British Journal of Industrial Medicine, 32, 1975, 102-109

The purposes of occupational medicine'

P. A. B. RAFFLEThe London Transport Executive, Griffith House, 280 Old Marylebone Road, London NW1

Raffle, P. A. B. (1975). British Journal of Industrial Medicine, 32, 102-109. The purposes ofoccupational medicine. The purposes of occupational medicine are described in terms of itsclinical medical, environmental medical, research, and administrative content. Each of thesecomponents is essential in different proportions in comprehensive occupational healthservices for different industries, and can only be satisfactorily provided by occupationalphysicians and occupational health nurses who are an integral part of their organizations.

Two-thirds of the working population in the United Kingdom are without the benefits ofoccupational medicine. The reorganization of the National Health Service and of localgovernment presents the opportunity to extend occupational health services to many moreworkers who need them. It is suggested that area health authorities should provide occupa-tional health services for all National Health Service staff and, on an agency basis, for localgovernment and associated services, eventually extending to local industry. Such area healthauthority based services, merged with the Employment Medical Advisory Service, couldconveniently then be part of the National Health Service, as recommended by the BritishMedical Association, the Society of Occupational Medicine, and the Medical ServicesReview Committee.

Every occupational physician has at some time orother been asked socially 'Are you in practice?''No, I'm a doctor working in industry'; then there isthat pause and a slightly blank stare-'What doyou do?' He starts to explain that he is concernedwith the effects of work on health and of health onwork. But I, at any rate, end up by saying thatoccupational medicine is an exciting mixture ofclinical medicine, environmental medicine, research,and administration, and that our function is toinfluence people, and to help others to help them-selves. Influence, rather than educate; adults shyaway from being educated as being somethinginsulting. Mackenzie knew this in the different andsubtle approaches he made to encourage manage-ment and workers to aim at health at work.An advantage of the honour of being asked to

deliver the Mackenzie Industrial Health Lecture is"The B.M.A. Mackenzie Industrial Health Lecture deliveredat the Annual Provincial Meeting of the Society of Occupa-tional Medicine at York on 18 July 1974

that the lecturer has to re-read what his distinguishedpredecessors said. Those particularly germane to mytopic are Meiklejohn (1959), Norman (1963), Rogan(1964), Scott (1967), and Lee (1973). I am gratefulto them all for their stimulus. It is encouraging howmuch of the way these giants felt occupationalmedicine could and should develop has actuallyhappened. One pleasing developnlent is the partner-ship which has grown up between the occupationalphysician and the occupational health nurse, to theextent that now any discussion of the activities of anoccupational health service includes the work of boththe occupational physician and the occupationalhealth nurse.

However, whatever progress has been made in thelast 25 years in occupational medicine, perhapstwo-thirds of the working population is without anyof its benefits. The purposes of occupational medicinehave just not got across. Many of our medicaladministrators started in public health departmentsin some of which the most junior doctor did the

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superannuation examinations of the staff. If theythought that this chore was the whole of occupa-tional medicine, it is not surprising that they did notrate it very highly. This may be why Secretaries ofState are still being advised that the National HealthService, the Department of Employment, and localauthorities can deploy the services needed by theworking population. We know that they do not andon present form cannot fulfil these needs.

I propose first to discuss the purposes of occupa-tional medicine in the terms of its clinical medical,environmental medical, research, and administrativecontent. Lowe (1974) used the terms clinical medicine,community medicine, and laboratory medicine: thelabels of the ingredients do not matter, their blendinginto the final product does.

Lest I appear to be falling into the trap whichLee (1973) pointed out, of describing occupationalmedicine as what doctors in industry do, I wish toemphasize that I am answering the question heposed, 'Why is it done?', by claiming that most ofthe purposes of occupational medicine are fulfillinga human need not otherwise satisfied by the presentstate of development of society or of medicine. Ifthe needs are otherwise satisfied then almost certainlythey should not be duplicated by occupationalmedicine.

Clinical medicine

The clinical content of occupational medicinedepends on recognizing the two-way track relation-ship between work and illness. Some work canproduce illness and every illness to some extentaffects the capacity to work (Raffle, 1965). Historic-ally (Meiklejohn, 1959), the pioneer occupationalphysicians were concerned with the recognition ofthe early signs and symptoms of industrial disease,and of course there is still scope for this. Ourtechniques have become more elaborate so thatdiagnosis occurs earlier, as in the use of exfoliativecytology in the detection of occupational bladdercancer and lung function tests in early occupationalchest disease. Better still, biological monitoringprovides advance warning of excessive absorptionof toxic materials before pathological damage hasoccurred. But more and more, we are having tostudy the effect of work on individual and grouphappiness, morale, and efficiency. We are learning torecognize the clinical symptoms and signs inindividuals and groups of the stress that these majorchanges in their work can produce. Equally we mustbe confident that we can assure management andworkers after adequate investigation that not allchanges are harmful and that fears of ill health fromthem are groundless. All this part of clinical occupa-tional medicine is post hoc. Our aim is to avoid harmarising from work by adequate planning of new or

reorganized methods of work, but this belongs tothe environmental medicine content of occupationalmedicine.

Clinical occupational medicine has much to givein the other and larger interaction, that betweenillness and the capacity to work. This contributionof occupational medicine to health and happiness isinadequately recognized. It was totally ignored inthe definition of occupational medicine given by theDepartment of Employment to the Robens com-mittee (Safety and Health at Work, 1972) and ac-cepted by that committee. This led to the contradic-tion ofexcluding consideration of the effect of healthon the capacity to work from occupational medicineand at the same time commending the inclusionof rehabilitation and advice on the employabilityof persons in the Employment Medical AdvisoryService. Occupational physicians with their intimateknowledge of the variousoccupations in their organiz-ation and of its administration can ensure far moreeasily and effectively than anyone else that personswith disabilities are safely employed in jobswhich usetheir remaining abilities to the full. They can then bekept under surveillance so that those who deterioratecan have their work further modified, and those whoimprove can be moved to more exacting work untilthey can bereturned to theirold jobs. Doctorsoutsideindustry are handicapped in deciding on the employ-ability of a patient in a particular job. A patient canseldom give his doctors a valid description of hiswork because he fears that if he minimizes itsdemands his doctor will recommend a return tonormal work and thus do his condition furtherharm; or that if he exaggerates his doctor willrecommend a change of work with all it entails andconfirm the patient's worst fears about his prognosis.

In the future the community will recognize thatinadequate attention to rehabilitation and resettle-ment on the job is a major deficiency in health care,especially the lack of continued surveillance. Nothingin the reorganization of the National Health Serviceor in the setting up of the Employment MedicalAdvisory Service will provide for that two-thirds ofthe working population without occupational healthservices the skill and compassion of doctors actuallyworking in industries in dealing with these humanproblems.

It shows a total lack of understanding of the needsof workers and of the nation for a reduction in theduration of absence from work due to sickness oraccident to leave rehabilitation with the Departmentof Employment in isolation from the NationalHealth Service, against the recommendations of theTunbridge Committee on Rehabilitation (Depart-ment of Health and Social Security, 1972). Theassessment clinics at each district general hospital,recommended by Tunbridge, would in time en-courage our colleagues in hospital and general

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practice to think of re-ablement as the beginning ofthe illness or accident and not following the com-pletion of treatment. These assessment clinics willbe all the more effective with the influence ofexperienced local occupational physicians.Horder (1956) pointed out that the relationship

between medicine and industry is also a two-waytrack. In one direction it takes the art and science ofmedicine into industry; in the other directionoccupational physicians have in many ways theopportunity to contribute to general medicine byscientific observation of their defined thoughselected populations, including observation of theeffects of known environmental conditions on thehealth of populations. In another field they havebeen evaluating the effect of illness on the capacityto do certain types of work and studying methods ofascertaining these illnesses. Much of this knowledgeis unpublished. Perhaps our colleagues in generalpractice and in hospitals would welcome some moreprecise definition of what remaining abilities areneeded to be able to do specified types of work. Iunderstand that the Occupational Safety Committeeof the Medical Commission on Accident Preventionhas a project of this kind under study. Sometimes ithas been possible to extrapolate from experiencewithin one industry to suggest guidelines of fitnessfor other occupations, as for example in MedicalAspects ofFitness to Drive (Medical Commission onAccident Prevention, 1971). It has also been possibleto evaluate with precision the different methods ofascertainment of disabilities of importance. Forinstance I recently confirmed how much more valu-able post-sickness and post-accident medical exam-inations were than routine age examinations in theascertainment of disabilities believed to be of import-ance to the safety of other road users (Raffle, 1974).

In all clinical work, indeed in all his work, theoccupational physician must be impartial in hisdecisions-impartial, and not neutral and failing togive an opinion, as Norman (1963) pointed out. Hisimpartiality, his sense of belonging, his sense ofinvolvement in the organization, and his dedicationto knowing what is happening and going to happenin it puts him in a unique position to deal withdifficult situations. Where work people develop amisconception about the relationship between somechange in work and illness his influence may beenormous. When a trade union claimed that one-man operated buses increased the stress of thedriver's job and therefore increased coronary heartdisease, demonstration that there was no differencein the incidence of coronary heart disease betweenthe drivers of double-deck vehicles and driver/operators was readily accepted by the union.

It is sometimes said that an outside expert'sopinion is more readily accepted by managementand unions than that of their own occupational

physician. I cannot believe that this is true in thenormal run of clinical problems in industry. Thisrefers not to the use of external diagnostic expertisewhere necessary but to the giving of opinions on therelationship between work and illness, and on theeffect of illness on the capacity to perform particularforms of work.

Referring back to Lee's question 'Why is it done ?',the clinical content of occupational medicine is donebecause it is the only satisfactory way at the momentof providing for the wide range of needs of workersand of industry, and of ensuring that the clinicaladvice given to the worker/patient about employ-ment is based on a detailed and intimate knowledgeof the work. The prevention of industrial disease canno doubt be satisfactorily undertaken by the Employ-ment Medical Advisory Service and the FactoryInspectorate. It is doubtful whether they can dealmore than superficially with the huge problem ofthe effect of health on the capacity to work.

Environmental medicine

The environmental medicine content of occupa-tional medicine is changing much more than theclinical content. In each ofthe three main componentsof this field, control of general working conditions,elimination of toxic hazards, and ergonomics, wehave learnt to work willingly with experts from otherdisciplines. Historically the occupational physician,having identified the results oftoxic processes throughhis clinical work, was also involved in suggestingenvironmental solutions, but often there was littlehe could do without engineers and other experts.Much of the environmental work is now done byoccupational hygiene teams of physicians, chemists,physicists, and engineers, not only in controllinghazards but in identifying or even predicting them.Sometimes the expertise needed is not availablewithin the industry. In an investigation of anallegation that underground railway tunnel dustcontained hazardous quantities of free asbestos,calculations on firm theoretical bases and simplescientific observations suggested that the fears ofunderground railway workers and public wereunfounded, but proof by direct measurement had towait for the marshalling of outside independentexperts and equipment. Together the TUC CentenaryInstitute of Occupational Health, the AsbestosisResearch Council, and the London TransportScientific Advisers' Laboratory have shown con-clusively that the fears were groundless.

Routine monitoring of hazards has now passedvery largely to other disciplines. Repeated medicalexaminations of those exposed to hazards, andbiological monitoring with clinical interpretation ofthe results is in many instances being replaced byenvironmental monitoring. Are we to regret this

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handing over of some of our preventive functions toothers? No more I suggest than we look on thetranslation of the Medical Officer of Health intocommunity physician as a retrograde step. This cansurely be counted as one of the great successes ofmedicine in the past century. The Medical Officer ofHealth successively recognized more and moremeans of preventing illness and hardship, devisedmethods of dealing with them, administered theircontrol until firmly based, and then handed themover to others to run. The influence of the MedicalOfficer of Health in persuading local and centralgovernment to think in terms of prevention andmobilization of resources to mitigate hardship isineradicable. Similarly, the influence of the occupa-tional physician on managements and workers tothink in terms of prevention of hazards by sub-stitution, enclosure, automation, segregation, ven-tilation or personal protection will endure. His verypresence in the industry subconsciously remindsthose responsible to think in these terms, and evenchance remarks can have their effect. After inspectinga steam chassis cleaning method which, although hot,humid and unpleasant, was a great advance on theold method of hand cleaning with paraffin it was toreplace, I suggested to the engineer responsible thatmen should not have to do this type of work andthat it should be possible to run the vehicle througha chemical bath to remove the caked mud. Eighteenmonths later I was taken to see the prototype of anautomatic high-pressure cold water chassis cleanerwhich the engineers had been working out in secret.

It is perhaps in the ergonomic component ofenvironmental work that the progress of the occupa-tional physician's influence is best seen. Working inthe industry he is well placed to identify physicaland mental stress arising from the bad design ofequipment. He can cajole designers into doingbetter and encourage the formation of teams ofengineers, designers, work study experts, andoperational research workers among others, and byconstant contact influence these teams into realizingthat men and machines should and can workcomfortably together. Outside experts may beneeded for some problems: we shall always beindebted to Broadbent (unpublished) for his help inthe theoretical concepts of the design of automatedsignalling control on the Victoria Line of the LondonUnderground Railway. The object is to get theteams to plan with man and machine in mind andnot just the machine. The occupational physicianfinds that this influence continues within the organi-zation in all other planning and that designers areautomatically thinking about human factors in theirequipment design. What the occupational physicianmust watch is that fragmentation does not lead toloss of impetus. In the jargon of the administrationof the reorganized National Health Service he must

monitor from the background the performance ofthese other professional people.To answer again the question 'Why is it done?',

the environmental medicine content is done becauseby this means prevention precedes events and doesnot follow them, to prevent subsequent events. It isonly by constant surveillance of what is going onand by being totally involved, knowing what isplanned for the future, and foreseeing possibleproblems that we can successfully influence manage-ment. This type of influence cannot be provided byoutside agencies.

Research

Horder's two-way track relationship betweenmedicine and industry is well illustrated by theresearch content of occupational medicine. Definedindustrial populations and environments can provideopportunities for fundamental research into theaetiology and natural history of disease, and theresults and methods of research from academic andother fields can be applied in investigating particularproblems in industry. There are many examples offundamental research carried out within industries,most of them being collaborative efforts betweenoccupational health services and academic bodies.Three examples are the investigation of the relation-ship between coal dust concentration and thedevelopment of pneumoconiosis, with the spin-offof the quantification of observer variation in chestradiograph reading and lung function tests; thestudy of the natural history of chronic bronchitis inPost Office and transport workers; and the study ofpredictive factors in ischaemic heart disease inbusmen. The first was totally industry-orientatedand, except for the radiograph reading and lungfunction tests, the results were applied to thatindustry's problems. The second was whollyacademic, for which industry provided convenientfacilities. The third, which started as academicresearch for which an industry provided facilities,produced results which were of great importance tothe industry.Epidemiology is probably the technique of applied

research most commonly used in industry with suchdiverse examples as Taylor's (1968) study of thevarious factors affecting sickness absence in the oilindustry and Case's (1966) study of the incidence ofbladder cancer in the rubber industry. An ambitioususe of the epidemiological technique is the large-scale long-term mortality survey among the refiners,blenders, transporters, and users of oil productsnow being sponsored by the Institute of Petroleumwith the assistance of the Chester Beatty ResearchInstitute. The chemical industry has applied thetechniques from fundamental research to the in-vestigation of the toxicity of new products. The

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proposals put forward in the consultative paper forcontrol of toxic substances and for the formaltesting of new products will greatly increase this.The aircraft industry, airlines, and armed Forcesutilize the results of research into applied psychologyin the ergonomic design of equipment and ofprocedures.Sometimes a two-pronged attack on a problem is

needed as in the study of the effects of variability inwork load on signal regulators in automatedsignalling control rooms. This was a situationcommon in automation where for long periods thehuman monitor has very little to do, often for manyshifts. Then some abnormality develops and he isvery busy for a period during which he takes many,often critical, decisions. Observation of signalregulators at times of interruption to the train servicesuggested that they were stressed by the change frompassive monitoring to -highly active involvement inreturning the service to normality. Two methods ofstudy were used. Epidemiological techniques demon-strated that any stress which they did undergo wasnot affecting their health in the long term; they hadonly 50% of the spells and 58% of the days ofsickness absence of the signalmen from whom theywere promoted. However, short-term effects weredemonstrable by Sayers' (1973) technique of studyingthe rate of change of heart rate by computer analysisof electrocardiograms radio-transmitted and tape-recorded during periods of normality and of highactivity. This demonstrates more accurately andsensitively than straight heart rate measurement theeffect of mental work load on a subject's physiology.Results showed that signal regulators at the time ofdisruption of the service had physiological responsessimilar to those volunteers doing laboratory taskswhich were very hard but not impossible, and theyrapidly returned to normal. This finding gave addedimpetus to the provision of a computer which amongother things will reduce the work load on the regu-lators at times of disruption of the service.The role of the occupational physician is unique

in his recognition of situations in which facilities forfundamental research can be provided in his industryand which might have long-term benefits to theworkers, but especially in recognition of the factthat solutions to human problems could be moreeasily found by applying research techniques frommany varied fields. Without his help these toolswould not be used.When applying Lee's question 'Why is it done?'

to the research content of occupational medicineit must be admitted that industrial populations andenvironments would continue to be used in funda-mental research in the absence of occupationalphysicians. But academic research workers wouldhave much more difficulty in identifying suitablesituations and getting consent from management and

workers. Without the influence of occupationalphysicians there would be much less application ofresearch methods to human problems in industry,because there is no one else who combines theintimate knowledge of the industry, of the humandemands of the processes, and what scientificbiological and physical research can contribute.

Administration

The administrative content of occupational medicineis the means by which we deploy the clinical, en-vironmental, and research content of occupationalmedicine, in varying proportions, for the benefit ofan industry and its workers, that is, how we providea comprehensive occupational health service. It isevident from what I have said so far that much ofoccupational medicine can be provided satisfactorilyonly by a team of physician and nurse who areintegrated into the organization, who providecontinuity, and whose prime object is the health ofthe whole enterprise and of all its constituent partsdown to the last individual. This does not necessarilymean a full-time service to one organization whichwould be enormously wasteful of scarce resourcesin many cases, but that the team even if part-timeshould identify completely with the organization.This has been successfully achieved in many large,medium, and small organizations by providing theirown full-time or part-time service or throughmembership of one of the group occupationalhealth services. Altogether they possibly care forone-third of employed persons, though perhaps theservice could not be called comprehensive in somecases. Even assuming that existing occupationalhealth services are all satisfactory, a dubiousassumption, the Employment Medical AdvisoryService now has the task of trying to care for theremaining two-thirds of the working population.Say that half of that two-thirds because of the natureof their employment have no real need of occupa-tional medicine at this stage, the task for the 120Employment Medical Advisers is overwhelming.There was a welcome ministerial statement duringthe second reading of the Health and Safety Bill inthe House of Commons that the EmploymentMedical Advisory Service would be recruiting asubstantial number of extra whole-time advisers.But even with this augmentation it is very doubtfulwhether they could even give the type of surveillanceof environmental matters which I have indicated,much less provide the clinical and research contentwhich is needed.

Future developmentsFor many years the British Medical Association andthe Society of Occupational Medicine have recom-

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mended that occupational medicine should be partof the National Health Service and that responsibilityfor occupational health care should be transferredto the Department of Health and Social Securityfrom the Department of Employment. The PorrittCommittee (The Medical Services Review Com-mittee, 1962) recommended that occupational healthservices of the future should be based on AreaHealth Boards, with parallel development of privateand National Health Service based services. There-organization of the National Health Service andof local government has stimulated further thoughtand discussion on the administration of occupationalhealth services. Following the stimulus of theTunbridge Committee recommendations on occupa-tional health services for hospital staff (Departmentof Health and Social Security, 1968), a number ofhospitals formed occupational health services. Someof these services are comprehensive in scope, butothers have caused concern as it seems that someappointments of part-time doctors and full-timenurses have recently been made without any clearunderstanding of the difference between the role ofan occupational health service and the treatment roleprovided by general practitioners. Some newservices plan for these doctors to spend a great dealof time performing unnecessary and costly medicalexaminations, and many of those recently appointedhave no training or experience in the preventive andenvironmental aspects of occupational health. Thissituation has arisen largely because hospital manage-ment committees and the new area health authoritieshave had little guidance on the subject, and themessage of the Tunbridge Report has been largelyignored or forgotten. Perhaps this is an under-statement because in a National Health ServiceReorganization Circular (HRC (73) 37) on theOrganization for Personnel Management, the taskof the district personnel officer includes the provisionof advice and service to line managers and staff inthe fields of, inter alia, staff safety, health, andwelfare. Later in the document he is required toreview conditions of district staff and identifyhazards with the aid of available staff health services.In a somewhat confused situation the area healthauthorities, who have become heir to the hospitaloccupational health services, are examining theadministrative arrangements for them and byimplication for the rest of area health authority staff.The Society of Occupational Medicine has

welcomed the development of comprehensiveoccupational health services for National Healthstaff and has recommended that for their properdevelopment consultants in occupational medicineare needed at regional health authority level. Scarceas occupational physicians are, it should be possibleto find 14 for these posts. The British MedicalAssociation has recommended to the Secretary of

State for Social Services that occupational healthservices for hospital staff should not be providedwithout taking into account the Tunbridge Reportwhich included the appointment of regional con-sultants in occupational medicine. The BritishMedical Association has set up a working group tostudy the establishment, development, and staffingof occupational health services for National HealthService staff. The regional consultants in occupa-tional medicine would have to monitor the provisionof occupational health services at area level. Theywould, no doubt, also provide as a separate functionclinical occupational medical expertise to theirconsultant colleagues in hospitals. In other words,they would advise in cases of possible occupationallyinduced disease and in the assessment of illness anddisability on the capacity to do certain types ofwork.Until all undergraduates are introduced to occupa-tional medicine, especially to the effect of illness onthe capacity to work, and these undergraduates havebecome senior registrars or consultants, this clinicalservice to consultant colleagues will be needed. Theregional consultants could also be a stimulus insetting up the assessment clinics at district hospitalsas recommended by the Tunbridge Committee onrehabilitation and for teaching occupational medicineto undergraduates. No doubt the regional consultantswould meet together and gradually develop commonpolicies throughout England and Wales and alsodevelop links with occupational physicians in theprivate and nationalized sectors in their regions.There are not sufficient occupational physicians

available to provide comparable facilities atarealevel,nor is the need yet there, hence the recommendationis that the focus at area health authority level shouldbe an occupational health nurse adviser holding anoccupational health nursing certificate, who wouldhave professional help from a part-time doctor,possibly a general practitioner, who had had sometraining in occupational medicine. They would bothhave the help and guidance of the regional con-sultant. In order to maintain confidentiality andindependence, the ultimate responsibility for occupa-tional health at area level must be vested in thearea health authority itself though probably throughan advisory subcommittee, but it would be acceptedthat for day-to-day administrative purposes theservice could be under the aegis of the Area MedicalOfficer.'

Before the reorganization of local governmentsome local authorities provided through the MedicalOfficers of Health some form of occupational healthservice for their staffs. Many authorities providedsimilar clinical facilities for other services like fire,police, and education. With the reorganization oflocal government, these services are no longer

'See addendum on p. 109.

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formally available and many local authorities arelooking to the area health authorities to providethem on an agency basis. Though the NationalHealth Service Reorganization Act 1973 places noduty on the Secretary of State to provide an occupa-tional health service to local government, theNational Health Service Working Party on Colla-boration (Department of Health and Social Services,1973) recommended that area health authoritiesshould make one of their medical staff responsible foradvising on staff health matters, and this wassubsequently accepted by the Department of Healthand Social Services, the arrangements to be madeaccording to local circumstances. This designatedmedical officer of the area health authority couldwith advantage be the part-time adviser in occupa-tional health to the health authority.

If this opportunity is grasped it could lead to theprovision of comprehensive occupational healthservices for National Health Service staff by the areahealth authority and a developing occupationalhealth service on an agency basis for local authoritystaff and the associated services like fire, police, andeducation. The fear is that argument about financialarrangements between the two sets of authoritieswill delay this development, and the opportunity ofmaintaining one of the traditional links betweenlocal government and preventive medicine will belost. Already some local authorities have appointedor are considering appointing their own staffmedical officers. It would be sad for two serviceswhich should be one to develop in parallel. Thiswould help to perpetuate the isolation of occupa-tional medicine and lose the opportunity of develop-ing it.Why should development of occupational health

services stop at area health and local authoritycollaboration? Why should this agency service notgradually become available on payment to anyindustry in the area which needed it? This would,of course, eventually mean full-time occupationalphysicians at area level. These would have to betrained, but the need for and the training of doctorsand nurses would be a gradual process developingtogether. The question will immediately be raisedwhere the resources in man and woman power areto come from. Most of the resources are alreadythere, being used in a haphazard fashion. Harte(1974) has pointed out that there has always been aform of health care in hospital, but this was un-organized, ad hoc, wasteful of time, and probablyinefficient. Much money is b-ing wasted on un-necessary routine medical examinations, radiographsand investigations by hospitals and local authorities.Properly channelled, these resources could befashioned into comprehensive occupational healthservices. Can we attract the doctors and nurses ofthe necessary quality? I believe we can, once the

opportunities for comprehensive care of workingcommunities are realized. That occupational medicinenow stands beside all the other medical specialtiesin provision for higher specialist training also helps.The main stress would fall on those institutionswhich provide training for future occupationalphysicians and occupational health nurses. Morefull-time and especially part-time courses would beessential. The training should be provided on thesame basis and terms as for any other specialisttraining for doctors and nurses in the NationalHealth Service.Having postulated a National Health Service

based occupational health service providingagency services, why stop there? Why not coalescethe Employment Medical Advisory Service and thearea health authority based occupational healthservices? Could there be a more convenient methodof occupational health services becoming part ofthe National Health Service and of reaching byevolution the Porritt recommendations (MedicalServices Review Committee, 1962) and the im-plications which flow from them which Rogan (1964)detailed; the National Health Service, the largestemployer of labour in the country, providingoccupational health services for its own one millionstaff and providing similar services for anothernationwide large employer of labour, the localauthorities, on an agency basis and then combiningwith the Employment Medical Advisory Service toprovide services for those industries in the localitywhich need them. The Employment Medical Ad-visers would also bring to the area health authoritybased services the expertise in occupational medicinewhich for a time would be short. Together thesemerged services could provide the clinical, environ-mental, research, and administrative content ofcomprehensive occupational health services to thoseindustries and organizations which were without andbecause of the nature of the work needed it. Theycould provide the type of service which has theessential ingredient of being capable of being anintegrated part of each industry. A cadre of occupa-tional physicians would be needed at the Departmentof Employment or the Commission on Health andSafety as expert advisers in occupational medicineto the Commission. The key to this evolution is theappointment of regional consultants in occupationalmedicine who believe in the clinical, environmental,and research content of occupational medicine. Ofcourse there are administrative and organizationaldifficulties, but I submit, on nothing like the scale ofthe reorganization of the National Health Serviceor the formation of the Health and Safety Com-mission.

I believe that the influence for good of the occupa-tional physician is like the influence that the familydoctor of yesteryear had on the village community.

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Being part of the community he subtly changedthings without this being recognized. By answeringthe question 'What do you do ?', I have tried todefine what comprehensive occupational healthservices of different types can and should do tocontribute to the health and dignity of man at work,the man himself, the group in which he works, andthe organization made up of the groups. These.comprehensive occupational health services shouldbe available where there is a need, spreading as theirvalue is realized. I believe that at last we can havethe opportunity to bring the benefits of occupationalmedicine to all those workers who need them.

References

Case, R. A. M. (1966). Tumours of the urinary tract as anoccupational disease in several industries. Annals ofthe Royal College ofSurgeons ofEngland, 39, 213-235.

Department of Health and Social Security (1968). TheCare and the Health of Hospital Staff. Report of theJoint Committee, Central and Scottish HealthServices Councils. Tunbridge, R., Chairman. HMSO,London.

(1972). Rehabilitation. Report of a Sub-Committeeof the Standing Medical Advisory Committee. HMSOLondon.

Department of Health and Social Services (1973).Reorganization of the National Health Service:A Report from the Working Party on Collab-oration between the National Health Service andLocal Government on its activities from January-July 1973.

Harte, J. D. (1974). Royal Society of Health Congress.Papers for discussion, Occupational health for areahealth authority staff, p. 149.

Horder, Lord (1956). In Health in Industry, LondonTransport Executive. Butterworths, London.

Lee, W. R. (1973). An anatomy of occupational medicine.British Journal ofIndustrial Medicine, 30, 111-117.

Lowe, C. R. (1974). Occupational medicine and epidemi-ology. Proceedings of the Royal Society of Medicine,67,643-646.

Medical Commission on Accident Prevention (1971).Medical Aspects ofFitness to Drive. London.

Medical Services Review Committee (1962). A Review ofthe Medical Services in Great Britain. Social Assay,London.

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Addendum

Since preparing this lecture I have been persuaded that therewould be many advantages in the occupational health servicerelating to the area administrator (in his personnel function)rather than to the Area Medical Officer.

Received for publication 31 July 1974Accepted for publication 29 August 1974

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