 ... 3.53 8.75 4.49 9.07 In addition to the milk samples submitted to the Public Analyst, informal samples are taken and tested in the department’s own laboratory. It would not be possible to take legal action on the results of an informal analysis of this nature, but-the information received from such testing serves mainly as a useful guide to the need for formal sampling. These samples are usually taken from the larger dairies, as a supplement to formal sampling, and at farms, where the results are of value both to the producer and to the department in following up indications of poor quality milk. 610 informal samples were tested last year (compared with 591 the previous year) and the averages of the fat content (3.6%) and of the solids-not-fat content (8.7%) are very similar to those shown in the table above, in spite of a tendency to select for sampling milk more likely to be of doubtful quality. Included in this total are 111 samples taken from milk supplied to schools. All were of satisfactory quality, giving an average content of 3.54 per cent fat (3.59) and 8.72 per cent solids-not-fat (8.75). The figures given in brackets are those for last year. 3. Samples other than Milk 763 samples were examined during the year and 572 of these were sent for analysis to the Public Analyst. He reported that 24 samples were unsatisfactory. One of the incorrect samples consisted of a drink which might properly be described as a “ non-excisable beverage ”, and which was sold in a bottle which was similar in size, shape, colour and labelling to an ordinary lager beer of the type produced by the manufacturers. The label contained no information to suggest that the drink contained less than one-third ol the proof spirit normally found in lager and legal proceedings were successfully taken for giving a label which was calculated to mislead as to the quality of the drink. The firm was, in addition, convicted for describing this beverage as “ non-alcoholic ” when it contained an appreciable proof spirit content. It was necessary to warn several manufacturers for the application of the term “ nonalcoholic ” to drinks which contained less than 2 per cent proof spirit when the proper description should have been “ non-excisable ”. These warnings served to indicate an increase in the production of tinned and bottled drinks for sale generally in unlicensed shops, but with proof spirit contents only fractionally less than 2 per cent. This is the limit of the Customs and Excise Act, 1952, which would restrict the sale to licensed premises. These non-excisable drinks need have no indication of their proof spirit content and need provide no warning to prevent consumption by very young children. This problem was the subject of a special report to the County Council, who suggested to the County Councils Association that it should request the Food Standards Committee to consider amendment of the Labelling of Food Order, 1953, to require that all beverages which contained between 0.5 per cent and 2.0 per cent proof spirit should be clearly marked with a statement of the proof spirit content. A sample described as Indian Chicken Curry was found to consist only of chicken giblets, including the gizzard, in a curry sauce. It had been handed in by a housewife whose husband had found that the meat it contained was too tough to eat. Since this was a rather expensive product which was described as being prepared by a famous Indian chef using only the finest genuine curry and other ingredients, legal proceedings were taken against the manufacturers for the sale of a food not of the quality demanded by the purchaser. In one case a sample was submitted to the Public Analyst at the request of the Chief Public Health Inspector for the Kettering Corporation. This consisted of a liquid which had been supplied to a woman at a public house when she asked for a bottle of “ spruce ”, the local name used for lemonade and similar drinks. It was supplied in a bottle labelled “ Sparkling Orange Crush ”, but was found to be a solution of sodium hypochlorate for use as a domestic bleach. The woman had drunk some of this liquid and as a result had been in hospital for some days. The Kettering Corporation prosecuted the landlord of the public house, who was convicted and fined £30 with £12/10/- costs. One sample described as ‘‘Top of the Milk ” was found by the Public Analyst to be sterilised cream containing only 18.67 per cent of milk fat, whereas the standard for sterilised cream required it to contain 23 per cent of fat. The sellers claimed that although the name of the product suggested that it was cream, they did not need to comply with the standard if they did not label it as cream. A number of food and drugs authorities have taken up this point with the firm concerned and the matter is still under consideration. One of the processes used in the production of certain types of potato crisps results in the washing away of a small amount of starch from the cut surfaces of the crisps. The reduction in the starch content of the crisps, as a result of this, is, however, so small that it does not exceed the normal variation in the starch content of potatoes generally. One sample of such potato crisps described as being “ starch reduced ” was the subject of a report by the Public Analyst that the claim was quite unjustified. When the manufacturer was shown figures for the normal variation in the starch content of potatoes, and also of the results of the analysis of potato crisps produced without this washing process, he agreed that the degree of starch reduction did not justify his claim, and undertook to remove this from the packet immediately. Following the issue by the Food Standards Committee of its “ Report on Canned Meat " and “ Report on Meat Pies ”, the Minister of Agriculture, Fisheries and Food has indicated that he proposes to make regulations prescribing the composition and labelling of canned meat products and of meat pies. Legislation has become increasingly necessary with the wide variety of tinned meats on sale and there have been particular difficulties during the year in ensuring that certain imported tinned poultry or meat products contained an adequate proportion of meat. Difficulty is also being experienced in the naming of the various types of meat products and it would be extremely helpful if some Code of Practice could be developed to provide for the proper description of the various foods. Comminuted meat products made up into the shape of cutlets and steaks and described, generally, as “ cutlettes ”, or as " steakettes ” or " steak- lettes ”, normally contain almost 100 per cent of meat, whereas food sold as hamburgers ” or " beefburgers ” very often contains a reasonable proportion of starch filler and may have a meat content of only about 75 to 80 per cent. Another group, consisting mainly of foods with names like " rissoles ” or ‘‘ croquettes ” may have a starch content of 50 per cent or more. One sample described as “ Shrimp Croquettes ” was reported by the Analyst to contain only 4 per cent of shrimp, and the manufacturer was informed that this was regarded as a misleading description. Although the proposal to provide standards for canned meat and meat pies is viewed with approval, there is no sign that, as far as this County is concerned, there is any need for a standard for the meat content of sausages and sausagemeat. Pork sausages should contain 65 per cent of meat and the 64 samples which were taken in the County last year had meat contents ranging from 65 per cent to 82 per cent, with an average of 69.6 per cent. (The average for last year was 70.7 per cent.) Beef sausages, which should contain at least 50 per cent of meat, gave an average of 52 per cent, compared with last year’s figure of 53.6 per cent. Pork pies, meat pies and sausage rolls have been examined for meat content and the usual wide variations were found, mainly directly related to the price of the article. In one case, samples of sausage rolls were found to have so low a percentage of meat, when compared with the average, that the maker was advised of this, and he took immediate steps to improve the meat content. The average meat content of the pork pies examined was 31.95 per cent, which compares well with the standard of 25 per cent suggested for the new regulations. A number of claims were made for the presence of vitamin C in foods such as Blackcurrant Jam, Blackcurrant Syrup, Blackcurrant Drink, and similar fruit products, without the amount present being stated in the manner required by the Labelling of Food Order, 1953. In one or two cases there was not sufficient vitamin C present to justify the claims made on the label. In all cases the manufacturers agreed to correct the labels used on their products. A sample of Stoneground Wholemeal Flour was obtained from a supermarket and the label on the bag from which the sample was taken stated that two loaves made from this flour were as nourishing as three loaves made from ordinary white or brown flour. The Public Analyst reported that this claim was quite untrue, and also that inaccurate claims were made for the presence of minerals and vitamin B1 which were not set out in the manner required by the Labelling of Food Order. The managing director of the firm concerned admitted that they had not checked the claims made on the bags since, some six or seven months previously, they had taken over the mill producing the flour. He agreed that the claims were not justified and undertook to have bags re-printed immediately. A wide range of foods were found to have incorrect or incomplete descriptions, or failed to comply with the labelling requirements in various respects. The department is being asked, to an increasing extent, for advice by manufacturers on labelling problems. The department is very happy to give whatever advice is possible, particularly to local manufacturers, since it is almost impossible to obtain this information from any other source. Enquiries from all over the country, on specific items, have been dealt with as fully as possible, since this is the best way of ensuring compliance with the complicated provisions of the many Orders and Regulations. 4. The Preservatives in Food Regulations, 1962 The Public Analyst reported that he had examined the samples submitted to him for the presence of preservatives. One sample of Shrimp Salad was found to contain 258 parts per million of Benzoic Acid, a preservative which is not permitted in a food of this type. Enquiries showed that the firm which imported the Shrimp Salad from Sweden had been warned of the presence of this prohibited preservative by another food and drugs authority some six months previously. Since no action had been taken to recall the affected stocks, legal proceedings were taken against the firm concerned. Two samples of imported prunes were labelled as containing sorbic acid used as a preservative, and the Public Analyst found amounts of up to 525 parts per million of sorbic acid in the samples submitted to him. The importers claimed that the Ministry of Agriculture, Fisheries and Food was considering the advisability of including sorbic acid as one of the preservatives permitted for use in prunes. The Ministry, however, said that there was no intention at present to make any amendment to the present Regulations for the wider use of sorbic acid in food. The importers were therefore warned that legal proceedings would be likely if any further stocks were found on sale ; they agreed to withdraw all remaining stocks and to ensure that prunes with sorbic acid would not be imported in future. None of the remaining samples contained any prohibited preservative, and in all cases where a permitted preservative was used, the amount did not exceed the prescribed maximum. 5. Legal Proceedings Details of legal proceedings taken during the year are set out below : Fines Costs £ s. d. £ s. d. 1. Brewery Agents Giving with a bottled drink a Food and Drugs Act, label which was misleading as to its quality 1955, Section 6(1) ... 25 0 0 2. Brewery Agents Publishing an advertisement Food and Drugs Act, Absolute which falsely described a drink as non-alcoholic 1955, Section 6 (2) discharge 27 18 6 3. Food Importers Selling shrimp salad containing Preservatives in Food benzoic acid, a prohibited Regulations, 1962... 20 0 0 10 10 0 preservative ... Regulation 8. Food and Drugs Act, 1955, Section 113 ... 4. Food Selling a tin of Indian Chicken Food and Drugs Act, Manufacturers Curry not of the quality 1955, Sections 2 and manded 113. 10 0 0 11 15 0 £55 0 0 £50 3 6 Total Fines and Costs—£105 3s. 6d. ENVIRONMENTAL HYGIENE 1. Water Supply and Sewage Disposal (a) Approval in Principle The following schemes were submitted to the County Council in accordance with the provisions of the Rural Water Supplies and Sewerage Acts, 1944-1951, and were approved in principle. A uthority Brackiey R.D.C. Brixworth R.D.C. Daventry R.D.C. Towcester R.D.C. Scheme Estimated Cost Eydon sewage disposal works £19,469 Main drainage of Crowfield £2,300 Extensions to Hollowell sewage disposal works £25,800 Charwelton sewerage and sewage disposal £21,750 Norton sewerage and sewage disposal £22,100 (revised scheme—original estimate at cost of £12,800 approved in principle in February 1957) Gayton sewerage and sewage disposal—Extension £4,677 (b) Contributions Made The County Council agreed to make the following contributions in accordance with the approved scale. Estimated Ministry of Housing and County Council’s Contribution A uthority Scheme Cost Local Government Grant (Capital Sum) Daventry R.D.C. Charwelton sewerage and sewage disposal £21,750 Half-yearly payment of £87 for 30 years £2,375 Crick sewerage— Watford Road Extension £1,500 £239 (capital sum) £239 Everdon sewerage £43,000 Half-yearly payment of £322 for 30 years £8.573 Bucks. Water Board Water main extension, Wappenham Road, Syresham £3,080 £315 (capital sum) £315 Mid-Northants Water Board Agricultural main at Lamport £2,310 £105 (capital sum) £105 (c) Revised Contributions The County Council revised its contributions in the light of revisions made by the Ministry of Housing and Local Government, as follows : A uthority Scheme Brixworth Moulton village R.D.C. sewerage and sewage disposal Estimated Cost Original Revised £49,600 £52,688 Ministry of Housing and County Council's Local Government Grant Contribution Original Revised Original Revised £22,000 (capital sum) Half-yearly payment of £700 for 30 years Annual payment of £927/5/- for 30 years Annual payment of £1,055 for for 30 years Ministry of Housing County Council's and contribution Authority Scheme Estimated Cost Local Government Grant (capital sum) Original Revised Original Revised Original Revised Oundle and Chelveston-cum- £8,336 £7,808 £1,600 £1,500 Yearly Yearly Thrapston Caldecott (capital (capital payment of payment of R.D.C. water sum) sum) £95 for £89 for 30 years 30 years Mid-Northants Southern £404,160 £522,035 £170,000 Half-yearly £134,720 £174,012 Water Area (capital payment of (capital (capital Board water sum) £6,650 for 30 years sum) sum) Mid-Northants Western £142,000 £193,972 £50,000 Half-yearly Yearly £64,657 Water Area (capital payment of payment of (capital Board water sum) £2,050 for £2,737/5/- sum) 30 years for 30 years 2. Rural Housing The activities of rural housing authorities during 1963 are summarised in this table which also indicates their achievements in the entire post-war period. Population Est. 1962 Under construction at 31/12/63* Completed up to 31/12/62 Completed during 1963* Total post-war houses completed at 31/12/63 Post-war houses completed per 1,000 population Brackley 11,650 26 (27) 710 27 (18) 737 63.3 Brixworth 18,800 -(-) 696 -(-) 696 37.0 Daventry 16,520 12 (-) 1,003 6 (24) 1,009 61.1 Kettering 11,720 33 (8) 828 10 (39) 838 71.5 Northampton 29,540 46 (13) 1,739 32 (23) 1,771 60.0 Oundle and Thrapston 18,460 21 (13) 820 13 (40) 833 45.1 Towcester 15,640 11 (24) 1,111 17 (16) 1,128 72.1 Wellingborough 13,840 15 (3) 918 3 (9) 921 66.5 136,170 164 (88) 7,825 108 (169) 7,933 mean = 58.3 * Figures in parentheses show corresponding statistics for 1962. The building of 7,933 houses by the Rural Districts, whose total population is 136,170, represents one new house for every 17.2 persons. During 1963 a total of 907 houses were completed by private enterprise, making a post-war total of 7,582. Combining the figures for public and private housing, a total of 15,515 houses have been completed in the rural districts of the County since the war, representing one for every 8.8 members of the population. 3. National Survey of Air Pollution The Director of the Warren Spring Laboratory of the Department of Scientific and Industrial Research asked the County Council for assistance in carrying out a national survey to provide evidence for the Medical Research Council about the distribution of air pollution throughout the country. The object of the survey is partly to judge the effectiveness of the Clean Air Act, partly for research into general health matters, and partly to determine the distances over which pollution from a given source such as a large city can be detected. The Director asked for financial help so that instruments could be operated in a small compact town or village, well away from a large town, and also in an isolated site. The County Council agreed to reimburse the cost of the apparatus, which was estimated at £240, and the Kettering Rural District Council found the sites, in Geddington village and at the Thorpe Malsor reservoir. The Public Health Inspectors of the Kettering Rural District Council are responsible for visiting the instruments, which are semi-automatic, and for keeping a record of the readings for transmission to the Warren Spring Laboratory. CAUSES OF DEATH IN ADMINISTRATIVE AREAS—URBAN DISTRICTS. 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P o O dJ 45 P O S I a rHCMX^iOCDt^XOO’ (CMC0^iOcDI>00a5OrHCMC0rfu0CDr-0005OrHCMC0^iOCD irHrHT-HrHrHT-HrHrHCMCMCMCMCMCMCMCMCMCMCOCOCOCOCOCOCO X 42 S M ^ a. >« — bO 0 ^ rt Xfl o 8 3 Q •ag> 45 P P 45 45 rH ^ bo Mi J5 ^ ■§ 0 53 4|:l d -jH tuo -M bO 45 O 45 P HPw X -M> C P aJ o P 45 p ^ 45 bo Ml HH X 45 O P T3 P G 2 3 Q G Oh o P 05 s o S3 Mi ci 45 i s 45 +J aj a w CO CO rH O ( m i 03 PQ o p -M 3 p Mi rt Gl a o CJ 'eath CAUSES OF DEATH IN ADMINISTRATIVE AREAS—RURAL DISTRICTS. TABLE VI. (b) CAUSES OF DEATH. Brackley R.D. Brixworth R.D. Daventry R.D. Kettering R.D. Northampton Q « Oundle and Thrapston ! R.D. Towcester R.D. ! Wellingborough R.D. Aggregate of R.Ds. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. ALL CAUSES . 56 49 91 118 118 84 78 64 167 185 124 89 117 64 77 82 828 735 1 Tuberculosis, respiratory . ... 2 1 ... 1 1 2 5 2 2 Tuberculosis, other . 1 1 3 Syphilitic disease. 1 1 4 Diphtheria . 5 Whooping Cough. 6 Meningococcal infections . 7 Acute Poliomyelitis . 8 Measles. 9 Other infective and parasitic diseases 1 1 10 Malignant neoplasm, stomach . 2 1 2 2 4 3 1 3 3 4 2 3 2 2 2 21 15 11 Malignant neoplasm, lung, bronchus 3 7 11 2 11 4 5 1 1 3 43 5 12 Malignant neoplasm, breast . 2 2 5 1 7 5 1 1 4 2 26 13 Malignant neoplasm, uterus . 1 1 2 4 14 Other malignant & lymphatic neoplasms 7 4 12 5 12 7 5 7 11 12 13 8 15 10 11 5 86 58 15 Leukaemia, aleukaemia. 1 2 1 1 1 1 6 1 16 Diabetes . 1 1 1 3 2 1 2 4 7 17 Vascular lesions of nervous system 5 3 7 35 12 15 7 10 25 51 10 13 15 12 8 12 89 151 18 Coronary disease, angina . 14 13 23 16 33 12 14 10 43 23 23 13 23 6 13 14 186 107 19 Hypertension with heart disease... 1 1 1 1 2 3 1 3 1 1 2 5 12 20 Other heart disease . 9 6 9 34 11 19 11 18 15 27 16 19 18 16 10 12 99 151 21 Other circulatory disease . 2 3 4 5 3 4 9 12 10 5 3 2 6 5 39 34 22 Influenza . 1 1 1 1 2 2 2 1 6 5 23 Pneumonia . 6 2 3 4 3 4 4 2 8 8 7 2 6 3 9 6 46 31 24 Bronchitis. 2 1 7 2 7 2 6 3 6 3 12 3 12 6 5 58 19 25 Other diseases of respiratory system 1 1 1 1 1 2 5 2 26 Ulcer of stomach and duodenum... 2 i 2 1 1 i 4 1 1 i 2 2 13 6 27 Gastritis, enteritis and diarrhoea... 1 i 2 1 i 1 5 28 Nephritis and nephrosis . 2 l 1 1 2 1 1 1 5 5 29 Hyperplasia of prostate . 2 1 1 4 30 Pregnancy, childbirth, abortion ... 31 Congenital malformations. 1 i 2 2 4 1 1 8 4 32 Other defined and ill-defined diseases 1 6 4 9 7 3 8 3 10 23 14 9 5 5 2 5 51 63 33 Motor vehicle accidents. 3 2 5 4 3 1 4 1 1 22 2 34 All other accidents. 4 2 3 i 2 2 3 3 3 3 3 1 1 4 19 16 35 Suicide . 1 1 1 2 1 4 2 36 Homicide and operations of war ... Live Births r Total 106 105 132 156 168 138 86 82 283 273 164 157 149 155 118 96 1206'l 162 Legitimate 102 100 124 149 153 131 81 78 276 268 157 150 143 149 110 88 1146 1113 t Illegitimate 4 5 8 7 15 7 5 4 7 5 7 7 6 6 8 8 60 49 Still Births r Total 1 1 3 2 1 4 3 2 2 3 1 2 2 3 2 13 19 -< Legitimate 1 1 3 2 1 4 2 2 2 3 1 2 2 3 2 12 19 l Illegitimate ... 1 1 Deaths of Infants <- Total ... 1 1 1 2 4 4 2 5 4 12 1 1 3 3 31 13 under 1 year J Legitimate 1 1 1 2 3 4 2 4 4 12 1 1 3 2 29 12 of age l Illegitimate ... 1 1 1 2 1 Deaths of Infants r Total ... 1 2 3 4 1 3 4 7 1 1 3 18 12 under 4 weeks -1 Legitimate 1 2 2 4 1 2 4 7 1 1 2 16 11 of age t Illegitimate .. 1 1 ... 1 2 1 Deaths of Infants r Total ... 1 2 2 4 1 3 4 7 1 1 3 17 12 under 1 week -j Legitimate 1 2 2 4 1 2 4 7 1 1 2 16 11 of age l Illegitimate .. ... 1 1 1 1 Estimated mid-year Home Population 11,650 18,800 16,520 11,720 29,540 18,460 15,640 13,840 136,170 Comparability Factors Births 1. 12 1.07 1. 15 1.13 0.95 1 .11 1.09 1 10 1.07 Deaths 1.05 0.79 0.94 1.02 0.86 1.03 0.96 0.96 0.96 TABLE VII. (continued). APPENDIX THE NORTHAMPTONSHIRE MENTAL HEALTH PROJECT, 1963 AN EXPERIMENT IN MENTAL HEALTH EDUCATION Preliminary report by A. Gatherer, M.D., Ch.B., D.P.H., D.I.H., Deputy County Medical Officer of Health “ The aim of enabling the mentally disordered to take their part in the life of the community cannot be realised without the co-operation of the public ” 1 PART I 1. Introduction Rapid and exciting developments have occurred in the field of mental health over the past decade but there is now general agreement that further advances in the realm of social psychiatry will occur only with the shift of emphasis from hospital to community care of the mentally disordered recommended by the Royal Commission.2 An educated public is an essential part of the development of community care and the local health authority must regard mental health education as part of its duty in the prevention of mental disorder and in the care and after-care of the mentally ill. Much has already been done to increase public understanding of mental ill health, especially by psychiatric hospital open days ; by television programmes such as “ The Hurt Mind ” series ; and by the activities of voluntary organisations such as the National Association for Mental Health. The recent report of the Cohen Committee3 on health education indicates that much more is required and it is essential that local authorities should pay more attention to this subject in their health education activities. The difficulties involved in mental health education are numerous and would seem to discourage the use of the accepted methods of a mass education campaign. This paper is an account of an experiment in mental health education which was carried out in Northamptonshire in 1963 and in which an effort was made to put across to the public the part which they, by their attitudes and co-operation, could play in the growth of a comprehensive system of community care. 2. The need for mental health education To appreciate the need for mental health education it is necessary to consider briefly three aspects of the modern mental health scene : (a) The revolution in psychiatry : Since the beginning of this century there has been a complete revolution in psychiatry. This can be seen historically in the change from madhouses to hospitals, neatly summarised as follows : “ In the 18th century madmen were locked up in madhouses. In the 19th century lunatics were sent to asylums. In the 20th century the mentally ill receive treatment in mental hospitals.”4 A therapeutic revolution of equally great impact has led to an increasing ability to treat the mentally ill and to a better prognosis for most of the patients suffering from mental disorder. The despondency created by the inability to treat has given way in a matter of a few years to the present optimism and enthusiasm. Another aspect of the revolution is the increased status of psychiatry and its greater acceptance by the public. The final part of the revolution is shown in recent legal and administrative changes. The Mental Health Act, 1959, has restored at least some of the dignity of the mental patient and has prepared the way for establishing for him a " parity of esteem ” with the physically ill patient.5 The administrative consequences are far-reaching, but every effort must be made to ensure that modern mental health legislation is not simply transferring the care of the mental patient from the perhaps sheltered, but highly developed, hospital unit to a mythical community health service.6 In these revolutionary changes new challenges are arising. Recent surveys have shown that much still requires to be done in the residential care of the mentally disturbed.7 The early discharge of patients has been accompanied by a disturbingly high rate of readmission and by the realisation that the " open door ” policy of the British mental hospital has become a revolving door. There is also a suspicion that patients may be discharged with inadequate consideration of the after-care which they will require and of the burden which will result on the family and on the community.8 Many of these challenges can only be met by mental health education of everyone in the community. (b) The continuing fundamental importance of public attitudes to mental illness : Every disease has its public image. Even the name of a disease conjures up in the mind a picture which will vary from individual to individual with his experience and understanding of its cause and prognosis and with the folklore with which he has been surrounded. The public image of a disease can influence behaviour towards it. It can influence the demand for medical services as is periodically seen in the panic for mass vaccination and public health action brought about by a small outbreak of smallpox. It can influence the prognosis as, for example, in the case of some types of cancer where fear of the disease can lead to delay in seeking medical advice. But the public image of mental disorder brings with it a fear and prejudice which can influence the chances of recovery at almost every stage. Nowadays to treat an illness or to cure the symptoms of a disease is no longer sufficient- The aim is full rehabilitation. In mental disorder this means that the symptoms are cured or alleviated, that the patient is back at home and that he has successfully picked up again the social links and relationships which were at first threatened by his illness and finally broken by his hospitalisation. Rehabilitation can be partly brought about by doctors, nurses and social workers, but the rest depends upon the patient himself. He can only succeed if he is accepted and helped by understanding relatives, friends, workmates and indeed by everyone in the community. If relatives and friends are to be expected to play a part in the care and recovery of the psychiatric patient they must understand their roles and must, therefore, understand something about mental health. (c) The exciting possibilities of community care : The third aspect of the present scene which underlines the need for mental health education is the trend towards community care. Although intitially due to the desire to avoid the effects of institutionalisation in the hospital care of the mentally disordered, the rapid development of community care is being encouraged by the realisation that it offers exciting possibilities of a new approach to the whole problem. It is perhaps important to consider briefly the reasons for the rise of this concept and to realise that it is a natural development of recent advances in medicine and in social welfare. These include the change in attitudes towards the handicapped with the acceptance of community responsibility and the provision of services for the handicapped as a matter of social justice rather than of charity. It arises from an appreciation of the effects on anyone of institutional care, with the development of over-dependence and of fear of withdrawal of support. This applies, of course, to children in large residential homes, to prisoners and to the elderly, just as it used to apply to tuberculosis patients in sanatoria. Community care arises also from the change in the pattern of disease in the community, with the change from the " all or none ” diseases to the problems of long-term care, with the general practitioners’ work becoming more and more concerned with “ maintenance medicine ”.9 Community care has also developed with the changing role of the hospital as it becomes merely a highly specialised therapeutic episode in the continuum of care. Community care, therefore, presents a present-day challenge to all concerned with medical care. The care of the mentally disordered in the community will develop only as the result of public appreciation and education. The Royal Commission 1957s states (para. 601, page 207) : “ Community care of increasing numbers of mentally disordered will mean increased responsibilities for individuals, families and local authorities. . . . The general public will have to learn to tolerate in their midst persons with mild abnormalities of behaviour or appearence hitherto in hospital.” The importance of public attitudes was also emphasised by the Ministry of Health in its report on plans for the development of the health and welfare services of local authorities1 : “ The development of mental health services . . . should in turn increase the public’s understanding of mental disorder and their sympathy with what the services are trying to do. Thus the expansion of the services and the growth of public appreciation of their objects must go hand in hand. In no other aspect of health and welfare is it so necessary to demonstrate the existence of the need in order to be able to meet it.” 3. The Difficulties The need for mental health education of the public is so obvious that it is surprising that so little has so far been done in this country. There are, of course, several difficulties which have to be considered in planning action in this field. The first is the lack of precise knowledge of the present attitudes. It is widely assumed that great strides have been made in improving public attitudes by the upgrading of the mental hospital; by the increased skills of psychiatry ; and by the recent changes in legislation. There is an increased willingness to seek psychiatric help and a welcome frankness in discussion on mental health in press, radio and television. However, there are abundant indications that present-day attitudes still fall far short of the ideal. There is still the reluctance of out-patients to accept the need for psychiatric hospital treatment.10 To enter such a hospital still results in an invidious evaluation of the patient by his friends and relatives; with his judgement, his ability to cope, his confidence and self-control all suspect.11 Such an evaluation is well recognised by the ex-patient12 and indeed by astute members of the public as was clearly shown during the mental health education campaign in Northamptonshire when one member of an audience asked why the village eccentric was accepted until he entered a psychiatric hospital and was then rejected. In a retrospective assessment of all the cases in which they were involved in 1962, the mental welfare officers in Northamptonshire felt that in 27% patients were reluctant to accept advice due to the stigma attached to mental illness, and that in 17% their work was made more difficult by the attitudes of relatives. Public attitudes are revealed also by the resistance in many communities to training centres for mentally handicapped children and to the opening of community hostels for ex-patients. Another difficulty involved in mental health education is that there is no single and simple message which can be publicised, nor is there a well-defined end result at which to aim. This contrasts markedly with campaigns aiming, for example, at increasing the number of people accepting vaccination and immunisation, where the rate of acceptance can indicate the success or otherwise of the campaign. A further difficulty is the problem of lightening the approach by using humour. As one of the aims must be to expose the unfairness to the psychiatric patient of the joke approach to mental disorder, the methods used must be essentially serious. When dealing with a subject in which personal emotions amongst members of the audience may easily be involved, it is important that the overall impression should be one of honesty and sincere concern for the lot of the mentally disordered. The creation of a demand for services which cannot be met is another hazard in mental health education. This is especially so at the present time when there is a shortage of hospital and local authority staff and when the mental health services are in a state of flux. The final difficulty is perhaps the most discouraging of all, and that is the great danger of arousing anxieties and feelings of guilt in the audience and, in fact, producing the opposite effect to that intended. The experience of the Cummings' so well described in their book13 has no doubt dissuaded many enthusiasts from embarking on a similar venture. In advertising and in the audience research of the B.B.C. the danger of producing an “ anti-effect ” is well recognised.14 Every part of a campaign must therefore be carefully considered before it is launched, and procedures should be incorporated in the programme so that any anti-effect can be detected at the earliest possible moment. In the Northamptonshire Project it was hoped that the difficulties outlined would be, as far as possible, overcome by careful planning, but it was realised that the task would be an arduous one. PART II THE PROJECT 1. The organisation of the project (a) The Project Committee : The Project was a joint one between the County Health Department and the Northamptonshire British Red Cross Society. The detailed planning throughout was done by the Project Committee (see Part V) and the aim was to divide the work and responsibilities according to the particular attributes and availability of the members of each body. At a very early stage the efforts of the Committee were greatly encouraged by the ready support given by H.R.H. The Duke of Gloucester who graciously consented to be patron to the Project ; by the Chairman of St. Crispin Hospital Management Committee ; by the National Headquarters and Branch Council of the British Red Cross Society ; and by the Chairman and members of the Mental Health Sub-Committee of the County Council. (b) The local organisation : It was considered important that the plans of the Project Committee could be interpreted and carried out at field level. In order to facilitate this the county was divided into 56 localities and in each of these a local organiser was responsible for duties such as suggesting suitable groups for talks, publicity methods and generally promoting interest. Their activities were co-ordinated by area organisers of whom there were 30. It was hoped that these would act as a link between the central organisation and the field workers and that difficulties arising at the periphery would soon be picked up and referred to the Committee. Further co-ordination was obtained by the five district medical officers of health, each of whom formed a district committee with the help of senior administrative nursing officers and area organisers. The aim was to overcome the difficulties imposed by geography in the planning of a complicated campaign in a predominantly rural county. The plan offered the opportunity of maintaining central control of the Project while at the same time encouraging local enthusiasm and participation. (c) Training : The main worry of volunteers and indeed of Health Department staff when asked to participate in the Project was their strongly felt lack of expertise in the subject of mental health. It was therefore important to ensure that as full a programme of training as possible was arranged before anyone was involved in a job for which he or she felt inadequately prepared. Training was especially required for interviewers and for speakers. (i) Interviewers : The interviewers required an understanding of the principles of social survey work and a deeper knowledge of the rationale of the questions on the interview schedule. In order to give them the former, notes were drawn up outlining in some detail the rules which they had to obey concerning non-response, permissible prompting and general conduct of the interview. These notes were discussed section by section at one of the three training sessions which each interviewer was required to attend. Each training session was repeated several times in different parts of the county so that the number of interviewers attending was seldom more than 8-10, and at all times the importance of the work which they were going to do was stressed. The schedule of questions was presented to them and each question in turn was discussed in order that they might understand the thinking which lay behind it. (ii) Speakers : The original plan was to draw up in good time a panel of speakers who could be trained at leisure. However, the problems created by the hard winter of 1963 and by pressure of other work prevented this desirable intention from being realised. It was also soon discovered that the training of lay people to act as speakers on a subject as difficult as mental health required very much more time and effort than could be spared. It was therefore decided that the speakers would be drawn mainly from the ranks of those already with some knowledge of this subject. In the event, most of the talks were given by'the medical members of the Project Committee, other doctors and psychiatrists, psychiatric nurses, senior nurses in the Health Department, health visitors and B.R.C.S. volunteers. Occasionally the speakers went as teams comprising a professionally trained person and a volunteer, and this proved an extremely successful arrangement because it gave the audience the benefit of an expert and, at the same time, the value of hearing from a lay person how the subject affected them as individuals. It was also beneficial in so far as the working link between the statutory and the voluntary speaker allowed each to see the particular value in the other. The main problem was to standardise the approach and the message. This was achieved in three ways : in the first place by holding meetings between the speakers to discuss the relative emphasis to be placed on different aspects of the talk ; secondly, by the use of an outline talk which was drawn up by the psychiatric adviser and the committee ; and thirdly, by the use of agreed visual aids by the speakers. 2. The aims of the Project The original aims of the Project were formulated in October, 1962, and comprised two main parts. The first one was to alter the attitude of the public to mental disorder in order to remove stigma, and the second was to attempt the prevention of mental illness by more intensive education of selected groups. It soon became apparent, however, that these aims were idealistic and over-ambitious and the lack of knowledge of present attitudes in the community would hamper the first, while the second would require a very different approach and would better follow on at a later stage. It was therefore decided that the overall object of the Project would remain the altering of public attitudes, but that a clearer definition of specific aims would be required. It was eventually agreed that these should be : 1. to make the public aware of mental disorder as a social problem ; 2. to spread some knowledge of the aetiology (in general terms) of mental disorder ; 3. to indicate the advances made in the treatment and care of the mentally disordered ; 4. to explain what community care means, how lay people can themselves play a part and why it is, from the medical point of view, important that they should do so. Once the aims had been clarified, the Project fell naturally into three parts. First a mental health education campaign with the aims as outlined above ; secondly, an evaluation of the campaign ; thirdly, the establishment of aids for community care. 3. The methods of approach used in the campaign It was obvious that no single message could adequately cover the aims of the campaign and that the educational programme had to be carefully tailored to the understanding and interest of particular groups in the community. It was therefore decided to develop the approach to the public along three lines : (a) Voluntary Societies : The easiest channel of communication was to use existing voluntary society meetings and every society or group in the county known to hold regular meetings was offered a free speaker service. The talks given were varied according to the particular needs of the group with, for example, young wives’ and mothers’ clubs being told about the emotional development of children, and W.V.S. groups about the mental health aspects of loneliness in the elderly. Each talk had a basic outline—the problem ; the modern approach ; the Project and the part to be played by the public and, in particular, by the group being addressed. (b) Special Groups : In drawing up the programme certain groups of people were selected whose opinions and attitudes were considered to be of particular importance in the care of the mentally disordered ; to whom people turned in distress ; or whose work enabled them to promote sound mental health. With these groups it was felt that special themes should be developed as a single talk would seldom be sufficient. Day or half-day conferences were arranged for these groups, with guest speakers to attract interest and group discussions to encourage the interchange of ideas. The groups covered in this way included the clergy ; secondary school head teachers ; industrialists ; trade union officials ; the police ; and youth club leaders. (c) The general public : The most difficult people to reach were the rest of the general public. Three methods of approach were tried : (i) mass media : The local press were approached at a very early stage. In February 1963 the County Medical Officer invited the editors and deputy editors of the two main local papers to an informal meeting where they heard a brief preliminary outline of the Project and met the members of the Project Committee. It was agreed that both papers would be invited to attend all open meetings and would have free access to the Committee, rather than obtaining all information through a press liaison officer. Press statements were therefore seldom used. It was important to obtain the support of radio and television, and the news rooms of B.B.C. radio and television, and of A.T.V. (Midlands) were kept fully informed of all activities. It was realised that insufficient radio and television time would be granted to make a marked impact on the community as far as the content of the campaign was concerned, but nevertheless the frequent mention of the Project on television and radio aroused much interest locally. (ii) Exhibitions and Open Days : A mental health exhibition was jointly organised with the staff of St. Crispin Hospital and smaller exhibitions took place at various fetes and flower shows. Open Days were held at the four junior training centres in the county and also at the hospital. (Hi) The ground level approach : As it was realised that the approaches outlined above would reach only certain members of the community, an attempt was made to spread the information further to the ordinary man in the street by making full use of the local helpers. They were asked to talk about the aims of the campaign as much as possible in their districts, especially to those they considered to be local opinion leaders, in the hope that the latter would in turn influence others. 4. The Campaign The first public announcement of the Project followed the press meeting in February 1963, and was timed to precede by a few days the start of the first survey of public opinion. In order to prevent the initial publicity surrounding the news from influencing the results of the survey, the content was limited to a general statement. Nevertheless there was an immediate and impressive local and national interest, with news reports on television and radio and in newspapers. The inaugural meeting of the Project was held in Northampton on April 5th, 1963. The Lord Lieutenant of Northamptonshire, the Earl Spencer, presided at the meeting and the principal guest speaker was Mr. Kenneth Robinson, M.P., Vice-President of the National Association for Mental Health. A message was read from H.R.H. The Duke of Gloucester expressing best wishes for the success of the campaign, and further talks were given by the County Medical Officer of Health and a Vice-President of the Northamptonshire Branch of the British Red Cross Society. The audience of over a hundred people included representatives from the Ministry of Health, the National Association for Mental Health, the Oxford Regional Hospital Board, all church denominations, and many local statutory and voluntary associations. The meeting was well reported in the local and national press. The first month of the campaign had been deliberately kept free from too many engagements so that final training and planning could be completed. Nevertheless six organisations were addressed during that month and the pressure on speakers built up rapidly. The intention was that May and June would be active campaign months and that after a break in July/August, the peak months would be September/October, with the campaign finishing at the end of November. During these five busy months 130 talks were given, the majority in the autumn. On May 9th the B.B.C. television featured mental health and the Project in its 30-minute Midlands’ programme “ Scan A film unit had previously spent four days in the district and at St. Crispin Hospital filming facilities and interviewing patients. In the studio several of those engaged in the mental health service and in the Project were interviewed and the programme finished with a recorded interview with the then Minister of Health, Mr. Enoch Powell. Local reaction to the broadcast was excellent. The first conference wras held in Northampton on Tuesday, May 14th, 1963. It was arranged by the County W.V.S. on behalf of the Project and the theme of the conference was “ The Mental Health of the Elderly ”, One of the main points emphasised was the importance of such activities as meals-on-wheels and visiting services and other work of W.V.S. volunteers in preventing many elderly people from sinking into social isolation. On June 6th the second major conference was arranged by the Northamptonshire Churches Group Steering Committee which was formed with the help of the Northamptonshire Rural Community Council to bring together representatives of churches of all denominations with members of the voluntary and statutory services. This conference began by considering the theme “ Mental Disorder Today ” and involved talks from a consultant psychiatrist, a general practitioner and a medical officer of health. The problems of the mentally ill in the community were outlined and the need for the public and voluntary societies to co-operate with the hospital, family doctor and the statutory community services was emphasised. The next part consisted of an address by Dr. Frank Lake, Medical Director, Clinical Theology Association, on the need for the clergy to extend their work for those with emotional difficulties. In the afternoon the audience of clergy and social workers divided into groups for discussion. For four weeks from the middle of June the emphasis of the campaign was on the needs of the mentally handicapped. Open Weeks were planned for each of the County Council training centres at Kettering, Northampton, Wellingborough and Corby, and as the pattern of the Week was similar in each case only one will be described in detail. On Monday June 17th the Open Week at the Kettering Junior and Adult Training Centres was inaugurated by a public presentation to the Adult Centre of a motorised cultivator by the Kettering Rotary Club. Organised parties visited the Centre by appointment on the Monday, Tuesday, Thursday and Friday while, on Wednesday June 19th, the centres were open to all parents, friends and the general public. On Monday a film evening was held which was so successful that a repeat of the film/discussion had to be hastily organised because of the numbers present. Towards the end of September two evening conferences were held. The first of these was on September 24th and was organised in Northampton by the Knights of St. Columba. A large audience of voluntary workers of the Roman Catholic Church attended to hear the speakers outline the problem of mental ill health and the possible ways in which they could increase the help they were already giving. The second evening conference was held two days later and was organised by the Northamptonshire Conference of the National Voluntary Youth Organisations for youth club leaders, the theme being based on the following extract from the Bessey Report on the Training of Youth Leaders : “ The job of leadership is to help young people to grow up and to enjoy the process and to develop good personal relationships.” The audience heard a specialist in child psychiatry talking about the development of relationships, and a wide-ranging discussion brought out many challenging aspects in which youth club leaders could play a major role. The personal interest of the Chief Constable of Northamptonshire led to special meetings being arranged in each of the five police divisions. It was decided that the aim of these meetings should be to bring to the attention of the members of the police force the relevance to their work of some knowledge of mental health, and consisted of a general introductory talk by a doctor, a film on mental illness and a general discussion with the doctor assisted by a mental welfare officer. The American Embassy kindly lent a copy of the recently issued Chicago Police Training film entitled " The Cry for Help ” which dealt with the handling of attempted suicide cases and this added to the interest of the evenings, although its content varied to a considerable and sometimes humorous extent from practice in this country. One outstanding conclusion was the great need for similar training films in Britain. One of the highlights of the Project took place on October 9th 1963 with the luncheon at Knuston Hall Adult Residential College at which the principal guest was H.R.H. The Duke of Gloucester. The occasion was a planning meeting arranged so that the senior representatives of the Health Department and the Northamptonshire Branch of the British Red Cross Society could hear a review of progress and consider future plans. The campaign reached a climax during the week commencing Sunday October 20th which was designated Mental Health Week. The first event was Mental Health Sunday when a special service was held in the chapel of St. Crispin Hospital. A large congregation of representatives of statutory and voluntary bodies attended, with patients from the hospital. On the same Sunday, reference was made to the Project in other churches throughout the county and the Roman Catholic Bishop of Northampton arranged an octave of prayer. On Monday October 21st a large exhibition, organised by St. Crispin Hospital and the County Health Department, was opened in the Guildhall, Northampton, by Mr. Ewart Marlow, C.B.E., M.C., the Chairman of Northamptonshire County Council. The exhibition was entitled " Hospital to Community—Focus on the Hurt Mind ” and covered many aspects of diagnosis, treatment and rehabilitation of the mentally disordered. The exhibition was attended by just over 1,000 people during the week. For one day the exhibition was open to senior school children, and parties from two schools attended. The emphasis in the exhibition on machines and apparatus greatly interested them and many intelligent questions were asked. On Tuesday October 22nd 1963 a special one-day conference was arranged for the Project by St. Crispin Hospital Management Committee and was held in the hospital. The theme was " Industry and Mental Health ” and the audience comprised industrialists, business managers and trade union officials. The morning’s programme covered “ Industry as a cause of mental ill-health ”, the main speaker being Dr. K. P. Duncan, Medical Adviser to the United Kingdom Atomic Energy Authority, and this was followed by “ Industry in the treatment of mental ill-health ”, with a description of the Industrial Therapy Organisation at Southall by its industrial manager, Mr. V. C. McDonnell. The afternoon subject was " Intelligence and work ” and Professor A. D. B. Clarke of the University of Hull outlined recent discoveries relating to the training potential of mentally handicapped adults. Much interest was engendered by this meeting amongst those engaged in industry, and a tour of the hospital, with the opportunity of meeting members of the staff, caused many of them to state that until then they had been quite unaware of the importance of sympathetic acceptance at work in the rehabilitation of the mentally disordered. On Friday October 25th St. Crispin Hospital held its annual Open Day and linked it with the Project. The speaker was Dr. R. F. Tredgold, and his subject " Community Care ”. A large audience subsequently toured the hospital. In the evenings during Mental Health Week films were shown to invited audiences, and the subsequent discussions were led by senior nurses from the hospital, and mental welfare officers. On another evening the exhibition hall was given to the Northampton Branch of the National Society for Mentally Handicapped Children, who arranged a successful meeting, with the assistant secretary from the National Society’s headquarters as guest speaker. On the Wednesday evening the inaugural meeting of a Northamptonshire branch of the National Association for Mental Health was held. An enthusiastic audience representing many local societies and with people from all parts of the county, heard Mrs. P. R. Burnet, J.P., Chairman of the Executive Committee of Cambridgeshire Mental Welfare Association, talk about the achievements of her association. It was agreed that the Northamptonshire Association for Mental Health be formed, a significant result of the interest created by the Project and a logical step in ensuring the continuation of the process of mental health education. A conference was held for secondary school head teachers and concentrated on attitudes, problems of mental ill-health in school, and possibilities of promoting sound mental health. A panel discussion in the afternoon helped to show the enormity of the subject and its fascinating challenges to them. The final conference was arranged by the Northamptonshire Federation of Women’s Institutes. The organisers felt that a whole day on mental health matters was too much and so the morning only was spent on this subject. The afternoon, however, was on care of the elderly, and it soon became a discussion on the psychological effects of loneliness ! The concept of community care was well developed and the role of the Women’s Institutes in the rural parts of the county was stressed. In November a nation-wide radio broadcast entitled “ My Brother’s Keeper ” was made inspired by the Project. Concentrating on attitudes to mental illness, the broadcast set out to show that acceptance of the mentally disordered was seldom an easy or straightforward affair, especially from the point of view of relatives, and that community care was still not a universally accepted policy. In describing the numerous meetings which took place during the months of active campaign, three specific points have not yet been covered. In the first place the value of local enthusiasm in arranging a mass meeting was demonstrated by the success of a meeting in Daventry. Here the district medical officer, with the help of a senior administrative nursing officer and local British Red Cross officers and cadets, arranged a film evening with the late Doctor the Honourable W. S. Maclay as principal speaker. The very large audience appreciated hearing about the modern mental health service from one of its principal architects. The second point which should be mentioned is the tremendous help given to the campaign by certain societies with several branches in the county. The best example here is the St. John Ambulance Brigade, where the county headquarters drew the attention of their officers to the Project and thereby facilitated the arrangement of meetings all over the county. The main interest of the St. John Ambulance Brigade meetings was in the possibility of developing the idea of psychiatric first aid as a useful corollary to ordinary first aid. Finally the success of the village meetings must be mentioned. One of the obvious drawbacks to the method of approach used was that on several occasions multiple meetings were arranged in certain villages, and the audiences inevitably overlapped considerably, with a fascinating permutation of officials. In some areas the local organiser arranged a single meeting in the village with representatives from all societies and, where this happened, a particularly successful meeting resulted. 5. Evaluation of the Project As previously mentioned it had been decided that attempts would be made to evaluate the results of the Project. No single simple measurement could be made as there were several different aspects of interest, for instance the impression, either favourable or unfavourable, which the campaign was creating in the community; the effectiveness of the campaign methods; and, most important of all, the effect of the campaign in achieving the aims of the Project. (a) The impact : One of the constant dangers of propaganda is that it may produce effects which are very different from, and in fact the opposite of, those desired. Distortion and selective assimilation are well recognised hazards in communication, and any process of evaluation should attempt some measurement of these factors. This possibility of producing an anti-effect has already been mentioned as one of the difficulties in mental health education. It did not prove very easy to arrange a suitable method for detecting the development of an anti-effect at its earliest stage, but several steps were taken. In the first place a careful check was made on the press coverage, in case editorial comments, letters and the general tone of articles, revealed any sign of antagonism, or lack of understanding. Secondly the speakers were asked to note all questions from the audience and to send these to the Project Secretary ; it was felt that this would give an indication of the most troublesome points in mental health in the minds of the audiences and in addition would reveal any marked failure to receive the information correctly. Also, the speakers were asked to state how, in their opinion, the meetings had gone and thus give a subjective assessment of audience reaction. (b) Effectiveness of methods : It is virtually impossible to assess accurately the coverage achieved in a campaign of this nature because of the variety in the methods of approach over a relatively long time and large geographical area. Two steps were taken to try to give some estimate of the numbers reached by the campaign ; first, details of the approximate numbers attending the meetings were kept and, secondly, a question was inserted in the follow-up survey to find out whether the persons interviewed had in fact heard of the campaign. (c) Evaluation of the effect of the campaign : The major effort at evaluation concerned the measuring of short term and long term effects of the campaign. The aim here was to measure the existing knowledge in the community and, at the same time, the attitudes to at least some aspects of mental disorder. The scheme for evaluation included the following : base line measurements ; practicable research design ; a public opinion survey before and after the campaign ; the analysis of the data collected. (*) Baseline measurements : A survey of public opinion took place before the campaign started in order to establish a baseline against which any variation in attitude or knowledge could be measured. It was also important to establish that the mental health scene locally was in no way unique or unusual, as the type of mental health service available could easily influence community opinions either favourably or otherwise. This point was discussed at length with the consultant staff at the local hospital and the conclusion was that the psychiatric services in the county, with a 1,000-bed largely Victorian mental hospital with out-patient clinics in other parts of the county and, at that time, with no day hospital in operation, was in fact fairly typical of the mental health services in the region. Another measurement undertaken to ensure that there were no obvious local factors to be considered, was a comparison of the county mental health statistics for 1962 with the national figures, including those which revealed the interpretation and use of the legislation under the Mental Health Act 1959, and the percentage of re-admissions and age-structure of new admissions. In each of these points the local figures did not differ to any significant extent from the national picture. (it) The research design : One of the questions which had to be answered early on was the usual one confronting anyone attempting a social survey, namely, how near to a fully scientific evaluation was it possible to get with the local limitations in staff, finance, time and specialist knowledge. Compromise between the ideal and the practicable was essential. It was realised that the most worthwhile research design would mean an experimental and a control group, both of which would be surveyed before and after the campaign. The difficulty was in getting a control group for, to be of value, it would have to be essentially the same as the experimental group in every respect except that it had not been exposed to the campaign. Careful consideration was given to using two parts of the county, but this was found to be impossible because of the difficulties in getting two areas, one of which could be shielded from the campaign. The second possibility was to approach another county health department with a request that a control group from their area be surveyed, but this was again found to be impracticable. Reluctantly, it was concluded that the research design could not include a control group, but would instead rely on a before and after survey in Northamptonshire. The sampling method used was a random selection of one in 200 from the electoral roll, giving a sample size of 1,000, the first number being obtained from a book of random numbers. The initial sample was made in February 1963 from the new electoral roll and the same roll was used for the second sample as the survey was to finish before the 1964 roll was issued. The geographical coverage of the sample was satisfactory and no part of the county was missed. The collection of the data was by interview and, as previously mentioned, care was taken to train those taking part. (Hi) The interview schedule The questions to which answers were required were divided into two groups—(1) those designed to measure knowledge and (2) those aimed at eliciting attitudes. (1) Knowledge (see Part IV—copy of questionnaire). Questions 1-9 and Question 15 : The information required was the interviewees’ awareness of the size of the mental health problem (Q. 1, 2); their ideas on aetiology (Q. 3, 7) ; and their acquaintance with the modern approach to mental health services and with the implications of community care (Q. 4, 5, 6, 8, 9, 15). (2) Attitudes In considering questions which would bring to light some indication of public attitudes to mental disorder, the basic assumption was made that most people were prejudiced in their feelings towards the mentally disordered in the same way as towards any minority group. Prejudice was defined as a hostile attitude towards a person who belongs to a group simply because he belongs to that group.16 Three aspects of prejudice were distinguished16 : the holding of stereotyped beliefs about the mentally disordered ; feelings against the group ; ideas about social provision for the group. Suitable questions were then drawn up. The extent to which stereotyped beliefs were held about the subject of mental disorder, the mental patient, and those who work in a mental hospital, were evaluated by Q. 17, although it was realised that much more could have been made of this particular approach. The feelings held for the mental patient were interpreted mainly as a willingness or unwillingness to associate with him and as an awareness of the stigma attached to mental illness. Here it was fortunate that two series of questions from the “ Hurt Mind ” investigation17 admirably suited the needs of the survey with minor modifications and so Qs. 13 and 16 would have the added value of possible superficial comparison with the earlier study. Finally, two questions (11, 12) tried to find out the public’s level of priority for social help for the mentally handicapped and the maladjusted child. The personal data collected (Qs. 18-24) was the minimum considered necessary for sub-analysis and for sample comparisons. Age and level of education are invariably strong factors in community attitudes to mental ill-health11 and had therefore, to be measured. The final question (Q. 25) on acquaintance with someone who suffered from mental disorder was carefully considered before being used because of the danger of intrusion into private affairs. However, it seemed so necessary to have this information, however incomplete, that it was eventually included. Once the questionnaire was in draft form detailed criticism was invited from several sources. It was then pre-tested twice, once with a group of 72 B.R.C.S. volunteers, and later with 30 clerical and administrative staff. The interviewers completed a trial interview and their forms were scrutinised ; they were also given the opportunity of commenting on any apparently difficult or confusing question. Despite these precautions two questions in the final questionnaire gave rise to difficulty, namely, sub-question 5 of Q. 13 which was confusing, and Q. 21 where the instructions were not clear enough. Both of these points were stressed in the pre-survey discussions with interviewers. (tv) The analysis of the data : The completed schedules were coded by a small team of clerical staff and volunteers for subsequent analysis by electronic computer. It is intended that the results will be given in two main groups : (1) the details of the first survey as an indication of state of present knowledge and attitudes in the county ; (2) the two surveys compared to measure any differences. The detailed results will be given in the full report on the Project. PART III PRELIMINARY IMPRESSIONS A reliable estimate of the results of the Project will have to await the detailed statistics relating to the surveys and other measurements, but it is possible at this stage to give some initial idea of what has been achieved. The end results can suitably be considered under the following headings : 1. The establishment of aids to community care. 2. The effect of the Project on the mental health services. 3. The effect on those taking part. 4. The effect on the community. 1. Aids to community care There is little doubt that the timing of the Project coincided with a considerable interest in mental health amongst the voluntary societies. Time and time again it was found that the approaches made were met more than half-way and the offers of help and goodwill were impressive. Several ways were suggested in which voluntary societies could help the achievement of the aims of the Project, for example by considering carefully their collective and individual attitudes to the mentally disordered, by financial support of mental health research, and by increasing their own knowledge of the subject. Several societies approached the hospital with a view to arranging visits to patients, while other societies became more interested in the welfare of the mentally handicapped children at the training centres. In one part of the county the interest is likely to lead to the formation of the first social-therapeutic club in the area due to the initiative of the local branch of the British Red Cross Society. Amongst certain industrialists there has been an increased interest in mental health factors in industry and in the possible support which can be given to industrial therapy, and there is at present active interest in the formation of an industrial therapy organisation in Northampton. The Rotary Clubs have formed an Industrial Advisory Board, linked to the Henley Industrial Unit for mentally handicapped adults, with the object of assisting and advising the Unit on job placement, suitable contract work and industrial methods. The interest created by the Project helped to launch a local Association for Mental Health with the dual purpose of encouraging the further development of mental health services in the area and continuing the process of mental health education. 2. The effect of the Project on the mental health services The staff of the psychiatric hospital probably saw more immediate results of the Project than most, and some of them volunteered the impression that their work was being appreciated much more by the public than had previously been the case. The meetings for planning and discussion throughout the year led to a very close partnership between the hospital and the Health Department. At the same time the British Red Cross volunteers and, to some extent other societies, came to develop a deeper understanding of the problems of the psychiatric hospital. As far as the community mental health services were concerned it became clear that there was great need for a definition of the roles of the various types of staff. The part which the health visitors should play in the future development of the mental health services was raised in internal discussion, and the limits of their knowledge and training were also discussed. Perhaps the most impressive feature was their great potential as educators in mental health and as those who could be primarily concerned with the prevention of mental illness. The mental welfare officers took part in the Project as far as possible and their value in mental health education lay especially in the many human stories which they could recount to illustrate the important effects of present-day attitudes. 3. The Project workers The most obvious effect on those closely involved in the Project was undoubtedly profound exhaustion ! The overtime which was required and the constancy of effort certainly created a strain on the whole Health Department and on the Red Cross Society. To a large extent this followed from the very success of the Project which evoked a demand for talks and meetings which stretched resources to the limit. By the end of the year it was apparent that the pressure could not have been maintained much longer without breakdown in the smooth running of the Department. 4. Effect on the Community The full effect of the campaign on the community can be adequately judged only after the detailed results of the surveys are known. There are however one or two definite results which can be mentioned now. For example the interest created by the Project was marked, and it was encouraging to find that by the end of the year many people felt that they wanted more detailed information about various aspects of mental health. Another result was an approach to the Project Secretary by the area organiser for the Workers’ Educational Association for a class on mental health and this, in fact, started in January 1964. It was so successful that demands for similar courses were received from several other parts of the county. Some idea of the effect of the campaign on audiences was obtained from the questions which they asked at the meetings. In many cases these showed a surprisingly deep understanding of the problems of the mentally ill. At other times the audience was cautious about, for instance, the trend towards community care and, on several occasions, questioners raised the issue of too early discharge from hospital. 5. Conclusions The experiment was well worthwhile even if the detailed results and eventual evaluation do not reveal obvious gains. The difficulties in mental health education and the pitfalls to be avoided may discourage large scale attempts to alter public attitudes, but the rapid development of community care demands the co-operation of the public, and campaigns such as this offer a valuable opportunity to link the statutory and voluntary agencies in establishing community participation in health and welfare services. Another lesson gained from this work was the importance of careful planning and sufficient time. It is undoubtedly true that, had the difficulties in the campaign been allowed to cause a postponement, it would in all probability have led to a cancellation of the Project. It was fortunate that the British Red Cross Society were determined that the Project should be held during their centenary year. On the organisational side the great benefit from close co-operation between local authority, hospital and voluntary society was impressive. It was plain that no one body alone could have undertaken an experiment of this magnitude. Looking back over the Project as a whole, the most vivid impression which remains is that of the willing co-operation and complete dedication of those involved. It was as though the plight of the mentally disordered was accepted as a challenge to everyone in the community, with the lay playing a significant role side by side with the professional. The genuine concern for the problems of mental ill-health and the eagerness to help tackle them revealed by the Project augurs well for the further development of community care. Acknowledgements The Northamptonshire Mental Health Project was the result of the enthusiasm and hard work of many people and it will be a great pleasure to give detailed acknowledgement of their valuable contributions in the full report on the Project. PART IV Strictly Confidential NORTHAMPTONSHIRE PROJECT 1963 Serial No.: BQ/1 Introductory Remarks Perhaps you have heard that the Northamptonshire County Council with the help of the British Red Cross Society are asking certain selected people for their views on a health problem. Your name has been selected, quite by chance, and I would very much like to ask you some questions. These are straightforward questions which are in no way meant to measure knowledge, nor to sell you something, nor to trick you. The doctors who have organised this survey are wanting to know your opinions on various matters and from the answers which will be collected from all over the County they will perhaps understand more clearly what services should be provided. Remember 1. there is no right or wrong answer—it is just your honest opinion that is required ; 2. there is no name on this form ; 3. these forms are strictly confidential and all information given will be used by doctors only ; 4. now that your name has been selected, it is very important that I have your opinions, for no substitutes are possible ; 5. no discussion is allowed. (.Please note : The first question must be asked before the words “ Mental Health”, “ Mental Illness or Disorder ” are mentioned !) Please follow all instructions carefully 1. I would like to ask you to tell me, from the list of conditions which follows, which three you consider to be serious social problems in Britain today ? (Indicate the most serious by placing (1) in column beside it, next most serious by placing (2), and the third most serious by placing (3).) Air Pollution Tuberculosis Alcoholism Ignorance Mental Disorder Dental Decay Venereal Disease Prejudice (If asked, you can explain what is meant by any of these terms, by “ alcoholism ” for example.) [Note : Once Question 1 has been answered, you may explain further that the questions to follow will be about mental disorder, and this term is to include mental illness and mental subnormality.) 2. About what proportion of hospital beds in this country are occupied by the mentally disordered ? Less than quarter Ouarter Half Three quarters More than three-quarters Don’t know 3. Do you think anyone, including ourselves, can suffer from a mental illness ? True Don’t know Probably true Probably false False 4. About what proportion of patients who enter mental hospitals do so of their own free will ? Less than quarter Three-quarters Quarter More than three-quarters Half Don’t know 5. Have you ever heard the term “ Community Care ” for the mentally ill ? Yes Don’t know No If yes, what do you think it means ? 6. Do you think that patients admitted to a mental hospital can in a short time be discharged cured ? No Majority Very few All Some Don’t know Half 7. Can you tell me anything which you feel is likely to cause mental illness ? Yes Don’t know No If yes, please list : 8. Do you feel that we ourselves could do anything to prevent some types of mental illness in other people ? Yes Don’t know No If yes, what ? 9. We have already discussed treatment in a mental hospital. Do you know from what other sources one could obtain help in mental illness ? Yes Don’t know No (.Please list answer—no prompting.) If Yes, what ? 10. If you were a patient in the local general hospital, which of the following patients would you prefer in the next bed ? (Put (1) against first choice, then 2, 3, 4 down to (5) against fifth choice.) Remember—All must be numbered. A patient with a stroke. A patient who had taken an overdose of tablets. A patient who was mentally ill. A patient with tuberculosis. A patient with cancer. 11. Which of the following groups of handicapped children do you feel most sorry for ? (Put (1) against first choice, then 2, 3, 4 down to (5) against last choice.) Remember—All must be numbered. Blind Mentally Retarded Deaf Spastic Thalidomide 12. The parents of most handicapped children have social and other problems to cope with in caring for their children. Which of the following do you consider should have more help from the community than they receive at present.? (Note : (a) All to be answered ; (b) “ Don’t know ” will include “ I do not know what they get already ” type of answer.) 1. Parents of blind children. YEs/Don’t know/No 2. Parents of deaf children. YEs/Don’t know/No 3. Parents of maladjusted or delinquent children. YEs/Don’t know/No 4. Parents of mentally retarded children. YEs/Don’t know/No 5. Parents of spastic children. YEs/Don’t know/No 13. An acquaintance of yours who has had much the same education as yourself, who appears to be all right and is as pleasant as anyone else, tells you that he is attending a hospital out-patient department for treatment of a mental illness. Indicate whether you agree with the following statements about your feeling towards him. (Note: Ask the respondent to give careful thought and answer as truthfully as possible.) 1. Would you feel sorry for him. 2. Would you feel you wanted to help somehow. 3. Would you be a bit uneasy. 4. Would you feel a certain amount of fear. 5. Would you never feel quite the same towards him. 6. Would you feel a bit strange and embarrassed in his presence. 7. Would you feel you wanted to avoid him. 8. Would you wonder what was going on under the surface. YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No Remember He appears to be all right, is as pleasant as anyone else; he is out-patients department for treatment of a mental illness. 9. Would you feel a bit repelled by this person. 10. Would you mind being left alone with this person for long. 11. Would you feel you couldn’t rely on him as much as before. 12. Would you feel you couldn’t trust him as much as before. 13. Would you feel that people ought to be warned in some way. 14. Would you feel that he really ought to be kept in a mental hospital while ill and not left to mix freely with ordinary people. attending a hospital YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No 14. If you or a member of your own family had been treated for a mental illness would you : (Note : Circle (a) or (b) or (c). (a) keep very quiet about it ? (b) tell a few people ? (c) make no secret about it ? 15. If a person has recently suffered from a mental illness, is there anything that you could do to help him to get better ? Yes Don’t know No If Yes, what ? 16. An acquaintance of yours who has received the same education as yourself and seems to be all right and is as pleasant as anyone else has been discharged from a mental hospital after being cured of a mental illness. {Note : Ask the respondent to give careful thought and answer as truthfully as possible.) 1. Would you be quite willing to mix with this person in the street or in shops ? 2. Would you be quite willing to work next to such a person ? 3. Would you be quite willing to have this person as a next-door neighbour ? 4. Would you be quite willing to have such a person drop in on you j ust as others do ? 5. Would you be quite willing to introduce such a person to your close friends ? 6. Would you be quite willing to employ such a person ? 7. Would you be quite willing to work for such a person ? 8. Would you be quite willing to become friendly enough to discuss your personal affairs with such a person ? 9. Would you be quite willing to have such a person in a position with authority over others ? Remember He appears to be all right, is as pleasant as anyone else; he has a mental hospital after being cured of a mental illness. 10. Would you be quite willing to have this person marry your son or daughter or someone closely related to you ? 11. Would you be quite willing to allow such a person to look after children, e.g. as a teacher or a children’s nurse ? 12. Would you be quite willing to allow such a person to look after your own children as a baby-sitter ? 17. Which of the following statements do you think are true ? (a) You only suffer from mental illness if it runs in the family. True Probably false Probably true False Don’t know (b) Once you have been in a mental hospital you are never quite the same again. True Probably false Probably true False Don’t know (c) A mental breakdown is a sign of weakness and lack of willpower. True Probably false Probably true False Don’t know been discharged from YES/Not sure/No YES/Not sure/No YEs/Not sure/No Yss/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No YEs/Not sure/No (d) All those who are mentally ill should be taken away for their own sakes. True Probably false Probably true False Don’t know (e) A lot of the psychiatrists and nurses in a mental hospital are a bit queer themselves. True Probably false Probably true False Don’t know (f) You can usually tell someone who has been mentally ill by his or her appearance. True Probably false Probably true False Don’t know Introduction Because people’s opinions sometimes vary with their age, occupation and general living conditions, the doctors who will look at these forms would like to know a few facts of this kind about the people selected for interview. (Note : In each case, please tick the answer which is correct.) 18. Age group : 21-40 years 41-60 years 61 years-f 19. Sex : Male Female 20. Marital state : Married Single Widowed or other 21. Occupation : (a) Self. PresentjFormer Occupation (in detail). (If housewife not working, give husband’s occupation; if housewife working, complete 21(b).) (b) Spouse. Presentj Former occupation (in detail). (Important : Please indicate whether it is a manual or a non-manual occupation.) 22. At what age did you finally stop receiving full-time education ? Under 14 years 14 years 17 years 15 years 18 years 16 years Over 18 years 23. Which daily morning newspapers do you read ? Daily Express Daily Mirror Daily Herald Daily Mail The Times Daily Telegraph The Guardian Other (please state) None 24. Which Sunday newspapers do you read ? Sunday Express The People News of the World Sunday Pictorial Sunday Citizen Sunday Telegraph Sunday Times The Observer Other (please state) None 25. Do }mu know or have you known anyone who has suffered from a mental disorder ? mental illness and mental retardation.) (Note : If further information requested as to what constitutes a mental illness, i requiring the care of a psychiatrist or mental hospital treatment.) Yes Don’t know No (Remember : Note any further information given.) 26. If answer to Question 25 is Yes, (a) What is your relationship to that person ? Neighbour Workmate Friend A relative who does/did not live with you A relative who does/did live with you (b) Is there anything further you would like to tell me ? To be answered by Interviewer (a) Did you know respondent before interview ? (Please circle answer.) Well Through work Not at all (b) How did the interview go ? Very well All right Very difficult (c) Do you feel that the answers given are on the whole reliable ? Yes Not sure No (Both means (d) Any remarks PART V The members of the Project Committee were : Mrs. A. W. Walker, Deputy President, Northamptonshire Branch, British Red Cross Society ; Mrs. P. L. Newnes, Branch Director, Northamptonshire Branch, British Red Cross Society ; Miss J. A. Forester, Health Education Organiser, Health Department, Northamptonshire County Council ; D. A. G. Williams, General Practitioner ; P. H. Rogers, Consultant Psychiatrist and Deputy Physician Superintendent, St. Crispin Hospital, Duston ; A. Gatherer, Deputy County Medical Officer of Health, Northamptonshire County Council. PART VI References 1. Ministry of Health (1963) : “ The Development of Community Care ” ; London; H.M.S.O. 2. “ Royal Commission on the Law Relating to Mental Illness and Mental Deficiency ” (1957) ; London; H.M.S.O. 3. Ministry of Health (1964) : “ Report of a Joint Committee of the Central and Scottish Health Services’ Councils on Health Education ” ; London ; H.M.S.O. 4. Jones, K. (1959) : “ Lunacy, Law and Conscience ” ; London ; Routledge & Kegan Paul. 5. Jones, K.: “ Revolution and Reform in the Mental Health Services ” in “ Trends in the National Health Services ” (1964) ; ed. by W. A. J. Farndale ; London ; Pergamon Press. 6. Titmuss, R. M. (1961) : “ Community Care—Fact or Fiction ? ” in “ Emerging Patterns for the Mental Health Services and the Public ” ; Proceedings of a Conference ; National Association for Mental Health. 7. Townsend, P.: “ Prisoners of Neglect ” ; The Observer, 5th April, 1964. 8. National Association for Mental Health (1964) : “ The Whole Truth ” ; Report of the Annual Conference. 9. Backett, E. M.: “Towards Maintenance Medicine ” ; New Society, 16th July, 1964. 10. Carstairs, G. M. (1963) : “ The Distant Goal ” ; Proceedings of a Conference ; London ; National Association for Mental Health. 11. World Health Organization (1959) : “ Technical Report Series No. 177 ” ; Geneva. 12. Mills, E. (1962) : “ Living with Mental Illness ” ; Routledge & Kegan Paul ; London. 13. Cumming, E. and Cumming, J. (1957) : “ Closed Ranks ” ; Cambridge : Harvard University Press. 14. Belson, W. A. (1961) : “ Communication and Persuasion through Broadcasting ” ; Reprint Series No. 133, Research Techniques Division, London School of Economics. 15. Allport, G. (1954) : “ The Nature of Prejudice ” ; England ; Doubleday. 16. Sellitz, C. and Barnitz, E. (1955) : “ The evaluation of intergroup relations programmes ’’ ; International Social Science Bulletin, Vol. VII, No. 3. 17. British Broadcasting Corporation (1957) : “ The Hurt Mind An Audience Research Report ; London. INDEX Pages Pages Aftercare of patients ... 39, 46 Immunisation ... 58 Air pollution—national survey 78 Infant mortality ... ... 10, 11, 12, 80, 81 Ambulance service 53 Infectious diseases 58, 59 Area 10 In-service training 36 “ At risk ” register 20 Joint sub-committee of Health and Welfare B.C.G. vaccination 62 Committees 69 Birth control ... 15 Liaison 33, 68 ,, rate 3, 10 Lung cancer 3, 37 „ statistics 10, 11, 12, 80, 81 Mantoux tests 62 Cancer ... 3, 10 Mass radiography 62 ,, of lung ... 3, 37 Mass media 38 Care of mothers 14 Maternal mortality 10, 11, 14 „ „ young children 17 Maternity accommodation 14 Cars 25 Maternity outfits 25 Census, 1961 10 ,, and nursing homes 30 Chest clinics 63 Mental Health Project 4, 38, 84 ,, diseases ... 62 ,, health services 4, 45 ,, physicians, reports of 62 ,, welfare officers ... 8, 45 Child guidance 18 Midwifery and maternity services ... 24 ,, welfare centres ... 17, 22, 23 Milk, examination of ... 72 Children, care of young 17 ,, in schools 72 Chiropody service 39 Mobile clinic 17, 22, 23 Comparability factors 80, 81 Mothers, care of 14 Convalescent home treatment 39 ,, clubs ... 17 Deaths ... 3, 10, 80 to 83 Mothercraft classes 14, 25, 36 Dental care 19 National Health Service Act, 1946— Diabetes Mellitus 33 Sect. 22 (Care of mothers) 14 Diphtheria immunisation 58 Sect. 22 (Care of young children) 17 Diploma in Public Health 5 Sect. 23 (Midwifery) 24 Displays 36 Sect. 24 (Health visiting) ... 31 Disposable equipment... 25 Sect. 25 (Home nursing) ... 27 Domiciliary births 14 Sect. 26 (Vaccination and immunisation) 58 Dwellings, number of ... 10 Sect. 27 (Ambulance service) 53 Environmental hygiene 77 Sect. 28 (Prevention of illness, care and Equipment, nursing ... 25, 39 after-care) 39 Exhibitions 36 Sect. 29 (Home helps) 42 Extra nourishment 62 Neonatal mortality ... ... 10, 11, 12, 80, 81 Family care 34 Non-nursing visits 29 ,, planning clinics 15 Nurseries and Child-Minders Regulation Act, Fluoridation 5 1948 . 18 Food—inspection and supervision of 71 Nurses’ training scheme 29 Food and drugs 71 ,, houses... 26 General practitioners—co-operation with ... 24, 33 Nursing, domiciliary ... 27 Health education 32, 35 ,, equipment ... 25, 39 Health visiting 31 ,, homes 30 Helicopter, use of 57 Obituaries ... 6, 45 Henley Centre, opening of 51 Occupational therapy 40 Home helps 42 Other departments, co-operation with 69 Home nursing 27 Oxygen apparatus 25 Hospital births 14 Parentcraft classes 14, 25, 36 Houses for nurses 26 Perinatal mortality ... ... 10, 11, 13, 80, 81 Housing... 10, 78 Peterborough Diocesan Family and Social Illegitimacy ... 10, 15, 16 Welfare Council 15 INDEX—cont. Phenylketonuria Pages 32 Staff . 6, 7, 8, 9, Pages 45, 54 Play centres 17 ,, meetings 36 Poliomyelitis vaccination 61 ,, training ... 29, 32, 36, 43, 45 Population 10, 80, 81 Stillbirths . 10, 11, 12, 13, 80, 81 Post graduate courses 25, 29, 32 Student nurses 29 ,, ,, visitors... 70 Television 38 Prematurity 14 Ten-year plan ... 4 Prevention of illness 39 Tetanus vaccination ... 61 Publications 70 Training centres 51 Radio 38 Training of staff 29, 32, 36, 43, 45 Rateable value 10 Tuberculosis 32, 66 Red Cross clubs 41 Unmarried mothers, care of ... 15 Relaxation classes 14, 25, 36 Vaccination 58 Research 70 Venereal disease 33, 67 Rural housing 78 Visual aids 35 Rural Water Supplies and Sewerage Acts 77 Vital statistics ... 10, 12, 13 St. Crispin Hospital—joint scheme with 47 Water supplies 77 Sewage disposal 77 Welfare centres 17, 22, 23 Smallpox 60 Welfare foods—distribution of 18 Smoking ... 3, 37 Whooping cough vaccination 58 Speech therapy 18 Yellow fever vaccination 62 PRINTED BY STANLEY L. HUNT (PRINTERS) LTD., GEORGE STREET, RUSHDEN, NORTHANTS