What patients bring to occupational health services

Pub/. Hlth, 1.zmd_ (1981)95;. 322-333

W h a t Patients Bring t o Occupational Health Services James tVIcEwen MB.. Ch.B., M.F.C.M, M.F.O.M., D,i.H

James C. G. Pearson B.Sc,, M.Sc, Ph.D., Dip. S'~at:

Alison Langham S.R.N.

UniversitF of Nottingham; Department o f Community Health, University Hospital. Queen's Medical Centre, C/[fton Boulevard, Nottingham NG7 2UH

The diversity of practice in occupational health sere'ices is well known. This study examines certain aspects of the treatment component o f occupational health services in 20 organizations. Considerable variation in contact with these services was shown, mainly accounted for by non-occupational diseases, with lessthan half of the contacts being due to occupational conditions. The vast majority of the contacts result in the patient returning to work. It is evident that occupational health services can make a valuable and extensive contribution to primary care.

Introduction The diversity o f practice in occupalional health services has been widely acknowledged j,'2 as the service-..provided is dependent on a number of factors which include: the attitude of management; the ~rovision that management is prepared to make; the requests of'employees and unions and the training experience and attitudes o f the staff involved. Gauvain 3 has clearly stated the present position. "'The concept of what is meant by occupational medical services differs not only between countries, but between governments and government departments; industries and organizations, large and small, national and private; between employers and employees; between doctors, nurses and first aiders; but also, of course, between members o f the public .... Within our own country there is a marked diversity of views. It is thel'efor¢ no surprise that there has been a lack o f unanimity in the development o f occupational medical services. There has been n o agreement on their role, their function or the staff required". This is a critical period in the development o f occupational health and in planning for the future. The speciality o f occupational medicine has been recognized by the establishment of the Faculty o f Occupational Medicine wi~.~hinthe Royal College o f Physicians of London. The RoyalCollege of Nursing has been discussing the expanded role o f the nurse, and has been concerned to clarify the responsibilities for diagnosis and treatment.4 Much needs to be done to define and review the roles, functions and status required of

0033-3506/81/060322+.12$0J:.00/0

(~j 1981The Societyof CorrrmunityMedicine

Paticnt Contact with Occupational Health serrices

323

different members o f the occupational health team and to examine the practical needs and problems ofnurses workingon their own. Equally, the relationship between the occupational health team and other health care professionals requires to be reviewed. Although there is considerable literature dealing with what occupational health services should or should not d o , ' a n d what should be the balance between "prevention" and "'treatment", ~here is relatively little evidence as to what is actually being done in occupational health services. While it is clearly recognized5 that an account of what is being done does not mean that this is the true practice o f occupational health or that such activities should be done, it provides a useful basis and indeed perhaps is a necessary prerequisite for a new approach to planning of services and policy making. It can lead to proposals for relevant stafftraining and further research. It may be useful in what is one of the over-riding concerns at present - what ways can be devised t'or the provision of an occupational health service to small industries and what sort of service should it be. The recent E.M.A.S. survey6.: which was on reported activities and not on recorded activities, did provide an overall picture of occupational health services 'in Britain. With regard to the extent ofcare provided by occupational health services, it indicated that about 8570 of all firms employing about 3270 o f the workforce had no occupational health service other than first aiders employed less than 10 hours/week in that capacity; about 5 70 o f firms, employing 52% of the workforee, employ medical and/or nursing staff; and about 2[% o f firms, employing 31 70 o f the workforce, have both medical and nursing staff. Fromthe same survey it was noted that the most commonly practised activity within.these services was the treatment of acute emergencies and of minor illness and injury; this was followed by pre-empioyment or pre-plaeement medical examinations and screening procedures. The factor o f greatest significance in determining the nature of the service is the size of the firm, with large firms generally providing a comprehensive occupational health service-treatment service, preventive medical service, environmental screening, rehabilitation, pre-employment medical examinations and research. Where small firms had a service, this tended either to concentrate on providing an emergency treatment service or on carrying out pre-employment medical examinations.

Occupational Health Services: Treatment Provision The treatment function in occupational health services has been a matter for considerable debate and an important ethical issue. The emergency treatment of illness and injury arising in the work situation, the expert treatment of specific industrial disease and the overall review of those exposed to toxic hazards have all been widely accepted. The provision of a treatment service for general complaints of a non-occupational nature is the main controversial point, and this raises the question of the relationship with the general practitioners. To many, simple symptomatic treatment is all that should be provided, but from discussion it is evident that there is a wide variation in philosophy and practice. Accordingly, a study was set up to examine some aspects of the treatment component o f occupational health services, Although studies of individual companies have been reported there have been relatively few studies involving comparison of different industries and different types of service. Most studies that do exist have used routinely collected data which is seldom comparable because each company has its own individualistic records. This paper will describe the conditions that were presented to the occupational health services, the varying rates o f contact, and will examine the outcome of these contacts with the services. Subsequent papers will discuss the interface between the occupational health

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J. McEwen et aL

services a.'~d the National Health Service and the activities o f the occupational health services with regard to treatment. Methods Prior to the commencement o f the main study there was considerable discussion with doctors and nurses involved in occupational health services and two pilot studies were carried out. Because of the diversity of recording systems it was decided that it was impossible to obtain the desired information from existing records and accordingly a specially designed recording system was produced, one form for initial contacts and one ~or follow-up visits. It was considered that these forms contained the maximum information that could be obtained ,without adding an impossible workload to those staffing the service. The f~rm was designed to ensure the minimum of writing, by having as many categories as possible that just ~required ticking. The population for study was defined as all occupational health services in the Nottingham area. As the study progressed, this was widened slightly to include some from the surrounding area, although no attempt was made to be comprehensive in this wider area. This extension was partly to include specific types of industry and partly due to availability of certain occupational health units belonging to larger organizations where the unit in the immediate area was not available for study. As there is no comprehensive~ist &occupational health services, a list was compiled from individual knowledge. As the s'cudyprogressed, new names were mentioned by nurses and added to the list. Services whick consisted o f only a doctor who visited occasionally were not included, nor were serv~ices where there were only first aiders. Since the original list contained relatively few occupational health units and the study would require the staff to do additional work, it was decided not to sample, but to invite all of the units to participate, in an effort to obtain a suitably large and representative population for study. The services were classified a c c o r d i n g t o staffing arrangements into five categories, (a) "Visiting nurse". In these services a nurse was responsible for several different factories/sites, visiting them in turn. (b) "Full-rime nurse/no ,doctor". In these services a nurse was on site throughout the working day. No doctor was employed to make routine visits to the factory, although in some cases there were relatively informal emergency arrangements with a lo¢ai practice. (c) "Full-time nurse/part-time doctor". In these services a doctor was employed to pt'ovide a number o f sessions on a routine basis..The number of sessions varied widely, from almost daily to monthly or less. (d) "Full-time nurse/central doctor". In these services the unit was part of a large organization which employed full-time doctors to supervise the O. H. services at the different si~es, but no doctor was located at the specific site. (e) '" Full-time nurse/full-time doctor". In these services a dgctor was on site throughout the working day. Letters were sent to an appropriate person in each organization (this varied according to the nattire of the service and the available contact). Considerable interest was shown by the organizations approached and there were no direct refusals. A total of 25 organizations were approached. Where an organization had several similar units in the area, a request was made for access to a sample, e.g. two collieries out of a total of 12 in the N.C.B. area. A unit was considered to be a geographically distinct factory or site which had a separate occupational health service. Seven units felt that because o f staffing problems, including

Patient Contact with Occupational Health services

325

retirement or long term sickness of the nursing staff, they could not participate. This restflted in 20 organizations making up a total of 23 units finally participating in the study. All organizations participating were asked to complete the forms for ! month. One of the main problems was to decide which categories of people seen in the occupational health services should form the study population. All people who came of their own volition for care, treatment or advice of any kind were included. Those attending for any form ofroutine medical were not included, but if a request for care, treatment or advice was made during the medicals, staff were asked to record this. Full discussions with the staff of the services regarding collection of the data were held prior to the recording period and visits were made at regular intervals throughout. In these discussions, it was stressed that all treatments were required, in particular those carried out by non-nursing staff, e.g. doctors, physiotherapists, chiropodists, etc. In some cases these operated rather separately from the main service and some of the contacts may have been missed. An aide mdmoire giving the definitions o f the categories used in the recording sheet was left in each surgery. in addition to recording all contacts with the occupational health service, basic information regarding the type and staffing o f the occupational health service and the number of employees was obtained. When the data were being processed, every attempt was made to cheek on any records where data had been inadvertently omitted, or where the sequence departed from the usual treatment. These represented a very small proportion of the total and in most eases were easily resolved by reference to the surgery records. Th~ research team recognized and appreciated the enormous contribution made by all the occupational health staff who participated in the study.

Results Although an .attempt has been made to provide an overall picture of occupational health services, the summary tables conceal a great deal of variation due to the diversity of industries and practices. It should be noted that even in the summary tables, some rates and percentages, especially for females, are based on very small numbers and are subject ,to qarge sampling variation.

Study p.opulation The population consisted of 23 occnpational health units serving a workforce of 41,000 employees (Table 1). In all, more than 13,000 contacts with the occupational health services were recorded. The number of employees served by the different units ranged from 200-7000 and the numbers of contacts recorded during a month from 28-1800. The final study population contained a number ofexamples ofcaeh type of service and covered a wide range of industries.

Contacts witli service The overall rates ofcontact/person employed are also shown in Table 1. This demonstrates a large degree o f variation between the units. In particul~d,,it is interestin~ to note that in the National Health Service there are very low rates for contact for treatment since this is essentially a preventive health service.

d. h~rcEwen et a L

326

TxBt~ I. Population studied, showing occupational health units, industries, numbers employed, total number of contacts and rates of contact during the observation month Rates of contact person employed

No. employed Male

Female

Contacts with O.H. Service

Male

Female

239 568 226

11 22 200

28 66 124

0.t I 0-10 0.22

0,18 0.27 0.36

242 352 230 590 302 144

96 131 13 358 26 464

386 120 124 307 188 642

0.83 0.27 0'52 0"39 0.56 0.61

!'92 0,19 0,23 0.20 0.65 1.19

197 48Z2 381 21'] 924 524

364 1576 40 57 4706 300

629 1544 399 192 226 1118

0.70 0-25 0.96 0-81 0-05 1.36

1"30 0-19 0.80 0.33 0-04 1-35

2248 202 1521 217

30 413 15 575

1017 107 1038 346

6,44 0.21 0-6~ 0'27

0.46 0.15 1-20 0,50

1555 3703 2575 4021 25.994

141 430 2093 3272 15,333

848 1277 969 i 843 13.538

0-53 0-32 ff22 0-26

0-15 0-17 0.20 0-25

(a) VL~iting nurse AI Power station A2 Power station A3 Textiles (b) Full.lime nurse~no doctor BI Printing B2 Food industry B3 Heavy engineering B4 Lit'~t engineering B5 Light engineering B6 Electronics (c) Full-time nurse/part-time doctor CI Textile (?2 Electronics C3 Training (24 Food C5 N.H.S. C6 Pottery (d) JZull-time nurse~central

0.I-1. doctor DI D2 D3 D4

Mining Textile Mining Shop

(e) Full.time nurse/full-time doctor El E2 E3 E4 Total

Heavy engineering Heavy engineering Chemical Chemical population studied

41,327

TABLE2. Rates of contact v,i t h Occupational Health Services related to nature of condition. (rate/person employed) Nature of condition

Male

Female

Occupational Disease Injury All

0.02 0.14 0.16 (0.16)

0.02 0,t4 0.06 (0.07)

0-17 (0.17) 0.002 0,1206 0-03 0-21 (0-21)

0.17 (0.24) 0,002 0,001 0.03 0.2t (0-29)

Non-occupational Disease Road traffic accident Sport injury Other injury All

Figurc~ in parcntheses are the rates when the N.H,S. service (C5) is excluded,

Patient Contact witt~ Occupational Health services

327

TABLE3. Rates of contact ~th each type of OccupationalHealth Servicefor malesand,femaleswith occupationaland ~aon.oeeupationalconditions.(Rate/personemployed) Occupationalhealth servicetype Sex (a) (b) (e) (d) (c'~ All

Nature of condition Occupational Non--o~apational

M F M F M F M F M F M F

0.05 0.10 0.20 0'25 0.12 (0.13) 0'05 (0-08) 0.34 0'08 0.12 0.03 0.16 (0-16) 0,06 (0.07)

0.08 0.25 0.29 0.54 0.26 (0.30) 0.16 {0.46) 0.17

0"29 0.t9 0.19 0"21 (0"21) 0,21 (0,29)

Figuresin parenthesesare the rates when the N.H.S. service(C5) is excluded.

Occupatianal and non-occupational conditions Table 2 shows the rates of contact for occupational and non-occupational conditions, showing disease and injury separately. The main categories are occupational injury, especially in males, and non-occupational disease. The general picture tends to be distorted by the National Health Service with its completely different pattern of occupational health provision, employing a large proportion of the female population in the study. When the National Health Service is excluded, it is seen that, in general, the rates for males are higher than females for occupational conditions, while females have higher rates for nonoccupational conditions. Most types of occupational health services show higher rates of" contact for nonoccupational disease in females (Table 3). This is especially so in the nurse-only and part-time doctor services [types (a) (b) and (c)], where the rates for both sexes tend to be higher than in the other services. This variation in the contact rates means that the proportion of the workload dealing with the treatment ofoecupational conditions varies considerably. In the majority of firms, occupational conditions account for less than half of the contacts. This is particuarly the case for females, although this may be due to low risks of occupational disease/injury, as well as higher rates for other conditions. For males the range is 13-75~ occupational conditions, with a median o f 38~, while for females the range is 0--81 ~ with a median of

19% Contacts may be first attendanees, which are wholly determined by the employee, or return visits, which are largely determined by the administration of the service. Overall, 6 I of contacts were first attendances. However, within the different units the percentage of first attendance5 ranged from 39 to 91 ~o- Those services with doctors [(c) (d) and (e)] show higher rates of return visits t4t2, 38 and 41 ~ respectively) than do those with no doctor [(a) 16~o and (b) 15~].

328

J. McEwen et aL

"I'AnLt:4. The relationship of the diagnosis to the rate of return to work and other disposals (9,;) following contact with Occupational ltealth Services Disposal (o~,)

Diagnostic groupings tnt~ctious diseases Neoplasms Allergic, endocrine, metabolic diseases Dimases of blood and blood forming organs Mental d;sorders Diseases of the nervous system Disea~s of Ihe eye Disea~s of the ear Distains of the circulatory system Upper respiratory tract infections Other respiratory diseases Diseases of tile mouth and teeth Di~rders of function of stomach Other diseases of digestive system Dysmenorrhoea Diseases of urinary system Diseases of genital system Complications of pregnancy and puerperium Rash and ill-defi~ed skin conditions Other diseases o[ skin Pain in back Pain in joint Other pain Other disea~s of mu~ulo-skeletaI system Congenital abnonnaliti~ Headache Other symptoms and ill-defined conditions Personal problems Rehabilitation Prophylactic procedures Fractures Internal injuries Dislocation Strains and sprains Lacerations Superificial inju.,ies Contusions Adverm affects of industrial substances Burns Other accidents A]I diagnoses No diagnosis recorded for 35 contacts.

Return to work end of shift

Home

Not at work

Hosp/G.P.

Total no with diagnosis

96.3 00 91.7

0.3 100.0 5-6

2-4 0.0 0.9

0-3 0,0 1.9

295 1 108

100.0

0-0

0.0

0.0

1

80.3 85.9 97.4 97.4 72-7 95.1 84.4 93.3 86.0 93-5 90.6 82.2 63.2 60.0

14.8 13-! 0.6 19-0 3.8 9-9 3-1 i 3"0 6"5 9.4 15.6 36.8 33-3

0-0 0-0 0-3 0.9 0-8 0-3 2-8 0-5 0-4 0-0 0.0 0-0 0.0 0"0

3"3 00 1.5 0"3 5'8 0.0 2-1 1.5 0.4 0'0 0.0 0.0 0-0 6.7

61 99 612 340 121 1660 14I 195 897 31 ~!27 45 19 !5

96-1 96-8 95-3 95-9 90. I 91.1

3-4 1-0 3-6 2-0 7-0 3-3

0-0 1-0 0-5 0. ! 0.0 3.9

0-0 0.8 0-5 1.0 2.8 0"6

204 t079 193 98 71 180

100.0 96-2 71-2

0"0 2-9 25-0

0"0 0.4 3.0

0'0 0.3 0-0

! 762 132

91-3 73.3 95.6 20.0 0.0 0'0 92.4 95.3 96-9 89-6 90.4

7-2 4.0 0-0 15-0 0.0 0~0 4-8 1-2 1-0 4-6 1-2

1-4 6.7 3-3 5.0 0.0 0.0 O.8 1.4 0.6 2-4 1.4

0.0 1.3 0-0 70.0 I00.0 100-0 1.3 1.9 1.3 3.0 6.8

69 75 274 20 I 2 709 2202 685 839 644

97-5 89.7 93-I

0.5 4.6 3-8

0-7 0.0 1-1

0.7 3.4 1.5

408 87 13.,503

0"2

5

'

100 94

97 68

--

3

3

3

94 96

92 88

98

--

§

95

t

t

94

t

i00

*

(a)

t

2

7

!

2

(b)

--

--

--

t

* Return lo work; t home; ~ not at work; § hospital/G,P.

Disease Road trame accident Sport Other injury

Non.occupational

Disease Injury

Occupational

Nature of condition

6 2

[ 12

4

§

91 95

93 95

96

96

*

t

3 I

6 3

1

I

(c)

1

2 --

0

--'

t

Serv/¢e type

6 4

1 3

3

1

§

87 91

88 88

88

97

*

6

---

7 12

~

t

(~)

13 6

4

3

2

t

i

3

-I

~

§

90 97

93 95

94

94

*

4 1

4 3

2

2

t

(e)

1

2

-0

~

t

3 I

I

2

3

§

91 95

93 93

93

97

'

3 1

6 3

3

!

t

Total

2 I

t

2

I

~

TAnLe 5. Nature of condition related to tile rate of return to work and other disposals (%) following contact with different Occupational Health Services

4 2

i 2

3

0

§

k~ IO

t4 ,.q "!

7" a

~.

J. McEwen et aL

330

TABLE 6. Comparison of rale ~ofreturn to work ("~) at first altendances and follow-up visits in lhe different lypes of Occupational Heahh Services

Set,See type (a) (b) (c) (d) (e} All

First altendances

Follo~-up dsils

All conlacls

94"6 94.3 92-6 86.1 92-8 91.8

97. t 90.5 96-6 94-0 95-4 95.2

95-0 93,4 94-3 89.1 93-9 93-1

Diagnostic groupings The most frequently occurring diagnoses tended to be for relatively minor complaints: upper respiratory tract infectio~s, upset stomach, headaches and minor injuries (Table 4). lnjvries primarily related to work tended to be reported more frequently in males. In females the most frequent diagnoses were the minor diseases, although there were industries where there was a specific hazard (e.g. paper cutters in the printing industry). When the different services were compared, it was seen that the most frequent diagnoses noted above tended to be lower in the larger organizations. At approximately 3 ~ of attendances, a second complaint was mentioned. There were similar rates in the different types of service, although there was a very considerable variation between the different .units (0--23~). The diagnoses recorded for secondary complaints showed a similar distribution to that of the presenting complaints, with an emphasis on minor disease.

Disposal A very high percentage of contacts ended with the employee returning to work (Table 4), There is no clear relationship between the type of service, diagnostic category and disposal, particuarly when the small numbers of observations in some categories are considered. In general, it might be said that under 4~0 go home and about 2~, go to hospital or directly to the general practitioner. Patients who were advised to see the general practitioner later are not included in this figure. The details of referrals to the National Health Service will be examined in a subsequent paper. Table 5 shows the overall similarity in the way that different types of service deal with different categories of conditions presented to them. Although there is a lower rate of return to work in industries demanding a high standard of fitness, this lower rate is also found in some other industries and can only be explained by the attitude of the staff. The differences in the rate of return to work between the first attendances and follow-up visits in the different types of service are examined in Table 6. Overall, the majority of decisions for referral are made at the first visit. Type (b) services show an overall low rate of return to work at follow-up, but this is due to two units rather than the entire group, while all units in type (d) have a low rate of return to work on the first visit. This is surprising as it is a very diverse!group, composed of mining, textiles and a retail shop. Specific and different reasons must account for this. While it may be due to the high level of fitness required in the mining industry, this cannot apply to the other units,

331

Patient Contact with Occupational Health services 30

I ,.,,

'

O~Cut)o~onOl(:hseose

50{

~or'1 - occtJD b--~lonl i| d(s~O~1~

IO

i ,° 3C

OCCupO~On01 Injury

I

10

1 ,

..

j

Mon Tue Wed Thu

Fri

:

So!

:

=

Mort Toe Wed Tho Frl

Sun

Sot Sun

Doy of week

Figure t. Day of the wed~ on which first attendances for different types of condition occurred.

~3F

F-F--] Non.oCCupo~w)r,o!

t~r

40

7

Non-occopolmr~l

(IT 20

I0 0

'~

8

12

16

20

Z4

O

4

B

12

16

20

24

Time of dQy (h} Figure 2. Time of day at which first attendances for different types o f condition occurred.

Time of presentatiotz to service Figure I shows the day of the week on which first attendances occurred. Follow-up visits were excluded as they are partly determined by service administration. Non-occupational conditions, especially injuries, tend to present at the beginning of the week, but there is no clear pattern for occupational conditions. Figure 2, which is ~lso based on first attendanees, shows the distribution by time of arrival. Here there is a distinctly different pattern for occupational and non-occupational conditions. Non-occupational conditions tend to occur at the beginning of the day, while the occupational ones are more evenly spread out. There is likely to be some distortion due to the administrative arrangements in the different services and there was evidence of distortion due to shift times, especially in the mining industry, where the beginning and end of the shift are the only times when the underground workers can come to the surgery.

332

J. M c E w e n et aL

Discussion

This survey has indicated both the volume and t.he range of conditions that are presented for care to occupational health services. The diversity of industries, the variation in size of establishment and the differing types o f occupational health services are evident from this study. The varied background of the staff involved in the treatment and in the organization of occupational health services must be noted and appears to be one o f the key factors in determining the nature of such services and policies related to the activities. This is not a random sample, but gives an indication of the range of activities in a wide spectrum of occupational health services. Some of the differences are quite dramatic. Even if the National Health Service and the visiting nurse services are excluded, there is a six-fold variation in the rates of contact for males between different units and a 10-fold difference for females. This clearly indicates that it is impossible to reach a conclusion about occupational health, based on a single factory: there is too much variation. Much of this variation is due to non-occupational disease. It is extremely unlikely that this can be accounted for by variation in risk and must be due to the attitudes of the staff or managment. The lower rates of contact noted with full-time nursing or medical services may be the result o f training in occupational health and a resultant policy on not treating non-occupational disease, or it may result from the larger size of these industrial units making the surgeD' less easily accessible and thus discouraging visits to the occupational health service. In general, occupational conditions account for less than half o f the contacts, it is evident that a considerable contribution is made by these services to the overall health care of the people who work in the various industries and organizations. At first sight, it would appear that many o f the problems and conditions might be labelled "trivial'" and could, in the absence o f such services, be dealt with by self-care or no care. There are less o f these trivial conditions in the larger organizations and this again might reflect a policy o f the services, but might also be related to the distance from the surgery acting as a deterrent; first aiders or first aid boxes providing supplies for treating these conditions without going to the surgery, it is unfortunately impossible to decide from the results o f the study either the a m o o n t of more serious illness or injury that is prevented by prompt and efficient treatment, or indeed how much the quality o f life is improved by such care. It is however unlikely that consultations for such conditions would continue if the service and its treatment was not considered to be useful and acceptable. Indeed, non-occupational conditions, especially injuries, tend to present at the beginning of the week, which tends to confirm the belief of occupational health service staff that the convenience and acceptability of their service encourages people to keep problems till Monday morning. Similar reasons probably account for the increased attendance with non-occupational conditions during the early part of the day. It Ks interesting to note that in one firm which does not work on Mondays, there is a similar increase in attendances on the Tuesday morning which suggests that patients choose to use the service as a first approach for general health problems although it would have been easy for them to attend their general practitioner on the Monday. In all services, the vast majority of people return to work. There are low rates o f referral to hospital or general practitioner and these are usually for defined, more serious conditions. There are also low rates for people being sent home and again the reasons are usually obvious. This suggests therefore'that occupational health services do help to keep employees at work.

Patten, Ctmtacl with Occupational Heallh services

333

The higher ta~es on first altendance~ suggest that occupational health staff do not delay more specialized treatment :o the detriment of lhe patient. It is impossible to know from this study how many people would stay at home if there was no occupational health service to provide treatment during the day (or in some cases, night). The rate of use suggests that in the employees eyes. it is a valuable service. This study has confirmed the contribution that is made by occupational health services to general health care. It must be noted that the study examines one component, treatment, and is not a statement on general occupational health, since other components are important to the interface. Inevitably this study raises a number of questions. Whal is the nature of the interface between occupational health services at~d the National Health Service? Should occupational health be providing primary care? What happens when there is no occupational health service? How do the workforcc cope? These and many related questions on the health needs in the occupational setting and the most appropri,"te means of meeting these needs, indicate the necessity for a significant effort to overcome the lack of health services in this field.

Acknowledgements The staff involved in this project express their appreciation to all who provided encouragmeat for this study or who helped in any way. Without the financial support of the Health and Safety Executive the study could not have been carried out, nor would it have been possible without the ready agreement of the management of the various industries concerned. To all who filled in the forms and so willingly gave of their time, the staffwould like to express their deep gratitude, not only for the work involved, but also for the very competent way in which the task was tackled.

References .I. Duncan, K. P. (1976). Health care of people at work in Britain. Occupational heallh services. Journal t~ the Society vf Oca@ational Medicine 26, 31--4. 2. Raffle, P. A. B. (1975). The purposes of occupational medicine. British Journal of Industrial Medicine 32, 102-9. 3. Gauvain, S. ~1975). Recent developments in occupational medical services. Jour~2alo]the SocieO, of OccupationalMedicine 25, 78-85. 4. Royal College of Nursing. (1979). Duties and responsibilities of occupational health nurses. lntbrmation Leaflet No. 11 London: R.C.N. 5. Lee, W. R. (! 973). An anatomy of occupational medicine. 8ritislt Journaloflndustrial Medicine 30, 111-7. 6. Health and Safety Commission (1977). Occupational Health Services: the Way Ahead. London:H.M.S,O. 7. Phillips, M. & MeEwen, J. (1979). Private occupational health services in Britain. The E.M.A.S. Survey.1976. Produced for the Health and Safety Executive. Nottingham: Department of Community Health.