Four pillars of occupational health.

Abstract

Most occupational health services in this country and in the Western world are in private industry. They vary in quality and offer little cover for workers in companies with fewer than 300 or 400 employees. The main reason for their development was interest; enlightened in that most employers had genuine concern for the wellbeing of their workers, and self interest in that they hoped to reduce absenteeism, lost time, and compensation claims, and to attract the best labour. These are valid reasons but may or may not result in the best services. Moreover, normal economic competition between companies may inhibit the level of frank collaboration necessary for epidemiological surveillance and research. As for the rest of those who work for a living?self-employed or in smaller companies?they have virtually no cover, apart from the limited advisory and enforcement services of the Health and Safety Executive (HSE): These men and women, comprising half the working population, probably experience far more than their share of accidents and occupational disease; this is not surprising, since conditions and health supervision in small work places are sometimes bad. Various approaches have been tried to cope with this problem. There are a few co-operative group schemes in the United Kingdom but they have proved difficult to finance and have had little impact. France, Finland, Norway, and Sweden all have programmes for small enterprises but progress has been slow, mainly through lack of professional staff. Not only are those at greatest risk insufficiently protected at work but they tend also to be omitted from systematic epidemiological sur? veillance. Responsibility for this task is seldom explicit and only the resources of HSE are available for the purpose. Generally speaking, private occupational health services are hierarchical structures with doctors at the top. Some are excellent, but the arrangement has its disadvantages. It is expensive and tends to inhibit the development of any service if no doctor can bf ' and, and it encourages clinical and therapeutic procedures at the expense of primary prevention. It tends to separate health from safety and is not really compatible with the multidisciplinary nature of occupational health. Usually the medical director is employed by the company, with little security of tenure, sometimes subordinate to the personnel manager. Too often he is seen by the work force as the mouth