J. Soc. Occup. Med. (1976) 26, 31-34
Health Care of People at Work in Britain Occupational Health Services Director of Medical Services, Health and Safety Executive Occupational Health Services are spread unevenly across the United Kingdom; they are uneven in quality and activity and they are uneven in geographical and occupational distribution. Present Industry-based Services It is not proposed to discuss here the scope and purpose of governmental activity in this field. The relevant agencies, and notably the EMAS, have been well described elsewhere (Davies, 1973). Suffice it to say that in terms of medical or perhaps more importantly nursing manpower, industryprovided services dwarf the official governmental arrangements. Size alone is no guarantee of worth and consequently we must assess whether the industry-provided machineries are essential, useful or extravagantly redundant. It is necessary only to refer in passing to the comments on this subject in Chapter 12 of the Robens Report (Safety and Health at Work, 1972); these were as ill informed as they were unhelpful and stand merely as a commemorative symbol of an era of friction between a government department and those working in the field. As such, like other memorials, they have a chastening merit in pleading the avoidance of repeated error, but they should not be allowed to become enchanted relics for those anxious to keep scars painful and to perpetuate bitterness. There are at present about 700 full-time doctors in industry, and, if membership of the Society of Occupational Medicine is any guide, that number is slowly rising. In addition, there are several hundred 'substantial' part-time doctors, who, in many instances, provide a similar service. There is a much larger number of highly 'unsubstantial' part-timers, even untrained, who can for the present purpose be ignored. About 40 take a DIH or equivalent course annually but these do not all stay in this country.
It is important to consider occupations in total rather than industry as a specialized kind of occupation. Some of the fastest-growing Occupational Health Services are those for hospitals and universities and perhaps also for local authority employees. The rather random developments in these areas highlighted the need to signpost more clearly the occupational health road at the present time. It is much harder to get good figures for the number of nurses employed; and here the variation in training and job description is even wider, particularly among those working single-handed with little or no qualified supervision. The Royal College of Nursing estimate that some 2000 have taken the Occupational Health Nursing Certificate and an increasing number (presently about 130 and increasing) qualify in this specialty annually. In addition, there is a growing number of industrial hygiene teams composed of scientists and technicians from different disciplines and it appears likely that future developments will lend everincreasing importance to the environmental aspects of the work. Qualifications are harder to define here but the British Occupational Hygiene Society qualifications are taken by about a dozen people annually. Fully qualified practitioners may total under 100. The distribution of these resources in industry is varied. In general, while some quite small concerns have very full services, the most fully developed lie in the areas of the nationalized industries such as the National Coal Board, the Post Office, the British Steel Corporation, London Transport, British Rail, the Atomic Energy Authority, large private concerns such as ICI, Unilever, oil companies, the car industry, and government departments such as the Ministry of Defence. In spite of the general slow growth, there is also some lost ground. For example, when English Electric were swallowed by GEC, an 31
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 19, 2015
KENNETH P. DUNCAN
32
OCCUPATIONAL MEDICINE
Duties Covered The functions of industry-sponsored occupational health services are as diverse as their organizational patterns. There is quite extensive literature on this; the Appendix, which is derived from the recent evidence by the Society of Occupational Medicine to the Pearson Committee, provides a fair summary of the present view, but the emphasis will vary from industry to industry. In the steel industry, with huge works employing tens of thousands and a high serious-accident rate, much more elaborate treatment facilities will be provided than in an industry such as the Post Office. Again, science-based organizations such as the Atomic Energy Authority or ICI might be expected to have a highly developed research and technical content in their services. A further stimulus is the existence of a grave hazard, and the NCB's great contribution to pneumoconiosis studies is a fine example in this category. The central point is that some consideration has. to be made for all the functions enumerated in the Appendix as part of one integrated organization. It is true that all services recognize that some of the actions they undertake could be undertaken elsewhere, but a theoretical alternative provision which always removes the patient from the work situation to the physician has not up to this point commended itself to industrial managements. Many services were in fact set up to save time, money or absence though it is doubtful if they can really be justified in this way. It is obvious that all these functions are not going to be found in, or ever likely to be provided for, every work place in the country, and such provision may well not be necessary in any case. Future Developments There are financial factors which have not been covered but, strangely enough in this case, they may
not be the primary problem. The two present problems which are the subject of discussion quite often are (a.) the shortage of doctors and (b.) that the health services in this country are founded on the family practitioner service. The first argument would be valid if doctors in industry were used in some particularly wasteful role; until relatively recent years this may have been true as there was an obsession with routine medical examination and an unwillingness to delegate tasks to others in the health and health ancillary professions. In large measure this has now been overcome by better study of the medical role in industry and by better training of those entering the field. This training applies not only to doctors but also to nurses and health-related professions. What we still need is more training of managers to increase their understanding of the potential of their services. The opportunity now exists in the discussions going on about the appropriate preparation for specialist registration to guide this process even more formally in the correct direction. The second argument is much less valid than may appear at first glance. Very few general practitioners are equipped or anxious to do the type of work which is envisaged in the Appendix, only in very exceptional circumstances could a family doctor fill the full role and, in any case, the idea of a personal doctor who regards the patient as his own personal possession should be of historical interest only. Where there may well be scope for much greater cooperation is in the provision of casualty and out-patient services on industrial premises or at health centres associated with industrial estates; an organizational approach embodying this aspect was discussed in the concept of the proposed medical services for Milton Keynes (Middle Article, British Medical Journal, 1969). That approach still seems valid; perhaps with the passage of the years since the original report one would now put more emphasis on the development of technical and environmental services as part of the unit because it seems likely that the tendency to stricter environmental control will continue and the clinical toxicological role will diminish. However, the general clinical role of fitting people to tasks becomes even more demanding as the nature of industry changes and manning requirements become even tighter. There is no doubt that environmental standards will become stricter. Where risks are known and
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 19, 2015
established service was disbanded. This highlights the need for consideration of management philosophy. The problems of grouping small industries together are obvious; various attempts to do this by the mechanism of a group service, such as those at Dundee, Harlow, Rochdale, West Bromwich and Slough, have been made though expansion has been slow. Further progress is being made but large expansion seems unlikely.
HEALTH CARE
quantified, technical and medical experts are largely successful in combating them. However, our progress in ergonomics, in industrial mental health, non-physical stress and social psychology is nothing like so impressive. There are many strongly held opinions untroubled by scientifically researched facts in all those areas. Much of this work should be done inside occupational health services with the fullest worker support, and this will only be achieved if the service's scientific integrity is credible.
largest part but this brings its own problems. Joint consultation is, as yet, rarely genuine enough and suspicions, usually financially directed suspicions, are common among trade unionists. There has to be much clearer thought about the financial contribution made by occupational health services. In this country, with an NHS, they all cost money. Their professional independence is also worth a glance. Personal experience is that this is complete, but some safeguard might well be wise. These are not new thoughts nor original questions, but the various reorganizations now going on present an opportunity for quite radical thinking and decision making that may not come again for many years. Acknowledgements These notes are from discussions with many people. I would particularly acknowledge advice and help from Professor Mair, Dr Peter Taylor and Dr Robert Murray—though the views expressed are personal.
REFERENCES Davies L. T. A. (1973) Whither occupational medicine? Proceedings of The Royal Society of Medicine 66, 818. Middle Article (1969) Milton Keynes. A Joint Approach to Planning. British Medical Journal 1, 628. Safety and Health at Work (1972) Report of Robens Committee, 1970-72. Cmnd 5034. London, HMSO.
Appendix Occupational medicine is concerned with three main activities: 1. Preventive medicine—primary prevention. 2. Clinical medicine—secondary prevention. 3. Research. The various activities under these three headings are listed below in some detail. The functions of safety, health and welfare in industry are becoming increasingly combined in a single unit, and it is usually an occupational health doctor who heads the team. Primary Prevention This activity is carried out in liaison with industrial hygienists, chemists and engineers. 1. Knowledge of existing plant and process. 2. Identifying and measuring environmental hazards with advice to management where hazard is dangerous. (These hazards include heat, dust, noise, radiation, etc., together with a large number of toxic substances.)
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 19, 2015
Discussion It is important to look at the needs rather than to consider present government departmental factors or historical frontiers between various parts of medicine. If these needs are looked at with regard to the nature of the present provisions it seems that a role could be specified for the Employment Medical Advisory Service, wherever located in government, to provide guidance for the very many smaller industries that for the foreseeable future will be unable to provide their own service, and to link in a shared partnership with the larger organizations as they develop their own service along the lines indicated here. A more controversial but probably essential role for the EMAS is that of setting and monitoring the standards of industry-based services. As these services develop, the career path both for young doctors and nurses coming into occupational medicine will become clearer and their professionalism greater. Environmental science development will push forward obtainable standards of health and safety. In parallel with this there has to be a review of the mechanisms by which essential clinical and special treatment services are to be provided in industrial populations and to the ever-increasing role of occupational health services in mental health. It is hard not to be forced to the conclusion that the present departmental allocation of responsibilities may be blurring some of these issues. A part of our present purpose should be to seek the path for organized development that is based on the improvement of services because this improvement is clearly and urgently needed. The quality of a service cannot be divorced from the motivation for its construction and the ethos it has developed. It is a cliche to say that management must be responsible for health and safety. It has been management initiative which has played the
33
34
OCCUPATIONAL MEDICINE
Secondary Prevention 1. Treatment of injury and illness arising at work— involving such systems as skins, eyes, chest, etc. 2. First-aid training. 3. Rehabilitation and assessment after illness and injury with resettlement in suitable work. 4. Supervision of a broad spectrum of medical care
including nursing services, physiotherapy, sight testing, audiometry, respiratory physiology, X-rays, blood and urine examinations, etc. 5. Screening new employees. 6. Examining employees for public safety—crane and loco drivers, heavy goods vehicle drivers, etc. 7. Biological monitoring (see Prevention). 8. Disaster training and rescue. 9. Health education. 10. Mental health and stress factors. Research 1. Provision of effective system for recording data derived from total health programme. 2. Research to provide statistical evidence of health hazard, e.g. general mortality and morbidity surveys. 3. Ad hoc statistical and prospective studies of particular groups. 4. Studies to validate provisionally established threshold limit values. 5. Specialized physiological, radiological, audiometric or other projects. 6. Trials of proposed protective substances or systems. 7. Associated clinical and 'natural history of disease' investigations.
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 19, 2015
3. Substitution by less toxic materials, and elimination of hazards. 4. Containment. Enclosure of plant, exhaust ventilation, enclosure of men. 5. Advising management and the workforce on the use of personal protective devices, e.g. special clothing, respirators, ear muffs, etc. 6. Biological monitoring of exposed personnel (chest X-rays, examination of blood, urine, audiometry, respiratory physiology). 7. Planning of new processes to eliminate potential toxic and health hazards at the drawing-board stage. 8. Ergonomic studies of work and machinery to make the task easier to perform. 9. Hygiene inspection of kitchens and cooking facilities. 10. Liaison with safety function in accident prevention, including disaster contingency planning.
Health Care of People at Work in Britain Occupational Health Services Director of Medical Services, Health and Safety Executive Occupational Health Services are spread unevenly across the United Kingdom; they are uneven in quality and activity and they are uneven in geographical and occupational distribution. Present Industry-based Services It is not proposed to discuss here the scope and purpose of governmental activity in this field. The relevant agencies, and notably the EMAS, have been well described elsewhere (Davies, 1973). Suffice it to say that in terms of medical or perhaps more importantly nursing manpower, industryprovided services dwarf the official governmental arrangements. Size alone is no guarantee of worth and consequently we must assess whether the industry-provided machineries are essential, useful or extravagantly redundant. It is necessary only to refer in passing to the comments on this subject in Chapter 12 of the Robens Report (Safety and Health at Work, 1972); these were as ill informed as they were unhelpful and stand merely as a commemorative symbol of an era of friction between a government department and those working in the field. As such, like other memorials, they have a chastening merit in pleading the avoidance of repeated error, but they should not be allowed to become enchanted relics for those anxious to keep scars painful and to perpetuate bitterness. There are at present about 700 full-time doctors in industry, and, if membership of the Society of Occupational Medicine is any guide, that number is slowly rising. In addition, there are several hundred 'substantial' part-time doctors, who, in many instances, provide a similar service. There is a much larger number of highly 'unsubstantial' part-timers, even untrained, who can for the present purpose be ignored. About 40 take a DIH or equivalent course annually but these do not all stay in this country.
It is important to consider occupations in total rather than industry as a specialized kind of occupation. Some of the fastest-growing Occupational Health Services are those for hospitals and universities and perhaps also for local authority employees. The rather random developments in these areas highlighted the need to signpost more clearly the occupational health road at the present time. It is much harder to get good figures for the number of nurses employed; and here the variation in training and job description is even wider, particularly among those working single-handed with little or no qualified supervision. The Royal College of Nursing estimate that some 2000 have taken the Occupational Health Nursing Certificate and an increasing number (presently about 130 and increasing) qualify in this specialty annually. In addition, there is a growing number of industrial hygiene teams composed of scientists and technicians from different disciplines and it appears likely that future developments will lend everincreasing importance to the environmental aspects of the work. Qualifications are harder to define here but the British Occupational Hygiene Society qualifications are taken by about a dozen people annually. Fully qualified practitioners may total under 100. The distribution of these resources in industry is varied. In general, while some quite small concerns have very full services, the most fully developed lie in the areas of the nationalized industries such as the National Coal Board, the Post Office, the British Steel Corporation, London Transport, British Rail, the Atomic Energy Authority, large private concerns such as ICI, Unilever, oil companies, the car industry, and government departments such as the Ministry of Defence. In spite of the general slow growth, there is also some lost ground. For example, when English Electric were swallowed by GEC, an 31
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 19, 2015
KENNETH P. DUNCAN
32
OCCUPATIONAL MEDICINE
Duties Covered The functions of industry-sponsored occupational health services are as diverse as their organizational patterns. There is quite extensive literature on this; the Appendix, which is derived from the recent evidence by the Society of Occupational Medicine to the Pearson Committee, provides a fair summary of the present view, but the emphasis will vary from industry to industry. In the steel industry, with huge works employing tens of thousands and a high serious-accident rate, much more elaborate treatment facilities will be provided than in an industry such as the Post Office. Again, science-based organizations such as the Atomic Energy Authority or ICI might be expected to have a highly developed research and technical content in their services. A further stimulus is the existence of a grave hazard, and the NCB's great contribution to pneumoconiosis studies is a fine example in this category. The central point is that some consideration has. to be made for all the functions enumerated in the Appendix as part of one integrated organization. It is true that all services recognize that some of the actions they undertake could be undertaken elsewhere, but a theoretical alternative provision which always removes the patient from the work situation to the physician has not up to this point commended itself to industrial managements. Many services were in fact set up to save time, money or absence though it is doubtful if they can really be justified in this way. It is obvious that all these functions are not going to be found in, or ever likely to be provided for, every work place in the country, and such provision may well not be necessary in any case. Future Developments There are financial factors which have not been covered but, strangely enough in this case, they may
not be the primary problem. The two present problems which are the subject of discussion quite often are (a.) the shortage of doctors and (b.) that the health services in this country are founded on the family practitioner service. The first argument would be valid if doctors in industry were used in some particularly wasteful role; until relatively recent years this may have been true as there was an obsession with routine medical examination and an unwillingness to delegate tasks to others in the health and health ancillary professions. In large measure this has now been overcome by better study of the medical role in industry and by better training of those entering the field. This training applies not only to doctors but also to nurses and health-related professions. What we still need is more training of managers to increase their understanding of the potential of their services. The opportunity now exists in the discussions going on about the appropriate preparation for specialist registration to guide this process even more formally in the correct direction. The second argument is much less valid than may appear at first glance. Very few general practitioners are equipped or anxious to do the type of work which is envisaged in the Appendix, only in very exceptional circumstances could a family doctor fill the full role and, in any case, the idea of a personal doctor who regards the patient as his own personal possession should be of historical interest only. Where there may well be scope for much greater cooperation is in the provision of casualty and out-patient services on industrial premises or at health centres associated with industrial estates; an organizational approach embodying this aspect was discussed in the concept of the proposed medical services for Milton Keynes (Middle Article, British Medical Journal, 1969). That approach still seems valid; perhaps with the passage of the years since the original report one would now put more emphasis on the development of technical and environmental services as part of the unit because it seems likely that the tendency to stricter environmental control will continue and the clinical toxicological role will diminish. However, the general clinical role of fitting people to tasks becomes even more demanding as the nature of industry changes and manning requirements become even tighter. There is no doubt that environmental standards will become stricter. Where risks are known and
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 19, 2015
established service was disbanded. This highlights the need for consideration of management philosophy. The problems of grouping small industries together are obvious; various attempts to do this by the mechanism of a group service, such as those at Dundee, Harlow, Rochdale, West Bromwich and Slough, have been made though expansion has been slow. Further progress is being made but large expansion seems unlikely.
HEALTH CARE
quantified, technical and medical experts are largely successful in combating them. However, our progress in ergonomics, in industrial mental health, non-physical stress and social psychology is nothing like so impressive. There are many strongly held opinions untroubled by scientifically researched facts in all those areas. Much of this work should be done inside occupational health services with the fullest worker support, and this will only be achieved if the service's scientific integrity is credible.
largest part but this brings its own problems. Joint consultation is, as yet, rarely genuine enough and suspicions, usually financially directed suspicions, are common among trade unionists. There has to be much clearer thought about the financial contribution made by occupational health services. In this country, with an NHS, they all cost money. Their professional independence is also worth a glance. Personal experience is that this is complete, but some safeguard might well be wise. These are not new thoughts nor original questions, but the various reorganizations now going on present an opportunity for quite radical thinking and decision making that may not come again for many years. Acknowledgements These notes are from discussions with many people. I would particularly acknowledge advice and help from Professor Mair, Dr Peter Taylor and Dr Robert Murray—though the views expressed are personal.
REFERENCES Davies L. T. A. (1973) Whither occupational medicine? Proceedings of The Royal Society of Medicine 66, 818. Middle Article (1969) Milton Keynes. A Joint Approach to Planning. British Medical Journal 1, 628. Safety and Health at Work (1972) Report of Robens Committee, 1970-72. Cmnd 5034. London, HMSO.
Appendix Occupational medicine is concerned with three main activities: 1. Preventive medicine—primary prevention. 2. Clinical medicine—secondary prevention. 3. Research. The various activities under these three headings are listed below in some detail. The functions of safety, health and welfare in industry are becoming increasingly combined in a single unit, and it is usually an occupational health doctor who heads the team. Primary Prevention This activity is carried out in liaison with industrial hygienists, chemists and engineers. 1. Knowledge of existing plant and process. 2. Identifying and measuring environmental hazards with advice to management where hazard is dangerous. (These hazards include heat, dust, noise, radiation, etc., together with a large number of toxic substances.)
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 19, 2015
Discussion It is important to look at the needs rather than to consider present government departmental factors or historical frontiers between various parts of medicine. If these needs are looked at with regard to the nature of the present provisions it seems that a role could be specified for the Employment Medical Advisory Service, wherever located in government, to provide guidance for the very many smaller industries that for the foreseeable future will be unable to provide their own service, and to link in a shared partnership with the larger organizations as they develop their own service along the lines indicated here. A more controversial but probably essential role for the EMAS is that of setting and monitoring the standards of industry-based services. As these services develop, the career path both for young doctors and nurses coming into occupational medicine will become clearer and their professionalism greater. Environmental science development will push forward obtainable standards of health and safety. In parallel with this there has to be a review of the mechanisms by which essential clinical and special treatment services are to be provided in industrial populations and to the ever-increasing role of occupational health services in mental health. It is hard not to be forced to the conclusion that the present departmental allocation of responsibilities may be blurring some of these issues. A part of our present purpose should be to seek the path for organized development that is based on the improvement of services because this improvement is clearly and urgently needed. The quality of a service cannot be divorced from the motivation for its construction and the ethos it has developed. It is a cliche to say that management must be responsible for health and safety. It has been management initiative which has played the
33
34
OCCUPATIONAL MEDICINE
Secondary Prevention 1. Treatment of injury and illness arising at work— involving such systems as skins, eyes, chest, etc. 2. First-aid training. 3. Rehabilitation and assessment after illness and injury with resettlement in suitable work. 4. Supervision of a broad spectrum of medical care
including nursing services, physiotherapy, sight testing, audiometry, respiratory physiology, X-rays, blood and urine examinations, etc. 5. Screening new employees. 6. Examining employees for public safety—crane and loco drivers, heavy goods vehicle drivers, etc. 7. Biological monitoring (see Prevention). 8. Disaster training and rescue. 9. Health education. 10. Mental health and stress factors. Research 1. Provision of effective system for recording data derived from total health programme. 2. Research to provide statistical evidence of health hazard, e.g. general mortality and morbidity surveys. 3. Ad hoc statistical and prospective studies of particular groups. 4. Studies to validate provisionally established threshold limit values. 5. Specialized physiological, radiological, audiometric or other projects. 6. Trials of proposed protective substances or systems. 7. Associated clinical and 'natural history of disease' investigations.
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 19, 2015
3. Substitution by less toxic materials, and elimination of hazards. 4. Containment. Enclosure of plant, exhaust ventilation, enclosure of men. 5. Advising management and the workforce on the use of personal protective devices, e.g. special clothing, respirators, ear muffs, etc. 6. Biological monitoring of exposed personnel (chest X-rays, examination of blood, urine, audiometry, respiratory physiology). 7. Planning of new processes to eliminate potential toxic and health hazards at the drawing-board stage. 8. Ergonomic studies of work and machinery to make the task easier to perform. 9. Hygiene inspection of kitchens and cooking facilities. 10. Liaison with safety function in accident prevention, including disaster contingency planning.
