246 about the
working conditions is the responsibility and prerogative of the employer, though under the new legislation, this should be made in consultation with representatives ofworkers. The employer can sometimes silence the object of my affection with gewgaws or promises to abandon his commitment to me. The temptation of danger money, dirty money, nuisance money, or just money may dazzle his naive eyes, but now that the worker is being given by the new law a measure of responsibility for health and safety, the wisdom to see through the meretricious, I may make an honest woman of her yet. The worker is of course wooed by political and academic seducers. The political seducer asks why the worker should wash the dishes or scrub the floor or bake the cakes. It is the masters who should carry out these chores. There is a certain measure of poetic justice about the reversal of the upstairs downstairs situation, but it would create endless confusion for too long, in the course of which my sympathies might revert to the downtrodden masters as the victims of exploitation. The academic Casanovas are those with pure ideas of pre Raphaelite perfection who cannot bear to see a worker or any member of his family sullied with a particle of lead or asbestos and spend much ingenuity in persuading the general public that all its ills can be traced to the presence of one or other sinister pollutant. Most of them have never had to deal with the real worker or to cope with a real industrial situation. They are aesthetes and as ridiculous as Gilbert made them appear in &dquo;Patience&dquo;. They are greenery-yallery characters which no self-respecting red blooded female should have anything to do with. Aspirations to days of wine and roses are valid enough, but the real world has to have some sweat and toil in it as well. &dquo;BUT THE DEAR KNOWS WHO I’LL MARRY&dquo; THERE
ARE
many alternatives to monogamy. Already has had a liaison with the Home
occupational health
Office, the Ministry of Labour and the Department of
Employment and
now
the Health and
Safety Executive.
many arguments in favour of remaining single though in this present permissive society there would inevitably be a great deal of promiscuity. Another suggestion might be to have a menage à trois. The new Health and Safety at Work Etc. Act raises acutely the problem of what occupational health is and of where and how should it be administered. Time was when the subject was confined to the classical occupational diseases, but now when these are disappearing and the effects of work are merging ever more closely with the general problems of disease in the community and as
There
are
standards are engendering greater expectations on the part of workers, there is a need for reappraisal of the nature of the problem, in particular how those provisions concerned with the health and safety of workers can most effectively be brought together to maintain and improve these standards and to enhance the capacity of industry on which the country depends for its prosperity to
rising
operate
as
efficiently
as
possible.
If monogamy is to be insisted upon for socio-anthropological or respectability reasons, then occupational medicine, nursing, hygiene, and ergonomics ought to be part of the Department of Health and Social Security, leaving considerations of safety with the present Executive. This is obviously an unsatisfactory arrangement because the amount of cross-fertilization and inbreeding may well produce symptoms of social embarrassment to the most permissive society. None the less the time is now ripe and the wording of the new legislation is sufficiently flexible for a joint meeting of the Secretaries of State of Health and Employment to decide how the various aspects of occupational health have to be administered. With my own calvinistic background, if I have to decide to marry, I would rather go to the Department of Health and Social Security though I would prefer to retain a close and not improper, if not entirely platonic, liaison with the Health and Safety even
Executive.
(b) WHITHER OCCUPATIONAL MEDICINE: THE RESPONSE TO NEW CHALLENGES SUZETTE GAUVAIN, M.A., M.R.C.P., M.F.C.M., D.P.H., D.I.H. Acting Chief Employment Medical Adviser, Health and Safety Executive
HE concept of the need for medical intervention in the working environment started in the last century t
when
men, such as Owen, Shaftesbury and Chadwick, observed the effects of the industrial revolution on the working population and particularly on the health of
children. However, it 1844 that the four
was
not until the Factories Act of
Superintending Inspectors were appoint surgeons, &dquo;certifying factory the purpose of certifying that children
permitted to surgeons&dquo; for starting work in textile factories had the appearance and development appropriate to the youngest age at which
employment was permitted. It was then nine years. This was the beginning of the Appointed Factory Doctor (A.F.D.) system which lasted until 1973. ‘A.F.D.s’, who were normally general practitioners, were appointed by the Chief Inspector of Factories to carry out certain statutory duties under the Factories Act. The
most
of these were the medical examinations of all young persons in factory employment on entry to employment and at annual intervals until the age of 18, and the medical examinations required under the Act and Regulations of persons working in hazardous trades.
important
Downloaded from rsh.sagepub.com at NORTH CAROLINA STATE UNIV on April 13, 2015
247
The
employer paid
the A.F.D. for
carrying
out the
statutory medical examinations. The first medical
inspector of factories,
Sir Thomas
Legge,
was
appointed
in 1898. In 1939 a small group of doctors who were employed by industry met together to set up the Association of Industrial Medical Officers. From this small beginning the association has now become the Society of Occupational Medicine with a membership of over 1,000 doctors, its own medical journal, and regular scientific meetings. It has influenced profoundly the development of occupational medicine in Britain. In 1964 the Industrial Health Advisory Committee on which the Society of Occupational Medicine was represented and which advised the Minister of Labour on all matters relating to industrial health, set up a subcommittee to review the A.F.D. service in the light of modern social conditions. The sub-committee’s report published in 1966 unanimously recommended a number of changes both in the duties of A.F.D.s and the organization of the A.F.D. service. In particular they advised that: (a) The routine medical examinations of young persons under the Factories Act should be abandoned in favour of a more selective system concentrating on those young persons in need of medical advice; (b) The 1,500 A.F.D.s with their narrow range of statutory duties should be replaced by a much smaller number of doctors with a wider range of duties and more expertise in occupational health matters. These recommendations were accepted by the then Minister of Labour. Meanwhile the Medical Inspectorate had increased in size. In 1970 there were 22 medical in addition, they were joined by the 48 medical officers employed part-time to advise on rehabilitation problems and to provide general medical supervision in Industrial Rehabilitation Units and Government Training Centres, originally provided as a result of the Disabled Persons Act 1944. The Medical Inspectorate was now the Medical Services Division of the Department of Employment. The scene was being set rapidly for the initiation of
inspectors and,
major changes. The Robens Committee under the chairmanship of Lord Robens, had been sittirig since 1970 and in 1972, their Report on Safety and Health at Work was published. Dr. Lloyd Davies, Chief Employment Medical Adviser, in his presidential address to the Section of Occupational Medicine at the Royal Society of Medicine, 25 January 1973 stated: &dquo;Clearly after 128 years of statutory fossilization a new look is wanted. The Robens Report (1972) says this cannot be based on a priori argument and it is by no means clear that more physicians in industry mean greater health or efficiency. What sort of medical intervention is wanted in the affairs of industry and when? Both questions must be answered in terms of demonstrable benefit commensurate with the manpower and resources committed.&dquo; On the first day of February 1973 a turning point occurred in the development of occupational medicine in this country. On that date the Employment Medical Advisory Service, set up by the Department of Employment under the Employment Medical Advisory Service Act 1972, came into operation. From then on, for the first time a nationwide service has been available to give advice about the medical aspects of all employment
problems.
In 1974 The Health and Safety at Work etc. Act received the Royal Assent implementing the main recommendations of the Roben’s Report (1972).
This has resulted in the setting up of the Commission Health and Safety, and the Health and Safety Executive about which you will hear from the Chairman of the Commission, Mr. Bill Simpson. on
THE EMPLOYMENT MEDICAL ADVISORY SERVICE (E.M.A.S.) THE EMPLOYMENT Medical Advisory Service has become the medical arm of the Health and Safety Executive. The Director of Medical Services and Head of E.M.A.S. has a seat on the Management Board of the Health and Safety Executive and is responsible for giving medical advice to all the members, which include the Heads of the other Inspectorates, the Directors of the Hazardous Substances Group, the Safety and General Group, Research and Legal Services. In addition to this responsibility E.M.A.S., through the Health and Safety Executive, provides medical advice to the Manpower Services Commission. Following the 1973 Employment and Training Act, the Department of Employment’s Employment and Training Services have been re-organized and have become the responsibility of the new Manpower Services Commission, which has two executive agencies,he Employment Service Agency and the Training Services Agency. Employment (industrial) rehabilitation and re-settlement services for disabled people are the responsibility of the Employment Service Agency; training in Skillcentres (Government Training Centres) is the responsibility of the Training Services Agency. Employment Medical Advisers and their nurses have medical centres in the Employment Rehabilitation Centres (E.R.C.s) and Skillcentres in which they conduct medical examinations and provide medical advice to rehabilitees and trainees
employment problems. Through the Health and Safety Executive E.M.A.S. continues to have responsibility for providing medical advice on all employment problems to the Secretary of State for Employment. It also has a similar responsibility towards the Advisory, Conciliation and Arbitration Service. This Service is independent of the Department of on
Employment, and the Council has a full-time Chairman and nine part-time members, three representing the C.B.I. three the T.U.C., and three independent members, as do the Manpower Services and the Health and Safety Commissions. NEW CHALLENGES
THE
of E.M.A.S. having been the Employment Medical Advisory Service should now be considered. Are we in a position to respond and how can we set about being more effective in reacting to these new RESPONSIBILITIES
outlined,
the
new
challenges facing
challenges ? take Dr. Lloyd Davies’ first point &dquo;It is by no clear that more physicians in industry mean greater health or efficiency.&dquo; To come anywhere near to answering this proposition we must consider whether the occupational physician is in fact the professional who will provide greater health and efficiency. In many cases what may well be needed is the engineer to provide engineering control and safer working conditions, in conjunction with the occupational hygienist who will monitor the environment and the safety officer or adviser who will ensure that the management and employees appreciate the need for safe or safer working conditions. The Factory Inspector will be able to give advice on all these aspects, Let
us
means
Downloaded from rsh.sagepub.com at NORTH CAROLINA STATE UNIV on April 13, 2015
248 and under the Health and Safety at Work etc Act 1974, ensure that satisfactory working conditions exist. The role of the occupational physician and the occupational health nurse will be in the field of clinical appreciation of a hazard to health, biological monitoring and epidemiological studies of morbidity and mortality. In industry first-aid will be provided. In large industries, with their own occupational health services, facilities for emergency treatment are available, though treatment is the responsibility of the National Health Service through general practitioners and the hospital service. I do not decry the role of the occupational physician. It is immensely important, but far more effective in co-operation with the other members of the occupational health team. The Employment Medical Advisory Service has access to the necessary expertise in the Health and Safety Executive. Whether or not we have sufficient doctors and nurses in our own service at the present time I cannot say, since we are in the process of assessing our needs and determining whether our facilities match up to these needs in operational research exercises. I believe we shall find that we need more expert staff at headquarters, that in some, or probably all, of the regions we shall need more nurses and that in some areas we may need less doctor time and in others more.
HEADQUARTERS
AND A REGIONAL ORGANIZ-
ATION HOUSES representatives of the expertise in the Service-specialists in epidemiology, statistics, toxicology, mental health, rehabilitation and advice and information on all occupational
HEADQUARTERS
necessary
medical matters. These facilities are at the service of the regions. Research is co-ordinated at headquarters. To be effective it depends on the co-operation and expertise in the regions. Policy and direction must come from headquarters, but this policy must be flexible, and influenced by the advice and alerting service on newly suspected hazards fed into headquarters by the staff in the regions and other sources including the branches of the Health and Safety Executive. Additional research potential is provided through the transferred funds allotted to the Health and Safety Commission under the terms of the Rothschild Report (1971) for its use with the Medical Research Council on topics requiring further or new research. In summary, health and efficiency depend on an expert, highly trained, advisory medical service working in conjunction with other branches of the Health and Safety Executive, Government Departments, particularly the Department of Health and Social Security, the C.B.I. (management) and the Trade Unions (employees). How this may be achieved in practice is exemplified by the working party set up by the Chief Inspector of Factories to formulate the Code of Practice on vinyl chloride, health and safety precautions in manufacture. In addition to the Inspectorate and E.M.A.S., the C.B.I., the T.U.C., D.H.S.S. and the Department of the Environment were represented. Two working groups, one environmental and the other medical, were set up on which all sides were represented. On the environmental working party were members of the Inspectorate, engineers and hygienists from industry, and the T.U.C. On the medical working party were representatives of industry who were occupational physicians, the medical adviser to the T.U.C.,and a member of the T.U.C. as well as the Employment Medical Advisory Service and the Department of Health and Social Security. A co-operative venture of this type
effective than an occupational physician working own. I believe this presages a pattern for the future which should help to ensure health and efficiency. A corollary to the need for efficiency in occupational health matters is the need for training of physicians and nurses. The role of the University Departments of occupational health and the Royal College of Nursing in the provision of training is of paramount importance. In-service training in the field and through specially organized courses within our own service is one aspect, but academic training leading to higher degrees and diplomas is essential for the provision of an expert service. is
more
on
his
WHAT SORT AND WHEN?
OF
MEDICAL
INTERVENTION
OCCUPATIONAL PHYSICIANS in private industry need to be acquainted with new information which may affect the health of the workers for whom they are responsible, equally a State advisory service needs to receive information from doctors working in industry who may, from their own clinical observations or in other ways, suspect that there may be a new or emerging hazard to health. Two-way communication is essential in order that medical intervention may take place at a stage of intellectual suspicion rather than when a hazard to health is an established fact. There will be a network of committees to advise the Health and Safety Commission in which both sides of industry and experts, including medical experts, will be
represented. Statutory medical examinations have developed on an historical basis. The efficiency of these examinations will need to be reviewed. Medical screening techniques which are specified and effective in measuring the health of the individual and the group will need to be continuously developed. In order that epidemiological studies can take place these examinations will need to be recorded in such a way that the findings can be used for statistical analysis. Planning in advance with these objectives in mind is essential if progress is to take place. Again, I would state that this desired co-operation and agreed planning is being achieve in the studies being undertaken on vinyl chloride workers. Management and workers must be fully informed of the hazards that are suspected and of the precautions which are being taken to endeavour to prevent occupational disease. In short, medical intervention should be early, at the stage of prevention. BENEFIT COMMENSURATE WITH MANPOWER AND RESOURCES JUDGMENT ON this aspect can be anticipated to some by careful planning and by learning from past experience in previous exercises. Planning must take into account the objectives of the exercise, validation of screening tests, sparing use of appropriate personnel in full consultation with statisticians and epidemiologists. Future generations will judge whether or not health and efficiency has been achieved. We must, however, endeavour to plan our actions in such a way that this judgment is likely to be favourable. The resources of the country in terms of money and medical and nursing manpower are limited. We are, I believe, in a position to respond to these new challenges, but we must remain flexible. We must not be afraid to look at ourselves and to be looked at critically, and we extent
Downloaded from rsh.sagepub.com at NORTH CAROLINA STATE UNIV on April 13, 2015
249 must be prepared to make changes in order that we may react quickly and efficiently to these new challenges. REFERENCES Employment and Training Act 1973, H.M.S.O., London Employment Medical Advisory Service Act 1972, H.M.S.O., London
Framework for Government Record and Development 1972, H.M.S.O., London Health and Safety at Work etc Act 1974, H.M.S.O. London LLOYD DAVIES, T. A. (1973). Whither Occupational Medicine. , 818-822 Proceedings Royal Society of Medicine 66 Safety and Health at Work. Report of the Committee 1970-72 (Chairman, Lord Robens). H.M.S.O., London.
(c) THE HEALTH AND SAFETY AT WORK ETC. ACT 1974
W. SIMPSON
Chairman, Health and Safety HE Health and Safety at Work Act has been t described as the most significant advance in the of health and safety at work since the Shaft-
field
esbury Factory Act of 1833. The objective of the early Factory Acts was to protect workers in the textile industries; subsequently legislation was introduced for other industries, particularly the mines and quarries. It is a long step from those early days, but a summary of this early legislation is a useful background to the new Act and what it sets out to achieve.
THE EARLY ACT THE FIRST Act of 1802, then called the Health and Morals of Apprentices Act, was the result of investigations into the working conditions of children in textile factories and set out to limit the working conditions of apprentices and lay down general standards of heating, lighting and ventilation as well as their education. Though admirable in its intentions this Act was quite ineffective, as were other ad hoc measures in following years. In those days there were no consistent attempts to enforce regulations until the Shaftesbury Act of 1833, which was in effect the real turning point. This Act retained shorter hours though they were still long enough, extended the scope throughout the textile industries and, most important, introduced effective means of enforcement by the appointment of factory inspectors. These inspectors had rights of entry, powers to make rules and regulations, and orders to implement the Act. With the growth and ever changing pattern of industry in the nineteenth century, Acts proliferated, with intermittent attempts at consolidation ; each Act was the result of some transient propaganda about a particular hazard. Although by 1890 the Factory Inspectorates were well established throughout industry and were giving their attention to the physical environment of employees, it became very clear that it was impracticable to use Acts of Parliament to lay down detailed control over particular processes. The statutes of 1891 and 1895 gave the Home Secretary powers to draw up special regulations for particular industrial activities, and to limit and prohibit the employment of certain categories of workers in various processes. Further consolidating Acts were introduced in the intervening years, culminating in the 1961 Factories Act.
Commission
During the nineteenth century other sectors of employsubject of safety legislation. An Act of 1842 forbad the employment of women and children underground; and the first Inspector of Mines was appointed a year later. The legislation and official enquiries culminated in the comprehensive safety provisions of the 1954 Mines and Quarries Act. Similar Acts were introduced over a widely spaced period of time relating to the railways, agriculture, nuclear installations, petroleum, and off-shore minerals. The Offices, Shops and Railway Premises Act of 1963 went a long way towards filling the gap of those workpeople who were without any statutory safety and health at work protection. Up to now a number of government departments have been controlling seven Inspectorates who in turn were dealing with nine statutes and over five hundred subordinate statutory instruments. Where the problem was spread over several government departments no one Inspectorate and its parent department could take any ment also became the
initiative at all without close and extensive consultation with other interested departments. Much of the existing legislation was either obsolete or inadequate; progress was slow-the pace of the slowest. These are some statistics: Every year nearly 1,000 people are killed by accidents at work-between three and four every working day. Between 500,000 and 700,000 are injured-between 2,000 and 3,000 every working day. Over twenty-three million working days are lost through absences from industrial accidents and prescribed diseases. Some 250,000 people are receiving disablement benefits, and some 30,000 wives have become widows. Faced with the conclusion that in dealing with such matters of life and death, of minor and serious injuries, of the plight of widows and families, it was impossible to consider continuing the old system, and impossible to avoid the conclusion that there had to be one central body to deal with all matters of safety and health at work. In 1967 Mr. Ray Gunter, then Minister of Labour, announced in the House that it was his intention to introduce a major Bill to consolidate existing legislation. This was developed further by Mrs. Barbara Castle, who invited Lord Robens to preside over a Committee on safety and health at work. The Robens Report, published in 1972, formed the basis of a Bill introduced by the then Conservative Government, it was lost when Parliament
Downloaded from rsh.sagepub.com at NORTH CAROLINA STATE UNIV on April 13, 2015
working conditions is the responsibility and prerogative of the employer, though under the new legislation, this should be made in consultation with representatives ofworkers. The employer can sometimes silence the object of my affection with gewgaws or promises to abandon his commitment to me. The temptation of danger money, dirty money, nuisance money, or just money may dazzle his naive eyes, but now that the worker is being given by the new law a measure of responsibility for health and safety, the wisdom to see through the meretricious, I may make an honest woman of her yet. The worker is of course wooed by political and academic seducers. The political seducer asks why the worker should wash the dishes or scrub the floor or bake the cakes. It is the masters who should carry out these chores. There is a certain measure of poetic justice about the reversal of the upstairs downstairs situation, but it would create endless confusion for too long, in the course of which my sympathies might revert to the downtrodden masters as the victims of exploitation. The academic Casanovas are those with pure ideas of pre Raphaelite perfection who cannot bear to see a worker or any member of his family sullied with a particle of lead or asbestos and spend much ingenuity in persuading the general public that all its ills can be traced to the presence of one or other sinister pollutant. Most of them have never had to deal with the real worker or to cope with a real industrial situation. They are aesthetes and as ridiculous as Gilbert made them appear in &dquo;Patience&dquo;. They are greenery-yallery characters which no self-respecting red blooded female should have anything to do with. Aspirations to days of wine and roses are valid enough, but the real world has to have some sweat and toil in it as well. &dquo;BUT THE DEAR KNOWS WHO I’LL MARRY&dquo; THERE
ARE
many alternatives to monogamy. Already has had a liaison with the Home
occupational health
Office, the Ministry of Labour and the Department of
Employment and
now
the Health and
Safety Executive.
many arguments in favour of remaining single though in this present permissive society there would inevitably be a great deal of promiscuity. Another suggestion might be to have a menage à trois. The new Health and Safety at Work Etc. Act raises acutely the problem of what occupational health is and of where and how should it be administered. Time was when the subject was confined to the classical occupational diseases, but now when these are disappearing and the effects of work are merging ever more closely with the general problems of disease in the community and as
There
are
standards are engendering greater expectations on the part of workers, there is a need for reappraisal of the nature of the problem, in particular how those provisions concerned with the health and safety of workers can most effectively be brought together to maintain and improve these standards and to enhance the capacity of industry on which the country depends for its prosperity to
rising
operate
as
efficiently
as
possible.
If monogamy is to be insisted upon for socio-anthropological or respectability reasons, then occupational medicine, nursing, hygiene, and ergonomics ought to be part of the Department of Health and Social Security, leaving considerations of safety with the present Executive. This is obviously an unsatisfactory arrangement because the amount of cross-fertilization and inbreeding may well produce symptoms of social embarrassment to the most permissive society. None the less the time is now ripe and the wording of the new legislation is sufficiently flexible for a joint meeting of the Secretaries of State of Health and Employment to decide how the various aspects of occupational health have to be administered. With my own calvinistic background, if I have to decide to marry, I would rather go to the Department of Health and Social Security though I would prefer to retain a close and not improper, if not entirely platonic, liaison with the Health and Safety even
Executive.
(b) WHITHER OCCUPATIONAL MEDICINE: THE RESPONSE TO NEW CHALLENGES SUZETTE GAUVAIN, M.A., M.R.C.P., M.F.C.M., D.P.H., D.I.H. Acting Chief Employment Medical Adviser, Health and Safety Executive
HE concept of the need for medical intervention in the working environment started in the last century t
when
men, such as Owen, Shaftesbury and Chadwick, observed the effects of the industrial revolution on the working population and particularly on the health of
children. However, it 1844 that the four
was
not until the Factories Act of
Superintending Inspectors were appoint surgeons, &dquo;certifying factory the purpose of certifying that children
permitted to surgeons&dquo; for starting work in textile factories had the appearance and development appropriate to the youngest age at which
employment was permitted. It was then nine years. This was the beginning of the Appointed Factory Doctor (A.F.D.) system which lasted until 1973. ‘A.F.D.s’, who were normally general practitioners, were appointed by the Chief Inspector of Factories to carry out certain statutory duties under the Factories Act. The
most
of these were the medical examinations of all young persons in factory employment on entry to employment and at annual intervals until the age of 18, and the medical examinations required under the Act and Regulations of persons working in hazardous trades.
important
Downloaded from rsh.sagepub.com at NORTH CAROLINA STATE UNIV on April 13, 2015
247
The
employer paid
the A.F.D. for
carrying
out the
statutory medical examinations. The first medical
inspector of factories,
Sir Thomas
Legge,
was
appointed
in 1898. In 1939 a small group of doctors who were employed by industry met together to set up the Association of Industrial Medical Officers. From this small beginning the association has now become the Society of Occupational Medicine with a membership of over 1,000 doctors, its own medical journal, and regular scientific meetings. It has influenced profoundly the development of occupational medicine in Britain. In 1964 the Industrial Health Advisory Committee on which the Society of Occupational Medicine was represented and which advised the Minister of Labour on all matters relating to industrial health, set up a subcommittee to review the A.F.D. service in the light of modern social conditions. The sub-committee’s report published in 1966 unanimously recommended a number of changes both in the duties of A.F.D.s and the organization of the A.F.D. service. In particular they advised that: (a) The routine medical examinations of young persons under the Factories Act should be abandoned in favour of a more selective system concentrating on those young persons in need of medical advice; (b) The 1,500 A.F.D.s with their narrow range of statutory duties should be replaced by a much smaller number of doctors with a wider range of duties and more expertise in occupational health matters. These recommendations were accepted by the then Minister of Labour. Meanwhile the Medical Inspectorate had increased in size. In 1970 there were 22 medical in addition, they were joined by the 48 medical officers employed part-time to advise on rehabilitation problems and to provide general medical supervision in Industrial Rehabilitation Units and Government Training Centres, originally provided as a result of the Disabled Persons Act 1944. The Medical Inspectorate was now the Medical Services Division of the Department of Employment. The scene was being set rapidly for the initiation of
inspectors and,
major changes. The Robens Committee under the chairmanship of Lord Robens, had been sittirig since 1970 and in 1972, their Report on Safety and Health at Work was published. Dr. Lloyd Davies, Chief Employment Medical Adviser, in his presidential address to the Section of Occupational Medicine at the Royal Society of Medicine, 25 January 1973 stated: &dquo;Clearly after 128 years of statutory fossilization a new look is wanted. The Robens Report (1972) says this cannot be based on a priori argument and it is by no means clear that more physicians in industry mean greater health or efficiency. What sort of medical intervention is wanted in the affairs of industry and when? Both questions must be answered in terms of demonstrable benefit commensurate with the manpower and resources committed.&dquo; On the first day of February 1973 a turning point occurred in the development of occupational medicine in this country. On that date the Employment Medical Advisory Service, set up by the Department of Employment under the Employment Medical Advisory Service Act 1972, came into operation. From then on, for the first time a nationwide service has been available to give advice about the medical aspects of all employment
problems.
In 1974 The Health and Safety at Work etc. Act received the Royal Assent implementing the main recommendations of the Roben’s Report (1972).
This has resulted in the setting up of the Commission Health and Safety, and the Health and Safety Executive about which you will hear from the Chairman of the Commission, Mr. Bill Simpson. on
THE EMPLOYMENT MEDICAL ADVISORY SERVICE (E.M.A.S.) THE EMPLOYMENT Medical Advisory Service has become the medical arm of the Health and Safety Executive. The Director of Medical Services and Head of E.M.A.S. has a seat on the Management Board of the Health and Safety Executive and is responsible for giving medical advice to all the members, which include the Heads of the other Inspectorates, the Directors of the Hazardous Substances Group, the Safety and General Group, Research and Legal Services. In addition to this responsibility E.M.A.S., through the Health and Safety Executive, provides medical advice to the Manpower Services Commission. Following the 1973 Employment and Training Act, the Department of Employment’s Employment and Training Services have been re-organized and have become the responsibility of the new Manpower Services Commission, which has two executive agencies,he Employment Service Agency and the Training Services Agency. Employment (industrial) rehabilitation and re-settlement services for disabled people are the responsibility of the Employment Service Agency; training in Skillcentres (Government Training Centres) is the responsibility of the Training Services Agency. Employment Medical Advisers and their nurses have medical centres in the Employment Rehabilitation Centres (E.R.C.s) and Skillcentres in which they conduct medical examinations and provide medical advice to rehabilitees and trainees
employment problems. Through the Health and Safety Executive E.M.A.S. continues to have responsibility for providing medical advice on all employment problems to the Secretary of State for Employment. It also has a similar responsibility towards the Advisory, Conciliation and Arbitration Service. This Service is independent of the Department of on
Employment, and the Council has a full-time Chairman and nine part-time members, three representing the C.B.I. three the T.U.C., and three independent members, as do the Manpower Services and the Health and Safety Commissions. NEW CHALLENGES
THE
of E.M.A.S. having been the Employment Medical Advisory Service should now be considered. Are we in a position to respond and how can we set about being more effective in reacting to these new RESPONSIBILITIES
outlined,
the
new
challenges facing
challenges ? take Dr. Lloyd Davies’ first point &dquo;It is by no clear that more physicians in industry mean greater health or efficiency.&dquo; To come anywhere near to answering this proposition we must consider whether the occupational physician is in fact the professional who will provide greater health and efficiency. In many cases what may well be needed is the engineer to provide engineering control and safer working conditions, in conjunction with the occupational hygienist who will monitor the environment and the safety officer or adviser who will ensure that the management and employees appreciate the need for safe or safer working conditions. The Factory Inspector will be able to give advice on all these aspects, Let
us
means
Downloaded from rsh.sagepub.com at NORTH CAROLINA STATE UNIV on April 13, 2015
248 and under the Health and Safety at Work etc Act 1974, ensure that satisfactory working conditions exist. The role of the occupational physician and the occupational health nurse will be in the field of clinical appreciation of a hazard to health, biological monitoring and epidemiological studies of morbidity and mortality. In industry first-aid will be provided. In large industries, with their own occupational health services, facilities for emergency treatment are available, though treatment is the responsibility of the National Health Service through general practitioners and the hospital service. I do not decry the role of the occupational physician. It is immensely important, but far more effective in co-operation with the other members of the occupational health team. The Employment Medical Advisory Service has access to the necessary expertise in the Health and Safety Executive. Whether or not we have sufficient doctors and nurses in our own service at the present time I cannot say, since we are in the process of assessing our needs and determining whether our facilities match up to these needs in operational research exercises. I believe we shall find that we need more expert staff at headquarters, that in some, or probably all, of the regions we shall need more nurses and that in some areas we may need less doctor time and in others more.
HEADQUARTERS
AND A REGIONAL ORGANIZ-
ATION HOUSES representatives of the expertise in the Service-specialists in epidemiology, statistics, toxicology, mental health, rehabilitation and advice and information on all occupational
HEADQUARTERS
necessary
medical matters. These facilities are at the service of the regions. Research is co-ordinated at headquarters. To be effective it depends on the co-operation and expertise in the regions. Policy and direction must come from headquarters, but this policy must be flexible, and influenced by the advice and alerting service on newly suspected hazards fed into headquarters by the staff in the regions and other sources including the branches of the Health and Safety Executive. Additional research potential is provided through the transferred funds allotted to the Health and Safety Commission under the terms of the Rothschild Report (1971) for its use with the Medical Research Council on topics requiring further or new research. In summary, health and efficiency depend on an expert, highly trained, advisory medical service working in conjunction with other branches of the Health and Safety Executive, Government Departments, particularly the Department of Health and Social Security, the C.B.I. (management) and the Trade Unions (employees). How this may be achieved in practice is exemplified by the working party set up by the Chief Inspector of Factories to formulate the Code of Practice on vinyl chloride, health and safety precautions in manufacture. In addition to the Inspectorate and E.M.A.S., the C.B.I., the T.U.C., D.H.S.S. and the Department of the Environment were represented. Two working groups, one environmental and the other medical, were set up on which all sides were represented. On the environmental working party were members of the Inspectorate, engineers and hygienists from industry, and the T.U.C. On the medical working party were representatives of industry who were occupational physicians, the medical adviser to the T.U.C.,and a member of the T.U.C. as well as the Employment Medical Advisory Service and the Department of Health and Social Security. A co-operative venture of this type
effective than an occupational physician working own. I believe this presages a pattern for the future which should help to ensure health and efficiency. A corollary to the need for efficiency in occupational health matters is the need for training of physicians and nurses. The role of the University Departments of occupational health and the Royal College of Nursing in the provision of training is of paramount importance. In-service training in the field and through specially organized courses within our own service is one aspect, but academic training leading to higher degrees and diplomas is essential for the provision of an expert service. is
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WHAT SORT AND WHEN?
OF
MEDICAL
INTERVENTION
OCCUPATIONAL PHYSICIANS in private industry need to be acquainted with new information which may affect the health of the workers for whom they are responsible, equally a State advisory service needs to receive information from doctors working in industry who may, from their own clinical observations or in other ways, suspect that there may be a new or emerging hazard to health. Two-way communication is essential in order that medical intervention may take place at a stage of intellectual suspicion rather than when a hazard to health is an established fact. There will be a network of committees to advise the Health and Safety Commission in which both sides of industry and experts, including medical experts, will be
represented. Statutory medical examinations have developed on an historical basis. The efficiency of these examinations will need to be reviewed. Medical screening techniques which are specified and effective in measuring the health of the individual and the group will need to be continuously developed. In order that epidemiological studies can take place these examinations will need to be recorded in such a way that the findings can be used for statistical analysis. Planning in advance with these objectives in mind is essential if progress is to take place. Again, I would state that this desired co-operation and agreed planning is being achieve in the studies being undertaken on vinyl chloride workers. Management and workers must be fully informed of the hazards that are suspected and of the precautions which are being taken to endeavour to prevent occupational disease. In short, medical intervention should be early, at the stage of prevention. BENEFIT COMMENSURATE WITH MANPOWER AND RESOURCES JUDGMENT ON this aspect can be anticipated to some by careful planning and by learning from past experience in previous exercises. Planning must take into account the objectives of the exercise, validation of screening tests, sparing use of appropriate personnel in full consultation with statisticians and epidemiologists. Future generations will judge whether or not health and efficiency has been achieved. We must, however, endeavour to plan our actions in such a way that this judgment is likely to be favourable. The resources of the country in terms of money and medical and nursing manpower are limited. We are, I believe, in a position to respond to these new challenges, but we must remain flexible. We must not be afraid to look at ourselves and to be looked at critically, and we extent
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249 must be prepared to make changes in order that we may react quickly and efficiently to these new challenges. REFERENCES Employment and Training Act 1973, H.M.S.O., London Employment Medical Advisory Service Act 1972, H.M.S.O., London
Framework for Government Record and Development 1972, H.M.S.O., London Health and Safety at Work etc Act 1974, H.M.S.O. London LLOYD DAVIES, T. A. (1973). Whither Occupational Medicine. , 818-822 Proceedings Royal Society of Medicine 66 Safety and Health at Work. Report of the Committee 1970-72 (Chairman, Lord Robens). H.M.S.O., London.
(c) THE HEALTH AND SAFETY AT WORK ETC. ACT 1974
W. SIMPSON
Chairman, Health and Safety HE Health and Safety at Work Act has been t described as the most significant advance in the of health and safety at work since the Shaft-
field
esbury Factory Act of 1833. The objective of the early Factory Acts was to protect workers in the textile industries; subsequently legislation was introduced for other industries, particularly the mines and quarries. It is a long step from those early days, but a summary of this early legislation is a useful background to the new Act and what it sets out to achieve.
THE EARLY ACT THE FIRST Act of 1802, then called the Health and Morals of Apprentices Act, was the result of investigations into the working conditions of children in textile factories and set out to limit the working conditions of apprentices and lay down general standards of heating, lighting and ventilation as well as their education. Though admirable in its intentions this Act was quite ineffective, as were other ad hoc measures in following years. In those days there were no consistent attempts to enforce regulations until the Shaftesbury Act of 1833, which was in effect the real turning point. This Act retained shorter hours though they were still long enough, extended the scope throughout the textile industries and, most important, introduced effective means of enforcement by the appointment of factory inspectors. These inspectors had rights of entry, powers to make rules and regulations, and orders to implement the Act. With the growth and ever changing pattern of industry in the nineteenth century, Acts proliferated, with intermittent attempts at consolidation ; each Act was the result of some transient propaganda about a particular hazard. Although by 1890 the Factory Inspectorates were well established throughout industry and were giving their attention to the physical environment of employees, it became very clear that it was impracticable to use Acts of Parliament to lay down detailed control over particular processes. The statutes of 1891 and 1895 gave the Home Secretary powers to draw up special regulations for particular industrial activities, and to limit and prohibit the employment of certain categories of workers in various processes. Further consolidating Acts were introduced in the intervening years, culminating in the 1961 Factories Act.
Commission
During the nineteenth century other sectors of employsubject of safety legislation. An Act of 1842 forbad the employment of women and children underground; and the first Inspector of Mines was appointed a year later. The legislation and official enquiries culminated in the comprehensive safety provisions of the 1954 Mines and Quarries Act. Similar Acts were introduced over a widely spaced period of time relating to the railways, agriculture, nuclear installations, petroleum, and off-shore minerals. The Offices, Shops and Railway Premises Act of 1963 went a long way towards filling the gap of those workpeople who were without any statutory safety and health at work protection. Up to now a number of government departments have been controlling seven Inspectorates who in turn were dealing with nine statutes and over five hundred subordinate statutory instruments. Where the problem was spread over several government departments no one Inspectorate and its parent department could take any ment also became the
initiative at all without close and extensive consultation with other interested departments. Much of the existing legislation was either obsolete or inadequate; progress was slow-the pace of the slowest. These are some statistics: Every year nearly 1,000 people are killed by accidents at work-between three and four every working day. Between 500,000 and 700,000 are injured-between 2,000 and 3,000 every working day. Over twenty-three million working days are lost through absences from industrial accidents and prescribed diseases. Some 250,000 people are receiving disablement benefits, and some 30,000 wives have become widows. Faced with the conclusion that in dealing with such matters of life and death, of minor and serious injuries, of the plight of widows and families, it was impossible to consider continuing the old system, and impossible to avoid the conclusion that there had to be one central body to deal with all matters of safety and health at work. In 1967 Mr. Ray Gunter, then Minister of Labour, announced in the House that it was his intention to introduce a major Bill to consolidate existing legislation. This was developed further by Mrs. Barbara Castle, who invited Lord Robens to preside over a Committee on safety and health at work. The Robens Report, published in 1972, formed the basis of a Bill introduced by the then Conservative Government, it was lost when Parliament
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