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Future of the Occupational Health Services
LEADING ARTICLES
717
in preventive services into one preventive health unit enforcing and maintaining health standards." Dr. DAVIES claimed that this step would solve the essential and immediate problem for the small factories. For the large industrial organisations, and for single industrial units employing large numbers, special arrangements may be necessary ; but even there, he held, the main bias of the service must essentially be preventive in character, leaving treatment to the N.H.S. He recognises that this may make too sharp a distinction between preventive and curative medicine ; but preventive medicine, he said, requires the enforcement and maintenance of standards arrived at after research and investigation and then embodied in law and administrative procedure. He thinks that a new medical inspectorate at three levels - central, regional, and local-should be created to work under the authority of statute and in close association with the general inspectorate, both centrally and locally. The present medical inspectors of the Ministry of Labour would provide the regional level, and it would be one of their functions to establish medical liaison with the administrative medical officer of the regional hospital board and through him with the hospital and specialist services. At the local level it is suggested that the medical officer of health and his staff, assisted by the appointed factory doctor, should be responsible, in association with the local factory inspectorate, for detailed enforcement and maintenance of health standards and for medical Dr. DAVIES believes that such an examinations. arrangement could be made now at very little additional cost and without disturbance of medical man-power. This approach by a medical officer of health to the problem of occupational health is refreshing and original, and seems to us more promising than that of the Glasgow city council, which is endeavouring to solve its local problem directly by setting up an industrial medical service staffed by full-time medical officers of its own. It is natural, and in a way logical, that medical officers of health should wish to take over industrial health, but in urging their case they have sometimes tended to play down the importance of occupational medicine and to ignore the experience and pioneering work of the Factory Department and others in the field. The Ministry of Health, too, has not been altogether guiltless in this respect, and its attitude has probably contributed to the resistance of the Ministry of Labour to the proposal that the health departments should control all health affairs. This conflict came into the open at the Caxton Hall conference in 1943, when Mr. ERNEST BEViN and Mr. ERNEST BROWN each put forward the claims of his own Ministry, and it may be partly responsible for inactivity and lack of progress in occupational health matters. Addressing the Association of Industrial Medical Officers six months ago, Dr. H. WYERS4 said that industrial medicine must come to terms with the medical officer of health sooner or later, and the sooner the better: " his passion for administration should be exploited, but his pre-occupation with community health tempered." In Dr. WYEps’s view, preventive and curative medicine should be united. Certainly
tory health officers already engaged health
THE LANCET LONDON:SATURDAY, OCT. 11, 1952
Future of the
Occupational
Health Services
SINCE the Dale Committee on the Industrial Health Services produced its disappointingly modest proposals nearly two years ago, there has been a lull on this front. Even the interdepartmental advisory committee which the Dale report recommended has not yet been formed. Recently, however, some guns got into action at Margate, where the Trades Union Congress and the Royal Sanitary Institute held their annual meetings. In the T.U.C. the general council accepted a resolution by Dr. BRUCE CARDEW calling on the Government to set up " a comprehensive occupational health service to be welded into the National Health Service "-though it " wanted to be careful that such welding does not produce integraThis tion for the sake of administrative ease."1 reservation was an echo of BERTRAND RussELL’s warning (quoted by Dr. R. S. F. ScHrLLmG2 at the other Margate meeting) of the " administrative fallacy in which the tidiness of the plan is regarded as a model of order-an end in itself-and of men in control... who forget what human beings are like and try to fit men to systems, rather than systems to men." Dr. CARDEW seriously overstated his case when he said that, while the National Health Service was the best in the world, when " once a man left his home for his office, shipyard, factory, or mine the provisions for his health became perhaps the worst in the word." And Mr. ALFRED RoBERTS went a little too far when he spoke of the " appalling lack of knowledge of occupational hazards and diseases among general practitioners." But at the Royal Sanitary Institute’s meeting the statements were more measured. Prof. 1. G. DAVIES, medical officer of health for Leeds, in a thoughtful and well-balanced paper3 on the future organisation of the occupational health services, drew attention to the danger of an artificial separation between treatment at work and at home.
Any proposed industrial health arrangements must not, he said, have the effect of creating fresh divisions among the medical profession ; rather should they aim at drawing the existing sections closer together, and, where possible, making a common service. There is urgent need, in his opinion, for development of a preventive health service for all places of work, including those beyond the scope of the Factories Act, and this could be done by fusing the duties of the three kinds of medical officers who are already operating statutory services of the kind requirednamely, the medical inspectors of factories and mines, the appointed factory doctors, and the medical officers of health. One difficulty here, he thought, would be the administrative gulf (almost an abyss) which lies between officers appointed by central and by local government departments. But " it is worthy of serious consideration that, as a first step, legislative and administrative means be found to fuse the statu1. Manchester Guardian, Sept. 3, 1952. 2. J. R. sanit. Inst. 1952, 72, 534. 3. Ibid, p. 528.
1. Trans. Ass. industr. med.
Offrs, 1952, 2, 64.
718 Dr. DAVIES’s idea of the rqle of the medical officer Cord Cervical Osteo-arthritis and the of health should be more acceptable to the other THE association of cervical osteo-arthritis or cervical interested parties than that put forward by some with disorder of the spinal cord has only previous spokesmen of the public-health service, who spondylosis been recognised as a fairly common occurrence. lately have not recognised that occupational health is a and LLOYD 12 have described 21 cases, and SPILLANE field in which they have little or no experience. RUSSELL NORTHFIELD, and WILKINSON 3 38 ; BRAIN, Dr. DAVIES appreciates the objection to his scheme result their work the condition should be as a of and that it would entail delegation of central functions to more readily. Men are affected more often diagnosed local authorities, but he thinks that a medical officer the commonest age of onset being the than women, of health could be seconded for medical inspectorial fifties. Disability usually starts with stiffness and functions to the factory inspectorate without the early of the weakness legs, which gradually increase, and actual responsibility being placed in the -hands of the be associated with paræsthesiæ and clumsimay local authorities. It would be essential to such an ness the hands in and, less commonly, with pain in the arrangement that the medical officer of health should arms. Only rarely does the patient complain of pain work in close association within the administrative the in neck. The symptoms slowly become worse over framework of the local factory inspectorate, as indeed the course of two to three years, and then not uncomhe does now to some extent. In this way, Dr. DAVIES become stationary, without further deteriorabelieves, liaison with the N.H.S. could be secured-at monlyfor a There is a variable regional level with the specialist and hospital services, tion, of considerable time.and some degree spastic paraparesis, patients have and at local level with general practitioners through of the atrophy shoulder-girdle muscles, often with the medical officer of health. while others have only a slight generalfasciculation, In a paper which we published a few weeks ago5 ised weakness. The arm reflexes vary ; it is perhaps Dr. PETER NASH urged that occupational-hygiene find that all the armjerks are pathocommonest to laboratories should be set up in various parts of the in but some cases the biceps jerks are brisk, logicallv This attractive idea be be cannot said to new, country. there and is inversion of the radial diminished, been time for it has to time by put forward from reflexes. is less constant than Sensory impairment various individuals and organisations over the past but motor there be diminution of disability, may fifteen years or so. Nor is the concept of the " health sense in the hands, giving a clumsiness to the position engineer " really a novelty in Britain, for the engineerand, less frequently, a loss of ing and chemical branch of the Factory Department finger movements, and sense in the feet. vibration Cutaneous position has long been carrying out the procedures he describes. was found in three-quarters of sensory impairment It is true that there is no special laboratory for the the patients in the London Hospital series 3 ; it was use of the Factory Department ; but work is done by commoner in the arms than in the legs, but it was the Government Chemist and the National Physical seldom more than a slight loss. There may be Laboratory, and the Mines Department is fortunate in little to on clinical find examination of surprisingly that routine and emergency tests of environmental the movements are neck ; passive usually free and conditions are made in the Safety in Mines Research be but there some limitation painless, occasionally may At the same time we Laboratories in Sheffield. of movement. the of In majority patients lumbar cordially agree that there is need for extension of the a in the normal Queckenstedt puncture gives response facilities and staff in the Factory Department and we and the no fluid shows test, cerebrospinal abnormality; welcome Dr. NASH’S paper as a basis for discussion. but in a few cases there may be a slow rise on jugular He usefully drew attention to the precedent set by the laboratories of the Public Health Laboratory compression, The protein content of the c.s.F. was to between 70 and 80 mg. per 100 ml. in Service, administered by the Medical Research Coun- raised 5 of SPILLANE’s patients, and it was over 50 mg. cil : there are 18 special or reference laboratories and in 10 in the second series, the highest value patients a further 49 constituent laboratories. For work on 160 100 ml. mg. per occupational hygiene, fewer centres would be needed, being examination of the cervical spine is the most X-ray and possibly some of the public-health laboratories at times the results may but could be used or adapted. As Dr. NASH says, there is helpful investigation ; be difficult to interpret, for, osteo-arthritic changes, a strong case for the centres to become part of the with unassociated clinical symptoms or signs, are not Factory Department of the Ministry of Labour, and uncommon in middle age. In cases where there is another possibility is that industry itself should be about the diagnosis, myelography is encouraged to set up such centres. The need for them uncertainty The most necessary. important abnormalities to be is shown by the fact that his own laboratory at the found on straight X-ray examination are narrowing London School of Hygiene and Tropical Medicine is of or one more, of the intervertebral disc spaces ; getting more requests for help than it can deal with. on the anterior and posterior aspects Surely the time has come for the interested Ministries osteophytes of the vertebral bodies (the latter being particularly to get together and hammer out an acceptable scheme significant) ; changes in the articular surfaces of the for the better organisation of the occupational health neurocentral joints ; and projection of osteophytes New legislation services to cover all occupations ? the into intervertebral foramina (best shown in oblique will be needed and it is inevitable that one or more If myelography is needed, it should be Ministries or departments should surrender some of projections). carried with out the patient prone, 3-5 ml. of opaque its sovereignty, though we must always bear in mind oil being injected. The significant findings are one that a tidy administrative plan is not necessarily the or more transverse breaks in the oil column opposite best. Until this is done, little or no progress can be
Spinal
expected. 5.
Lancet, Sept. 6, 1952, p. 478.
1. 2. 3.
Spillane, J. D., Lloyd, G. H. T. Lancet, 1951, ii, 653. Spillane, J. D., Lloyd, G. H. T. Brain. 1952, 75, 177. Brain, W. R., Northfield, D., Wilkinson, M. Ibid, p. 187.
717
in preventive services into one preventive health unit enforcing and maintaining health standards." Dr. DAVIES claimed that this step would solve the essential and immediate problem for the small factories. For the large industrial organisations, and for single industrial units employing large numbers, special arrangements may be necessary ; but even there, he held, the main bias of the service must essentially be preventive in character, leaving treatment to the N.H.S. He recognises that this may make too sharp a distinction between preventive and curative medicine ; but preventive medicine, he said, requires the enforcement and maintenance of standards arrived at after research and investigation and then embodied in law and administrative procedure. He thinks that a new medical inspectorate at three levels - central, regional, and local-should be created to work under the authority of statute and in close association with the general inspectorate, both centrally and locally. The present medical inspectors of the Ministry of Labour would provide the regional level, and it would be one of their functions to establish medical liaison with the administrative medical officer of the regional hospital board and through him with the hospital and specialist services. At the local level it is suggested that the medical officer of health and his staff, assisted by the appointed factory doctor, should be responsible, in association with the local factory inspectorate, for detailed enforcement and maintenance of health standards and for medical Dr. DAVIES believes that such an examinations. arrangement could be made now at very little additional cost and without disturbance of medical man-power. This approach by a medical officer of health to the problem of occupational health is refreshing and original, and seems to us more promising than that of the Glasgow city council, which is endeavouring to solve its local problem directly by setting up an industrial medical service staffed by full-time medical officers of its own. It is natural, and in a way logical, that medical officers of health should wish to take over industrial health, but in urging their case they have sometimes tended to play down the importance of occupational medicine and to ignore the experience and pioneering work of the Factory Department and others in the field. The Ministry of Health, too, has not been altogether guiltless in this respect, and its attitude has probably contributed to the resistance of the Ministry of Labour to the proposal that the health departments should control all health affairs. This conflict came into the open at the Caxton Hall conference in 1943, when Mr. ERNEST BEViN and Mr. ERNEST BROWN each put forward the claims of his own Ministry, and it may be partly responsible for inactivity and lack of progress in occupational health matters. Addressing the Association of Industrial Medical Officers six months ago, Dr. H. WYERS4 said that industrial medicine must come to terms with the medical officer of health sooner or later, and the sooner the better: " his passion for administration should be exploited, but his pre-occupation with community health tempered." In Dr. WYEps’s view, preventive and curative medicine should be united. Certainly
tory health officers already engaged health
THE LANCET LONDON:SATURDAY, OCT. 11, 1952
Future of the
Occupational
Health Services
SINCE the Dale Committee on the Industrial Health Services produced its disappointingly modest proposals nearly two years ago, there has been a lull on this front. Even the interdepartmental advisory committee which the Dale report recommended has not yet been formed. Recently, however, some guns got into action at Margate, where the Trades Union Congress and the Royal Sanitary Institute held their annual meetings. In the T.U.C. the general council accepted a resolution by Dr. BRUCE CARDEW calling on the Government to set up " a comprehensive occupational health service to be welded into the National Health Service "-though it " wanted to be careful that such welding does not produce integraThis tion for the sake of administrative ease."1 reservation was an echo of BERTRAND RussELL’s warning (quoted by Dr. R. S. F. ScHrLLmG2 at the other Margate meeting) of the " administrative fallacy in which the tidiness of the plan is regarded as a model of order-an end in itself-and of men in control... who forget what human beings are like and try to fit men to systems, rather than systems to men." Dr. CARDEW seriously overstated his case when he said that, while the National Health Service was the best in the world, when " once a man left his home for his office, shipyard, factory, or mine the provisions for his health became perhaps the worst in the word." And Mr. ALFRED RoBERTS went a little too far when he spoke of the " appalling lack of knowledge of occupational hazards and diseases among general practitioners." But at the Royal Sanitary Institute’s meeting the statements were more measured. Prof. 1. G. DAVIES, medical officer of health for Leeds, in a thoughtful and well-balanced paper3 on the future organisation of the occupational health services, drew attention to the danger of an artificial separation between treatment at work and at home.
Any proposed industrial health arrangements must not, he said, have the effect of creating fresh divisions among the medical profession ; rather should they aim at drawing the existing sections closer together, and, where possible, making a common service. There is urgent need, in his opinion, for development of a preventive health service for all places of work, including those beyond the scope of the Factories Act, and this could be done by fusing the duties of the three kinds of medical officers who are already operating statutory services of the kind requirednamely, the medical inspectors of factories and mines, the appointed factory doctors, and the medical officers of health. One difficulty here, he thought, would be the administrative gulf (almost an abyss) which lies between officers appointed by central and by local government departments. But " it is worthy of serious consideration that, as a first step, legislative and administrative means be found to fuse the statu1. Manchester Guardian, Sept. 3, 1952. 2. J. R. sanit. Inst. 1952, 72, 534. 3. Ibid, p. 528.
1. Trans. Ass. industr. med.
Offrs, 1952, 2, 64.
718 Dr. DAVIES’s idea of the rqle of the medical officer Cord Cervical Osteo-arthritis and the of health should be more acceptable to the other THE association of cervical osteo-arthritis or cervical interested parties than that put forward by some with disorder of the spinal cord has only previous spokesmen of the public-health service, who spondylosis been recognised as a fairly common occurrence. lately have not recognised that occupational health is a and LLOYD 12 have described 21 cases, and SPILLANE field in which they have little or no experience. RUSSELL NORTHFIELD, and WILKINSON 3 38 ; BRAIN, Dr. DAVIES appreciates the objection to his scheme result their work the condition should be as a of and that it would entail delegation of central functions to more readily. Men are affected more often diagnosed local authorities, but he thinks that a medical officer the commonest age of onset being the than women, of health could be seconded for medical inspectorial fifties. Disability usually starts with stiffness and functions to the factory inspectorate without the early of the weakness legs, which gradually increase, and actual responsibility being placed in the -hands of the be associated with paræsthesiæ and clumsimay local authorities. It would be essential to such an ness the hands in and, less commonly, with pain in the arrangement that the medical officer of health should arms. Only rarely does the patient complain of pain work in close association within the administrative the in neck. The symptoms slowly become worse over framework of the local factory inspectorate, as indeed the course of two to three years, and then not uncomhe does now to some extent. In this way, Dr. DAVIES become stationary, without further deteriorabelieves, liaison with the N.H.S. could be secured-at monlyfor a There is a variable regional level with the specialist and hospital services, tion, of considerable time.and some degree spastic paraparesis, patients have and at local level with general practitioners through of the atrophy shoulder-girdle muscles, often with the medical officer of health. while others have only a slight generalfasciculation, In a paper which we published a few weeks ago5 ised weakness. The arm reflexes vary ; it is perhaps Dr. PETER NASH urged that occupational-hygiene find that all the armjerks are pathocommonest to laboratories should be set up in various parts of the in but some cases the biceps jerks are brisk, logicallv This attractive idea be be cannot said to new, country. there and is inversion of the radial diminished, been time for it has to time by put forward from reflexes. is less constant than Sensory impairment various individuals and organisations over the past but motor there be diminution of disability, may fifteen years or so. Nor is the concept of the " health sense in the hands, giving a clumsiness to the position engineer " really a novelty in Britain, for the engineerand, less frequently, a loss of ing and chemical branch of the Factory Department finger movements, and sense in the feet. vibration Cutaneous position has long been carrying out the procedures he describes. was found in three-quarters of sensory impairment It is true that there is no special laboratory for the the patients in the London Hospital series 3 ; it was use of the Factory Department ; but work is done by commoner in the arms than in the legs, but it was the Government Chemist and the National Physical seldom more than a slight loss. There may be Laboratory, and the Mines Department is fortunate in little to on clinical find examination of surprisingly that routine and emergency tests of environmental the movements are neck ; passive usually free and conditions are made in the Safety in Mines Research be but there some limitation painless, occasionally may At the same time we Laboratories in Sheffield. of movement. the of In majority patients lumbar cordially agree that there is need for extension of the a in the normal Queckenstedt puncture gives response facilities and staff in the Factory Department and we and the no fluid shows test, cerebrospinal abnormality; welcome Dr. NASH’S paper as a basis for discussion. but in a few cases there may be a slow rise on jugular He usefully drew attention to the precedent set by the laboratories of the Public Health Laboratory compression, The protein content of the c.s.F. was to between 70 and 80 mg. per 100 ml. in Service, administered by the Medical Research Coun- raised 5 of SPILLANE’s patients, and it was over 50 mg. cil : there are 18 special or reference laboratories and in 10 in the second series, the highest value patients a further 49 constituent laboratories. For work on 160 100 ml. mg. per occupational hygiene, fewer centres would be needed, being examination of the cervical spine is the most X-ray and possibly some of the public-health laboratories at times the results may but could be used or adapted. As Dr. NASH says, there is helpful investigation ; be difficult to interpret, for, osteo-arthritic changes, a strong case for the centres to become part of the with unassociated clinical symptoms or signs, are not Factory Department of the Ministry of Labour, and uncommon in middle age. In cases where there is another possibility is that industry itself should be about the diagnosis, myelography is encouraged to set up such centres. The need for them uncertainty The most necessary. important abnormalities to be is shown by the fact that his own laboratory at the found on straight X-ray examination are narrowing London School of Hygiene and Tropical Medicine is of or one more, of the intervertebral disc spaces ; getting more requests for help than it can deal with. on the anterior and posterior aspects Surely the time has come for the interested Ministries osteophytes of the vertebral bodies (the latter being particularly to get together and hammer out an acceptable scheme significant) ; changes in the articular surfaces of the for the better organisation of the occupational health neurocentral joints ; and projection of osteophytes New legislation services to cover all occupations ? the into intervertebral foramina (best shown in oblique will be needed and it is inevitable that one or more If myelography is needed, it should be Ministries or departments should surrender some of projections). carried with out the patient prone, 3-5 ml. of opaque its sovereignty, though we must always bear in mind oil being injected. The significant findings are one that a tidy administrative plan is not necessarily the or more transverse breaks in the oil column opposite best. Until this is done, little or no progress can be
Spinal
expected. 5.
Lancet, Sept. 6, 1952, p. 478.
1. 2. 3.
Spillane, J. D., Lloyd, G. H. T. Lancet, 1951, ii, 653. Spillane, J. D., Lloyd, G. H. T. Brain. 1952, 75, 177. Brain, W. R., Northfield, D., Wilkinson, M. Ibid, p. 187.