Postgrad Med J (1992) 68, 663 - 670 i) The Fellowship of Postgraduate Medicine, 1992

Occupational Medicine

Occupational medicine in the National Health Service

Ian S. Symington

Director - Occupational Health Service, Greater Glasgow Health Board, 20 Cochrane Street,Glasgow GJ IJA, UK

Introduction

For many doctors working within the NationalHealth Service (NHS), occupational medicine re-mains a specialty on the fringe of their awareness.Undergraduate exposure to the subject is limited inmost medical schools and at postgraduate levelhealth and safety training in relation to medicalwork is given little emphasis. The fact that themajority of those who work in occupational medi-cine are employed outside the NHS in commercialenterprises or government departments has tendedto isolate them further from the mainstream ofmedical activity.During the past 15 years much has been done to

overcome these barriers. The establishment ofoccupational medicine as a specialty within theframework of the Joint Committee for HigherMedical Training (JCHMT) has been one majoradvance which has led to the creation of postsconsidered acceptable for training and of a stan-dard equivalent to other medical disciplines. Thereare now over 100 senior registrars working inapproved training posts of this kind, most ofwhichare outside the Health Service. In tandem with thisdevelopment, the Faculty of Occupational Medi-cine within the Royal College of Physicians ofLondon was established in 1978 with three majorobjectives: to promote the advancement of know-ledge in occupational medicine; to act as anauthoritative consultative body; and to developand maintain high standards of training, com-petence and professional integrity. These two init-iatives have done much to raise the profile ofoccupational medicine and already many doctorsare being attracted into an emerging specialtywhich combines clinical skills with a strongemphasis on health promotion and the preventionof ill health in the workplace.

Within the NHS itself a further major develop-ment is taking place through the gradual establish-ment of Occupational Health (OH) Services forNHS staff, including medical staff, in hospitals andthe community. This more direct interface with theprofession may help to enable better understandingof the main aims ofOH activity and achieve higherlevels of professional collaboration than haveexisted in the past.

Development ofNHS Occupational Health Services

Barriers to development

While OH Services have been established in mostlarge industries within the United Kingdom formany years, it is only comparatively recently thattheir development has been seriously consideredfor the one million employees within the NHS.A number offactors may have inhibited develop-

ment. These include the widely held perception thatthe NHS is a relatively safe place in which to work,but when objective comparisons are made withother organizations it is clear that this view is notentirely justified. The higher relative risk for anumber of occupationally related infections ingroups of health care workers certainly meritsconcern. The epidemic ofwork-induced back prob-lems, particularly in nursing staff, is comparable inscale with that found in mining and steel manufac-turing, and the range of hazardous chemicalshandled by a large health authority (8,000 sub-stances were recorded in one) is equivalent to thatencountered even in parts of the chemical industryitself.

While some industries such as the lead industryhave had longstanding legal requirements toundertake health surveillance of the workforce, it isonly within the last 20 years that the NHS hasbecome subject to formal legislation. In otherindustries the need for optimum physical fitness tocope with a particular task has led to close medical

Correspondence: I.S. Symington, M.B., Ch.B., F.F.O.M.,F.R.C.P.(G.).Accepted: 13 February 1992

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scrutiny, but it has only been recently appreciatedthat the energy expenditure expected of nursesworking in high dependency units is comparablewith some of the heavier tasks commonly under-taken on construction sites.Even where no major hazards caused by work

exist, many employers have taken the view thatpromoting OH Services for staffmay contribute tothe health of their employees. In return they expectgreater efficiency, increased productivity and lowerabsenteeism. In any labour-intensive organizationeven small increments in the health status ofemployees can be of major benefit to the overallefficiency of the organization but NHS manage-ment has tended to be cautious in putting thishypothesis to the test.

Stimulusfor development

As early as 1968 a joint committee of the Ministryof Health and the Scottish Home and HealthDepartment (the Tunbridge Committee), set up toreport on the need for OH Services in the NHS,made a detailed study of services in a number ofmajor industries and concluded that the conceptshould be extended to the NHS.' This led to theestablishment of some pilot services in the early1970s but coordinated development did not followuntil later.The major stimulus towards change occurred in

1974 through the establishment of the Health andSafety at Work Act and its subsequent regulations.This has contributed substantially to increasedpublic awareness of health and safety issues in theworkplace and has also placed responsibilities onthe employer 'to ensure, as far as is reasonablypracticable, the health, safety and welfare at workof all his employees.' Health care workers wereformally incorporated into this legislation in 1976and in 1978 the Health and Safety Commissionestablished a separate Health Services AdvisoryCommittee, comprising representatives of NHSmanagement and NHS trades unions, to consideritems of concern, and to produce agreed advisoryguidance which health authorities could use to helpfulfil their Health and Safety responsibilities. Therange of documents published to date is listed inTable I.

In 1986, the NHS (Amendment) Act finallyremoved the protection of Crown Immunity fromhealth authorities in relation to health and safety atwork. Although in theory this has not substantiallyaltered the responsibility of a health authority, itdoes place a more identifiable commitment on itschairman and management, who can now be heldpersonally or collectively responsible for breachesofhealth and safety legislation. The lessons learnedfrom the disasters at King's Cross, Zeebrugge andPiper Alpha have documented how heavy the

Table I Health Services Advisory Committeepublications

Title Date

The Safe Disposal of Clinical Waste 1982Asbestos Hazard in Health Service Buildings: 1983A Pocket Warning Card for Works Staff

Safety Policies in the Health Service 1983The Lifting of Patients in the Health Services 1984Guidelines on Occupational Health Services in 1984

the Health ServiceA List of Guidance on Health, Safety and 1984

Welfare in the Health ServiceSafety in Health Service Laboratories: 1985

Hepatitis BAIDS: Prevention of Infection in the Health 1986

Service: A Fact Sheet for StaffGuidance on the Recording of Accidents and 1986

Incidents in the Health ServicesSafety in Health Service Laboratories: 1986The Labelling, Transport and Reception ofSpecimens

Violence to Staff in the Health Services 1987Safety in Health Service Laboratories: Safe 1991Working and the Prevention of Infection inClinical Laboratories

Safety in Health Service Laboratories: 1991Safe Working and the Prevention of Infectionin the Mortuary and Post-mortem Room

Safety in Health Service Laboratories: 1991Safe Working and the Prevention of Infectionin Clinical Laboratories - Model Rules forStaff and Visitors

weight of that responsibility can be.Despite the initial impetus of the Tunbridge

Report, little progress was made during the remain-der of the 1970s. Yet a study2 commissioned by theEmployment Medical Advisory Service indicatedthat substantial investment had been made in termsof personnel employed. Approximately 100 wholetime equivalent (WTE) occupational physiciansand 600 WTE occupational health nurses wereidentified in occupational health services within theNHS in England and Wales at that time. Theoverall picture was of a large number of part-timedoctors and full-time nurses working in an unco-ordinated framework with little effective leader-ship. Most ofthe doctors and more than 50% ofthenurses had not received specific training for thework being carried out, and apart from a fewnotable exceptions, it was felt that most serviceswere not realizing their full potential. Agreement tocreate NHS consultant posts in occupationalhealth was therefore seen as a major step towardsbetter development and coordination of services.In 1981 the first consultant appointment was madein Scotland and since then over 50 posts have beenestablished throughout the United Kingdom with

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OCCUPATIONAL MEDICINE IN THE NHS 665

more in the planning stages. Arguably, this repre-sents the fastest growing medical specialty withinthe NHS during the past decade, but most of thenecessary resources have been funded throughrationalization of existing non-consultant postswhen vacancies arose. With similar recruitment ofproperly trained staff to key occupational healthnursing posts, OH services in the NHS are con-stantly improving in quality and scope.The Society of Occupational Medicine (SOM)

deserves credit for facilitating communication inthis development through the establishment in1983 of the SOM NHS Work Group. The groupestablished a regional communications networkwith the majority of doctors (full-time and part-time) working in NHS Occupational Health andpublished a series of discussion documents andguidance notes (Table II) on priority topics cover-ing aspects of organization, ethics and practice.From this group has developed an Association ofNHS Occupational Physicians (ANHOPS) whichis continuing with these tasks and extending itsinterest into the coordination of research.

Objectives of an NHS Occupational Health Service

Even where they are established, the main objec-tives of an NHS Occupational Health Service arenot always fully apparent to hospital doctors. TheInternational Labour Organisation in its Recom-mendation Number 112 (1959),3 which was subse-quently endorsed both by the EC Commission andthe Committee of Ministers of the Council ofEurope defined the broad purposes as follows:(a) protecting the workers against any health

hazard which may arise out oftheir work or thecondition in which it is carried on;

(b) contributing towards the workers' physicaland mental adjustment, in particular by theadaptation of the work to the workers andtheir assignment to jobs for which they aresuited;

(c) contributing to the establishment and main-tenance of the highest possible degree ofphysical and mental well-being of the workers.

The achievement of these objectives will involve theefforts of a multi-disciplinary team which caninclude: an occupational physician; an occupa-tional health nurse with appropriate postgraduatetraining and qualifications in this field; an occupa-tional hygienist with expertise in measuringcontaminants in the working environment andadvising on development of safe systems of work;and clerical support staff. When the consultant inoccupational health has specialist accreditation inoccupational medicine and is full-time, he or she isnormally expected to lead the team. The consultant

Table II Guidance notes for occupational physiciansproduced by a working group of the Society of Occupa-tional Medicine and the Association of NHS Occupa-

tional Physicians

Title Date

Health Assessment of Applicants for Nurse 1985Training

Prevention of Hepatitis B in NHS Staff 1985Alcohol Abuse and a Draft Policy for Problem 1986

DrinkingHealth Assessment of Applicants for Entry to 1986

Schools of PhysiotherapyProtection of NHS Workers against 1986

TuberculosisReferrals to Occupational Health Departments 1986Ambulance Staff - Health Assessment and 1987

Medical SupervisionConfidentiality of Records and Ethical 1987

Relationships for Occupational Health Staffin the NHS

Health Assessment for Employment in the NHS 1987Operational Policy for Occupational Health 1988

Services in the NHSPregnancy and Employment in the NHS, 2nd ed 1991

also requires to relate to many other groupsincluding NHS managers; trade union representa-tives; personnel staff; hospital engineers; radiationprotection advisers; safety officers; occupationalpsychologists and others (Figure 1).

Functions of an NHS Occupational Health Service

The range of functions of the OH team will dependon the type of health authority served and theadequacy of the funding arrangements. Within theideal OH service, however, an extensive range offacilities can be made available to NHS employeesand management. Some of these are as follows:

Health hazard evaluation services

(a) Workplace visits Occupational Health staffare often involved in visiting work areas to famil-iarize themselves with working conditions and toinvestigate situations where the environment issuspected of contributing towards health pro-blems. When potential problems are identified,appropriate action can be taken to effectivelyreduce the level of risk.

(b) Occupational hygiene services Many occupa-tional health services have access to simple equip-ment for measuring aspects of the workingenvironment such as noise, dusts or gases. Occupa-tional hygienists, where they are established, are

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NHS Management NHS Trade UnionsGeneral Managers OfficialsPersonnel Managers Stewards

IITheNHS Employee Safety Representatives

Others with Health andSafety Responsibilities The Occupational Health Team Committees

Health and Safety Advisers CommineesFire Officers Consultant InOccupationalHe lsth Control of Infection

Control of Infection Officers Occupational Hygealsthus Health & SafetyRadiation Protection Advisers Occupational Hygienist Radiation Protection

Hospital Engineers Clerical SupportErgonomists

Departments Providing Additional Clinical SupportPhysiotherapy

Clinical LaboratoriesRadiology

Clinical PsychologyClinical Consultants eg Orthopaedics, Psychiatry

Figure 1 Liaison required for effective occupational health care in the NHS.

usually supported by a wider range of sophisticatedtechnology to enable more detailed measurementof contaminants and relate these to establishedoccupational exposure standards. Glutaraldehydeexposure is one topical example where occupa-tional hygiene assessment can be of considerablehelp in risk assessment, enabling rational prioritiz-ing of action at the most heavily contaminatedsites.

(c) Investigations and surveys Sometimes moreextensive studies of working populations arerequired involving biological and environmentalmeasurement, often in conjunction with otherclinical departments. Some OH Departments, forexample, undertake back pain prevention pro-grammes to identify highly vulnerable groups whomight benefit from appropriate training withmechanical lifting techniques. Assessment of rou-tine data such as hospital accident statistics canassist with prioritizing the problems and finding thesolutions. In one health authority, three seriousladder accidents occurring in different hospitals ledto a more detailed 'safe system ofwork' designed toeliminate the problem.

Advisory services

(a) Influencing general policy The creation of asafe and healthy working environment cannot beachieved effectively without the wholehearted deter-mination of senior management. Organizationsthat have achieved high standards of occupational

health and safety are those that have incorporatedthis ideal as an integral part of total qualitymanagement. Studies by the Health & SafetyExecutive's Accident Prevention Advisory Unit4have made a convincing economic case that goodhealth and safety management means good busi-ness. Staff in occupational health services try hardto advocate this philosophy to senior managementand influence health authorities to develop effectivehealth and safety management systems which canbe audited and refined as necessary.

(b) Influencing specific policy While most healthauthorities have by now fulfilled the requirement todraw up a general health and safety policy, it is alsonecessary to develop more detailed policies onissues of concern. These policies have to be readilyunderstood and appropriate training given to thosewho are involved. Occupational Health Servicestaff with their understanding of the risks and thelegal requirements are well placed to assist. Thesteady stream of new Health & Safety legislationwill provide a ready source of material to work on.Apart from occupational health and safety issues,OH staff are also involved in influencing otherpolicies that affect staff such as workplace smokingpolicy; alcohol recovery programmes; and dealingwith disabled employees.

Control ofinfection services

Organization of immunization programmes forNHS employees requires considerable clinical and

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OCCUPATIONAL MEDICINE IN THE NHS 667

administrative effort if appropriate protection is tobe provided. An effective recall system can ensureupdates at the proper intervals. Hepatitis B vaccineis currently included in these programmes and allclinical medical staff should ensure that theyreceive this vaccine. For those travelling overseason health service business appropriate advice and,if necessary, immunization can be provided.

Counselling and follow-up are undertaken fol-lowing needlestick and similar incidents whereemployees are concerned about hepatitis B and/orHIV infection.

'Sentinel' cases of occupational infection such aspulmonary tuberculosis and hepatitis B are fullyinvestigated to identify causative factors andrecommend changes in policy ifindicated. OH staffalso participate in the activities of Control ofInfection Committees and contribute to the surveil-lance arrangements through these routes.

In conjunction with control of infection staff,occasional studies are mounted to assess infectionprevalence in groups of staff. Outbreaks of methi-cillin-resistant staphylococcus aureus (MRSA), forexample, cause great concern in hospitals. Com-munity outbreaks of chickenpox also cause alarmwhen known contacts who have not been previous-ly infected are nursing vulnerable patients.

Health promotion activities

Health promotion activities within the NHS work-force can bring personal benefit to the individualemployee. They can also enhance the concept ofthe'exemplar role' of the health professional and alsoof the health authority as an organization whichpractises what it preaches. Occupational healthstaff are often involved in the development ofstrategies for dealing with control ofsmoking in theworkplace and alcohol policies in relation toemployment.

Counselling and welfare services

A confidential counselling service can be providedto employees by Occupational Health Nurses withcounselling experience. Where occupational fac-tors contribute to stress, efforts are made toimprove the working situation. Pregnant employ-ees have particular concern about their workingenvironment and seek advice on issues such asexposure to cytotoxic drugs or anaesthetic gases. Inmost situations normal duties can be safely con-tinued, but a pragmatic policy ofproviding alterna-tive duties for those who remain unduly concernedafter full counselling is operated in most healthauthorities. Other problems include: dependencieson alcohol and drugs, post-traumatic stresses,concern about blood-borne diseases and generalhealth issues.

Health assessments

Most occupational health services have arrange-ments for screening potential employees to ensureadequate fitness to undertake specific duties. Sucharrangements are normally handled by a trainedoccupational health nurse, who has access tomedical advice from an occupational health physi-cian in cases causing concern.

Following exposure to a specific occupationalhazard assessments are undertaken to ascertainwhether a health problem is known or suspected tobe work related. Complaints of nurses wheezing atwork, for example, led to an investigation' whichlinked the symptoms to the use of a chlorhexidinein alcohol aerosol spray. Conversion to a simplemanual technique eliminated the problem.

Following long-term or intermittent short-termabsence from work through ill health or injury,assessment is undertaken at the request of mana-gers or personnel officers, to provide advice on anyindividual whose absence is causing concern. Everyeffort is made to identify health factors likely toimprove attendance and assist the individual. Inparticular, care is taken not to overlook occupa-tionally related ill health. Issues of rehabilitationand early retiral on health grounds are also con-sidered. Where levels of absence appear to be highin a specific department or group of employees theOH service is available to make a wider assessmentof factors which may be relevant.When a health problem may affect health and

safety at work assessments are undertaken at therequest ofmanagers. Examples include the cateringworker with a bowel infection, the driver whodevelops loss of consciousness, and the nurse withprogressive visual deterioration.

Regular health surveillance in relation to aspecific occupational exposure is conducted atregular intervals and may be required by specifichealth and safety legislation such as the Control ofSubstances Hazardous to Health (COSHH) Regu-lations7 which also applies to microbiological sub-stances. Some examples are:

clerical staff operating VDUs - vision test atentry;laboratory animal workers - routine lung func-tion tests and general questionnaire to detectearly allergic disease;high-risk tuberculosis workers - annual ques-tionnaires to identify possible infection;glutaraldehyde exposure worker - annual healthquestionnaire to detect early allergic disease.When there is concern about work performance

or behaviour at work it is important that managersdo not overlook possible underlying health prob-lems. Such assessments are often undertaken whenhealth problems are suspected to be contributory

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factors. These referrals include situations coveredwithin policies on alcohol and drugs in relation toemployment.

Training and information services

Although hospitals are never far from some sourceof assistance, the current first-aid regulations6require proper arrangements to be identified, par-ticularly for those working in areas far fromcasualty departments, e.g. dining rooms, labora-tories and laundries. Occupational health staff canadvise on requirements. Under the regulations,first-aid training programmes require to be app-roved by the Health and Safety Executive and anumber ofNHS occupational health services nowhold authorization to carry out this training.Members of the OH team can make regular

contributions to in-service training courses onsubjects which include: organizing for health andsafety, Health & Safety legislation, coping with theControl of Substances Hazardous to Health(COSHH) regulations, preventing back injuries,and managing stress at work. Many OH depart-ments can also provide up to the minute inform-ation on toxic substances through access to libraryand computer databases covering all aspects ofworkplace hazards.

Role of the NHS consultant in occupational healthservice provision for the NHS

The main role of the NHS occupational healthconsultant is to provide leadership within theoccupational health departments delivering a rangeof high-quality services described above. Theircontribution to occupational health practice on awider basis is also possible and like their medicalcolleagues in other disciplines, many are active inteaching and research.

Teaching

The existing input to occupational health trainingfor undergraduate medical students has alreadybeen identified as a deficiency in the curriculum ofmost medical schools.8 In health authorities wherethere are teaching commitments, NHS consultantsin occupational health are well placed to contributeto and facilitate the development of occupationalmedicine teaching in collaboration with universitycolleagues. A number of initiatives have alreadybeen established often involving other hospitalconsultants and occupational physicians in indus-try outside the NHS. It is feasible to ensure, withinexisting clinical teaching, that courses covering, forexample, ear, nose and throat surgery, respiratorymedicine, dermatology and psychiatry emphasize

the occupational aspects. Within the broad dimen-sion of public health teaching programmes there isalso scope to ensure that an occupational healthcomponent is established. In postgraduate medicaleducation a network of short introductory coursesin occupational medicine, approved by the Facultyof Occupational Medicine, has been set up to meetthe needs ofboth general practitioners and hospitaldoctors who wish to learn more about the subject.These are proving to be a popular addition to therange available.

Research and audit

Research into occupational health problems in theNHS is an area with considerable potential forgrowth and many of the new OH consultants aregrasping the challenge with vigour. Through closecontact with colleagues in clinical and laboratoryspecialties there are opportunities for multidiscip-linary collaboratve research on groups ofemployeesat special risk. While such activity is still at an earlystage of development, the Research Panel of theAssociation of NHS Occupational Physicians isnow established and is active in trying to stimulateinterest in research work; to help find suitablesources of funding; and to make best use of scarcemanpower resources. Medical audit can alsousefully be considered within this spectrum as mostof the systems used in occupational health practicerequire to be critically evaluated. Many NHS OHdepartments have now established audit proce-dures designed to ensure high-quality standards inthe work done.

Clinicalpractice

It has been shown in some health authorities thatreferral networks can be developed between theconsultant in occupational health and colleagues inhospital and general practice with a view to assis-ting with the clinical management of those patientswho may have work-related health problems.When used as an information resource on work/health interactions such contacts can range fromgeneral telephone advice to full clinical assessmentof individual patients. Those consultant occu-pational physicians with practical experience intoxicology and epidemiology are also able tocontribute to the assessment of environmentalproblems which affect the public health outside thehospital environment. In some areas, this has led toclose links being forged between NHS occupa-tional health consultants and specialists in publichealth and environmental health.

Services to organizations outside the NHS

Further major opportunities for development arebeing presented by the new NHS management

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OCCUPATIONAL MEDICINE IN THE NHS 669

changes. Once established, and having reached thecritical mass required to function effectively, thecapacity of NHS occupational health services toextend their activity to organizations outside theNHS has not gone unnoticed by the 'incomegeneration' strategists. Such activities are alreadybeing developed in some health authorities and therange of organizations to which services are pro-vided includes local authorities, fire authorities,educational establishments, construction com-panies, manufacturing industries and many others.These activities serve to increase substantially thenumber of employees covered by expert occupa-tional health services and at the same time provideadditional professional diversity, and opportuni-ties for teaching and research in a wider range ofoccupational environments. Those who negotiateadditional contracts of this kind should, however,take pains to ensure that the new activity is notdiverting resources away from the existing pro-vision of services to NHS employees. At the sametime, with the increasing pace of change towardscontracting out of ancillary services, developmentof independent hospital trusts and collaborativelinks with the private sector, it is important for thepurchasing authority not to lose sight ofthe need tomaintain adequate levels of occupational healthprovision in the units with which it is contracting.Whatever the nature of the OH contract with the

purchasing organization, whether within or outsidethe NHS, agreement should be reached if theschemes are truly income generating as to how thenew resources should be utilized. If at least aproportion of this income could be guaranteed todevelop better occupational health services orpromote occupational health research, there wouldbe stronger incentives for OH staff to participatewholeheartedly.

Can NHS Occupational Health Services benefitmedical staff?

Doctors as an 'at-risk' occupational group

Medical staff comprise a very small percentage ofthe total NHS working population and it followsthat most of the efforts of occupational healthservices will therefore relate to non-medical grades.The medical group, however, is the most influentialand, pro rata, the most expensive manpower re-source within the NHS. It is certainly the mostknowledgeable about health issues and probablythe best equipped to look after its own health on anindividual basis. Sickness absence rates in thisgroup are among the lowest of all grades within theNHS although mortality from alcohol-related pro-blems and suicide remains higher than that encoun-tered in the general population. It is, perhaps, the

most ambivalent group when it comes to confront-ing the health problems which relate to its ownwork and can be among the most resistant toaccepting routine measures designed to provideprotection. Part of the profession's defencemechanism against the daily exposure to death andserious morbidity understandably includes an ele-ment ofdenial - 'it can't happen to me'. Yet doctorsin the course of their work are not completelyimmune to infections such as hepatitis B, pul-monary tuberculosis or HIV. Nor are they speciallyprotected from the long tolerated health effects andinefficiency which arises from working prolongedhours without sleep. They can be the most difficultto coax into compliance with current immunizationschedules recommended by the health departmentsand have until recently tended to resist reform ofjunior doctors' hours. The presence of a con-veniently located hospital occupational health unitcan often help to facilitate access to appropriateimmunization procedures and more general adviceon work-related health problems.

The individual 'sick doctor'

When fellow medical colleagues are affected byhealth problems, they should be well placed to haveaccess to the best possible investigation and treat-ment, but this ideal is not always realized. Partic-ularly when illness affects the personality orbehaviour ofthe individual there is often reluctanceto seek professional advice and offers of assistancefrom concerned colleagues often go unheeded. It iswhen such problems, whether caused by alcohol,psychiatric or organic illness, encroach upon thequality and safety of patient care that ethicalconcerns can arise about the right action to take.Although all hospital doctors work within a con-tractual relationship with the Health Authority,their hierarchical relationships with one anotherare less well defined. For junior hospital staff thereis general acceptance of a 'line management' struc-ture, at least in professional terms, to the consul-tant in administrative charge of the department.Within this framework, deviations from normalhealth which encroach on work capacity wouldnormally be detected and dealt with. Where illnessaffects the work capacity ofa consultant colleague,who has more professional independence, there isgreater scope for significant health problems to gounattended. Informal mechanisms for dealing withsuch problems include a direct approach appealingto the 'sick doctor' to seek help, or an indirectapproach through anonymous reporting to theNational Counselling and Welfare Service for SickDoctors. More formal action can be taken byinvolving the 'Three Wise Men' system within thehospital or in extreme cases by involving the HealthCommittee of the General Medical Council.

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These cumbersome arrangements have arisen asa result of loose reporting mechanisms within themanagement structures, linked with a sense ofprofessional etiquette which cautions against im-plied criticism of colleagues. Recent changes in theconsultant contract, which define more clearly theworking relationships with general management,are likely to bring abnormal behaviour or alteredperformance at work under closer scrutiny, withopportunities for earlier consideration of assoc-iated health-related issues. The consultant occupa-tional physician in the NHS is accustomed todealing with the interactions between health andwork in every group of staff and is well placed toextend this role to medical staff themselves. Thesurgeon with multiple sclerosis, the cytologist withimpaired vision, the physician with manic depres-sion, are all examples which the NHS occupationalphysician encounters and every effort is made toplan suitable rehabilitation within a frameworkwhich ensures acceptable levels of care to patients.With increasing frequency, personal concernsabout HIV infection are considered on a highlyconfidential basis following appropriate ethicalguidelines.

The doctor as a manager

For those doctors who have an executive role in theorganization of their department, the use ofthe OHservice as an information and advisory resource inrelation to health and safety at work may be ofconsiderable assistance for fulfilment of dutiesfalling within the spectrum of risk management.The COSHH regulations7 require health authorit-ies to consider the work processes using chemicaland microbiological substances which can beharmful to health. An assessment is required foreach process, taking into account the knowntoxicology of the hazardous material. For somematerials, arrangements for environmental moni-toring will be necessary, involving the measure-ment of airborne contaminants by an occupationalhygienist. In a smaller proportion, it will be neces-sary to undertake health surveillance ofemployees,

and this may involve a physical examination and abiological assessment of exposure. OH services inthe NHS have a major role to play in thesedevelopments by advising what action to take, butit is the manager who will have the responsibility toensure that the legal requirements are fulfilled.

Careers in occupational medicine within the NHS

Although occupational medicine is currently thesmallest specialty in the NHS, its claim to be themost rapidly expanding (from one consultant postin 1981 to 50 in 1991) has been of interest to juniordoctors considering their choice of career. TheFaculty of Occupational Medicine's SpecialtyAdvisers in NHS regions report a steady stream ofenquiries from young medical graduates at an earlystage of their careers. Before considering thispossibility a broad general professional training of3 years (such as exists in general medicine orgeneral practice) is desirable prior to enteringHigher Specialist Training.

Considerable scope exists for training within theNHS and particularly in departments where ser-vices are also provided to a range of other indus-tries. An establishment of 26 NHS senior registrarposts has been agreed recently with the Departmentof Health's Joint Planning Advisory Committee(JPAC) and this will enhance training prospectsfurther. A move to occupational medicine, how-ever, is one which should be considered withparticular care for it may not be suited to those whothrive on the high drama ofthe operating theatre orthe intensive care unit. The specialty combines thestrategic approach of preventing ill health in theworking population with the maintenance of clini-cal skills. For those capable of working well withina multidisciplinary team, there are opportunitiesfor a stimulating career.

Acknowledgements

Thanks to Dr David Watt and Professor R.I. McCallumfor helpful comments and Mrs Sheila Marshall forpreparing the manuscript.

References

1. Ministry of Health and Scottish Home and Health Depart-ment, Central and Scottish Health Service Councils. The Careofthe Health ofHospital Staff. Report of the Joint Committee.HMSO, London, 1968.

2. Healey, B. Occupational Health Services in the NHS. OccupHealth 1982, 34: 474-476.

3. International Labour Organisation Conference, Recommend-ation 112. ILO, Geneva, 1959.

4. Successful Health and Safety Management. Health and SafetyExecutive. HMSO, London, 1991.

5. Waclawski, E.R., McAlpine, L.G. & Thomson, N.C.A.Occupational asthma in nurses caused by chlorhexidine andalcohol aerosols. Br Med J 1989, 298: 929-930.

6. First Aid at Work. Health and Safety (First Aid) Regulations1981 and Guidance. Approved code of practice 1990. HMSO,London, 1990.

7. Control of Substances Hazardous to Health Regulations andApproved Code of Practice. Health and Safety Commission.HMSO, London, 1988.

8. Harrington, J.M., Philip, R. & Seaton, A. Undergraduateoccupational health teaching in British medical schools. J RColl Physic Lond 1989, 23: 24-26.

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