§ 3.43 p.m.
§ Lord Gregson rose to move, That this House takes note of the report of the Science and Technology Committee on Occupational Health and Hygiene Services and of the Government's Response (2nd and 5th Reports, H.L. 99 and H.L. 289).
§ The noble Lord said: My Lords, your committee undertook this inquiry in response to continuous public debate over the field of occupational health and hygiene. It is some time since this subject was reviewed—in fact, it has not been reviewed since the Robens Committee, which reported in 1972 on the wider terms of safety and health at work; and given the rapid changes in the industrial scene, the ever-increasing technological change, with its effect on work practices, and continuous introduction of new materials and chemicals, it was indeed opportune to undertake this inquiry.
§ There was very lively interest from many quarters. Evidence was received from 114 bodies and indivi- 424 duals. On behalf of your committee I must express our gratitude to those very many people and organisations who helped us with our inquiries either by submitting written evidence or by coming along and giving oral evidence. The committee are also grateful to the specialist advisers for their assistance, and especially to the clerk for his valiant efforts.
§ Since it was some little time since this report was published, the Government's initial Response has been received by the Select Committee and since published for your Lordships' benefit. This takes the form of a letter to me, as chairman of the subcommittee, from the Secretary of State for Employment and a memorandum from the Health and Safety Commission, being the Government agency most concerned. We have therefore the somewhat unusual situation of having the Government's initial Response in advance of this debate. This, I believe, will allow a most useful discussion this afternoon.
§ I propose in my remarks to deal, first, with the report and then to make some comment on the Government Response. For the purpose of this inquiry your committee have distinguished between occupational health, representing the physical and mental wellbeing of the workforce, and occupational hygiene, the control of physical, chemical and biological factors in the workplace which may affect the health of the workers. We readily admit that this is an artificial distinction as many occupational health services will also provide hygiene services.
§ Occupational health and hygiene is a very complex subject covering many disciplines of medicine and science and technology. It is axiomatic that following our review there should be numerous detailed recommendations, and that is the case. There are in fact 38 recommendations. I have no doubt it will be some relief to your Lordships if I say that I do not intend to review them all in detail this afternoon but rather to address myself to the more important issues.
§ Considering that the working population spend approximately one-third of their waking hours in their place of work, it must be recognised that occupational medicine is a substantial part of primary health care. It would be easy and logical to suggest that primary health care should be provided by a National Health Service that would cover all activities all the time in a person's lifetime. This may well be a future ideal, but one must look at the practical reality of what is possible, and the committee recognise that the occupational health service has developed as a separate, wholly private activity quite distinct from the National Health Service, financed by the employer, and we explain in the report the many reasons for recognising this and building upon it. Nevertheless, occupational health is part of primary health and it should not remain uncovered or totally avoided.
§ As the work of the committee progressed, it soon became apparent that on the whole this country is well served by its occupational health and hygiene services, but this tends to be more so relative to the majority of the large organisations, be it in industry, the manufacturing sector, the services, Government and other bodies. There are, and always will be, of course, exceptions, but in the larger companies these appear to be a small minority. Where there appears to be some 425 problem is in the many diverse small and medium-sized organisations, whether it be small factory operation, offices, shops, etc. Because of this, the committee spent a good deal of time reviewing this area of endeavour.
§ Again, the situation is not black and white and many small organisations are well covered, but on the whole there are many units who have no recourse to any professional services whatsoever. This is not a very satisfactory situation, and while recognising the committee's view that it was not appropriate to clear this problem by a blanket application of primary health care within the National Health Service, your committee considered that there were three possible courses of action that might be pursued.
§ One is obviously to do nothing and hope for a miracle to happen. The second option would be to impose a statutory obligation on all employers to provide occupational health services to cover the working populations, and I must report to you that the TUC and the nursing profession were most persuasive in advocating this course of action.
§ However, after a great deal of discussion, the committee were reluctant to recommend a statutory requirement, and I give the following reasons in support of this consideration. First, it would create a demand for qualified personnel far greater than the possible supply. Secondly, it would impose an unwelcome additional cost on industry, with possible damage to industry's competitiveness, and would provoke hostility and resentment. It would need a large bureaucracy to enforce it, which would be costly, using funds that could be better spent elsewhere in the health service, and it would still be doubtful whether it could reach out to enforce statutory obligation in the many thousands of small organisations. Finally, your committee doubt whether a statutory arrangement would ever be sufficiently flexible for the widely varying needs of many different industries and numerous different workplaces covering manufacture, shops, offices, etc.
§ Your committee think that compulsion should be considered only as a last resort, and that there is a great potential for some kind of intermediate measure which would be necessary anyway prior to attempting a statutory code. That brings me to the third option, which would be to encourage employers to provide a service voluntarily by means of a non-statutory code of practice, and this is the major recommendation of your committee.
§ The code would follow the proposal of the TUC without statutory obligation. It should be possible to secure observance of the code by persuasion and by example. The commmittee recommend that the Health and Safety Commission, taking advice from their industry advisory committees, which would include the CBI and the TUC, should instruct the Health and Safety Executive to draw up codes of practice on the provision of occupational health and hygiene services in industry. It should be a flexible code based on the widely different needs and requirements of the many industrial sectors, and it should take account of the size of the organisation concerned. It would set out in general terms the qualifications of personnel, the provision of appropriate facilities, the working relationship between personnel, management 426 and unions, and the control of the services. The code of practice would, in fact, be a series of codes sharing a common purpose and to some extent a common form reflecting the widely different needs of the widely different forms of employment.
§ I have no doubt that many organisations that provide very adequate services of which your committee were made aware would fall well within the requirements of the code. But the code would bring home to those people who make insufficient provision, or, in fact, no provision at all. the need to provide this primary health and hygiene care for their employees.
§ Once the code is established, your committee concede that it will not be easy to secure observance, especially among the small employers, unless there is some form of monitoring. They think that the medical division of the Health and Safety Executive should play the chief role in persuading employers to apply the code. Close co-operation with the Factory Inspectorate would be essential in identifying those industries most in need of health and hygiene services. To enable it to discharge this important activity, your committee recommend that the medical division of the Health and Safety Executive should be considerably strengthened to at least its full complement of 100 full-time equivalent doctors, as originally envisaged by the Robens Committee.
§ It will be obvious that the promulgation of a code of practice in occupational health will require additional professional staff to allow the code to be practised, and, therefore, your committee looked very carefully at the provision of staff and their training. Although there are a small number of full-time medical specialists and consultants in the field of occupational medicine, the service on the whole is staffed by a large number of general practitioners, possibly as many as 2,000, who undertake the work of occupational medicine on a part-time basis, and your committee see no reason to change this general position. These and other practitioners should be encouraged to extend the occupational health side of their activities. Practitioners in occupational medicine should be listed by the Health and Safety Executive and encouraged to obtain specialist qualifications in a somewhat modified form compared with the rigid qualifications that have previously been suggested. Such a system would help considerably to enable doctors in general practice to understand the health needs of the occupational activity, and would go a long way to ending the current dichotomy between occupational medicine and the general medicine of the National Health Service.
§ Your committee were greatly impressed by the work of the special group occupational health centres located in high concentrations of mainly medium and small industry. Unfortunately they are few in number, and are difficult to bring into being. They require careful planning and a great deal of motivation and effort, but they are worthwhile, and the committee would like to ensure that any initiative to start new centres should be given every assistance, particularly by providing pump-priming loans.
§ Outside the concentrated areas of industry, 1,390 health centres have been created for the National Health Service either in modified buildings or in new premises. Your committee strongly recommend that 427 such premises could be used as an operational base for the provision of occupational medicine. They would provide cover for many small organisations, be it shops, small offices or small workshops that are within easy reach of a large number of these health centres.
§ Outside the medical cover of the qualified practitioner, the mainstay of the occupational health service is provided by nurses, and there are some 9,000 of these employed by industry and public organisations. Working from their treatment centres, they provide the continuous interface for the whole service, and we feel that this should be extended to smaller companies, at least on a visiting basis. Again, the health centres and group practice centres of the general practitioners would provide an extremely good base for these nurses to work from.
§ Arising from the development of professional services, there is obviously a need to look to education and training, and your committee were not happy with the existing provisions that are made. In Chapter 12 of the report your committee report in great detail their recommendations for education, qualification and training. Others more qualified to comment would no doubt wish to cover this later in the debate, but may I say just three things? First, I was agreeably surprised with the professional bodies concerned in the field, particularly the Royal College of Practitioners and the Royal College of Nursing, who have very clear ideas regarding the requirements, and I believe it behoves the Government and industry to give them considerably more support than they have done previously.
§ Secondly, if doctors and nurses outside the health service are trying to qualify in this important branch of medicine by full-time education, they should be financially supported like any other occupational training. And, thirdly, because of the widespread, very often isolated location of the majority of these people, the Government should support the development of distance learning facilities such as video teaching services, sound tapes, etc., which are widely used by other disciplines.
§ Finally, the committee looked at the question of research, which is so important in order that our occupational health service can keep abreast of the rapidly changing technology and the introduction of new chemicals and materials. Research is also an essential part of supporting an education and training facility, particularly in the universities.
§ Your committee were impressed by the example of the National Institute of Safety and Health, which is the United States equivalent of our Health and Safety Executive, and we were grateful for its director coming to give evidence to your committee. This American national institute has established the priority occupational disease groupings, and constantly reviews the research priorities for the future. But the most important aspect of their activity is their coordinating role, and your committee consider that, although a good deal of research is carried out in the United Kingdom—maybe not enough, £1.2 million compared with the American 40 million dollars annually—it could be better co-ordinated and, therefore, more cost-effective. The committee recommend that the Health and Safety Executive 428 should itself take on this task, making use of the Medical Research Council's environmental directors group.
§ The key to your committee's recommendations arising from this report is the establishment of the voluntary code of practice, and I would strongly urge that the Government and industry should very seriously consider this recommendation.
§ May I now turn to the Government's initial response? I should like to thank both the Secretary of State for Employment and the Health and Safety Commission for their timely initial response to our report. I must say that I find the Health and Safety Commission's memorandum somewhat more encouraging and positive than the Secretary of State's letter, but maybe that is the political dimension and one can understand, but not necessarily agree with, the effect of the extreme pressure to restrain public expenditure.
Your committee is encouraged by the response of the Health and Safety Commission, and are pleased that the commission are either supporting or looking carefully into so many of our recommendations. While I do not intend to weary the House by a blow by blow comment on the detailed response, I must express my concern on what I consider to be a fundamental issue. I do not detect in either the letter of the Secretary of State for Employment or the Health and Safety Commission's memorandum that there is any recognition whatever that any problem exists. Yet only last week, in presenting his annual report on manufacturing and service industries, Her Majesty's Chief Inspector of Factories would appear to be equally concerned as your committee on the lack of effective cover in the important area of small companies. I quote from his report:
New small enterprises are hard put to it to keep their financial heads above water. Whether they are the sort that make no concessions to new technology, efficiency or even old-fashioned good housekeeping or whether they are highly competent in instrument, computer or laser technology, the majority are not alert to the hazards to which their employees are exposed, and are not well briefed on health and safety legislation and practice. Furthermore, few small employers belong to the employer federations, many of which have done so much good work informing their members";
that is, of the codes of practice.
In any case there is an inevitable temptation to do only what shows a commercial and tangible benefit in the short term".
§ Two things seem to stem from this lack of recognition that any problem exists. Firstly, I do not follow the Secretary of State's argument, which seems to imply that occupational health care should not be considered as part of primary medicine. This I simply do not understand, because occupational health is certainly not secondary medicine and, heaven help us, neither is it tertiary medicine. But the Secretary of State seems to be under the mistaken idea that in our report we are suggesting that occupational medicine should become part of the National Health Service primary care. Nothing could be further from the truth, and we have gone to great lengths in the report to explain the historical background to this dichotomy, and to explain that we do not believe that now is the time to recommend drastic changes and that occupational health will remain almost completely in the private sector.429
§ Following on that point it is, therefore, very difficult to understand, when there are several hundred medical practitioners unemployed, how an additional private function would weaken the capacity of general practitioners to provide basic primary care services. I should have thought that the Government would have welcomed the job-creation aspect, especially as it would not cost the Government one penny. Secondly, the lack of recognition that the small company problem exists also appears to prevent the Health and Safety Commission from saying clearly whether it supports or rejects your committee's principal recommendation to establish the varied codes of practice. It seems to me that the first seven paragraphs of the commission's response attempts to avoid any definitive answer.
§ I hope that arising from this great debate this afternoon, the Government will recognise that a problem exists and that your committee in its recommendations has provided a possible solution that has a very minimal effect on Government expenditure, that is the least onerous to industry and especially small businesses, but yet satisfies a need that surely does exist. I hope that the Government will recognise that it is primary health care and take this opportunity to act, so that it does not finish up as a problem of secondary medicine, or even of tertiary medicine, as it has so often been in the past. I beg to move.
§ Moved, That this House takes note of the report of the Science and Technology Committee on Occupational Health and Hygiene Services and of the Government's Response (2nd and 5th Reports, H.L. 99 and H.L 289).—(Lord Gregson.)
§ 4.4 p.m.
§ Lord Lloyd of Kilgerran
My Lords, it has been my great privilege to have served on this Select Committee under the chairmanship of the noble Lord, Lord Gregson. This afternoon I must start my submission to your Lordships by expressing the most sincere and unstinted praise for the great work carried out by the noble Lord, Lord Gregson, as chairman of this committee, which had such a difficult subject with which to deal. There was a mass of evidence, as the report indicates, including a mass of oral evidence. But whatever the problems with which the committee had to deal, the noble Lord, Lord Gregson, dealt with them efficiently and, above all, with great tolerance and insight.
The noble Lord, Lord Gregson, has indicated to your Lordships this afternoon that we have the advantage of having the Government Response to the report; therefore, I propose to limit my submissions to one main theme. I entirely endorse the views expressed so fluently and eloquently by the noble Lord, Lord Gregson, in his concise speech this afternoon.
The one point to which I wish to draw your Lordships' attention is the surprising failure—whether deliberate or in ignorance—by large firms in particular, which know the hazards which their employees have to face, to use the services of physiotherapists. I have visited several firms lately, three of which had an apparently efficient occupational unit under the direction of doctors. I asked whether they used 430 physiotherapists and they said that they did not. One of the firms said that they had had to reduce the number of staff and that, although it was quite clear that the doctors were not perhaps so over-used as they might have been, it was the physiotherapist who was sacked.
Even this morning I was telephoned by a distinguished doctor—a member of one of the great professions—who asked me to urge upon your Lordships this simple matter. The hazards facing employees in some firms involve injuries to muscles, ligaments, soft tissues and joints. These injuries can cause a great loss of employment and, therefore, loss of production time. In my view the value on the staff of a physiotherapist under a doctor's control would be of great importance.
It seems to me that the use of physiotherapists in this situation has Government support. Perhaps I may refer to the Government's Response. On page 1 in the second complete paragraph of Section A the Response says:The Government particularly welcomes the Committee's broad conclusion that there is no universal best practice that is applicable across the whole of industry and that the responsibility for occupational health and hygiene services should therefore lie largely with individual employers".If the Minister would be good enough to turn to the next page, in the second complete paragraph under the title "Recommendation 3" the Government say:Many doctors providing primary care have not had the specialist training to practise in the occupational health field and their patients are, by and large, those whose homes rather than places of work are within the practice area".The noble Lord, Lord Gregson, pointed this out in his speech. Then comes a passage which is of considerable significance to Government policy:Furthermore the Government would be concerned if the volume of occupational health work became so great that it affected the capacity of general practitioners to provide basic primary care services".I shall not comment further on the points made by the noble Lord, Lord Gregson, that there is a large number of unemployed doctors who might be trained in this capacity. But I submit to the Government that, in dealing with this question of occupational health, perhaps they should have greater regard to the problems which could be solved by the inclusion of physiotherapy in the activities of the occupational health service.
Doctors who work near some large firms have informed me that often those large firms send patients to them who could have been much better treated, not by a medical practitioner, but by a physiotherapist. I have had some experience, if I may justify spending most of my speech on this one theme, in seeing the action of doctors with physiotherapists in a unit which has been set up in Addenbrookes Hospital, Cambridge—and with the setting up of it, if I may say so, I was closely concerned—in dealing with prevention and treatment of soft tissue injury. There again many of the soft tissue injuries which have been dealt with by the Addenbrookes Hospital are similar to the kind of injuries that arise from the hazards in large companies. I am conscious that there are many speakers to follow with far more experience in these matters than I have, and consequently I have limited my speech this afternoon to that one item.
§ 4.11 p.m.
§ Baroness Cox
My Lords, I wish to make a brief contribution to this debate, with particular reference to nursing. I shall leave consideration of wider issues to noble Lords who have greater experience and who can speak with greater authority than I can on those matters. But first I must emphasise that the nursing profession is delighted that occupational health has received such serious consideration, and that so many issues have been subjected to such expert analysis by the committee under the chairmanship of the noble Lord, Lord Gregson.
I shall limit my contribution to two of these issues: the quality of occupational health services, and the training of occupational health nurses. On the first matter, the Royal College of Nursing, along with many other witnesses, expressed grave concern over the patchiness of present provisions, which range from the very good to the barely adequate, to the non-existent. Where services do exist they differ widely in standards of practice and in the qualifications of practitioners.
Given this generally unsatisfactory situation the college was disappointed that the decision was taken to opt for a voluntary rather than a statutory code of practice. While appreciating the reasoning behind this decision there is still deep concern about the problem of enforceability. The college's Society of Occupational Health Nursing points out that the principle of voluntary provision has not led to any significant expansion of occupational health services over the years and that where employers have provided such services they tend to be vulnerable; they are among the first to be cut back in times of financial hardship and recession.
The Royal College of Nursing appreciates the fact that the Health and Safety Executive is adding to its list of voluntary codes, giving guidance of specific hazardous substances, and that it has also developed proposals for regulations and approved codes of practice on the general control of substances hazardous to health. The college welcomes these and other initiatives by the Health and Safety Executive as useful measures in encouraging employers to establish appropriate occupational health services. However, it is still worried that they will not be sufficient to ensure universal provision of such services. The Royal College of Nursing therefore reiterates its view that there is a need to prescribe by regulation that every employer should make arrangements to provide an occupational health service and/or to ensure that all employees have access to such a service.
My Lords, I now move on to offer a few comments on the training of occupational health nurses. The Royal College of Nursing welcomed the position adopted by the report of the Select Committee on this issue. It shares the committee's concern over the fact that too many nurses engaged in occupational health lack specialist qualifications, and it appreciated the recommendation that the Government should ensure the availability of OHNC courses by making financial provision available for both students and tutors in addition to funds currently available for nursing education.
However, there is considerable disappointment over the lack of any commitment by the Government to 432 help with such funding. Since the committee reported there is growing evidence that employers are not using the available training opportunities and that in consequence the uptake of places is actually decreasing. This is a serious anomaly, in that while it is generally recognised that there is a shortage of qualified occupational health nurses it is proving impossible, for financial reasons, to enable nurses to take advantage of the training places which are currently available and which, in some parts of the country, are now under-subscribed.
One of the factors which is exacerbating this situation is the problem that nurses are often not eligible for local authority grants to enable them to take occupational health nursing courses. The high cost of fees, together with costs of travel and subsistence, has to be borne by the individual nurse or by the employer. And because there is no statutory requirement for such training, there is little incentive for many employers to provide the necessary financial support—the cost of which may be prohibitive for individual nurses to meet out of their own pockets.
Therefore, it is to be hoped that the Government will provide funding for the training of occupational health nurses, perhaps through the Manpower Services Commission. Such funding will need to be additional to the resources already available to the statutory bodies responsible for nurse education. These bodies are currently experiencing great difficulties in trying to meet existing commitments in the context of serious financial constraints. My noble friend the Minister may perhaps be able to offer a ray of hope this afternoon, especially in view of his honourable friend's undertaking earlier this year to reconsider the Government's position on the funding of nurse education. My Lords, I conclude on that note of optimism and hopeful expectancy.
§ 4.17 p.m.
§ Lord Hunter of Newington
My Lords, as has been said, we are much indebted to the noble Lord, Lord Gregson, for chairing the committee so ably and presenting its findings so clearly to your Lordships. Of the many aspects of this important matter he has referred to, I should like to mention briefly the changes of a fundamental nature made possible by the Health and Safety at Work Act, and consider some of the challenges facing employers and those concerned with occupational health in the future, with particular reference to the Employment Medical Advisory Service and future research.
Historically in Great Britain safety at work was controlled by a series of industrial Acts. When a problem arose, or a hazard was identified, steps were taken to deal with it. The system worked wonderfully well. Responsibilities rested with the employer and the medical officer of health concerned. In many industries it was the custom to employ a medical officer and a nurse—often both unqualified in occupational health. An important person was the factory inspector. In fact, though most large companies in hazardous industries had a satisfactory medical service, generally speaking provision was patchy and inadequate.
The objective of the Health and Safety at Work Act 1973 was to radically change all that. Emphasis was to 433 be on prevention. The Act established the Health and Safety Commission and the Health and Safety Executive, and factory inspectors and others were incorporated in the new organisation. The Employment Medical Advisory Service was established within it.
The Employment Medical Advisory Service had been an imaginative idea of Doctor Lloyd Davies of the Department of Employment. He saw that occupational medicine had more to offer than the Victorian concept of medically qualified inspectors of factories. It was to be a nationwide independent medical service available to give advice to Government departments, employers and trade unions. It was to be a professional service capable of giving medical advice related to all forms of employment. In the early 1970s this concept received support from both Government and Opposition.
The passing of the Health and Safety at Work Act appears to have fundamentally changed the concept. The Health and Safety Commission and its executive were established outside the Department of Employment and took the Employment Medical Advisory Service with them, as had been recommended by the Robens Committee in 1972. So it has provided advice from outside the Health and Safety Executive and not as an independent medical advisory service, as had been originally envisaged. In our report we must consider whether the new role envisaged for it is compatible with its present responsibilities.
The old Factory Acts affected six to seven million people. The Health and Safety at Work Act affects the lives and working conditions of 20 million people. The consequence, as is pointed out in our report, is the need for increased professionalism in the environmental health field. This involves advanced training in medicine, nursing, industrial hygiene, safety engineering and other fields, but at the same time there should be a proper use of specialised resources, services and skills.
With modern technology, new machines, new work rooms, the challenge to assist industry and at the same time ensure the health and safety of workers is urgent and important. How has the Act worked out? What of the Health and Safety Executives? Have the inspectors found their correct role? What of the Employment Medical Advisory Service? Should it all be linked to the National Health Service in some more effective way?
The Select Committee under the chairmanship of the noble Lord, Lord Gregson, has considered the consequences of 10 years of the operation of the Health and Safety at Work Act and, hopefully, its recommendations will stimulate further steps forward. Central to such developments in its recommendations are the activities of the Health and Safety Executive and the Employment Medical Advisory Service.
As the noble Lord, Lord Gregson, has said, the key recommendation is paragraph 13.2. This is that the Health and Safety Commission should instruct the Health and Safety Executive to draw up a voluntary code of practice setting out the kind of services which should be provided in various types of industry. This has been welcomed by the commission. The Health and Safety Executive medical division (EMAS) should 434 be used to promulgate this code of practice and encourage employers to conform with the provisions appropriate to them. The medical division staff should be increased to help carry this out. It is also recommended that the Health and Safety Executive make its medical and hygiene services more readily available to private companies.
The Select Committee decided in its examination, as the noble Lord, Lord Gregson, said, to confine its limited inquiry to medical matters only. The Health and Safety Commission in its comment on the report states that future examination by its own committees should not be so confined,since the work of other practitioners and specialists is relevant to occupational health. They include the work of managers, technologists and safety officers and the work of specialists in noise control and the work of the trade unions including work place safety representatives".I am sure that members of your Lordships' committee would be the first to agree with this wide approach to safety and occupational health.
It remains to be seen whether reorganisation of the Health and Safety Executive or EMAS will be required. At present the occupational hygienists are located mainly where there are hazardous substances and in the research divisions are not part of the medical division.
I referred earlier to Dr. Lloyd Davies's imaginative ideas about an independent medical advisory service, not linked to the inspectorate. Making hygiene and other services more readily available to industry as recommended in the report raises this point again. Can EMAS be more effective in promulgating a code of practice if it is unconnected with enforcement? Paradoxically the committee is quite clear in its advice that if a voluntary code does not work it must be made statutory, as has happened in other countries. Perhaps the Minister could give the Government's first thoughts on these matters.
The report has referred to the lack of provision of services in small and medium sized companies. The Health and Safety Commission, in its report, has referred to the contribution of other technologies and particularly that of the safety officer. In these small companies it seems of vital importance that the safety officer, medical officer, nurse and hygiene roles should be shared and understood. It might almost mean a very special kind of training; a mixture of those roles to meet the needs of a small company. Does it matter if the job is done by the safety officer or the nurse as long as the person concerned has been adequately trained? The role of the trained occupational health nurse and the safety officer should be extended. Nurses should take up the role of advising management and something of the hygienists' and medical officers traditional roles.
One cannot stress too much, even in the small companies, the importance of records and research of that kind. The Health and Safety Executive should advise on a standard form of record-keeping, remembering that the desire of everyone and the objective of the Act is the early detection of new hazards. In fact, it is also important to preserve old company records when companies are amalgamated or taken over, and death certificates should include not 435 merely the occupation at death but other major occupations during a person's lifetime.
When one turns to the Government Response one finds the statement which has already been referred to:The Government particularly welcome the Committee's broad conclusion that there is no universal best practice that is applicable across the whole of industry and the responsibility for occupational health and hygiene should lie with the individual employer".I hope that does not mean that the Government feel that they have no responsibilities in these matters. This kind of comment worries me.
I quote further:Earmarking funding is felt by the UGC to be inconsistent with the autonomy of universities in determining the allocation of UGC funds".Why, then, did the University Grants Committee earmark funds for medicine between 1948 and 1972 and later for a considerable period for dentistry? It was argued that this was a special case because they had to produce matching funds with the Department of Health and the emerging NHS.
Universities will develop contracting partnerships with industry. They have, if you like, wakened up in the past few years in this occupational health field, but what the report is talking about is the development of three or four centres of excellence in this country. It is suggested that it is in the national interest to provide places where people can be trained and re-trained. This I submit is the responsibility of Government and they cannot honestly shirk it. If it is thought that it can be best discharged by the Health and Safety Commission, well and good, but part of this role could be discharged by the universities.
Lastly, there is the subject of co-ordination of research activities. This is a vital matter to which the Health and Safety Executive have accepted that they could make an important contribution. All industrial companies, which are subject to the new codes to be promulgated, require to be kept up to date. The Health and Safety Executive could sponsor a research report, perhaps given by a free-standing committee on which there would be representatives of the occupational health faculty, both sides of industry and academic interests. But there is something to be said, in a matter of this importance, for the development to be done independently and be circulated in a way that does not interfere in any way with the circulars and the other responsibilities of the commission which are so often concerned with its legal responsibilities for enforcement. To keep up the flow of information is almost as important as anything else I have spoken about. I believe that the future offers great opportunities to protect the health of working people.
§ 4.30 p.m.
My Lords, I, too, should like to thank the noble Lord, Lord Gregson, for both his speech and his chairmanship. I found myself agreeing with almost—although not quite—everything that he said in his speech, and his chairmanship was first class. He had the great capacity for getting our witnesses to come clean, as it were. So often, they were bound up with an official brief that they had prepared and this document was the sort of HCF or LCM of their organisation. Once we got them off that and on to the 436 actual work that they did in industry, a far more interesting and valuable picture emerged.
I, myself, must declare an interest, a very great interest, in this matter, since I spent 16 years working as an industrial medical officer, first, for Messrs. Richard Costain and, secondly, in building and running the Harlow Industrial Health Service, a group service for small and medium-sized industry in the new town of Harlow. My experience is really based on this. I should say that, when I started off, I did so with very great difficulty because we had no money. I was asked by the Nuffield Provincial Hospitals Trust to do it and I estimated that we should need £18,000 in the kitty before we could begin. This was some 20-odd years ago.
We eventually persuaded 12 industrialists in the new town of Harlow to join together and form a non profit-making limited company. They did it; and, with £18,000 and a hut donated by Messrs. Wimpey as our first industrial health centre, we got going. I may say that the Harlow Industrial Health Service now has 166 member firms; its annual turnover has risen from £8,700 to £270,000 a year; and the medical director, who used to get £1,250 a year when it was me, now gets a princely sum. The other interest that I should declare is that I am the author of the little tome that I have in my hands called First Aid in the Factory, which, I am pleased to say, goes on selling steadily although I wrote it 20 years ago; so I have got a vested interest.
To the Minister, I am making a special plea on behalf of the three million of our citizens who are employed in factories with virtually no health or occupational health or safety cover at all. It is a strange thing that it should be almost the same number as the number of unemployed. I hope that this will be of added interest to the noble Lord who looks after the unemployed. I hope that he will equally look after these under-privileged people in the small factories. It is an amazing thing, as the noble Lord, Lord Gregson, has pointed out, that, because their numbers are so small, people in small factories do not attract a great deal of attention from the CBI or the Institute of Directors or from the TUC or the trade unions.
I calculate that there are 160,000 of these factories employing less than 100 people. I think that the number is likely to grow because, in any industry, the number of employed persons in each particular unit tends to become less with increased technology. The higher the capital development, the lower the numbers employed. Of those 160,000, 90 per cent. have nothing at all in the way of health services except for a part-time first-aider. There are 11,000 factories with 100 to 500 employees, and half of those have no industrial cover. Contrast that with the situation of those factories which employ over 500 people, where 90 per cent. have proper industrial cover, including both nurses and part-time (and sometimes full-time) doctors.
We made another strange discovery on our committee. We discovered that the richer the industry, the more lavish was the provision for health services and, very often, the less the need. Thus, for example, the great oil industries, which do not carry very great hazards, nevertheless had extremely efficient, elaborate and expensive occupational health services.
437 One great firm which I shall not name but which we all admire, where the greatest risk is getting your finger caught on the coat hanger when you are taking a coat off one of their hooks, spends £66 per employed person per annum on providing a Rolls-Royce of industrial health services. It has, I suspect, the lowest risk of all. Yet its managing director and chairmen say that this is a very fine expenditure; and I am sure that it is right.
How on earth is one to deal with these 160,000 small factories and the three million people in total who are employed in them? As far as I can see, the only way is by grouping them together. The noble Lord, Lord Gregson, has suggested that general practitioners should deal with them from their health centres. There is something in that; it is by no means a bad suggestion for areas where the health centres are strategically located in the midst of an area with a good deal of industry in it. But the situation varies. Where there is an industrial estate, there is no doubt at all that the right thing is to have a proper co-operative service; but such a service is a very difficult thing to run.
When you ask the employer or the employee what he expects of an industrial health service, he does not talk about the prevention of accidents or industrial disease. He talks about swift and efficient treatment of those who are taken ill or injured at work. Speed and efficiency in dealing with accidents and injuries are the first things that are asked for. Unfortunately, in industrial medicine, a great deal of emphasis is given in training to occupational hazards from chemicals et cetera but much less to the treatment of these emergencies and, indeed, their diagnosis. When we were building the Harlow Industrial Health Service—and, indeed, indeed every industrial health service—we found that we had got to get mobility for our nurses. We achieved this by means of Morris Minor station wagons. We equipped them with the same sort of bag that the district nurse has, and we expected them, and indeed trained them, to deal with the emergencies which are likely to be met with. Lord Gregson is quite right when he says that it is first-line medicine. It is indeed first-line medicine. It is exactly the same thing as you would meet in general practice. The commonest cause of severe illness in industry is coronary thrombosis. I will not say that it has nothing to do with industry; but it has a good deal more to do with smoking. The next two common emergencies that we meet in the factory are epileptic attacks and hypoglycaemic attacks in diabetics who have forgotten to take their sugar after having given themselves their morning dose of insulin.
The real nub of the matter and the volume of the work that comes consists of small things, minor ailments—coughs, colds, strains, and so on—which nevertheless will take people off work if there is no one to treat them and no proper arrangements. The real thing is to have some arrangement which enables diagnosis and treatment to be done at the site of an accident or very near it. I have worked out the total volume of work one could expect: 20,000 people at risk produce 24,000 new cases per annum in a group of small factories. Just over half of these have nothing whatever to do with work. They are coughs and colds; quite often they are sporting injuries which people have sustained in their sporting activities over the 438 weekend; they are indigestion, occasioned by indiscretion after working hours; skin diseases and, above all, backache—and once a person goes off work with backache, he is likely to stay off for several weeks.
This is one of the great reasons for having a physiotherapist. As the noble Lord, Lord Lloyd, mentioned earlier, the value of having a physiotherapist in an industrial health centre in the middle of an estate is tremendous. You can keep people at work, treat them during their work and, surprisingly, they do not want to go off and they do not need to go off.
The other half of the work that one does is work-related, but most of it is small cuts, small bruises, small crushes, burns, chemical burns, skin troubles and eye troubles—in particular, foreign bodies in the eye; and skill in removing a foreign body from the eye and in dealing with skin trouble is very important. Only 0.14 per cent. represents specific industrial diseases. Given a good industrial health service in the centre of an industrial estate, 96 per cent. of patients treated can return to work, 3 per cent. must be sent home, and only 0.7 per cent. need go to hospital.
What a difference from the situation if you have nothing! You end up sending a great many of the patients to hospital; and if you send them to the doctor they have to take off half a day or a whole day to get to the doctor, and then they are usually off for several days. So there is a tremendous saving in working hours; but there is a further matter of importance. In small industries with, say, 12 or 15 people working in a factory, the absence of one person is much harder to make up than in a large factory; so again it is well worth doing.
What does it cost in fact? We started by charging employers £2 per employed person per annum for a full-time employee and £1 per employed person per annum for a part-time employee. I understand that now at the Harlow Industrial Health Centre the charge is approximately £14 per employed person per annum. It is payable quarterly in retard and employers find it sufficiently good value to do it even during a recession; indeed the service has actually grown during the recession. We could never have done it if we had not had that pump-priming grant to begin with, and in fact it took us eight years to get solvent before we were balancing our books, and then we were making enough money to pay off the costs of our health centre buildings. Those have now been paid off.
With regard to how to run it, the proper scheme is to have a non-profit-making charitable company. We had eight employers and two trade unionists on our board. Frequently the trade unionists asked: "Could we have some more representation?" I always used to say: "Yes, certainly, if you will pay an equivalent amount of the cost", and they always said that two were perfectly adequate thereafter.
We found that we needed a small X-ray machine and we also found that a physiotherapy department was invaluable. Our nurses were first-class. Incidentally, we trained them in eye work by sending them to the Royal Ordnance factory at Woolwich, where there were a lot of eye injuries and a lot of cases of foreign bodies in eyes. They became extremely proficient—much more proficient than most medical 439 men—in the removal of foreign bodies. Those were our experiences.
I should add one further experience, and that was in the use of general practitioners. I tried to start off the service using general practitioners only, and I got eight local general practitioners who were sufficiently interested to do it. We trained them in about a week—it sounds silly, but we did so—with excellent lectures. In the end it turned out that about one GP in every 10 is in fact interested in occupational health work. That is not bad; it is perfectly reasonable, and it would meet the needs, I think, of a great deal of industry if we had one in 10. There are about 26,000 general practitioners. If we had 2,600 really enthusiastic part-time GPs, it would work very well. They used to work very well in the old days when they were called appointed factory doctors, but that has all gone by.
I must say that I greatly agreed with our recommendation 13.1, in which it was said that,Provision of services in larger undertakings is already generous in many cases but is poor in medium-sized and small concerns and steps should be taken to remedy this".I was most distressed to read the reply of the Government. Our recommendation 13.9 strongly recommended the extension of group services and interest-free, pump-priming grants and the building up with these pump-priming grants, as they were paid back, of a rotating fund. The Secretary of State for Employment made no specific response to our recommendation 13.1, and there was no specific response to recommendation 13.9. In paragraph 3 we read that,any increase in expenditure must be accompanied by reductions elsewhere".I believe that is rather silly when we think of the fact that we have an enormous industrial burden in this country and we really have done awfully little about it.
The other point was the response of the Health and Safety Commission. In paragraph 9 we read that,the need for interest-free loans to set up further group services will depend on future demand".What on earth does that mean? It is an extraordinarily inverted chicken-and-egg situation. If there is a future demand, such loans will be needed; that is all they have said. At least that is the best translation I can make. But the demand and the need are there, and I must say that time and again, when industrialists came to me from other parts of the country when I was running this service, I had to say to them; "Look here, unless you've got £30,000 or £40,000 of capital in hand, don't start, because you won't be able to hire a good doctor to run the thing for you unless you can guarantee his salary for at least a couple of years". Now, I am afraid, the sum is much larger.
Should it be voluntary or compulsory? It is no good making it compulsory when you cannot do it, and that is really all there is to it. I reckon that if we set up three or four group services for occupational health per annum, we should be doing very well indeed. It would take us 20 years really to get a good coverage for the country as a whole. I do not think we should be dismayed about this because it is a very difficult job to do.
440 Like the noble Lord, Lord Hunter, I would emphasise the importance of an occupational hygiene service. This is quite a different job and it means monitoring continuously both the environment—whether it be the air, fumes or dust—and people, by taking from them blood or urinary specimens, and so on; and inevitably it means a great number of negative results. One perhaps gets one winner in a hundred. But that is very important indeed because that is the only way to detect the dangers. We have a very good example of this in the National Health Service in the shape of the Public Health Laboratory Service. I wish we had a public health laboratory service for occupational hygiene.
Finally, I should like to say one word about cooperation. There has sometimes been a feeling that nurses and doctors want to take over the work of other people—personnel officers, welfare officers, industrial hygienists, and so on. In practice, these difficulties do not arise. Co-operation is very easy, provided that no one stands on his dignity and everyone is ready to do his best. Good occupational health services do something else besides pursuing their immediate objective. They raise factory morale more than almost any other welfare measure. There is a case for cooperation between management and unions, with no split of interest. So I beg the Government to allow us to take the next step forward, by establishing a rotating fund to enable such services to be created in small industry and, by so doing, to put right a great injustice and encourage medium and small industries to give of their best.
§ 4.51 p.m.
§ Lord Rea
My Lords, when it was suggested that I might speak in this debate I was at first reluctant since I have had comparatively little first-hand experience of occupational medicine. I am a general practitioner who has had a little extra experience in child health and epidemiology at home and abroad in the third world, and an involvement in undergraduate and postgraduate teaching. But on reading the report, the BMA's comments and the Government's reply, I realised as a practising GP that there was plenty that needed to be said, even if I restricted myself to the role of the GP in occupational health—and I shall not promise to stick to that!
I should like to add my congratulations to the committee on a very clear exposition of a complex subject. I am in agreement with nearly all its recommendations in principle, though there are some details which I might criticise a little. Straightaway I should mention that it would have been useful to have had some comments on the experience of other countries, if only because literature is hard to get, particularly at short notice. We started occupational health in this country, but other countries have advanced beyond us in some respects. In Eastern Europe, much of primary care is based on occupational health services. It has not, in my view, been the best way, and it is against our tradition in Britain; but it would have been useful to have some information in the report to weigh in the balance. Other members of the EEC have more stringent regulations regarding occupational health and hygiene than we do. Possibly some are too draconian, and 441 statutory regulations may not be very welcome. On the other hand, they may be more effective. But we should take account of the experience of other countries. There are lessons to be learned from compulsion when not everyone is willing; for example, in France. I should like to know a little more about this.
Another thing that is missing from the report, although the noble Lord, Lord Taylor, has amply filled it in now, is information giving an accurate breakdown of the cost-effectiveness of occupational health services. Both the practitioners in occupational health and the workers in industries which have occupational health services are very pleased with what they have got, but it would have been useful to have some figures.
The division made by the committee between occupational health services and occupational hygiene is a valid one. One provides a service to personnel who have problems, whether or not these are occupationally related; and, as the noble Lord, Lord Taylor, said, many doctors and nurses working in occupational health services have to deal with many problems which have nothing to do with conditions at work. Occupational hygiene on the other hand is concerned with the environment at work and is fundamentally a preventive service.
The first—that is, occupational health care—involves clinical practice which is more easily comprehended by any trained physician; the other—occupational hygiene—is a more specialised discipline involving professions outside medicine, as well as doctors with special training and qualifications. Both the report and those occupational health practitioners that I have spoken to have emphasised that this highly trained branch of the profession is becoming very thin on the ground. There are only 70 doctors in post in the Employment Medical Advisory Service when there should be 100, and many of the 70 that are there are approaching retirement age.
I was somewhat disturbed to read that there are only 12 occupational health physicians who will work in this country being produced per annum at the moment by our postgraduate institutions, whereas something like three times as many as that number will be necessary in order to keep even the present inadequate establishment at its current level. The Employment Medical Advisory Service itself feels that it is somewhat engulfed in the Health and Safety Executive. I think that it should be given more independence, and this is suggested both by the report and by the BMA in their comments.
The trained occupational health physician may find himself doing both jobs at once—that is, both occupational health and hygiene—but I think the committee has recognised that the majority of doctors providing occupational health services are, and will continue to be, general practitioners often with no special training except "on the job". It has therefore made recommendations that provision for increasing their expertise and training should be made available. Two-month courses are suggested by the Royal College of General Practitioners, as well as a number of six-month posts to form part of the general practitioner vocational training scheme. These courses could form the basis of going on to become associate 442 or full members of the Faculty of Occupational Medicine for those doctors who are interested.
Funding of the short course training programmes presents problems, though I see no reason why Section 63 should not assist fully here. The present Government resist firmly any suggestion that expenditure should be increased, since their overriding philosophy at present is to cut public spending. But they must surely realise that there are some programmes in which a little investment will result in savings which are much greater. I think that every speaker so far this afternoon has used the term "pump priming". You put in a little water and you get out a lot, in this case money or worthwhile consequences, from your small investment in the first place.
It is the experience of occupational health physicians that sickness rates—and the noble Lord, Lord Taylor, spelled this out—and consequently sickness insurance costs, fall when an effective occupational health service is provided. Surely, to support training programmes on a relatively limited scale, as has been suggested in the report, will pay dividends in this way, quite apart from improving the morale of the employees in the firms in which occupational health services are provided. After all, the Government have just saved themselves £100 million a year by finally listening to the logic of our arguments about generic prescribing, backing up the Greenfield Committee. I hope that that £100 million will be ploughed back into primary care—and I think that occupational health care could be considered as part of primary care in this respect—rather than being swallowed up in the general funding of the health service.
While discussing training, I would strongly endorse the need to include attention to occupation in the training of all doctors at undergraduate level, but I personally would oppose the inclusion of occupational medicine as a separate subject for undergraduates. The curriculum is already grossly overloaded. However, attention to a patient's occupation as an integral part of medical history-taking must be regarded as a fundamental part of medicine, along with the consideration of other social, family and other environmental factors, as both causes and consequences of ill health.
The Government, in their reply, as the noble Lord, Lord Lloyd, has pointed out, seem to be very guarded about the further involvement of general practitioners in occupational health. The Department of Employment says:the Government would be concerned if the volume of work became so great that it affected the capacity of general practitioners to provide basic primary care services.And, again:there is no capacity for expansion except at the expense of the primary role of the general practitioner.These remarks seem to show scant regard for, or even ignorance of, the way in which general practice is evolving. As treatment for acute illness improves—and it is improving all the time—and care for the chronic and mentally ill and the elderly is increasingly shared by primary care teams, including nurses, social workers and other health professionals, the well-organised general practitioner is becoming more able to play a wider role in the community.
443 Preventive and anticipatory care will become an increasing part of the work of the general practitioner and new skills will need to be acquired. The future will see each member of a group practice developing a special interest in addition to the basic job of providing the traditional demand-led service—that is, treating patients who present them with problems. Interests will vary from one doctor to another. One doctor may be interested in maternal or child health or school health, while another may be interested in epidemiology—that is, recording the pattern of illness in the practice or in the community around the practice. Special clinical interests can be developed—for example, the prevention of cardiovascular disease, or the care of those suffering from diabetes in the community rather than in hospital. Or a doctor may take a special interest in those with mental health problems. There are many choices. Occupational health could well be one of these.
As the noble Lord, Lord Taylor, has said, about one general practitioner in 10 is very interested in occupational health. I consider that the general practitioner who is interested in occupational health could go regularly to one or more firms which have an occupational health service in the practice area, or he could hold sessions in the practice or health centre, as has been suggested in the report. It does not really matter whether it is a health centre or a group practice, provided that the premises are adequate. This could be done by arrangement with local firms for, say, pre-employment examinations or to study the particular problems of a member of the workforce. However, it is absolutely important that even if he sees the worker in his own surgery or premises the doctor should visit the place of employment in order to get an idea of the kind of problems which might arise.
Speaking from my own personal experience, my practice is just up the road from the TV-AM studios. We carry out their pre-employment examinations. Some employees are already working at TV-AM before they have their pre-employment examinations. I seemed to recognise a very high level of stress. It was only when I went there and saw the pressure that everyone was under, particularly in the early days when their future was very much in doubt, that I realised the kind of difficulties which give rise to these stress problems.
If the noble Lord, Lord Winstanley, were here he would probably feel uncomfortable at the prospect of each general practitioner having a special interest. He would say that it implies the loss of the personal, concerned general practitioner. I do not believe this to be the case. With care it is possible to maintain a personal service and yet to give to the general practitioner concerned the freedom to develop important related interests—interests related to the whole community that he looks after—rather than simply an interest in individual patients. This would help to keep his intellect in good state and would also provide an important service to the community.
For instance, for the past five years I have held a post as clinical assistant in the diabetic clinic at University College Hospital. I have recently given up this post in order to make it possible for me to attend the House 444 more regularly. I imagine that this latter interest of mine is one of the less common outside interests of general practitioners, though I would welcome more of them here! Together we might even be able to mount a better medical cover for the excellent nursing service which I think we all agree is provided to serve the needs of both Houses.
Finally, may I say a word about research. The basic discipline for research in occupational health is epidemiology which describes the pattern of illness in a population—in the case of occupational health, a population of people who work in the same environment. Occupational health doctors are in a special position to pick up problems as they are presented and to relate them to the occupational exposures of the worker. Part of their training is to be sensitive to this. If more general practitioners were trained in occupational health and epidemiology they might be more inclined to record and notify changes in patterns of disease which come before them and to alert industry or environmental health services to them.
Conversely, occupational health physicians—whether part-time general practitioners or full-time in industrial medicine—should be more aware of how family and emotional stress play a part in the performance of people at work. Accidents or poor performance may well be due to major difficulties at home, so occupational health doctors and nurses should be ready to liaise with the worker's own general practitioner or to refer, if necessary, to a social worker or even to a marriage guidance counsellor, if required. It could be a two-way traffic.
To summarise my comments, the Employment Medical Advisory Service should be brought back to full strength. That is spelled out in the report. The training facilities for specialist occupational health physicians should be increased. The Employment Medical Advisory Service should be helped to stand on its own feet and not be engulfed by the Health and Safety Executive. There should be encouragement for general practitioners to become more involved in industrial health. For this they should be trained, either through six-month vocational training courses or by short courses lasting about two months. It is essential that they do not lose financially in taking these courses. In the future, there might be some incentive to undertake these courses by industry offering a higher rate of pay to those doctors and nurses who can show that they have had specialist training. This takes up the point made by the noble Baroness, Lady Cox. There should be more communication between industrial health doctors and general practitioners, and vice versa.
To re-emphasise what the noble Lord, Lord Taylor, has said, much more effort should be made to provide a service for those in small undertakings. General practice has a very big part to play here. Two of the industries which make practically no provision are the construction industry and agriculture. Both of them are extremely dangerous industries. They rank among the top few dangerous industries in the country. If I may give an example, only a few weeks ago a worker in my own street who was working on some scaffolding was killed because a board had been placed carelessly and he missed his footing. There is plenty of scope to acquire increased expertise among general 445 practitioners and there is a great deal of interest which should be harnessed.
§ 5.9 p.m.
My Lords, to sit on your Lordships' committee under the chairmanship of the noble Lord, Lord Gregson, was to have a splendid coaching class in the art of amiable, penetrating inquiry. The report before your Lordships indicates the truth of that contention. It is not surprising therefore that the noble Lord emphasised very clearly that the main recommendation related to a voluntary code of practice. This conclusion was reached after very careful discussion. The trade unions do not agree. The Royal College of Nursing does not agree. The BMA does not agree. The Royal College of Physicians, through its Faculty of Occupational Health, does not agree. The possibility envisaged by the committee is as follows:It may be that, if voluntary measures fail, one day statutory measures will be needed".We cannot afford to have failure. It will take time to manifest itself, and the importance of getting a proper service throughout the country must have been made manifest to your Lordships by the speeches which preceded mine—notably, perhaps, that of the noble Lord, Lord Taylor.
I believe there is one way in which the possibility of failure can be reduced or dispelled altogether. That is through proper training and certification of those concerned with industrial health. It is a sad reflection that, so I am informed, of the 100 or so doctors who are employed in sessions in the National Health Service itself, in occupational health, few are trained or qualified in this particular discipline. In smaller factories, the number of those who have special training must be minuscule—and the same is probably true of nurses engaged in industrial work in smaller factories.
This lack of training is a great anomaly, because in no other aspect of the medical profession at the present time is there any lack of training in the postgraduate field—be it in general practice or in any of the specialties. As the noble Lord, Lord Rea, pointed out, we seem to be differing from Western Europe in our attitude to industrial medicine and its provisions. In fact, the United Kingdom and Ireland are the only two countries in Western Europe which do not have legal requirements for the training of doctors in factories.
On the educational front, in respect of doctors, we were encouraged in the committee by the evidence given to us by the Faculty of Occupational Medicine, when the point was put to its representatives that the faculty's training programmes and the requirements for its two diplomas—for associate membership and membership of the faculty—were too stringent and too difficult for GPs to undertake while continuing their own compelling discipline.
The committee was told that already the faculty was considering change. Now change has come. Regulations for associate membership of the faculty are now such that many general practitioners who wish to do industrial work at a fairly comprehensive level will be able to undertake that diploma. In addition, the faculty is arranging for a certificate of attendance to be granted to those people who attend 446 something under a week's course, either full-time or part-time. The noble Lord, Lord Taylor, commented that this seemed to be a very short time, but the faculty believes it will serve to give the GP who is considering a small commitment some basic understanding of the discipline, and will be useful to those who are contemplating becoming involved in the subject on a full-time basis.
How will better training, and an indication of the fact that an individual has undergone it, produce the results we all want; namely, a good service? By understanding the basis of the discipline, it will be possible for the doctors themselves to know what to look for in the industrial situation. It will be possible for them to educate management in what can be offered by industrial medicine. This point was made by the noble Lord, Lord Taylor. It was also strongly emphasised by the noble Lord, Lord Rea, that such individuals will be able to see at the place of work the problems which exist. And if they are fortunate, and very perceptive, they may see something new in those problems. They will be able then to determine the optimum position from which they can conduct their industrial health practice—either from their own premises or entirely on the site of the factory. Whatever they do, they must be familiar with the place of work.
The use of health centres is welcomed by many—notably, by the Royal College of Nursing. There is, however, a certain anxiety in the minds of the leaders of the Faculty of Occupational Health that there may be too much emphasis on routine examination and on examinations to determine fitness to return to work—and too little emphasis on trying to perceive matters which could be the basis of prevention. Prevention is indeed very difficult in medicine, as in so many other spheres of life, but it is something that we must all advocate.
The committee clearly appreciated the point I have been trying to make about the importance of training. The last three recommendations of the committee are devoted to this subject. It would seem that the strengthening of the voluntary code by education offers the best chance of achieving success in the formation of an overall service in the small factories as well as in the big concerns. The noble Lord, Lord Taylor, made very clear the advantages which could accrue from providing such a service throughout the land. Indeed, it would be most regrettable if the Government did not respond in practical terms to the relatively small demands on resources which could improve training and enable people to be trained. This point was clearly made by the noble Baroness, Lady Cox. The cost of actually getting trained and of living while being trained is considerable to the individual but inconsiderable to the state.
At consultant level, it was pointed out that there are very few consultants in training. An admirable source of training posts at senior registrar level could be obtained through the Health and Safety Executive, and not very great cost would be involved. Joint posts exist between industry and the hospitals. A notable one is that between St. Thomas' Hospital and the occupational health service of another place in this very palace.
447 I was looking through an American journal on public health which was published only last September, and reading the eponymous lecture given by a distinguished American professor from North Carolina, when I was struck by these words:The Harvard School of Business has completed a collection of cases or 'horror stories' of what has happened to companies which did not pay attention to the recognition, evaluation and control of occupational and environmental hazards".It is, I am sure, our purpose not solely to prevent those horror stories occurring in our country and in our life, but to ensure that ill health at work does not impair the individual and that health at work improves the quality of production.
§ 5.20 p.m.
§ Lord Nelson of Stafford
My Lords, I add my tribute to the noble Lord, Lord Gregson, for the way in which he chaired the committee on which I was privileged to serve. We received a tremendous amount of valuable evidence, as your Lordships may have seen from the record. I should also like to pay tribute to the devoted work being done by so many people in this important field. It impressed all of us who served on the committee.
It was reassuring to find that, by and large, occupational health and hygiene were catered for adequately among the larger firms. The criticisms which have been examined in some detail today apply largely to the small or very small firms, though, as has been mentioned, that involves a large number of people. It also covers a tremendous number of premises scattered across the country and a wide area of various industrial activities. As has been said, we came to the conclusion that a voluntary code of practice would help to stimulate coverage of those large numbers of people.
Why did we come to that conclusion? A number of points have been put forward today and I should like to add one or two more. My experience in industry is that once there is a statutory requirement, it has to be administered and policed. The number of people who can be afforded to do that is inevitably limited. The tendency is to devote the limited resources to the areas where they are least required—to the large firms, because it is easy to get at them. The resources do not penetrate the large number of small firms where the problems lie. I therefore strongly support the committee's recommendation for a voluntary code.
I would add one or two other points to those already made by the noble Lord, Lord Gregson, as to why it is a good thing. Presumably the code will be drawn up by the Health and Safety Commission, in consultation with the relevant parts of industry that would be able to contribute. That in itself will highlight the problem and draw it to everybody's attention. As was admitted by the Government's reply, and as has been mentioned by an earlier speaker, a number of the smaller firms do not know even what is being done in this field and what services are available. Attention will be drawn to all that.
The code having been drawn up it will lie on the desks of the managers of the smaller firms. It will also be in the hands of representatives of employees, who will be able to draw attention to it. I think that will be 448 a stimulus both to management and to employees to take care of this important aspect of industrial life.
I think that the voluntary code will also be a stimulus for local firms and occupational health practitioners to get together. The importance of that has been mentioned by a number of speakers today. The existence of the code will mean that managers will get hold of their local practitioners in this field and say, "What is this all about? Can you tell me about it? Can you help me?", and so on. That will get them together and talking.
Finally, in my opinion, the existence of a voluntary code will stimulate the expansion of group services. If I may say so, we all listened with fascination to the description of the noble Lord, Lord Taylor, of the one with which he was associated. I draw your Lordships' attention to the fact that that work, which attracted a large number of firms, was done without a voluntary code of statutory regulation. If I may say so, that shows what can be done given the enthusiastic leadership which that activity obviously received. That is what we want to see in many other places—its worth has already been proven.
The reply of the Health and Safety Executive on behalf of the Government is pretty ambivalent, if I may say so. It starts off in a good frame of mind, endorsing the aims recommended by the committee. It goes on to say that it is working on a number of specialised applications concerned with occupational health in particularly hazardous areas. It then says that when it has received the reports it will consider the matter again. I do not think that that is good enough. We want to get on with this, get the voluntary code going, and prove that it works. If it does not, we may then have to try a statutory code.
I ask my noble friend the Minister whether he can speed this up and get it moving. Do we have to wait for the specialised reports before the matter is examined? Let us get on with it, accept the recommendation and try it out. It is too important a matter to leave lying about for months. I even ask whether he will assure us that we shall hear when the decision has been taken, so that the issue will not just disappear and be forgotten by all the interested parties.
I should like to refer to another aspect of the report—the reference to the large number of nurses working in industry. I know from my experience that they do a tremendous amount of good. Is it not extraordinary that so few are properly qualified in this very important field of occupational health? I think that the attention of all employers should be drawn to the fact that their nurses should be properly trained. It is recorded in the report that adequate training courses exist, but proper use is not made of them. I made inquiries in my own firm as to how many of my nurses were properly qualified. I must admit that it was a very small proportion. That will be altered, and I hope that other employers will take exactly the same action. I was most interested to listen to my noble friend Lady Cox speak on the subject. I think that a tremendous amount more can be done to improve occupational health services in industry if we train our nurses properly.
I should like to refer to a matter that has not been touched on this afternoon, and that is the question of 449 distance learning or video tutored instruction. I hope that my noble friend will look at that to see whether the Government can give support to the idea of distance learning for this and other purposes in this field. I think that for relatively small amounts of money a great deal can be done, which could be of great benefit.
Reference is made in the report to the number of personnel in Her Majesty's armed services who are trained in the occupational health field. I should like to draw attention to that. It is important to examine what happens to the excellent people trained in that way when they leave the services. I think that there is talent there which could be used. Employers should look at those people when they leave the services. They should not attract them away from the services, but they should make use of them and their excellent experience when they leave.
Finally, it is not in my field—I am not a medical man—but I find it extremely difficult to differentiate between general health and occupational health. I cannot understand the difference. The people who work in industry spend one third of their lives in their place of occupation. This is a good proportion of their waking hours. The idea of separating the health arising out of their place of employment and the health arising out of the rest of their lives seems to me a bit of a nonsense.
A previous speaker—I think it was the noble Lord, Lord Taylor, again—referred to the fact that many of these people who suffer in industry suffer from complaints which arise from playing football on Saturday or from over indulgence at the weekend or on some other occasion. I may say here that I questioned one of my own medical staff on the tests that we were doing on the quality of the hearing of young people coming into our employ. I said, "Surely, all young people don't need to have their ears tested." The member of my medical staff said, "Oh yes they do because when they claim that their hearing has been damaged at their place of work, we have to find out whether it is due to conditions at their place of work, or whether it is due to those discos that they go to on Saturday night, those awful, noisy places, which are damaging their hearing much more than it is being damaged at their place of work."
However, coming back to this question of occupational health and primary health, I should like to endorse the recommendation which is put forward in the report that young medical students should receive an introduction to occupational health as part of their initial training, so that they get an awareness of the conditions in industry. The noble Lord, Lord Rea, referred to the fact that he went to see the conditions under which people work in a studio and the stress to which the younger people were submitted. I think these are matters about which general practitioners should know and they should be able to look for these symptoms in their patients in treating their general health, so that they can say, "Is this due to a hereditary disease or something else, or is it due to something that has happened in the patient's place of occupation?" That does not mean that every medical practitioner should be trained to be a specialist. I do not mean that at all. I mean that he should have an awareness, so that at least the specialist can pick it up where it is 450 appropriate or, alternatively, the general practitioner can treat it as he thinks appropriate. I would express the hope that the Government will urge the universities to take action on this.
§ 5.33 p.m.
§ Lord Kearton
My Lords, as all members who served on the committee have already said, it was indeed a privilege to take part in this investigation under the chairmanship of the noble Lord, Lord Gregson. His acuteness, the depth of his knowledge, his patience and his persistence, were quite extraordinary. The investigation was very thorough. There is a list of those who gave evidence, mostly written, some verbal. There were about 115 organisations. They included industrial, commercial and financial undertakings; the Trades Union Congress; the universities; many professional bodies; research councils; trade associations; the Ministry of Defence, etc. Seventeen witnesses gave verbal evidence and, as the noble Lord, Lord Richardson, and others have said, were very closely questioned.
I think all members of the committee were deeply impressed by the commitment and sincerity of all those who gave evidence. They all cared very much about occupational health and hygiene. This was particularly so in the case of the professional institutions. It may be invidious to single out particular institutions, but the Society of Occupational Health Nursing, the Faculty of Occupational Health and the Institute of Occupational Hygienists reached an amazingly high standard.
The report is comprehensive but not wordy. It needs close study to appreciate it fully. As has already been said, the report indicates that the overall position with regard to the occupational services for health and hygiene is not unsatisfactory. Obviously great strides have been made in the post-war years. However, there are ways in which matters can be improved and gaps filled. The committee concentrated on these. Emphatically, as the noble Lord, Lord Richardson, made so clear, there was a call for action to make what was already good better. It is interesting that the report has had a generally favourable reception. It has had a favourable reception from the professions, from the Government, from the Health and Safety Commission and from industry. Like most members of the committee, I have been inundated with written comments from these bodies.
Naturally, there were differences, the main one being whether future action should be statutory, regulatory and compulsory, or whether it should be voluntary. The committee came down firmly for the voluntary solution. The survey had indicated a very good attitude to occupational health and hygiene among major industrial and commercial enterprises. As has been said, the lack of cover was in the medium sized and smaller units. In many such units, particularly in the services sector, the risks were minimal. In others, such as construction and some manufacturing, the smaller units gave cause for concern, as the noble Lord, Lord Taylor, has indicated. However, the committee were not willing to see such units burdened with compulsory requirements. It was felt that they could be educated and supported to achieve proper facilities with little bureaucracy. The committee's recommendations are directed to this.
451 As the noble Lord, Lord Richardson, made clear, the professions were much keener that the new régime should be regulatory with statutory force. As part of the new regulations, they wanted the certificated expertise of doctors and nurses trained in occupational health and hygiene to be specifically recognised. One has sympathy with this view. I agree very much with the noble Lord, Lord Hunter, that if the voluntary approach is not successful, then a move to a regulatory statutory system will become inevitable.
The committee saw the voluntary approach as needing a very strong push by the Health and Safety Executive. The executive had to formulate, release and publicise voluntary codes to cover the wide range of enterprises and businesses existing. Some of this work was indeed already in hand but needed to be widened in scope. The committee also felt that the Health and Safety Executive was the body best placed to observe the working of the new codes in practice.
The Government Response, in a document dated 11th July and signed by the right honourable Tom King, was encouraging. But it also made plain that the comparatively small sums needed to enlarge the resources of the Health and Safety Commission and to encourage further professional training would have to be found by reductions from existing expenditure, and that those already in receipt of government monies in the health training and safety field would have to do the adjusting. It is fair enough as a first reaction, but not as the final decision.
The importance of occupational health and hygiene is such that it merits a very strong indication from the Government that it should have a higher ranking. Employers do have the main responsibility for funding occupational health and hygiene. The committee accepted this. But the Government do have an overall responsibility, too. There seemed to be insufficient regard in the Government's reply that what happened in the workplace could have a profound effect on health outside the workplace. That is a point which the noble Lord, Lord Nelson, so forcefully made. There are all sorts of ways in which the Government could indicate support of those employers who took their duties seriously in occupational health and hygiene—support at very moderate expense.
The noble Lord, Lord Richardson, has already made the point that the expense would be very moderate. I would estimate that one was talking of not more than an additional £5 million a year for all the committee's recommendations. The total cost to employers is of course, immensely more. The health service already costs some £ 17 billion. So much more could be achieved with just a little commitment from the Government in the field of occupational health and hygiene with the certainty, in my view, that net expenditure on the health service would be less because of the benefits in the better condition and morale of the millions working in industry and commerce, a point made so forcefully by the noble Lord, Lord Taylor.
The response of the Health and Safety Commission to the report has been most constructive. Naturally, the commission has reservations about accepting all the 30 or so recommendations without modification. 452 But the whole thrust of the recommendations is accepted. This is very satisfactory. What is less satisfactory is the caution shown by the commission in committing itself to the necessary, though in percentage terms very small, enlargement of its staff to enable the executive to carry out the recommendations effectively. If a cause is right—the commission fully accepts that this one is—then one would hope to see a little more enthusiasm and less bureaucratic caution in its undoubted commitment. All causes need zeal, and a voluntary system needs more zeal than most.
Other speakers have dealt with various points in the report and I shall not repeat what they have said. I was particularly pleased to hear the endorsement of the noble Lord, Lord Rea, of the committee's view on the most important part which the general practitioner plays and can play in the future. I am only going to mention on my own account one recommendation in particular, quite a small one. It is No. 25. It is that an individual's death certificate should indicate not merely his last occupation but any other major occupation. The accumulation of data would considerably help epidemiological investigations. That was made plain in the evidence that we heard. The Government paper, in its comments, thinks that asking for such information would be a burden and add to the distress of relatives. I do not see that this is so at all.
I hope that the Government, in their reply to this debate, will indicate that they are prepared to be somewhat more positive than in their July paper. That paper was weak in Government support for future action. Kind words for the committee were there in plenty. Kind words are all very well, but I would urge the Government to go beyond this. If they are able to say today that they will take specific action to encourage the reallocation of resources on a modest scale and will consider just a tiny token addition to the money spent in support of occupational health and hygiene services and in training help for the necessary specialists, then they will give heart to the dedicated professionals working in this vital area—an area which prevents ill-health, encourages efficiency and most certainly adds to happiness. I hope that the Minister will add to the happiness of the committee and the House in his reply.
§ 5.43 p.m.
§ Lord McCarthy
My Lords, I want to try to do three things this afternoon. First, I wish to congratulate the noble Lord, Lord Gregson, and his distinguished colleagues on their admirable report. Secondly, I want to say—I say it with some temerity—where I agree and where I disagree, although like the noble Lord, Lord Nelson, I am not a medical man and did not serve on the committee. Neverthless, there are two areas where I do not think yet that I quite agree with the committee. Finally, I want to comment on the Government's Response.
I agree with the committee, first of all, on the importance of the problem which they have investigated. Eight hundred workers a year die of industrial diseases recognised for compensation purposes. There are 12,000 cases of prescribed industrial diseases recorded every year. The direct 453 cost—very largely, the cost in terms of lost time—of accidents and occupational ill health has been put somewhere in the region of £2,000 million a year. If we add, as the noble Lord, Lord Taylor, suggested, the increased insurance costs, the claims on the resources of the National Health Service, and the misery that is involved so far as the individual is concerned, then we are clearly talking about estimates and values far in excess of those figures. So this is an important problem, and the committee recognises that it is an important problem.
Secondly, I agree with the committee about where we are now in this counytry at this time. We are, in fact, not very much further forward than we were at the time of the 1976 HSE survey done by Nottingham University. We have, on the whole, rather good provision in large firms and parts of the public sector, but by no means all of the public sector, by no means, for example, in local government. And we have virtually no provision, except the very elementary first-aid provision, described by the noble Lord, Lord Taylor, in the great majority of small firms. About one-third of the population work in establishments of 250 workers or less. That is where we are at the moment. The central objective must be to try to go forward, to try to move towards some way of producing an occupational health care system in those large areas of British industry where there is little or no provision at the moment.
Thirdly, I agree with the central thrust of the recommendations of the committee as to what must now be done. There must be a selective advance in areas most backward, where the risks are highest; this to be achieved by the formulation of a code of practice. That is really the first half of what the committee proposes. The second half is that in order to facilitate this code of practice and the dissemination and encouragement of its observance there must be some relatively small increase in the cost of public provision: more staff for the HSE's medical advisory service, more GPs probably, suitably trained in this field, more trained nurses working on a part-time basis in this field; more research and the establishment of a research centre in the university, and so on. All this, I think the committee has said very wisely and cogently.
My areas of disagreement, or perhaps I should say my areas of doubt, are two. First, I wish that the committee had found it possible to provide some actual estimates, some financial figures, of the kind of expansion that it wants to see and how much this would cost the Government. To me, the whole drift of the committee's argument is that this would cost the Government very little. There is at present an establishment of 100 doctors working for the medical advisory service. All that the committee, as I see it, is suggesting is that the number be brought up to establishment. The cost must be very small indeed.
There are 1,000 full-time health physicians in the National Health Service, 2,000 part-time, and 9,000 nurses. The implication of what the committee is saying is that there should be some marginal addition and that there should be some marginal improvement in the training of those employed at the moment. I wish that the committee could have seen its way to give some actual figures.
454 The central thrust of the Government's opposition, as I see it, is that within the budget of £80 million a year of the Health and Safety Executive there is no more money available. That budget has already been cut in real terms. Its factory inspectorate has been cut. The number of visits of the factory inspectorate has been cut. If the Health and Safety Executive is now to take on additional responsibilities in the area of occupational health and hygiene, I can quite see the reservations of the executive in its reply to the committee as to where those resources are to come from. So my first feeling of reservation is that it might have helped a little if the committee could have seen their way to tell us how much money is available, because if that sum were placed on record I think the Government would find it very difficult to demonstrate that it could not be found.
I come to the second thing which I am not sure I agree about—that is, the rejection of the notion of an enabling Act to buttress a voluntary code of practice, with the ultimate right of the Health and Safety Executive to set certain minimum legal standards. I must say that I thought I detected in the contributions of some members of the committee certain doubts they had themselves about this matter; and as the noble Baroness, Lady Cox, rightly said, the Royal College of Nursing and, for that matter, the British Medical Association and other professional organisations, including the TUC, favour a statutory back-up.
As I understand what the noble Lord, Lord Gregson, said, and as the report suggests, he had four main reasons for not advocating a statutory back-up: first, it would make too much demand on qualified personnel; secondly, it would invoke a certain unwelcome cost to industry, particularly to small firms; thirdly, it would create a new bureaucracy; and, fourthly, it would create resentment, particularly resentment in those areas of most doubtful provision. If I understand other speakers in the debate, they seem to be suggesting also that it might not be a good thing to have a statutory support system because it might be used just in those areas where it is least required.
I should reply in the following way to those objections. In the first place, surely it is the case that without some increase in qualified personnel, which the committee recognise is necessary, there can be no significant advance. This is particularly the case among general practitioners, as the Government rightly say in their reply. General practitioners are under strain. If general practitioners are to take on new and additional and more widespread responsibilities in respect of occupational health there must be some more general practitioners. So there must be some increases in qualified personnel or there will be no advance.
Moreover, those who propose that this is required and that there should be a back-up, a statutory backup, are not suggesting that that back-up should come in at the same time as the Health and Safety Executive write the draft code of practice. On the contrary. The TUC, for example, suggest that legal enforcement might be required after something like a five-year period. The noble Lord, Lord Gregson, if I understood him aright, said himself that if after a period of time it looked as though the voluntary system was not 455 working then we might have to have a statutory backup. If a programme is to be abandoned—this will be my final argument—because it might be resented, then what chance is there of its being adopted by voluntary means?
The fact is that I cannot see any reason why those of us who believe, as I do, in the central thrust of this report should not ask the Government not simply to accept the need for a code of practice, which admittedly will be a voluntary code of practice at its inception, but to commit themselves to the statutory enforcement of that code of practice if it turns out to be necessary over a specified period. I really feel those are the only two things about which I have any serious reservations on what the committee have said.
Therefore I turn to what the Government say. The noble Lord, Lord Gregson, said he was disappointed at the Government's Response. The noble Lord, Lord Kearton, as I understand him, said he was encouraged. I must say I feel closer to the noble Lord, Lord Gregson, than I do to the noble Lord, Lord Kearton. We have here 38 recommendations. It is difficult to know how to classify the Government's responses to all these recommendations, especially since some of them are responded to by the Secretary of State, who at least puts the recommendations and gives them numbers, and some of them are responded to by the Health and Safety Executive, who put their responses and their numbers buried away in the text.
I must say at the beginning of my classification that I have classified these responses under eight headings, and I start with two where I cannot find any answer at all. A complaint is made that the medical division of the Health and Safety Executive is understaffed, and because it is understaffed it is overworked. I cannot find the Government or the Health and Safety Executive taking on the committee on that question and telling us whether they believe there is any truth in it. Also, perhaps rather less significantly, I cannot find their recommendation about part-time hygienists who should be encouraged to take the appropriate BERBOH course. I cannot find that; perhaps it is buried somewhere.
But the other classifications are fairly easy to do. Seven recommendations are dismissed by saying, "It's nothing to do with us". The employers, say the committee, should tell the unions more about occupational health policy. The employers and the unions should do more research. There should be an increased role for the health and safety representatives in industry. There should be more courses for nurses in occupational health care, and all medical students should receive some training, and so on. To these proposals the Government say, in effect, "It's nothing to do with us; take it up with the employers; this is the responsibility of anybody but Her Majesty's Government". In some cases I agree, but in some cases I should have thought that a lead might reasonably have come from Her Majesty's Government.
Then we come to five recommendations where either the Government or the Health and Safety Executive say they will look into it; they will let us know. They say, "Don't ring us; we'll ring you". For example, the Health and Safety Executive should coordinate the hygiene services; they could co-ordinate 456 research; they should act as a clearing house for information on the causes of diseases; they should use mortality data more systematically; they should investigate the use of distance learning. We are to hope that in fact the Government or the Health and Safety Executive will ring us, that we shall be hearing, that with any good fortune perhaps we may be hearing tonight from the Minister what the Government feel they can do under this particular heading.
Then we come to three recommendations where the Government say, "Well, it may be all right in its way but it's impractical to make occupational health care an integral part of primary patient care". As the noble Lord, Lord Gregson, says, I cannot see for the life of me how they can resist that. There is a suggestion about earmarking grants for the establishment of research centres. As the noble Lord, Lord Taylor, says, I cannot see for the life of me why they should not say "yes" to that. Another proposal is to record occupational information on death certificates. As another speaker said, I cannot see any reason why that should be impractical, but at least it is not accepted by the Government. So we come to the next heading, No. 5. They say they are doing it already. For example, they are giving financial help to doctors who go on to approved occupational health courses.
That deals, on my analysis, with roughly half of the 38 recommendations of this committee. The others can be divided rather more quickly into three broad groups. First, there are those where what the Government are saying really is that it may be a good idea but it costs money; and if it costs money, if it requires additional resources, then it cannot be done. The recommendations include an expanded role for the general practitioners; NHS consultants on a fee basis working outside the NHS; more research into mobility data; increasing training posts for doctors or for nurses, and so on. All these things cannot be done because they require more money.
Secondly, there is a list of things which cannot be done not only because they cost more money, but because they are linked to the central proposal for the establishment of a voluntary code of practice about which, I think it is accurate to say, the Government are most unenthusiastic. In fact, they pass on this central issue—which is the single most important recommendation of the committee—to the Health and Safety Executive themselves; and they, within their small resources, have great difficulty in knowing what to do with it. As I understand it, they are saying that they are in agreement with the principle and that they made some kind of start in 1982—and I am now looking at paragraph 4 on page 6—with their booklet entitled Guidelines for Occupational Health Services, and they hope to produce some more.
Quite frankly, that is disingenuous. The Health and Safety Executive know all too well what the committee have in mind in a draft code of practice. It is not a general code. It is a specific code. It is to relate to particular occupations and particular areas, and it is to be as precise as possible. It is not just to be advice, it is to be comprehensive and remedial. That is all clearly set out in the Select Committee's report. To say that it has been started already by the publication two years' ago of Guidelines for Occupational Health Services, is disingenuous.
457 But I emphasise that I do not blame the Health and Safety Executive for that: I blame the Government. The Government say;Some of the detailed recommendations . . . call for increased expenditure by the Government. . . . The Government does, however, remain committed to reducing public expenditure"—and this is where we get to the point—in the interests of ensuring that the size and the expense of the public sector do not hinder economic recovery".This is where we get the Gradgrind philosophy. This is where the Government say:Where proposals made by the Committee call for increased spending in particular areas, the Government recognises that such increases can only come from reductions elsewhere".Of course, they do not even tell the poor old Health and Safety Commission from where these reductions are to come, because they know as well as we do that there are no significant areas where that commission can make significant reductions without reducing its existing services.
The trouble is that the Government, in this very small expenditure area of this very important field, are incapable of recognising a genuinely self-financing form of Government expenditure, a modest increase in Government expenditure which will be genuinely self-financing in that the savings will be felt for the most part in the private sector, and for the most part in those parts of the private sector where the services are at their worst. That is the position. That is where the Government have put us, unless the Minister can help us tonight.
§ 6.4 p.m.
§ The Minister Without Portfolio (Lord Young of Graffham)
My Lords, we are grateful indeed to the noble Lord, Lord Gregson, and to each and every Member of the Select Committee for the report which they have delivered to this House. Let me also say how much I welcome on behalf of the Government the opportunity that we have had today to debate the Select Committee's report, for we have indeed had a good debate. It has highlighted the thoroughness and the penetration with which the Select Committee itself and this House this evening have considered this most important subject.
The Government in their published Response, together with that of the Health and Safety Commission, agree that large companies on the whole make adequate provision for their employees, but they do not take that agreement as any cause for complacency. Occupational health and hygiene must be a concern of all employers where there are risks to health and safety, regardless of the size of the workforce.
I was particularly glad to see that the committee have given careful consideration to the respective responsibilities of the employer and the state, and have come down on the side of employer provision—that is, that the employer must assume the prime responsibility for the provision of professional advice and service in this field. That, of course, is in line with the principle of self-regulation which underlies the Health and Safety at Work Act. However, emphasising this does not in any way mean that the state itself does not have a role. Indeed, a great deal of Government-funded activity is pursued which is 458 relevant to the provision of occupational health services.
The report itself says a great deal about and, indeed, recommends that occupational health should become an integral part of primary health care. It also says that occupational hygiene should form an integrated part of occupational health services. In both cases the Government consider it proper that these services should complement one another.
But the question of their organisational relationship is somewhat more complex than appears at first sight. For example, occupational hygienists often need to work closely with health specialists. In some cases their proper role will be entirely independent of occupational medicine in such areas as design, engineering or laboratory services. Their role, indeed, goes far wider than some of the aspects covered by the Select Committee. General practitioners, for their part, clearly need to take account of the effect of occupation on health, and health on occupation. This is part of their responsibility in primary health care, but they cannot be expected to become specialists in the field of occupational medicine. The Government and the Select Committee are at one in wishing to see effectively co-ordinated teamwork in both these fields.
All this taken together reflects the fact that occupational health (and occupational safety) is a broad and multi-disciplinary area in which many practitioners have important contributions to make. But some of these groups, such as safety engineers and scientists, were, of course, outside the scope of the committee's report. What we really have to do, the road down which we really have to travel, is to develop a team approach to deal with the hazards actually present in any particular workplace.
I should now like to turn to the central recommendation of the report, about which a great deal has been said this evening. That is, that a voluntary code or series of codes of practice should be drawn up spelling out the kind of occupational health and hygiene services that should be provided by the various types of industry. I must confess that this is one part of the debate this evening where, if I may say so, I found some of the arguments put forward by the noble Lord, Lord McCarthy, a little curious.
The Health and Safety Commission has made it very clear that it will consider this particular recommendation very carefully. In fact, it has already taken the first step advocated by the committee itself—that is, it has asked its various industrial advisory committees to report to it on the needs of their own industries, particularly taking the circumstances of small firms into account. It has similarly asked its medical advisory committee to report to it on the occupational medicine questions common to all industries. These committees are now working on these questions as a matter of priority. I for one see little point in having a number of advisory committees and a medical advisory committee if they are not to be consulted as soon as the report is published. To decide to take decisions of principle on the question of a voluntary code of practice without taking the advice of your own committees would seem to me a curious step to take. We should of course let them report and then deal with the report as a matter 459 of priority. I hope that the noble Lord, Lord Nelson of Stafford, will accept our assurances as regards that.
Beyond that, the commission itself has said that it will carefully consider what further action to take. But in taking any action it must take its decision in a somewhat wider context than that considered by the Select Committee. In particular, a great deal of action is already under way which will have a very significant bearing on the provision of occupational health and hygiene services in this field. Much of this action already goes well beyond voluntary advice; that is, it consists of statutory regulations and codes with a special legal status known as approved codes of practice. Probably the most significant of these is a consultative document containing proposals for regulations and approved codes on the control of all substances hazardous to health. As foreshadowed in the commission's response, this document has now been published. It is known in the health and safety world, I understand, as "COSHH". Among other things, it sets out the circumstances in which employers must assess the need for medical surveillance, occupational hygiene measurements, monitoring, control, and so on. A good deal of guidance material will need to be issued as a consequential step once the proposals are finalised, and a number of very significant publications have also been issued already by the commission or executive.
I think it is a matter of considerable importance to note that these and other commission proposals are all "hazard-based"; that is, they take a specific hazard or class of hazards as a starting point. Given this, it is conceivable that there could be ways other than the issuing of a code to stimulate and guide employers to take the necessary action. But it must be remembered that this action must be centred upon the existing and possible future hazards in the workplace itself. As the Select Committee recognised, there is no universal best practice applying to the whole of industry. The situation requires detailed consideration industry by industry. I very much hope that all this demonstrates that the commission takes seriously indeed the problems mentioned in the committee's report.
I now come to the question of resources, which was mentioned by many noble Lords opposite. The Select Committee drew attention to the staffing of the medical division of the Health and Safety Executive, as did the noble Lord, Lord McCarthy. This and the other recommendations relating to resources will, of course, need to be considered in the light of the commission's work and that of its advisory committees when they report in due course. But for their part, the Government must remain committed to restraining the growth of public expenditure in the interests of ensuring that the size and the expense of the public sector do not hinder economic recovery. Indeed, there would be little point in having an expensive occupational health service with little industry for it actually to work in.
Where the Select Committee's proposals call for increased spending, such increases can come only from reductions elsewhere. I appreciate that the noble Lord, Lord Kearton, said that it would only be £5 million more, but £5 million upon £5 million upon 460 £5 million builds up to the massive increase in public expenditure which we have seen in this country and which has been characteristic of the last 15 years, and it is one which industry has paid for to its cost. But the Government provide a grant-in-aid to the Health and Safety Executive through the commission and will allow the latter to set its own spending priorities. Its criterion will be the best value for money in securing health and safety at work. I for one do not consider £90 million to be a small amount of money.
The noble Lord, Lord McCarthy, mentioned reductions in the Health and Safety Executive's manpower. Of couse, it is true that in recent years the number of staff employed by the Health and Safety Executive has fallen. But it is wrong simply to judge the effectiveness of an organisation by the number of people who work for it. Surely, the one lesson that we have learnt in the last few years is that it is the efficiency of an organisation and the way in which its money is spent that counts.
I am sure that your Lordships will appreciate that the Health and Safety Executive is organising its affairs in accordance with the Government's determination to get greater value for money in spending public money. The executive has improved the effectiveness of its operations, and in particular the growth of hazard-based, computerised assessment systems for determining priorities for inspection has enabled resources to be concentrated on the areas of greatest risk. I must confess that the noble Lord, Lord Taylor, slightly surprised me when he spoke of three million. I thought that I was in a debate on another subject until I appreciated that the three million were those in work.
The Government for their part greatly appreciate the excellent work carried out by the group occupational health services, of which the Harlow Industrial Health Service, established by the noble Lord, Lord Taylor, is a notable and highly successful example. We are grateful to him this evening for his history of it. I for one am particularly grateful to the noble Lord for bringing his expertise and experience to bear on the discussion of the role of group services in this debate. I wish to record that the noble Lord has sent me a most useful paper, which we shall study very carefully.
We agree that such services play a very useful part in providing occupational health advice to small firms, particularly those with small risks for which full-time occupational health staff could not be justified; these services therefore address a particular problem. We shall study the paper very carefully and I hope to return to it before too long.
My Lords, does that mean that in due course I can hope for a little of the £1 million a year for pump-priming purposes, or is that ruled out?
§ Lord Young of Graffham
My Lords, nothing is ruled out, but it would not be for me to anticipate the reply.
As the noble Lord will know, I have a particular interest in the subject of training. Indeed, some of your Lordships may appreciate that within this Chamber I am in the midst of a rather intensive training course 461 myself. Therefore, I should like to make a few comments on this matter in response to the points raised in the debate.
The Government have noted the committee's general view that there is a need for more staff with specialist training, including some training for GPs in occupational health. Education and training in this specialty is, in the main, privately funded by employers sponsoring candidates themselves. Questions have been raised about the shortage of employers willing to do this, and the committee therefore wishes to see more Government financial assistance. The Select Committee, in considering this matter, has taken a most comprehensive approach to this question and it has undoubtedly established a valuable framework for future consideration by the various bodies concerned, including the Health and Safety Commission and its advisory committees. On the general point, however, the Government expect industry to continue to play the major part in funding specialist training in occupational health and hygiene.
However, one very interesting development—and perhaps the noble Lord, Lord McCarthy, is hearing the telephone ring—which I am now delighted to announce is that the Open Tech has agreed to commit some £400,000 towards the development of a distance learning course covering basic occupational safety and occupational hygiene, which will be arranged with completely open and flexible access to all able to benefit from it, both specialists and managers, technically qualified staff in other fields, and so on. The Health and Safety Executive is strongly supporting this development, as it has already done in the case of distance learning courses for GPs and occupational health nurses.
§ Lord McCarthy
My Lords, may I intervene? In the light of what the noble Lord said earlier, can he tell us what service is being reduced in order to enable that service to be expanded?
§ Lord Young of Graffham
My Lords, of course I shall be happy to tell the noble Lord that the budget of £400.000 expenditure is within the existing budget of the Open Tech programme, which is part of that of the Manpower Services Commission. I have no doubt at all, if I may speak from my former interest, that the Manpower Services Commission is delighted to take part in that programme.
The Select Committee report has rightly commended this kind of training as a cost-effective means of ensuring that training is available for all who need it. I hope that as time goes by we shall take greater and greater advantage of distance learning techniques, for it seems to me that this is an appropriate and valuable field for it to play a part in.
The question of research is another important matter, and one that I have not yet mentioned. The Health and Safety Commission has made it clear that it will take action to implement the report's recommendation for greater co-ordination. It agrees too with the great importance attached to information collection and provision, which was highlighted in this debate by the noble Lord, Lord Hunter, and also by 462 the noble Lord, Lord Rea, in his interesting contribution.
I should like to thank the noble Lord, Lord Gregson, for clarifying the committee's view on the relationship between primary care and occupational medicine. It is particularly helpful to have on the record the point that the committee is not suggesting—at least for the present time—that occupational medicine should be part of the primary care within the NHS.
Several speakers have emphasised the important role of GPs in occupational medical practice. This was recognised by the Health and Safety Commission in its memorandum. The Health and Safety Commission is taking part in discussions with the relevant bodies on all the points about GPs made by the committee, including that of specialist training for GPs themselves.
I hope that noble Lords will bear with me and recognise that I cannot comment in detail upon every one of the points raised in the debate without trying the patience of the House. I can assure noble Lords concerned that the points they have raised will be carefully considered by the Government and by the Health and Safety Commission.
This has been an interesting and valuable debate. The views of the House will be noted by the Government and also by those who are responsible for looking at the detailed provision of services in this area, the Health and Safety Commission and, I would emphasise again, its advisory committees. Finally it would not be right if we did not pay tribute to those who work in occupational health and hygiene services at workplaces throughout the land. These people give great service, and their dedication is often taken for granted.
§ Lord Gregson
My Lords, at this late hour in the evening and with another debate to come, I do not intend to respond to detailed points in the debate except to say two things. First, I should like to say thank you to everybody who has taken part in this debate this afternoon. The debate has measured up well to the high standards of your Lordships' House. It has been a most useful debate for expressing and widening the questions that were raised by your Select Committee.
Secondly, I would say that I remain still a little disappointed. However, I shall await the further instalments of good things, or good suggestions, from the Government and the Health and Safety Commission. I hope that at the end of those instalments I may not be so disappointed as I feel at the present time.
§ On Question, Motion agreed to.