A Professional Service
1
915 LEADING ARTICLES A Professional Service THE LANCET LONDON 23 APRIL 1966 THE report on the Appointed Factory Doctor Service will arouse mixed feelings. It will be welcomed in so far as it recognises the need to reform a system designed to deal with the problems of a bygone era in our industrial history-a system, moreover, which is using medical man-power wastefully and ineffectively. Adolescents entering industry are healtheir than ever before, and the factories (with a few exceptions) are no longer dark satanic mills. Yet over half a million examinations of these young people are performed annually; less than 0-5% are rejected, and for about 5% provisional or conditional certificates are issued. In many factories this is the only form of medical supervision from one year to another; and in the smaller ones, where the need may be greatest, the examination need not even take place on works premises. It is, moreover, an open secret that many of these examinations are very perfunctorily carried out. Clearly, then, any proposal to divert medical skills from these unrewarding activities to more urgent tasks in the industrial environment should meet with at least quali- fied approval. The members of the subcommittee who prepared the report have shown themselves fully aware of the needs, but some of their proposals will arouse doubts. Perhaps two conflicting considerations were in their minds: firstly, the fact that the United King- dom, although a signatory to the Convention of the International Labour Office on the provision of occupa- tional health services, has done little or nothing to implement it, and should now at least appear to be attempting something of the kind; and, secondly, the present shortage both of doctors and of facilities for training them in occupational-health work. The idea of the new " A " doctor as a local or regional consultant on matters of industrial health is admirable; but many years of experience in this work, irrespective of formal train- ing, are needed to fill this role satisfactorily, and it is hard to see where sufficient suitable incumbents will be found. The report states that these appointments may be either full-time or part-time, though the probability is that most of them will be part-time. A bolder course would have been preferable-to recommend that the new posts should all be full-time, allowing for an occasional exception. This step would greatly ease the move from aspirations to reality, particularly in the wide range of permissive activities, including liaison and coordinating work, which the subcommittee hope to see included. A part-time man is hardly likely to undertake these duties with full vigour and enthusiasm. Indeed he may find that the terms of 1. The Appointed Factory Doctor Service: Report by a Subcommittee of the Industrial Health Advisory Committee. H.M. Stationery Office. 2s. 3d. See Lancet, April 16, 1966, p. 884. his appointment do not give him the office and the secretary which are essential to the job. The creation of an adequate number of attractive full-time posts would encourage doctors already working full-time in occupational health to apply-and this sector contains by far the greater part of the country’s strength in skilled man-power. Yet the report would almost com- pletely prevent the works medical officer from making his experience and skills available to a wider section of the community (" it would, in general, be inadvisable for a works medical officer to be appointed as an ’ A’ doctor ") although the door is reluctantly left a little ajar. Behind this statement no doubt lies the influence of the permanent officials of the Ministry of Labour, who have never felt easy at giving any statutory powers to the salaried company doctor, foreseeing conflicts of loyalties (or implying lack of integrity)-misgivings which in the circumstances of today are surely baseless. There can be no good reason why such a doctor should not investigate officially cases of notifiable disease or gassing accidents in the factory where he is employed; he would in any case be making such investigations as part of his job, and in the rare case of administrative difficulty he could have the support of the medical inspector of factories. Admittedly, his security of tenure, if he were so appointed, would need to be protected in much the same way as that of the medical officer of health. The alternative is a perpetuation of the amateurism which has held back effective developments for too long. Could it be that the Ministry sometimes favours such an arrangement because it ensures docile factory doctors who will not cause trouble by exerting uncomfortable pressures and introducing new ideas ? If this report is to be implemented, as it stands, by legislation, the results are likely to be presented to the country as the beginnings of a national occupational health service: in fact, while the subcommittee was sitting, the fact that it was doing so was given to Parliament in answer to a question about what the Government was doing to create such a Service. 2 However necessary some of the suggested reforms may be, they will certainly not do that. Our Factory Inspec- torate has a proud record of past achievement, and contains today many devoted public servants; but if its traditional thinking is allowed to exert too great an influence on forthcoming legislation, we shall fail to apply fully, and on a national scale, the existing body of knowledge and experience concerning health at work. Acute Pulmonary Embolism THE resurgence of interest in acute pulmonary embolism continues unabated, and rightly so; for it is an extremely important cause of pulmonary disease and death in hospital patients. Yet there remain large areas of ignorance and uncertainty; and the need is plain for long and controlled prospective studies of the natural history of the disease and various forms of prophylaxis and treatment.3 4 Many excellent controlled inquiries 2. Hansard, House of Commons, Nov. 1, 1965. 3. Lancet, 1965, ii, 70. 4. Thomas, D. P. New Engl. J. Med. 1965, 273, 885.
Transcript of A Professional Service
915LEADING ARTICLES
A Professional Service
THE LANCET
LONDON 23 APRIL 1966
THE report on the Appointed Factory Doctor Servicewill arouse mixed feelings. It will be welcomed in so faras it recognises the need to reform a system designed todeal with the problems of a bygone era in our industrialhistory-a system, moreover, which is using medicalman-power wastefully and ineffectively. Adolescents
entering industry are healtheir than ever before, and thefactories (with a few exceptions) are no longer darksatanic mills. Yet over half a million examinations of these
young people are performed annually; less than 0-5%are rejected, and for about 5% provisional or conditionalcertificates are issued. In many factories this is the onlyform of medical supervision from one year to another;and in the smaller ones, where the need may be greatest,the examination need not even take place on workspremises. It is, moreover, an open secret that many ofthese examinations are very perfunctorily carried out.Clearly, then, any proposal to divert medical skills fromthese unrewarding activities to more urgent tasks in theindustrial environment should meet with at least quali-fied approval. The members of the subcommittee whoprepared the report have shown themselves fully awareof the needs, but some of their proposals will arousedoubts. Perhaps two conflicting considerations werein their minds: firstly, the fact that the United King-dom, although a signatory to the Convention of theInternational Labour Office on the provision of occupa-tional health services, has done little or nothing toimplement it, and should now at least appear to beattempting something of the kind; and, secondly, thepresent shortage both of doctors and of facilities fortraining them in occupational-health work. The idea ofthe new " A " doctor as a local or regional consultant onmatters of industrial health is admirable; but many yearsof experience in this work, irrespective of formal train-ing, are needed to fill this role satisfactorily, and it is hardto see where sufficient suitable incumbents will be found.The report states that these appointments may be eitherfull-time or part-time, though the probability is that mostof them will be part-time. A bolder course would havebeen preferable-to recommend that the new posts shouldall be full-time, allowing for an occasional exception.This step would greatly ease the move from aspirationsto reality, particularly in the wide range of permissiveactivities, including liaison and coordinating work, whichthe subcommittee hope to see included. A part-time manis hardly likely to undertake these duties with full vigourand enthusiasm. Indeed he may find that the terms of1. The Appointed Factory Doctor Service: Report by a Subcommittee of
the Industrial Health Advisory Committee. H.M. Stationery Office.2s. 3d. See Lancet, April 16, 1966, p. 884.
his appointment do not give him the office and thesecretary which are essential to the job.The creation of an adequate number of attractive
full-time posts would encourage doctors already workingfull-time in occupational health to apply-and this sectorcontains by far the greater part of the country’s strengthin skilled man-power. Yet the report would almost com-
pletely prevent the works medical officer from makinghis experience and skills available to a wider section ofthe community (" it would, in general, be inadvisablefor a works medical officer to be appointed as an ’ A’doctor ") although the door is reluctantly left a little ajar.Behind this statement no doubt lies the influence of the
permanent officials of the Ministry of Labour, who havenever felt easy at giving any statutory powers to thesalaried company doctor, foreseeing conflicts of loyalties(or implying lack of integrity)-misgivings which in thecircumstances of today are surely baseless. There can beno good reason why such a doctor should not investigateofficially cases of notifiable disease or gassing accidentsin the factory where he is employed; he would in anycase be making such investigations as part of his job, andin the rare case of administrative difficulty he couldhave the support of the medical inspector of factories.Admittedly, his security of tenure, if he were so appointed,would need to be protected in much the same way asthat of the medical officer of health.The alternative is a perpetuation of the amateurism
which has held back effective developments for too long.Could it be that the Ministry sometimes favours such anarrangement because it ensures docile factory doctorswho will not cause trouble by exerting uncomfortablepressures and introducing new ideas ? If this report is tobe implemented, as it stands, by legislation, the resultsare likely to be presented to the country as the beginningsof a national occupational health service: in fact, whilethe subcommittee was sitting, the fact that it was doing sowas given to Parliament in answer to a question aboutwhat the Government was doing to create such a Service. 2However necessary some of the suggested reforms maybe, they will certainly not do that. Our Factory Inspec-torate has a proud record of past achievement, andcontains today many devoted public servants; but if itstraditional thinking is allowed to exert too great aninfluence on forthcoming legislation, we shall fail to
apply fully, and on a national scale, the existing body ofknowledge and experience concerning health at work.
Acute Pulmonary EmbolismTHE resurgence of interest in acute pulmonary
embolism continues unabated, and rightly so; for it is anextremely important cause of pulmonary disease anddeath in hospital patients. Yet there remain large areasof ignorance and uncertainty; and the need is plain forlong and controlled prospective studies of the naturalhistory of the disease and various forms of prophylaxisand treatment.3 4 Many excellent controlled inquiries
2. Hansard, House of Commons, Nov. 1, 1965.3. Lancet, 1965, ii, 70.4. Thomas, D. P. New Engl. J. Med. 1965, 273, 885.
