HC Deb 26 July 1972 vol 841 cc1967-79
Mr. Robert Hughes

I beg to move Amendment No. 2, in page 2, line 2, after 'patient', insert 'or his place of work'.

The object of this Amendment is quite clear, namely to empower the Secretary of State to proceed either with the establishment of an occupational health service or to proceed to think about the problem and begin to set one up. It is disappointing that all we have had so far from the Government is a technical reorganisation. The Minister in charge of the Bill keeps saying that this is all that is intended—that the Bill deals with a small, technical reorganisation matter and that we should not discuss matters of principle because they are not in the Government's mind at all.

After 25 years of the operation of the National Health Service, all that has been examined by the Government has been the operational efficiency of the tripartite system which has been in existence since the original 1947 Act. Surely the Government could have given some consideration to the lessons which have been learned over those 25 years. But it would appear that no thought has been given either to the principles of reorganisation or to the investigations which have been carried out in the last quarter of a century.

It is significant that in all the speeches by the Secretary of State and by the Minister on Second Reading and in Committee there was no mention of the problems of occupational ill health. The Government have been obsessed by other matters. They have been concerned about strikes almost to the exclusion of everything else. But let us leave aside their current difficulties on that subject and the fact that once again they appear to have been miraculously rescued by the intervention of the Official Solicitor. Let us also leave to one side the fact that many days have been lost in industrial disputes as a result of the Government's short-sighted Industrial Relations Act; although it is important to recognise that for every day lost in strikes, 10 days are lost through industrial injury and disease. It is even more significant that for every day lost in strikes, 100 days are lost in ordinary illness.

We should try to tackle the problems of ill health in an imaginative new way. Our problem in the Health Service at present is that we tackle the difficulties at the wrong end. Our emphasis is on the curative rather than on the preventive aspect of medicine. My own view is that the absorption of the local authority health service into the single unit of the area health board, tilts the already over-weighted balance even more towards the curative hospital services and away from the admittedly weak, but nevertheless important, preventive aspect of our National Health Service.

A major step forward in this reorganisation would be to introduce a proper occupational health service. I accept that the Government have made some move towards looking at the problem. They have put through the House the Employment Medical Advisory Services Act, which is expected to become operational towards the end of the year. It was similar to Part I of the Employed Persons (Health and Safety) Bill proposed by the Labour Government, but lost due to the dissolution of Parliament and the result of the 1970 election. However, I do not think that this can be regarded as a proper substitute for a fully comprehensive occupational health service.

To be fair to the present Government, they have never claimed that the Medical Advisory Service was intended to be a substitute for a fully comprehensive occupational health service. In the course of the Second Reading debate on the Employment Medical Advisory Service Bill on 13th December, 1971, the Under-Secretary of State for Employment made it clear that the Bill was not intended to provide a fully comprehensive occupational health service.

Similarly, the passing of that Bill laying down a limited occupational health service resting with the Department of Employment is not the end of the story. In fact, it is only the beginning of the discussion of what should be done about an occupational health service. I hope that the Under-Secretary of State for Health and Education will not use as an excuse for resisting this Amendment the fact that the Government have passed the Employment Medical Advisory Service Act and therefore that there is no need to do any more. That defence does not hold water.

On 13th December 1971, the Under-secretary of State for Employment said: When the National Health Service is reorganised, the proper home for the Employment Medical Advisory Service will undoubtedly have to be looked at again by the Departments concerned, and I can assure the House that there is nothing in the EMAS proposals as at present drafted which prejudices the issue of what arrangements might be most appropriate in the long term for occupational medicine. I hope that some medical authorities who have raised doubts about this will read these words in Hansard and accept this assurance as it is a sincere one from my Department. The Under-Secretary was pressed by my hon. Friend the Member for Plymouth, Sutton (Dr. David Owen) to confirm that he was not excluding the possibility of the reorganisation of the Health Service incorporating changes to allow occupational health centres under the NHS, and the hon. Gentleman replied: That is possible. As the hon. Gentleman knows, that is not a matter for me because the reorganisation of the Health Service is not for my Department to carry though the House. There is no doubt that there will be continuing consultations between Government Departments who are affected."—[Official Report, 13th December, 1971; Vol. 828, cc. 126–7.] So that at that stage there was the possibility of discussions being held in the future. But nothing has been said in this Bill about the position of an occupational health service. Apart from one or two minor references, as a result of our probing, there has been no reference to an occupational health service, and this is a very serious omission from both our discussions and the Bill.

There can be no doubt that such a service is needed urgently. The average number of working days lost a year due to certified sickness absence is about 300 million. Many people have tried to estimate the cost to the individual, and a number of different calculations have been done; for example, in the year 1967–68 it was estimated to have cost of the order of £1,750 million. That is a staggering sum, and it approaches the total cost of the Health Service, or 5 per cent. of the national income. Clearly there is a great cost to the individual in being off sick.

The cost to the nation can be calculated in different ways. It has been estimated that the cost to the Exchequer of sickness benefits in 1967–8 was £328 million, or roughly £1 for every working day lost due to certified sickness absence. There is a tremendous amount of money involved. By having a proper service which prevented illness and loss of work, we could save the nation a considerable amount of money.

10.45 p.m.

What cannot be calculated, in addition to all these calculations on which an accurate figure can be placed, is the actual loss of production due to the diminution of the operational efficiency of the person who is sick but who is still at work. Although we always try to see that sickness benefit is as high as possible so that people who are off ill do not suffer too much from the lack of finance and there is no real hardship to individuals, we must always recognise that this is only a palliative, because we must never forget that the individual has a right to good health in itself, and this is a basic right to be fought for at every opportunity.

If we can alleviate and/or prevent illness and human suffering, we shall have achieved something really precious and worth while. We are all agreed on this. I do not think there is any real difference in this House or in the country about the object we should be setting out to achieve. The only point of difference appears to be how we set out to achieve it.

We have had many reports on and investigations into an occupational health service, and it is astonishing that these investigations, by many diverse bodies, have gone on for so long and yet neither this Government nor the previous one really tackled the question. There have been plenty of studies, but very little action. For example, as long ago as 1949 the then Labour Government set up the Dale Committee to look at the relationship of occupational health and the National Health Service. This committee reported in 1951 and recommended that there should be a comprehensive provision for occupational health which covered not only industrial establishments, large and small, but also non-industrial occupations. These included occupations such as agriculture and people employed in offices.

I do not go the whole way with the Dale Committee, because it recommended that most of the occupational health service should be done on some kind of private basis. This means that, apart from anything else, it would be confined to the large firms which had the resources available. One can postulate different ways in which companies could group together for a kind of group occupational health service, but that would not be a proper way to run things. It would not be a satisfactory way. The best way is to have the occupational health service properly integrated into the National Health Service.

Although there may be difficulties in defining what we want, or what the object should be, the most acceptable definition of an occupational health service may be that laid down by the International Labour Organisation/World Health Organisation Committee on Occupational Health in 1950, which said—and this definition is very wide and covers what we are after: Occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well being of workers in all occupations; the prevention among workers of departures from health caused by their working conditions, the protection of workers in their employment from risks resulting from factors adverse to health, the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological equipment and, to summarise, the adaptation of work to men and of each man to his job. That is a wide definition, yet we see that although all kinds of medical practice and all kinds of diagnostics in medicine have changed in the last 20 years that broad definition, particularly the last sentence, is still relevant today.

In addition to those committees, there was the 1962 Porritt Committee on the British Medical Association, and again it reported that there should be some developments in the National Health Service. In 1968 there was the Royal Commission on Medical Education, and again it made comments, but nowhere is there a comment from the Secretary of State on what he sees in all this. This is disappointing, because the Secretary of State made available to us—and we are grateful to him for doing so—the discussion document put out by his Department in relation to all the topics to be discussed and there is nothing in this document which suggests that the question of an occupational health service was being looked at at all.

We in the Labour Party have looked at the matter often and long, and believe that a number of points should be taken into consideration. For example, doctors and nurses should work in factories or visit factories as required, to treat both accidents and illnessoccurring at work. There should be a medical examination of people undertaking jobs where physical fitness is essential, of those who are worried about the effect of work on their health, and of those engaged in dangerous processes. There should be a study of all health risks and working conditions and of how management can safeguard workers. There should be provision for accommodation for treatment at work wherever such provision is justified in improving health and saving work time. There should be rehabilitation facilities to enable the disabled to make their full contribution to industrial production. There should be the teaching of preventive medicine and positive health measures to the workers in factories. There lies a responsibility. There should beproper training and equipment for all first-aid workers.

Those are all important points, because there is now clear evidence that conditions of service at work have a bearing on the mental health as well as the physical health of people involved in work.

It is interesting to look at the changing pattern in absences from work due to illness, and the kind of reasons given by doctors in medical certificates. There has been a tremendous reduction in the absences, for example, due to tuberculosis. In 1967–68, the amount of absences due to tuberculosis was only 17 per cent. of the lost man days attributed to the same disease in 1954–55. That is a great reduction which reflects the great changes in the environment and the general health of the public which have taken place in the past 25 years. What is growing fast is incapacity due to psycho-neurosis and neuroses. Perhaps this is due not only to the great change in the stress of work and the conditions of work and the different patterns of work, but also to the different patterns of living.

We deplore not so much the lack of action, although that is bad enough, but the lack of thought and discussion. The Government have approached the Bill without a spark of imagination about the future. The Amendment offers the opportunity to put the situation right.

Dr. Miller

It would be churlish of me and my hon. Friends not to indicate that we are glad to have the opportunity to discuss this important Amendment, which indicates that the important aspect of the National Health Service is the patient. The important point is not the set-up of the service, the doctors, the nurses or the ancillary services, but the patient. It is the patient about whom and around whom the service has evolved.

I make no apology for taking a little time to point out that in the next six or nine months we will have similar points of view put forward when the United Kingdom Bill is brought before the House. We will then discuss similar aspects of the problem to those we are now discussing. It is perhaps indicative of the situation that there are few hon. Members listening at the moment, but I am not making any criticism of that.

I want to draw on my considerable experience of 20 years as a general prac- titioner in this respect. I know that no insoluble problem is involved in the Government accepting that some aspect at any rate of occupational health service should be incorporated into the Bill, even if it were a simple matter of saying that a man or a woman should have two doctors, one at the place of work and the other near the home, if necessary dividing the capitation fee, which would balance out in the long run. There would be no problem there.

There are many places in Scotland where it is impossible for the medical profession to provide a service at the time when it is possible for quite a number of patients on the doctor's list to go to him. Some of my hon. Friends represent constituencies where complaints have been made that after five o'clock in the evening it is impossible for a patient to see his doctor.

I am not levelling any complaint against the individual doctor because it may well be that he has somewhere else to go at that time, for there are places in Scotland, particularly in the rural areas, where a doctor covers a large area and has to have a surgery in one place at one time and a surgery in another place at a different time, which means that patients in one area cannot consult him after work because he is in another area at the time, seeing other patients.

I do not see why there cannot be incorporated into the Bill a provision which would make it possible for a patient to consult his practitioner at work. With our modern methods of computing, there should be no problem in making records available quickly between one point of contact between patient and doctor and another point of contact.

I appreciate that the Amendment does not cover the whole range of an occupational health service but only a very small part of it, but it is at least a start. It would at least mean that a man employed in a small factory—many of the larger factories have their own industrial health services—could contact a doctor. Many industrial estates are conglomerations of small factories and it may well be that a doctor in the vicinity could undertake to provide a medical service for the estate which at the moment is not being provided by the patients' own doctors. All I am asking is that the Under-Secretary of State should turn his mind to the possibility of making a dual capacity possible. Let the service be available at an industrial estate in the form of medical provisions, to anyone who needs it, without this infringing the relationship between doctor and patient in any way.

11.0 p.m.

In other words, let the doctor-patient relationship be entirely to the benefit of the patient in this respect. Let it be possible for a patient to have a doctor near his place of work in addition to having a doctor near his home, instead of the patient having to choose which is more convenient to him.

Even this matter of choosing is finely balanced. For a considerable part of the time it would be better for the patient to have a doctor near his place of work, and for a smaller part of the time it would be more advantageous and convenient to have one near his home. I ask that the Secretary of State should examine the possibility that a patient need not be faced with this difficult choice, often a finely balanced choice, as I know from my experience in general practice.

Fortunately I had hours which suited the majority of my patients but there were patients who had employment a considerable distance from where they lived. They tended to arrive at my surgery when I had to be in another place, and it is from that experience that I ask the Secretary of State to examine carefully the possibility of ensuring that patients are not neglected; are not denied necessary treatment and continuity of treatment; and to ensure that no loss of production is involved if it should be necessary for a man or woman to stay off work to consult a doctor near his home when it would be much easier and involve no loss of production to spend 15, 20 or 30 minutes consulting a doctor near his place of work.

This is not the whole substance of an occupational health service, but my hon. Friends would agree that with the necessary changes which would be made if there were a full occupational service, it would be a very encouraging start.

It is with a degree of plaintiveness that I ask the Minister not to discard the thought behind this Amendment because it does not, perhaps, entirely comply with drafting requirements.

It would go a long way to creating an aspect absent from the health service since 1948 and towards filling a gap in the comprehensive service.

I ask the hon. Member—perhaps not on bended knee but certainly with a great deal of humility, and bringing to him my 20 years' experience in general practice in which I met this problem day in and day out—to look favourably on the Amendment, at least to the extent of seeing whether it is possible to achieve its end in some way.

Mr. Monro

I agree to a large extent with the sentiments expressed by the hon. Members who have spoken to the Amendment. I would point out to the hon. Member for Aberdeen, North (Mr. Robert Hughes), who has been so constructive in the debates on the Bill, that it is a massive Measure, and that the amount of work that is to be done between now and April, 1974, is immense. It is wrong to think that quite major issues such as we have discussed on the first two Amendments can be popped in at the last moment. That would overload the working of the Bill in the next 18 months.

Strictly in terms of draftsmanship, the hon. Member should realise that the Amendment is unnecessary, because the Bill already refers to medical, nursing and other services, whether in such accommodation or premises, in the home of the patient or elsewhere. That can be carried out under the National Health Service. It is in Clause 2 (1) (c), and it covers the reference in the Amendment to "or his place of work" by the words "or elsewhere".

I know that hon. Members have used the Amendment as a vehicle for discussing the occupational health service, which is most important. Hon. Members have appreciated that the Employment Medical Advisory Service Act, which went through this Session, seeks to rationalise the existing arrangements both by concentrating medical expertise in fewer hands and by eliminating unnecessary routine examinations of fit young adults. Responsibility will still rest with the Secretary of State for Employment.

This reflects the background against which such services have developed, with the whole range of industrial health and safety—not merely its medical aspects—closely linked with the Factory Inspectorate.

Hon. Members do not seem to have taken on board the great importance of the Robens Report, which came out this month. I know that when they have studied it—especially paragraphs 375 to 380, dealing with occupational medicine in the future, and paragraph 371, dealing with the EMAS—they will realise that this would be the wrong moment to take any dramatic new initiative. The Government are studying this report urgently, and we have only just passed the Act to which I have referred. It would be wrong to take another important step tonight by putting anything further into the Bill to do with the occupational health service.

The hon. Member for Aberdeen, North made a point concerning my hon. Friend the Under-Secretary of State for Employment and subsequently the question asked by the hon. Member for Plymouth, Sutton (Dr. David Owen). In the Official Report of Standing Committee A, on 20th January, 1972, my hon. Friend made it quite clear that at the moment the balance of thought was that the service should remain under the Secretary of State for Employment. There is no likelihood of any immediate change of responsibility, but our detailed study of the Robens Report, the Act I mentioned, and what I am saying tonight show that we are very well aware of the importance of occupational health, and that we believe that in the immediate future the way ahead is through co-operation between the EMAS and the National Health Service. They must work together as closely as possible. Lord Robens, in his excellent report, saw a solution in the formation of an authority for safety and health at work. The matter will be given close scrutiny by the Government. As a result of all these deliberations, including what has been said tonight, I am sure the importance of this measure of occupational health will be accepted by the Government, and that at the appropriate time further legislation or administrative action will be taken. There is no question but that the Government are seized of the importance of the subject.

In view of the assurances I have given I ask the hon. Gentleman to consider withdrawing the Amendment.

Mr. Robert Hughes

I do not wish to swap quotations of what has been said by the Under-Secretary of State for Employment. We find that at different points the hon. Gentleman was being all things to all men.

It is significant that the Employment Medical Advisory Service Act took three sittings to complete its consideration in Committee, whereas, with the greatest of co-operation, this Bill took nine sittings. The Opposition do not feel adequately rewarded for their co-operation, even with what the hon. Gentleman has so far given us. It is all very well for the Minister to express certain sentiments and agree with the Opposition's general views. He argues that our proposal would so overload the machinery that it would be impossible to carry it out by the prescribed date in the Bill. My view is that it would have been possible under our Amendment to proceed to have a reorganisation. It might not have been complete by the operative date in the Bill, but I do not think that everything in the Bill must be ready by then.

I hope that there will be some action. We shall debate the Robens Report in greater detail on another occasion. I find the report disappointing. That was one of the reasons which prompted us to put down the Amendment, in the hope that the Minister's first thoughts on the matter might be more helpful. I know that there are differences of opinion. For example, the TUC believes that the occupational health services should be left with the Department of Employment. The other side of industry takes the opposite view.

I hope that the Minister does not have a closed mind on the subject. I hope that the view of his hon. Friend the Under-secretary for Employment, that the service should develop in the Department of Employment, is not the settled view of the Government, and that they will not feel that what is done in England and Wales is necessarily appropriate for the whole country. Our society is in many ways different from the general society in England and Wales. Perhaps a case can be made for such a service being with the health service in Scotland.

But in view of what the Minister said, and the lateness of the hour, I beg to ask leave to withdraw the Amendment.

Amendment, by leave, wihtdrawn.

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