455HEALTH SERVICES AT HOME

ROYAL AIR FORCE DENTAL BRANCH

Commissions are available in the Royal Air Force DentalBranch to candidates of either sex who possess a degree orlicence in dental surgery of a British university or licensingboard, and who are registered under the Dental Act in forcein the United Kingdom. Dental officers in the Royal AirForce have plenty of scope for all the aspects of dentistry ina branch which trains its own technicians and maintains itsown laboratories under senior dental officers. Dental officers

serving on short-service or National-Service commissions mayapply at any time for appointment to permanent commissions.The length of the period on a short-service commission andthe period required in the reserve on its completion is the sameas for medical officers. Similarly, dental surgeons may begranted permanent commissions if they can complete atleast 20 years’ service qualifying for retired pay. Antedatesof seniority, rank on appointment, and terms of promotionare similar to those set out above for medical officers. A tax-free gratuity, at the rate of U25 a year for each year of satis-factory active-list service, is payable to short-service officerson transfer to the reserve. Dental officers appointed topermanent commissions are encouraged to pursue theirstudies in postgraduate research and may be allowed up toseven months’ study leave on full pay and allowances to takeapproved postgraduate courses. Short-service or permanentcommission officers who have the appropriate higher qualifica-tions and the requisite experience may be recommended forspecialist appointments, which also attract the additionalantedates given to specialist medical officers. Further informa-tion may be had from the Under-Secretary of State for Air,Air Ministry (M.A.6), 2/8, Richmond Terrace, Whitehall,S.W.1 (Trafalgar 8811, ext. 6669).

Health Services at Home

PUBLIC HEALTH

POST-WAR legislation has brought many changes inthe duties of medical officers of health, and the prospec-tive entrant to the public-health service will wish toconsider the current trends in development. Responsi-bilities have been lost: the National Health ServiceAct has transferred the control of hospitals and theclinical care of infectious fevers, tuberculosis, andvenereal diseases to the regional hospital boards ; otherduties have passed to the newly created children’sdepartments and to the Ministry of Agriculture. In theirplace greater scope has been created in the personalhealth services, and, as a specialist in preventive andsocial medicine, the medical officer of health retainsa vital place in the community.The greatest changes have taken place in the work of

counties and county boroughs. Under part ill of theNational Health Service Act these have been designatedas local health authorities, and they must provide clinicsand other services for mothers and children, domiciliarymidwifery, health visiting, home nursing, immunisationand vaccination facilities, ambulances, and domestic-helpservices. Some have preliminary schemes for healthcentres. Much of this work has grown rapidly, particu-larly the ambulance, home-nursing, and domestic-helpservices, and their importance to the community is great.The Act gives these authorities wide powers to initiateschemes for the prevention of disease and the care andaftercare of sick persons. The responsibility for theadministration of all these services falls on the medicalofficer of health ; in most areas he is also the school medi-cal officer and is thus able to coordinate the preventivehealth services to cover children of all ages. In someareas further coordination has been secured by placingthe authority’s social welfare services also under themedical officer of health.

In environmental-hygiene the duties of the medicalofficer of health are comparatively unchanged. Theseresponsibilities have gradually evolved over the lasthundred years, but in contrast to the early days, whenthe medical officer of health was personally concernedwith the execution of many sanitary duties, health depart-ments are now organised to free him from much ofthe detailed work, which is performed by trained layofficers, or even transferred to the care of other depart-ments, as in the case of water-supply and sewage disposal.Naturally the extent of this devolution of responsibility

must vary widely, and in rural areas problems of water-supply and sanitation are a major concern of the medicalofficer of health. The supervision of housing conditionsis also a health-department responsibility. All this workmust remain under the general control of the medicalofficer of health, and he must supervise the purity ofwater-supplies even though their production is not hisconcern. Though less concerned with detailed work,supervision must be far wider than that by his predecessorof a hundred years ago.

Control of infection has always been one of the principalfunctions of the medical officer of health. Bacteriologistshave made great advances in the identification of differentstrains within certain pathogenic species, and these newtechniques applied to epidemic control have given himan instrument of precision in much of his epidemiologicalwork. The application of specific prophylactic measuresagainst various acute infections is now an importantfunction of all health departments. Drastic reduction, ifnot the complete extinction, of certain infectious diseaseshas become a feasible target for all health departments.

Recent developments have increased the opportunitiesfor the young medical officer to obtain a comprehensivetraining in public health. Additional posts of seniormedical officer grade have been created in many of thelarger towns, and in counties schemes of divisionaladministration have been evolved. The work of themedical officer of health to a number of county districtauthorities is often combined with an appointment asassistant or divisional county medical officer of health.The holder of such a post obtains a detailed knowledgeof the community under his care, and, while retaining ahigh degree of individual responsibility, he suffers noneof the disadvantages of rural isolation.A sound clinical background is an essential qualification

for the new entrant and a course leading to the diplomain public health should be taken at an early stage sincethis qualification is necessary for anyone seeking anappointment as a medical officer of health. For doctorsengaged in clinical preventive medicine a diploma inchild health or in obstetrics and gynaecology is anadvantage. -

Individual progress in a public-health career dependslargely, if not entirely, upon the doctor’s personal quali-ties ; for, as adviser to his authority, the reputation ofthe medical officer of health depends on the soundness ofthe advice he gives. Quite apart from his statutoryfunctions, he has an important part to play in promotingthe health education of the community, and in helpingto secure full coordination between the branches of thehealth service in his area. He is assisted by the regularliaison meetings, which are held in most regions, betweenthe hospital boards and the county and county-boroughmedical officers of health. Most hospital boards rely onthe medical officer of health to determine the urgency ofthe social grounds for admitting patients to hospital,especially in maternity cases and when considering thechronic sick. Many medical officers of health have beenappointed as members of hospital medical advisory com-mittees or of hospital management committees ; and,through the National Health Service Act, a closer relation-ship with the general-practitioner services has nowbecome possible. No other person is so well placed tosurvey the whole range of medical activity in an area.

INDUSTRIAL MEDICAL SERVICES

IN November last year the Minister of Labour andNational Service announced in the House of Commonsthat he had decided to take steps to stimulate the furtherdevelopment of industrial health services in work-placescovered by the Factories Acts. He also said that he wasappointing a standing advisory health committee toadvise him on developments, and that it was his intention,with the assistance of this committee, to carry out areview to ascertain where industrial health services mostneed to be extended and to promote surveys and fieldinvestigations to determine the need for preventivemeasures or research. His general aim was closecoordination with the preventive and curative healthservices provided by statutory bodies, to developindustrial health services on a voluntary basis, but hewould also consider making use of his statutory powersunder the Factories Acts.

456 STUDENTS’ GUIDE 1955-56

It is to be hoped that the deliberations of the industrial-health advisory committee will lead to the creation ofmore posts for doctors interested in occupational medi-cine. These posts fall into various categories, such asthose in the Civil Service, the nationalised industries,research organisations, the universities, and factories.But, though the importance and opportunities of industrialmedicine are increasingly recognised, it cannot yet besaid that in salary or prospects the openings in this workare always as favourable as those in the NationalHealth Service. For industrial posts within the CivilService, the prospects may improve after the RoyalCommission on the Civil Service reports, but at presentthis service does not offer enough senior appointments toassure promotion to all who earn it. Moreover, as thingsare at present, the top posts in the medical Civil Serviceare often filled by doctors who previously held appoint-ments outside the service, and this is a discouragement tothose who are contemplating entry through the basic grade.The appointments as medical officers to factories and

other industrial organisations vary in attractiveness,both as regards opportunities and salaries. In some theconditions and prospects are good, and the BritishMedical Association has laid down a scale of minimumsalaries.The main Government department supervising the

health of industrial workers is the Factory Departmentof the Ministry of Labour and National Service. Thisdepartment, which up to 1940 worked under the HomeOffice, dates from 1833 and administers the Factory Acts(1937 and 1948) with regulations on accident and sicknessprevention, hours of work, amenities, and canteens. Theinspectorate numbers about 412, of whom 16 are doctors.Members of the department, whether lay or medical, takepart in the activities directed towards the prevention ofillness and maintaining the health of the factory popula-tion. The medical inspectors are stationed in London,Birmingham, Sheffield, Liverpool, Bristol, Manchester,Glasgow, Leeds, and Wolverhampton ; and from thesecentres they are able to deal with factory health andconditions in any part of the country. Under them 1750general practitioners give part-time service as appointedfactory doctors (previously called examining surgeons),examining all young entrants into industry, and periodic-ally all those engaged in specific dangerous processes.In addition there are about 300 doctors employed whole-time in factories or groups of factories, and about 3000(maybe more) in part-time work. An interesting develop-ment in recent years has been the setting-up of medicalservices for looking after workers on trading estates.Three such schemes, at Slough, Hillington, and Bridgendare well established and others are projected to servethe trading estates at some of the " new towns." It hasbeen a common criticism of the industrial medical servicesthat the workers at small factories are not catered for,and these three group services might well form a modelfor a national service. It is well to bear in mind, how-ever, that even in factories where there are no doctors aclose watch on conditions is maintained by the factorydepartment.Apart from the factory department, other government

departments deal with various aspects of the industrialmedical services. For instance, the Post Office, whichemploys more workers than any other department, hashad a medical service since 1855 ; and since it deals withengineering and manual workers in addition to officestaffs, it is partly an industrial medical service. ThePost Office medical staff is now directed by the chiefmedical adviser to the Treasury, who has in addition astaff of 15 doctors which deals with the health problemsof the Civil Service. The Inspectorate of the Ministry ofFuel and Power has a medical section with a few full-timemedical inspectors. The National Coal Board provides acomprehensive industrial medical service for the industrywhich now has a large staff of whole-time doctors. TheMinistry of Supply Medical Service with 40 doctors,deals with the health of the workers in the Royalordnance factories, and in the research stations. The

Ministry of Pensions and National Insurance has a

medical staff both at headquarters and in the regions,which advises on compensation for industrial injuries aswell as for other causes of ill health. The former silicosisand asbestosis board is now a part of the medical serviceof the Ministry. On the staff of the pneumoconiosis

medical panels, ’as they are now called, are 24 whole-time medical officers who deal with the diagnosis andcertification for compensation of cases of silicosis,asbestosis, and some other forms of pneumoconiosis.They also carry out periodical medical examinations ofworkers engaged in some scheduled occupations in whichcases of pneumoconiosis are likely to arise. The centresfrom which the panels work are Swansea, Cardiff, London,Manchester, Sheffield, Bristol, and Edinburgh. Some ofthe newly nationalised industries have established medicalservices-for example, the London Transport Executive,a part of the British Transport Commission. TheLondon Transport Executive employs a chief medicalofficer with 9 full-time doctors. The National DockLabour Board also has a medical service consisting of 7full-time medical officers and 1 part-time medical officer.Some, but not all, of the regional boards of the nationalisedgas industry have appointed whole- and part-timedoctors to look after the health of the workers. A moveis on foot to set up medical services in all regions, andduring the year several new appointments have beenmade.

In addition to investigations and research into industrialdiseases conducted by medical inspectors of factories,mines medical officers, and works doctors, much funda-mental research into environmental conditions has beencarried out by the investigators of the Industrial HealthResearch Board of the Medical Research Council. Clinicaland field studies made under the aegis of the council’sindustrial pulmonary diseases committee include inquiryinto the pneumoconiosis of coalminers and the byssinosisof cotton workers. The London Hospital department forresearch in industrial medicine was established in 1943,and a few years later, in conjunction with the Ministry ofFuel and Power, a bureau for research into the pneumo-coniosis of South Wales coalminers was set up at Cardiff.Other units of the council dealing with industrial healthinclude the toxicological research unit at Porton, thegroups for research in industrial physiology and psycho-logy in Manchester, Cambridge, and London, and theindustrial medicine research unit at the BirminghamAccident Hospital. There is also a unit for research onclimate and working efficiency at the department ofhuman anatomy at Oxford, a social medical researchunit at the Central Middlesex Hospital, and a statisticalresearch unit at the London School of Hygiene andTropical Medicine. Problems on the health aspects ofatomic energy are being dealt with at Harwell. Researchinto industrial health matters is also being undertakenby the university departments mentioned below. TheInstitute of Social Medicine at Oxford, which worksunder a joint board, also undertakes investigations intovarious aspects of industrial health. University chairsdevoted to industrial or occupational medicine have beenset up at Manchester and Durham. The chair of socialmedicine at Birmingham includes industrial medicinewithin its terms of reference, and the University ofSheffield has appointed a professor.of social and industrialmedicine. Students are likely to hear more about thesesubjects in their undergraduate courses. Postgraduatecourses are held in London, Birmingham, Sheffield, andManchester, and occasionally at other centres. Diplomasin Industrial health (D.I.H.) have been instituted by theSociety of Apothecaries, the Conjoint Board of the RoyalColleges of Physicians and Surgeons, Edinburgh Univer-sity, and the Faculty of Physicians and Surgeons of Glas-gow. The Association of Industrial Medical Officers wasformed some years ago by doctors interested in industrialhealth, and branches have been established in variousparts of the country; the British Journal of IndustrialMedicine is sponsored by this association in conjunctionwith the British Medical Association. The association hasalso since April, 1951, published a quarterly journal, calledthe Transactions of the Association of Industrial MedicalOfficers, which is devoted to the dissemination ofinformation about the practical aspects of industrialmedicine rather than to original research.

PRISONS AND BORSTAL INSTITUTIONS

THE medical service is a part of the general serviceclass of the medical Civil Service. It is under theimmediate control of the Director of Prison MedicalServices at the Prison Commission. The service comprises