J. Soc. Occup. Med. (1976) 26, 120-126
The Future of Occupational Medicine" R. S. F. SCHILLING Emeritus Professor of Occupational Health, University of London
*The Apothecaries Lecture, given at a meeting of the Society on 26 March, 1976. 120
To biologists, symbiosis means a mutually beneficial partnership between organisms of different kinds, here it is used in context of relationships between man and man in which the balance is often 'knife-edge' requiring little to change a symbiotic into a parasitic existence. Let me give a simple example of human relationships, that between the PhD student and his supervisor. The student can be parasitic to the supervisor or vice versa, but, if the balance is just right, the student gets his PhD, the supervisor learns a lot and both may share in making an original contribution to knowledge. At international level and within nations there is the same knife-edge balance with the ominous instability of man-to-man relationships. There is the problem of resolving tensions between the nations 'which have' and the nations 'which do not have'. And, within nations, there is the problem of resolving tensions between various sections of society, both outside and inside the workplace. Occupational health has a contribution to make, albeit a small one, to both international and national human symbiosis. The practice of occupational health in developing countries can help to narrow the wide gap between their standards of working and living conditions and those of the affluent countries. This wide gap is a cause of international tension which is antagonistic to symbiosis. It is encouraging to see the importance given to occupational health in the Third World. At the London School of Hygiene and Tropical Medicine we have, between 1959 and 1975, trained 401 postgraduate students (DIH, 253; MSc Occupational Medicine, 100; MSc Occupational Hygiene, 48) in occupational health. Of these, 201 were from the United Kingdom and 200, from 48 other countries. More than half of the students in the latter group were from Third World countries. Inside the workplace, occupational health helps to control injury and disease arising from adverse physical, chemical and biological factors in the
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After nearly forty years in the field of occupational medicine I have no doubt that it is in much better heart than it was in 1937, when I started as an assistant Industrial Medical Officer in Birmingham. There were then about 30 members of this society; there are now over 1200. There was no formal training in occupational health; there are now at least 12 different courses leading to diplomas or degrees in occupational medicine, nursing, hygiene and safety. Even the most critical would be hard pressed to compare unfavourably occupational medicine of today with the industrial medicine practised before the last war. Futurology, a new science now taught in universities, is the study of sociological and technical developments to help planning for the future. Futurologists are particularly concerned with three prime factors which determine the destiny of mankind: population, energy and food —their message is usually gloomy. Meadows and his colleagues, in their well-known report The Limits to Growth (quoted by Ashby (1975)), sponsored by the Club of Rome, predict the collapse of the economic and industrial systems of affluent countries sometime around 2100 unless before then the birth rate equals the death rate and capital investment equals capital depreciation. Lord Ashby (1975), in what he calls 'A Second Look at Doom', takes a different view but an equally pessimistic one. 'If,' he says, 'we are headed for social decay, it will not be brought upon us by the factors emphasized by Meadows. It will be due to unresolved international tensions between nations which own raw materials and nations which need them, or to unresolved tensions within the nation; between sections of society which repudiate their interdependence and will not accept the discipline essential for social cohesion.' He concludes, 'The formula for our survival is not power but symbiosis.'
FUTURE OF OM
One of the important tasks of a good service is to detect all kinds of health hazards, from the apparently trivial to those that endanger life and limb. Why could they not help to identify those factors that contribute to social cohesion or a more effective symbiosis of working groups? The aims of occupational health were defined in 1950 by a joint committee of WHO and ILO as:
1. To promote and maintain the highest degree of physical, mental and social wellbeing in workers of all occupations 2. To prevent among workers departures from health, caused by their working conditions. We have concentrated more on the second aim than the first because our services are not equipped to achieve the second. As physicians we have to recognize that occupational health is multidisciplinary, medicine and nursing on their own are limited in what they can do to control hazards and promote health. There are at present two main disciplines in occupational health: Medicine and Nursing This aspect is concerned with (a) the influence of physical and psychosocial factors on health— especially the identification of such factors in groups and individuals, and (b) influence of health on work—fitness for work. Hygiene and Ergonomics This is concerned with (a) the control and improvement of the physical environment at work and Table I. Stoppages and working days lost* by size of plant Plant size
11-24 25-99 100-199 200-499 500-999
1000+
No. stoppages per 100 000 employees 8 19 23 25 30 29
No. working days lost per 100 000 employees 15 72 155 329 719
2046
*Annual average 1971-3, manufacturing industry, Great Britain.
(b) design and adaptation of machines, equipment and buildings to be compatible with health. Is a third discipline comprising social psychology and anthropology necessary? Industry needs to be more positively concerned with the control and improvement of the psychosocial environment at work, something which at present is a bit beyond the scope of medicine, nursing and hygiene. It is important to identify the positive factors which influence health and wellbeing, as well as the causes
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working environment. But these are no longer the major health problems of a modern industry. As important are those work factors or relationships which produce tensions causing the wild-cat strike, the go-slow, the sit-in, or just lower output and discontent. An occupational health service with a competent staff that serves the whole workforce rather than the sectional interests of management or Trades Unions can be a factor in promoting social wellbeing. By providing treatment for injuries, acute poisonings and minor ailments and counselling for people with their human problems, it can be a boost to morale, a symbol of management's concern for people as well as profit and production. But can an occupational health service do something more tangible in promoting social wellbeing? Let us examine the incidence of work stoppages and days lost in relation to size of working group. It could be argued that in larger plants, the greater professionalism of management, investment in skilled personnel management and provisions for health and safety would lead to a reduction of these losses. In 1971-3 work stoppages in manufacturing industries of Great Britain were closely related to size of plant, the smallest having an annual average of 8 stoppages and the largest, nearly 30 stoppages per 100 000 employees {Table I, Department of Employment, 1976). When these figures are computed into the number of working days lost per 100 000, the differences between small and large are even more striking. In Britain there is a similar relationship between size of workplace and accidents and sickness absence (Revans, 1960), which all point to higher morale in the small workplace compared with the large. Such figures indicate that the more sophisticated health and personnel services in the large organizations have contributed nothing of any significance to the control of industrial discontent. I submit that occupational health services could contribute if they became concerned with health and its promotion as well as disease and its prevention.
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The second line of development would be to integrate occupational health into the National
Health Service to make it a statutory duty for employers either to provide their own services or to use a publicly organized service. Both the privately and publicly owned services would be recognized as an essential part of the National Health Service. This is the course recommended by the British Medical Association and by our Society of Occupational Medicine in their evidence to the Robens Committee. The main arguments in its favour are that it would reduce overlap between existing occupational health services and the National Health Service and would prevent the isolation of occupational medicine from the mainstream of medicine and thus attract good professional staff by raising their status and job security. The third course, the one we are set on at the moment, is not to integrate occupational health into the National Health Service, but to leave the State's responsibility for occupational health and safety in the hands of the Health and Safety Commission and answerable to the Secretary of State for Employment. This is the course I favour for the time being, and not only because it is the one we are set on; the Department of Health and Social Security has yet to solve major problems which have arisen in the recent reorganization of the National Health Service. Secondly, I am against even more central direction of health services, which has brought an enormous increase in planners and a decrease in doers. It may be a temporary phase, butithassomeof the less attractive features of bureaucracy, which I found defined as follows in a dictionary published in 1899: a tendency to official interference in many of the properly private affairs of life; inefficient and obstructive performance of duty through: i. minute subdivision of functions, ii. inflexible formality, iii. pride of place.
In my recent travels to various parts of the world, I have found an international gut reaction against central bureaucratic power, not only of governments, but also the armed services, monopolies and the universities. This adverse reaction to central power, to Big Brother perhaps, is not only among the proponents of free enterprise. Let me quote from a statement in The Times (4 February, 1976) by Georges Marchais, Secretary General of the French Communist Party: 'We do not want uniformity which stifles, but diversity which enriches.' Thus, for the time being, I would favour keeping the Government responsibility for occupational health and safety with the Health and
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of disease. What are the factors which tend to make small workplaces happier than the large ones? Can they be identified and introduced into the large workplaces? How important are leadership style, group cohesion and communication to health and wellbeing? These are questions to which occupational health services do not know the answers. In summary, the main tasks facing occupational medicine and its allied disciplines in occupational health are: 1. The control and improvement of the physical environment. 2. The control and improvement of the psychosocial environment. 3. Preventing illness or disability in individual workers from jeopardizing the health and safety of themselves, other workers and the public. There are alternative ways of organizing occupational health services in order to fulfil these tasks. While the aims of occupational health may be similar in all countries, methods of achieving them will vary according to the form of government and the type of health service provided outside the place of work. What is right for one country may be quite wrong for another. I shall only consider the future of occupational medicine in Great Britain. Whatever the political system of the country, government involvement in medical care has become inevitable because of high and everincreasing costs. In Britain this is exemplified by the National Health Service. The crucial question is how much should be done by the State and how much left to the individual or groups of people to provide for themselves. There seem to be three possible lines of development of occupational health services in this country. The first is for the government to provide and pay for a comprehensive occupational health service integrated into the National Health Service. The service would be organized outside the workplace with the employer providing no more than space and equipment. It would follow the pattern of services in Eastern Eurpean Countries. I do not think this would be feasible in Great Britain. It would be unacceptable to both private and nationalized industries. Nor do I think it is desirable, as I believe an occupational health service is more likely to achieve the broad aims I have defined if it is part of the industry it serves.
FUTURE OF OM
I have been both a Medical Inspector of Factories and a medical officer in a workplace. I have no doubt that once I got the necessary experience, I achieved more in the plant to which I was attached, in the way of improving the work environment and in dealing with individual health problems, than I could have done as a medical inspector or medical adviser. Let me give two examples of the achievements of two outstanding physicians working in industry. Michael Williams—tragically killed at his prime in 1962—was the group medical officer in the ICI dyestuffs division. When ICI wanted to make 4-amino-diphenyl he predicted it might be carcinogenic because of its similarity in chemical structure to benzidine. This was confirmed by toxicity tests with the result that 4-amino-diphenyl was not
manufactured in Great Britain. It was, however, made and used in the USA and produced a high toll of bladder tumours, probably as many as 150. Thus, in-plant know-how and initiative by a first-rate occupational physician prevented British dyestuff workers from being exposed to this risk. The second example is taken from the leadbattery industry. Regulations were passed in 1925 in an attempt to control a rising incidence of lead poisoning in the manufacture of electric accumulators. They had some effect in reducing lead poisoning, except in a large factory where the yearly incidence of poisoning was still rising. The factory was advised by the Inspectorate to appoint their own occupational physician, Dr Ronald Lane, who is well known to you all as the holder of the first Chair of Occupational Health in this country. His factory and others which came under his supervision produced 90 per cent of lead batteries made in the United Kingdom, and gave rise to only 6 per cent of cases of lead poisoning in this industry {Table II). The small battery factories which Table II. Distribution of 370 cases of lead poisoning in electric accumulator factories in Great Britain— 1930-61 National production Group of factories with own health service Other factories with statutory medical service
Cases of lead poisoning
90%
6% (24)
10%
94% (346)
produced only 10 per cent of national output, but 94 per cent of cases of lead poisoning, were dependent on the regulations and the statutory medical service provided by appointed factory doctors. Examples could also be given of how an occupational physician in a workplace, through his intimate knowledge of workers and their work, can deal more effectively than anyone else with illnesses jeopardizing the health and safety of others—not just drivers of public vehicles, air pilots, or food handlers, but others, such as directors, physicians and pharmacists. Small Workplaces We must accept that it is not possible to provide in-plant occupational health services for small and scattered working groups. If this is attempted,
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Safety Commission but encourage much closer cooperation between the Department of Health and Social Security and the Employment Medical Advisory Service, both in formulating health policy and in the day-to-day operations of providing medical care. There are two alternatives within the framework of our present government policy: either to broaden the scope and power of the Health and Safety Executive, particularly, to expand the EMAS and to adopt a laissez-faire policy towards the in-plant services provided by employers, or, to encourage their development. The policy of the Robens Committee was to let employers run their own services if they wished, and were able to do so. The likely outcome would be either no significant development or a decline in in-plant services. The balance between the Health and Safety Executive and the services inside the workplace is fairly crucial to the future of occupational medicine. If occupational medicine is to broaden its scope in the ways I have already discussed, then I believe the State, through its Health and Safety Commission, should encourage the development of in-plant services by making it a statutory duty for employers to provide services for working groups of certain types and above a certain size. The functions of the Employment Medical Advisory Service would be advisory and supervisory, leaving much of the day-to-day duties of occupational health practice to the in-plant services. One of the main tasks of the Employment Medical Advisory Service would be to encourage employers to develop their own services and to be responsible for ensuring that high standards are maintained.
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for the health service such as is found in the group Industrial Health Service of Harlow New Town. 2. Staff must be professionally competent, which means that physicians, nurses and hygienists need to be trained in occupational health. Later I shall discuss the training of physicians in more detail. 3. Services should be statutory for workplaces of certain types and above a certain size. Codes of practice or standards should also be set for various components of the service, such as the professional training and qualifications of staff, size of premises and equipment. Training of Occupational Physicians I shall confine my remarks to physicians only because there is no space to discuss the training of hygienists and nurses, which is also important. For physicians, there should be three different types of training programme: undergraduate, specialist and proficiency training for those who practise occupational medicine but do not become specialists. Undergraduates The great majority of people at work are not covered by in-plant occupational health services. Even where there is such a service, a sick worker often seeks advice first from his general practitioner or, in an emergency, from the hospital. Thus a general practitioner or hospital physician may play a vital role in identifying an occupational cause of a disease or in spotting that a sick person, whatever the cause of his sickness, may be a danger to himself or others. It follows that every doctor who looks after patients needs to be aware of the influence that work can have on health and that health can have on work. In 1970, 9 our of 28 medical schools in the United Kingdom achieved the standard of 12 hours' formal instruction in occupational health recommended by ELO/WHO (1950). Elsewhere I have outlined the seven basic facts in occupational health that a medical student should know before completing his or her training as a doctor (Schilling, 1976). These can be covered in a programme of 8 hours' didactic lectures, at least three case conferences and two or three well-planned industrial visits. Proficiency Training There are many occupational physicians who will not be specialists in this subject but they need to
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limited resources of skilled people can be wasted if they spend a higher proportion of their time travelling between workplaces and not in them. The main health problems of the small workplace are those resulting from low standards of the physical environment and sometimes very long hours of work. If the larger working groups do more for themselves, the Employment Medical Advisory Service and the inspectorate will have more time to spend on the small ones. In every workplace the manager plays a vital role in promoting health and safety. What an in-plant health service can achieve is limited, if management are not interested in occupational health. Indeed, often the first and most important task of an occupational health service is to awaken and keep alive management's interest in the health of their organization. In the small enterprise with no occupational health service, even more depends on the attitude of the manager, hence there are good reasons for including some teaching in occupational health in undergraduate courses for engineers and other technical experts who are likely to fill managerial posts. This need is now recognized by bodies such as the British Institute of Management and the Industrial Society, who include occupational health in their management training courses. The initiative for promoting health and safety has to come from inside the workplace even where there is no in-plant service. I believe there are three essentials for health services in workplaces: 1. They must serve and be seen to serve the interests of the whole workplace, not any section of it. One criticism of services provided and paid for by employers is that they serve the interests of management and therefore are not trusted by workpeople. The confidence of employees in the health service will depend on management having a clear understanding of the service's functions and not abusing it, and on its staff being aware of their role of serving the community as a whole. Staff need to have adequate safeguards in their terms and conditions of service to encourage impartiality and dispel any fear of victimization, however unfounded it may be. Under s. 2 of the Health and Safety at Work etc. Act, employers have a duty to consult with Trades Union representatives to encourage joint cooperation in promoting and developing health and safety measures. I see no reason why this could not be extended to joint responsibility
FUTURE OF OM
Specialist Training Occupational Medicine is recognized as a specialty in Great Britain, but unlike other specialties has no clearly defined training programme. The Joint Committee on Higher Medical Training (1975) recommends that physicians proposing to seek specialist training in occupational medicine should take the MRCP; it is lukewarm about an alternative examination. The crucial question is, should there be a more definite alternative to the MRCP for those who, after registration, are more interested in preventive than in clinical medicine? I believe there should be another main pathway into specialist training. Out of 633 occupational physicians practising in Britain in 1974, only 46 (7 per cent) were Fellows or Members of the Royal College of Physicians (Sawtell and Cooper, 1975). Some of them, like myself, got their membership through the backdoor on published papers, and without any specialist training in clinical medicine. I had hoped that the specialist training programme for community physicians could be modified to meet this need for occupational physicians. I was wrong on two counts. Such a proposal was unacceptable, both to the Faculty of Community Medicine and to the representatives of this Society on the Specialist Advisory Committee on Occupational Medicine. The main stumbling block was that the faculty was unable to modify its training programme for a discipline with such a strong element of clinical medicine, and many occupational physicians orientated towards clinical medicine were reluctant to link occupational medicine with the Faculty of Community Medicine. We have, therefore, to think of an alternative.
The most hopeful development is that the Royal College of Physicians of London has set up a working party to consider how the college can make a contribution to occupational medicine— whether there should be a Faculty of Occupational Medicine. This was considered and turned down by the college at the time when the Faculty of Community Medicine was being formed. It was rejected mainly because it was not viable if it depended on the financial support of a relatively small body of occupational physicians who would be its fellows and members. But the situation has changed, and it is now essential for the further development of occupational health in Britain to have an enlightened specialist training programme in occupational medicine which attracts able young doctors. In my view, this can now best be achieved by having a Faculty of Occupational Medicine, which could be made viable by continuous financial support from industry, commerce and other sources with a special interest in occupational health and a need for competent services. If a Faculty of Occupational Medicine is formed, it should have a very close link with the Faculty of Community Medicine. There are cogent reasons for having a common element in the Part I examinations for membership to allow doctors interested in preventive medicine to switch without difficulty from occupational to community medicine, and vice versa, during or after their general professional training. Conclusion Occupational health has much to do in identifying and controlling the physical, chemical and biological hazards of the working environment. For this it needs professionally competent people in medicine, nursing and hygiene. In most industrialized countries these are no longer the major hazards in occupational health as defined by WHO and ILO. These are the psychosocial conditions of working groups which lead to strikes, sit-ins or simply low productivity and discontent. Health services inside the workplace rather than services imposed on industry and commerce from outside can be more effective in achieving the broad aims of occupational health. Medicine, nursing and hygiene are not competent to deal with them on their own. They need the help of other disciplines, such as social psychology and anthropology, which are still regarded as second-class citizens in
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have more training than they get in their undergraduate curriculum. They comprise three groups: (a) general practitioners working part time as inplant physicians; (b) specialists in other fields, such as dermatology, respiratory medicine and tropical medicine, for which some training in occupational medicine is desirable; (c) whole-time occupational physicians who are not in senior posts and do not wish to occupy a post for which accreditation as a specialist may be necessary. Such training can be met by the courses offered for those taking the examination for the Diploma in Industrial Health of the Conjoint Board—the Society of Apothecaries and the University of Dundee.
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the hierarchy of the sciences (Ashby, 1975). Ff we can accept a new partnership with behavioural scientists (Morris, 1976), they can help us to understand and promote the more positive influences that work can have on health.
Requests for reprints should be addressed to: Professor R. S. F. Schilling, 46 Northchurch Road, London, NI 4EJ.
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REFERENCES Lord Ashby (1975) A Second Look at Doom. Twenty-first Fawley Foundation Lecture, University of Southampton, 1975. Department of Employment (1976) Gazette, February. Industrial Labour Office/World Health Organization (1950) Expert Committee on Occupational Health, Report of First Session. Geneva, WHO.
Joint Committee on Higher Medical Training (1975) Second Report. London, Royal College of Physicians. Morris J. N. (1976) Uses of Epidemiology, 3rd ed. Edinburgh, Churchill Livingstone. Revans R. W. (1960) Morale and size of the working group. In: Schilling R. S. F. (ed.) Modern Trends in Occupational Health. London, Butterworths, p. 196. Sawtell I. J. and Cooper J. (1975) Medical officers in industry. Journal of the Society of Occupational Medicine 25, 38. Schilling R. S. F. (1976) Undergraduate medicine training in occupational health. (In press.)
The Future of Occupational Medicine" R. S. F. SCHILLING Emeritus Professor of Occupational Health, University of London
*The Apothecaries Lecture, given at a meeting of the Society on 26 March, 1976. 120
To biologists, symbiosis means a mutually beneficial partnership between organisms of different kinds, here it is used in context of relationships between man and man in which the balance is often 'knife-edge' requiring little to change a symbiotic into a parasitic existence. Let me give a simple example of human relationships, that between the PhD student and his supervisor. The student can be parasitic to the supervisor or vice versa, but, if the balance is just right, the student gets his PhD, the supervisor learns a lot and both may share in making an original contribution to knowledge. At international level and within nations there is the same knife-edge balance with the ominous instability of man-to-man relationships. There is the problem of resolving tensions between the nations 'which have' and the nations 'which do not have'. And, within nations, there is the problem of resolving tensions between various sections of society, both outside and inside the workplace. Occupational health has a contribution to make, albeit a small one, to both international and national human symbiosis. The practice of occupational health in developing countries can help to narrow the wide gap between their standards of working and living conditions and those of the affluent countries. This wide gap is a cause of international tension which is antagonistic to symbiosis. It is encouraging to see the importance given to occupational health in the Third World. At the London School of Hygiene and Tropical Medicine we have, between 1959 and 1975, trained 401 postgraduate students (DIH, 253; MSc Occupational Medicine, 100; MSc Occupational Hygiene, 48) in occupational health. Of these, 201 were from the United Kingdom and 200, from 48 other countries. More than half of the students in the latter group were from Third World countries. Inside the workplace, occupational health helps to control injury and disease arising from adverse physical, chemical and biological factors in the
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 8, 2015
After nearly forty years in the field of occupational medicine I have no doubt that it is in much better heart than it was in 1937, when I started as an assistant Industrial Medical Officer in Birmingham. There were then about 30 members of this society; there are now over 1200. There was no formal training in occupational health; there are now at least 12 different courses leading to diplomas or degrees in occupational medicine, nursing, hygiene and safety. Even the most critical would be hard pressed to compare unfavourably occupational medicine of today with the industrial medicine practised before the last war. Futurology, a new science now taught in universities, is the study of sociological and technical developments to help planning for the future. Futurologists are particularly concerned with three prime factors which determine the destiny of mankind: population, energy and food —their message is usually gloomy. Meadows and his colleagues, in their well-known report The Limits to Growth (quoted by Ashby (1975)), sponsored by the Club of Rome, predict the collapse of the economic and industrial systems of affluent countries sometime around 2100 unless before then the birth rate equals the death rate and capital investment equals capital depreciation. Lord Ashby (1975), in what he calls 'A Second Look at Doom', takes a different view but an equally pessimistic one. 'If,' he says, 'we are headed for social decay, it will not be brought upon us by the factors emphasized by Meadows. It will be due to unresolved international tensions between nations which own raw materials and nations which need them, or to unresolved tensions within the nation; between sections of society which repudiate their interdependence and will not accept the discipline essential for social cohesion.' He concludes, 'The formula for our survival is not power but symbiosis.'
FUTURE OF OM
One of the important tasks of a good service is to detect all kinds of health hazards, from the apparently trivial to those that endanger life and limb. Why could they not help to identify those factors that contribute to social cohesion or a more effective symbiosis of working groups? The aims of occupational health were defined in 1950 by a joint committee of WHO and ILO as:
1. To promote and maintain the highest degree of physical, mental and social wellbeing in workers of all occupations 2. To prevent among workers departures from health, caused by their working conditions. We have concentrated more on the second aim than the first because our services are not equipped to achieve the second. As physicians we have to recognize that occupational health is multidisciplinary, medicine and nursing on their own are limited in what they can do to control hazards and promote health. There are at present two main disciplines in occupational health: Medicine and Nursing This aspect is concerned with (a) the influence of physical and psychosocial factors on health— especially the identification of such factors in groups and individuals, and (b) influence of health on work—fitness for work. Hygiene and Ergonomics This is concerned with (a) the control and improvement of the physical environment at work and Table I. Stoppages and working days lost* by size of plant Plant size
11-24 25-99 100-199 200-499 500-999
1000+
No. stoppages per 100 000 employees 8 19 23 25 30 29
No. working days lost per 100 000 employees 15 72 155 329 719
2046
*Annual average 1971-3, manufacturing industry, Great Britain.
(b) design and adaptation of machines, equipment and buildings to be compatible with health. Is a third discipline comprising social psychology and anthropology necessary? Industry needs to be more positively concerned with the control and improvement of the psychosocial environment at work, something which at present is a bit beyond the scope of medicine, nursing and hygiene. It is important to identify the positive factors which influence health and wellbeing, as well as the causes
Downloaded from http://occmed.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 8, 2015
working environment. But these are no longer the major health problems of a modern industry. As important are those work factors or relationships which produce tensions causing the wild-cat strike, the go-slow, the sit-in, or just lower output and discontent. An occupational health service with a competent staff that serves the whole workforce rather than the sectional interests of management or Trades Unions can be a factor in promoting social wellbeing. By providing treatment for injuries, acute poisonings and minor ailments and counselling for people with their human problems, it can be a boost to morale, a symbol of management's concern for people as well as profit and production. But can an occupational health service do something more tangible in promoting social wellbeing? Let us examine the incidence of work stoppages and days lost in relation to size of working group. It could be argued that in larger plants, the greater professionalism of management, investment in skilled personnel management and provisions for health and safety would lead to a reduction of these losses. In 1971-3 work stoppages in manufacturing industries of Great Britain were closely related to size of plant, the smallest having an annual average of 8 stoppages and the largest, nearly 30 stoppages per 100 000 employees {Table I, Department of Employment, 1976). When these figures are computed into the number of working days lost per 100 000, the differences between small and large are even more striking. In Britain there is a similar relationship between size of workplace and accidents and sickness absence (Revans, 1960), which all point to higher morale in the small workplace compared with the large. Such figures indicate that the more sophisticated health and personnel services in the large organizations have contributed nothing of any significance to the control of industrial discontent. I submit that occupational health services could contribute if they became concerned with health and its promotion as well as disease and its prevention.
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The second line of development would be to integrate occupational health into the National
Health Service to make it a statutory duty for employers either to provide their own services or to use a publicly organized service. Both the privately and publicly owned services would be recognized as an essential part of the National Health Service. This is the course recommended by the British Medical Association and by our Society of Occupational Medicine in their evidence to the Robens Committee. The main arguments in its favour are that it would reduce overlap between existing occupational health services and the National Health Service and would prevent the isolation of occupational medicine from the mainstream of medicine and thus attract good professional staff by raising their status and job security. The third course, the one we are set on at the moment, is not to integrate occupational health into the National Health Service, but to leave the State's responsibility for occupational health and safety in the hands of the Health and Safety Commission and answerable to the Secretary of State for Employment. This is the course I favour for the time being, and not only because it is the one we are set on; the Department of Health and Social Security has yet to solve major problems which have arisen in the recent reorganization of the National Health Service. Secondly, I am against even more central direction of health services, which has brought an enormous increase in planners and a decrease in doers. It may be a temporary phase, butithassomeof the less attractive features of bureaucracy, which I found defined as follows in a dictionary published in 1899: a tendency to official interference in many of the properly private affairs of life; inefficient and obstructive performance of duty through: i. minute subdivision of functions, ii. inflexible formality, iii. pride of place.
In my recent travels to various parts of the world, I have found an international gut reaction against central bureaucratic power, not only of governments, but also the armed services, monopolies and the universities. This adverse reaction to central power, to Big Brother perhaps, is not only among the proponents of free enterprise. Let me quote from a statement in The Times (4 February, 1976) by Georges Marchais, Secretary General of the French Communist Party: 'We do not want uniformity which stifles, but diversity which enriches.' Thus, for the time being, I would favour keeping the Government responsibility for occupational health and safety with the Health and
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of disease. What are the factors which tend to make small workplaces happier than the large ones? Can they be identified and introduced into the large workplaces? How important are leadership style, group cohesion and communication to health and wellbeing? These are questions to which occupational health services do not know the answers. In summary, the main tasks facing occupational medicine and its allied disciplines in occupational health are: 1. The control and improvement of the physical environment. 2. The control and improvement of the psychosocial environment. 3. Preventing illness or disability in individual workers from jeopardizing the health and safety of themselves, other workers and the public. There are alternative ways of organizing occupational health services in order to fulfil these tasks. While the aims of occupational health may be similar in all countries, methods of achieving them will vary according to the form of government and the type of health service provided outside the place of work. What is right for one country may be quite wrong for another. I shall only consider the future of occupational medicine in Great Britain. Whatever the political system of the country, government involvement in medical care has become inevitable because of high and everincreasing costs. In Britain this is exemplified by the National Health Service. The crucial question is how much should be done by the State and how much left to the individual or groups of people to provide for themselves. There seem to be three possible lines of development of occupational health services in this country. The first is for the government to provide and pay for a comprehensive occupational health service integrated into the National Health Service. The service would be organized outside the workplace with the employer providing no more than space and equipment. It would follow the pattern of services in Eastern Eurpean Countries. I do not think this would be feasible in Great Britain. It would be unacceptable to both private and nationalized industries. Nor do I think it is desirable, as I believe an occupational health service is more likely to achieve the broad aims I have defined if it is part of the industry it serves.
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I have been both a Medical Inspector of Factories and a medical officer in a workplace. I have no doubt that once I got the necessary experience, I achieved more in the plant to which I was attached, in the way of improving the work environment and in dealing with individual health problems, than I could have done as a medical inspector or medical adviser. Let me give two examples of the achievements of two outstanding physicians working in industry. Michael Williams—tragically killed at his prime in 1962—was the group medical officer in the ICI dyestuffs division. When ICI wanted to make 4-amino-diphenyl he predicted it might be carcinogenic because of its similarity in chemical structure to benzidine. This was confirmed by toxicity tests with the result that 4-amino-diphenyl was not
manufactured in Great Britain. It was, however, made and used in the USA and produced a high toll of bladder tumours, probably as many as 150. Thus, in-plant know-how and initiative by a first-rate occupational physician prevented British dyestuff workers from being exposed to this risk. The second example is taken from the leadbattery industry. Regulations were passed in 1925 in an attempt to control a rising incidence of lead poisoning in the manufacture of electric accumulators. They had some effect in reducing lead poisoning, except in a large factory where the yearly incidence of poisoning was still rising. The factory was advised by the Inspectorate to appoint their own occupational physician, Dr Ronald Lane, who is well known to you all as the holder of the first Chair of Occupational Health in this country. His factory and others which came under his supervision produced 90 per cent of lead batteries made in the United Kingdom, and gave rise to only 6 per cent of cases of lead poisoning in this industry {Table II). The small battery factories which Table II. Distribution of 370 cases of lead poisoning in electric accumulator factories in Great Britain— 1930-61 National production Group of factories with own health service Other factories with statutory medical service
Cases of lead poisoning
90%
6% (24)
10%
94% (346)
produced only 10 per cent of national output, but 94 per cent of cases of lead poisoning, were dependent on the regulations and the statutory medical service provided by appointed factory doctors. Examples could also be given of how an occupational physician in a workplace, through his intimate knowledge of workers and their work, can deal more effectively than anyone else with illnesses jeopardizing the health and safety of others—not just drivers of public vehicles, air pilots, or food handlers, but others, such as directors, physicians and pharmacists. Small Workplaces We must accept that it is not possible to provide in-plant occupational health services for small and scattered working groups. If this is attempted,
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Safety Commission but encourage much closer cooperation between the Department of Health and Social Security and the Employment Medical Advisory Service, both in formulating health policy and in the day-to-day operations of providing medical care. There are two alternatives within the framework of our present government policy: either to broaden the scope and power of the Health and Safety Executive, particularly, to expand the EMAS and to adopt a laissez-faire policy towards the in-plant services provided by employers, or, to encourage their development. The policy of the Robens Committee was to let employers run their own services if they wished, and were able to do so. The likely outcome would be either no significant development or a decline in in-plant services. The balance between the Health and Safety Executive and the services inside the workplace is fairly crucial to the future of occupational medicine. If occupational medicine is to broaden its scope in the ways I have already discussed, then I believe the State, through its Health and Safety Commission, should encourage the development of in-plant services by making it a statutory duty for employers to provide services for working groups of certain types and above a certain size. The functions of the Employment Medical Advisory Service would be advisory and supervisory, leaving much of the day-to-day duties of occupational health practice to the in-plant services. One of the main tasks of the Employment Medical Advisory Service would be to encourage employers to develop their own services and to be responsible for ensuring that high standards are maintained.
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for the health service such as is found in the group Industrial Health Service of Harlow New Town. 2. Staff must be professionally competent, which means that physicians, nurses and hygienists need to be trained in occupational health. Later I shall discuss the training of physicians in more detail. 3. Services should be statutory for workplaces of certain types and above a certain size. Codes of practice or standards should also be set for various components of the service, such as the professional training and qualifications of staff, size of premises and equipment. Training of Occupational Physicians I shall confine my remarks to physicians only because there is no space to discuss the training of hygienists and nurses, which is also important. For physicians, there should be three different types of training programme: undergraduate, specialist and proficiency training for those who practise occupational medicine but do not become specialists. Undergraduates The great majority of people at work are not covered by in-plant occupational health services. Even where there is such a service, a sick worker often seeks advice first from his general practitioner or, in an emergency, from the hospital. Thus a general practitioner or hospital physician may play a vital role in identifying an occupational cause of a disease or in spotting that a sick person, whatever the cause of his sickness, may be a danger to himself or others. It follows that every doctor who looks after patients needs to be aware of the influence that work can have on health and that health can have on work. In 1970, 9 our of 28 medical schools in the United Kingdom achieved the standard of 12 hours' formal instruction in occupational health recommended by ELO/WHO (1950). Elsewhere I have outlined the seven basic facts in occupational health that a medical student should know before completing his or her training as a doctor (Schilling, 1976). These can be covered in a programme of 8 hours' didactic lectures, at least three case conferences and two or three well-planned industrial visits. Proficiency Training There are many occupational physicians who will not be specialists in this subject but they need to
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limited resources of skilled people can be wasted if they spend a higher proportion of their time travelling between workplaces and not in them. The main health problems of the small workplace are those resulting from low standards of the physical environment and sometimes very long hours of work. If the larger working groups do more for themselves, the Employment Medical Advisory Service and the inspectorate will have more time to spend on the small ones. In every workplace the manager plays a vital role in promoting health and safety. What an in-plant health service can achieve is limited, if management are not interested in occupational health. Indeed, often the first and most important task of an occupational health service is to awaken and keep alive management's interest in the health of their organization. In the small enterprise with no occupational health service, even more depends on the attitude of the manager, hence there are good reasons for including some teaching in occupational health in undergraduate courses for engineers and other technical experts who are likely to fill managerial posts. This need is now recognized by bodies such as the British Institute of Management and the Industrial Society, who include occupational health in their management training courses. The initiative for promoting health and safety has to come from inside the workplace even where there is no in-plant service. I believe there are three essentials for health services in workplaces: 1. They must serve and be seen to serve the interests of the whole workplace, not any section of it. One criticism of services provided and paid for by employers is that they serve the interests of management and therefore are not trusted by workpeople. The confidence of employees in the health service will depend on management having a clear understanding of the service's functions and not abusing it, and on its staff being aware of their role of serving the community as a whole. Staff need to have adequate safeguards in their terms and conditions of service to encourage impartiality and dispel any fear of victimization, however unfounded it may be. Under s. 2 of the Health and Safety at Work etc. Act, employers have a duty to consult with Trades Union representatives to encourage joint cooperation in promoting and developing health and safety measures. I see no reason why this could not be extended to joint responsibility
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Specialist Training Occupational Medicine is recognized as a specialty in Great Britain, but unlike other specialties has no clearly defined training programme. The Joint Committee on Higher Medical Training (1975) recommends that physicians proposing to seek specialist training in occupational medicine should take the MRCP; it is lukewarm about an alternative examination. The crucial question is, should there be a more definite alternative to the MRCP for those who, after registration, are more interested in preventive than in clinical medicine? I believe there should be another main pathway into specialist training. Out of 633 occupational physicians practising in Britain in 1974, only 46 (7 per cent) were Fellows or Members of the Royal College of Physicians (Sawtell and Cooper, 1975). Some of them, like myself, got their membership through the backdoor on published papers, and without any specialist training in clinical medicine. I had hoped that the specialist training programme for community physicians could be modified to meet this need for occupational physicians. I was wrong on two counts. Such a proposal was unacceptable, both to the Faculty of Community Medicine and to the representatives of this Society on the Specialist Advisory Committee on Occupational Medicine. The main stumbling block was that the faculty was unable to modify its training programme for a discipline with such a strong element of clinical medicine, and many occupational physicians orientated towards clinical medicine were reluctant to link occupational medicine with the Faculty of Community Medicine. We have, therefore, to think of an alternative.
The most hopeful development is that the Royal College of Physicians of London has set up a working party to consider how the college can make a contribution to occupational medicine— whether there should be a Faculty of Occupational Medicine. This was considered and turned down by the college at the time when the Faculty of Community Medicine was being formed. It was rejected mainly because it was not viable if it depended on the financial support of a relatively small body of occupational physicians who would be its fellows and members. But the situation has changed, and it is now essential for the further development of occupational health in Britain to have an enlightened specialist training programme in occupational medicine which attracts able young doctors. In my view, this can now best be achieved by having a Faculty of Occupational Medicine, which could be made viable by continuous financial support from industry, commerce and other sources with a special interest in occupational health and a need for competent services. If a Faculty of Occupational Medicine is formed, it should have a very close link with the Faculty of Community Medicine. There are cogent reasons for having a common element in the Part I examinations for membership to allow doctors interested in preventive medicine to switch without difficulty from occupational to community medicine, and vice versa, during or after their general professional training. Conclusion Occupational health has much to do in identifying and controlling the physical, chemical and biological hazards of the working environment. For this it needs professionally competent people in medicine, nursing and hygiene. In most industrialized countries these are no longer the major hazards in occupational health as defined by WHO and ILO. These are the psychosocial conditions of working groups which lead to strikes, sit-ins or simply low productivity and discontent. Health services inside the workplace rather than services imposed on industry and commerce from outside can be more effective in achieving the broad aims of occupational health. Medicine, nursing and hygiene are not competent to deal with them on their own. They need the help of other disciplines, such as social psychology and anthropology, which are still regarded as second-class citizens in
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have more training than they get in their undergraduate curriculum. They comprise three groups: (a) general practitioners working part time as inplant physicians; (b) specialists in other fields, such as dermatology, respiratory medicine and tropical medicine, for which some training in occupational medicine is desirable; (c) whole-time occupational physicians who are not in senior posts and do not wish to occupy a post for which accreditation as a specialist may be necessary. Such training can be met by the courses offered for those taking the examination for the Diploma in Industrial Health of the Conjoint Board—the Society of Apothecaries and the University of Dundee.
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the hierarchy of the sciences (Ashby, 1975). Ff we can accept a new partnership with behavioural scientists (Morris, 1976), they can help us to understand and promote the more positive influences that work can have on health.
Requests for reprints should be addressed to: Professor R. S. F. Schilling, 46 Northchurch Road, London, NI 4EJ.
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REFERENCES Lord Ashby (1975) A Second Look at Doom. Twenty-first Fawley Foundation Lecture, University of Southampton, 1975. Department of Employment (1976) Gazette, February. Industrial Labour Office/World Health Organization (1950) Expert Committee on Occupational Health, Report of First Session. Geneva, WHO.
Joint Committee on Higher Medical Training (1975) Second Report. London, Royal College of Physicians. Morris J. N. (1976) Uses of Epidemiology, 3rd ed. Edinburgh, Churchill Livingstone. Revans R. W. (1960) Morale and size of the working group. In: Schilling R. S. F. (ed.) Modern Trends in Occupational Health. London, Butterworths, p. 196. Sawtell I. J. and Cooper J. (1975) Medical officers in industry. Journal of the Society of Occupational Medicine 25, 38. Schilling R. S. F. (1976) Undergraduate medicine training in occupational health. (In press.)
