Initial signs and symptoms of cognitive impairment are subtle and may go unrecognized, or be misdiagnosed as stress or depression Poor insight can make management challenging. Clinical assessment and diagnosis History It is helpful if managers give speci \201 c exam ples of workplace dif \201 culties as this may alert the assessing physician to the possib ility of cognitive impair- ment. If suspected then explore the following; \200 The employ ee \200\231s perceptions of their dif \201 culties \200 Family history of dementia \200 Past medical history: history of head injury, brain tumor, etc. \200 Drug/alcohol histo ry \200 Educational history 23_Smedley_Chap23.indd 456 1/2/2013 12:36:34 PM COGNITIVE IMPAIRMENT AND FITNESS FOR WORK 457 Occupational history (exposure to occupational neurotoxins). \200 (cid:2) Consider treata ble causes of dementia: pseudo-dementia in those with severe depression \200 space-occupying lesions \200 alcoh ol misuse \200 hypothyroidism \200 vitamin B 12 or folate de \201 ciency \200 vascul itis. Investigation \200 If cognitive dif \201 culties are suspected then tests to screen for cognitive impairment such as the Addenbrooke \200\231s Cognitive Examination \200\223 Revised (ACE-R ) or the widely used, but less sensitive Mini-Mental State Examination (MMSE) 1 may be help ful. An MMSE score of <29 \200\22330 in a person of working age is unusual (anxiety may com promise performance). An MMSE score <24 indicates signi \201 cant cognitive dif \201 cult ies Referral to a psychologist for formal cognitive assessment. Prognosis \200 Prognosis depe nds on cause and the outcome of treatment \200 The prognosis of dementia is one of declin ing cognitive function, and employment cannot usually be sustained in the medium term Workplace adjustments: highly structured/routine work \200 regular supportive supervision \200 predictable wor kload. Factors that reduce the feasibility of remaining at work: highly variable work pattern \200 high decision latitude \200 multi-tasking \200 time pressures \200 cognitively demanding work \200 behavioral problems. Caution should be exercised in assessing workers in safety critical posts or key decision-makers. Medical management \200 Identify reasonably practicable workplace adjustments \200 If, despite adjustments, the worker is unable to cope with his/her current post, he/she may be eligible for ill-health retirement (if the condition is progressive and untreatable). Relevant legislation The Equality Act 2010. 1 Folstein MF, Folstein SE, McHugh PR (1975). \200\230Mini-mental State \200\231: a practi cal method for grading the cognitive state of patients for the clinician. Psychiatry Res , 12 , 189 \200\22398. 23_Smedley_Chap23.indd 457 1/2/2013 12:36:34 PM CHAPTER 23 Generic \201 tness for work and disorders 458 Depression Types The most common type of depression is unipolar depression; bipo- lar disor der (manic depression) affects around 1%. Prevalence \200 Major depressive episode: males \200\223 1.9%. females \200\223 2.8% \200 Mixed anxiety and depression: males \200\223 6.9%, females \200\223 11.0% \200 Li fetime risk of depression: 10 \200\22312% in men, 20 \200\22326% in women. Causation Predisposing factors \200 Genetic (> \227 2 increased risk if \201 rst degre e relative affected) \200 Adverse childhood experiences \200 Previous history of depres sion \200 Underlying physical illness. Precipitating factors \200 Major adverse life ev ents \200 Physical illness, e.g. onset, worsening of symptoms \200 Drug therapy, e.g. c orticosteroids \200 Work-related dif \201 culties, especially bullying. Perpetuating fac tors \200 Lack of con \201 ding relationship with partner \200 Misuse of alcohol or dr ugs \200 Combination of work and domestic problems \200 Isolation and lack of adequate support. Diagnostic assessment \200 Classi \201 cation: DSM-IV (APA) \200\223 \200\230Major depressive disorder \200\231 \200 ICD10 (WHO) \200 \223 \200\230Depressive episode \200\231/ \200\231Recurrent depressive disorder \200\231 both sets of criteria require impairment of social, occupational or other important areas of functioning. Clinical treatment \200 Psychological: CBT \200\223 linking thoughts, feeling and behaviors to challenge negative patterns of thinking Pharmacological: SSRIs most commonly used, e.g \202 uoxetine, sertraline, citalopram \200 Other drugs in clude, e.g. mirtazapine, venlafaxine, agomelatine \200 Maintain treatment for at least 6m ths from point of maximum recovery (2yrs if recurrent depression) Relapse rate of major depression: 60% in 5yrs if untreated. Occupational health input Facilitate early treatment. referral for psychiatric assessment/psychological 23_Smedley_Chap23.indd 458 1/2/2013 12:36:34 PM DEPRESSION 459 Fitness for work \200 Performance: poor motivation \200 reduced concentration and poor decision-making \200 lack of con \201 dence \200 impaired communication, withdrawal and/or irritability \200 lack of ene rgy \200 antidepressant medication. Sickness absence: signi \201 cant impairment of performance \200 non-compliance with medication \200 sid e effects of medication \200 premature reduction of dose. Fitness to attend disciplinary hearing \200 Legal \201 tness to plead criteria relate m ainly to capacity. Main question is whether the employee understands the allegations and their signi \201 cance \200\224can they take part in the decision making process? Useful guide to cognitive ability is the employee \200\231s own correspondence with the employer Understandable that employee is likely to feel anxious and preoccupied, and to eat and sleep badly around the time of any hearing but postponement of the hearing can only protract and intensify this natural reaction Speedy resolution helps to prevent chronicity and secondary morbidity, and can help both parties move on Location of the hearing is important; the workplace might be too aversive and a meeting in the employee \200\231s home would be intrusive. Therefore a neutr al location, e.g. hotel suite, might be more acceptable. Time off work See b p. 308, Stress 1 recognition and assessment; b p. 311, Stress 2: interv entions/risk control. Rehabilitation and reasonable adjustments at work \200 \200\230Rou nd-table \200\231 discussions can be helpful: \200 shared problem-solving approach \200 OH, HR, employee, manager +/ \200\223 treating psychiatrist/psychologist \200 realistic goal setting, job de \201 nition, and work routine \200 agreed hours and days of work, a nd how these change over time \200 manager \200\231s involvement \200 preparation of wo rk colleagues for employee \200\231s return. Further information Workplace intervention for people with common mental health prob- lems: Evidence review and recommendations. British Occupational Health Research Foundation, avai lable at: M http://www.bohrf.org.uk/downloads/ cmh_rev.pdf 23_Smedley_Chap23.indd 459 1/2/2013 12:36:34 PM CHAPTER 23 Generic \201 tness for work and disorders 460 Chronic fatigue syndrome/myalgic encephalomyelitis There is a broad range of disability amo ng patients with CFS. Some at the mild end of the spectrum manage to work normally, while o thers will need protracted adjustments to work. \200 Intervention studies have shown that 7 30 \200\22360% of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) patients do not return to work after treatment. Between 25 and 42% of CFS/ME patients are on disability bene \201 ts Work status is an important predictor of recovery. CFS/ME patients who are out of work have a poor overall prognosis compared with those who manage to maintai n some employment (even after adjustment for severity) Low likelihood of a good treatment outcome in CFS/ME predicted by: severe symptoms \200 psychiatric co-morbidity \200 long duration of symptoms. The prediction of return to work might be assumed for practical purposes to re \202 ect th ese factors, although, because few studies look at work out- comes, there is little direct evidence on this question. Medical management of CFS/ME The approach to clinical management follows a bio-psychosocial model. It is recognized that outcome is greatly in \202 uenced by psychosocial factors in cluding illness beliefs, personal experience, personality, and coping skills. Treatment inc ludes: \200 A multidisciplinary approach to rehabilitation, including the input of physic ians, pain specialists, psychologists, dieticians, physiotherapists, and sometimes alternat ive therapists Medical control of symptoms (e.g. treating pain and sleep disturbance) \200 Management of comorbid conditions (e.g. depression) \200 Of the speci \201 c treatment modalities, CB T and graded exercise therapy (GET) have been shown to be effective for CFS/ME, although GE T is not popular among patients Employers or insurance companies will sometimes fund or facilitate treatment by multidisciplinary clinical teams. This is particularly helpful in view of the scarcity of NHS resources in this area. Adjustments to work in CFS/ME It may be dif \201 cult for an employer to implement or sust ain prolonged adjust- ments to work. Therefore, it is important that there is close liaison between treating physicians and allied specialists, OH advisers, managers, and HR advis- e rs in supporting a return to work. In CFS/ME it is best if a work rehabilitation can be coo rdinated as part of an overall graded activity program. \200 A protracted phasing up of w orking hours with a low baseline (e.g. 2 \200\2233h, 2 \200\2233 days/week) and very gradual increase may be necessary. It may tak e many months (or even more than a year in some cases) to reach premorbid working hours 23_Smedley_Chap23.indd 460 1/2/2013 12:36:34 PM CHRONIC FATIGUE SYNDROME/MYALGIC ENCEPHALOMYELITIS 461 If a long commute to work exacerbates fatigue, home working or a change of work site should be considered. Alternatively, working hours can be tailored to a void peak traf \201 c times Frequent rest breaks should be built in to the work schedule \200 Reduction in heavy phys ical work or repetitive work is sometimes appropriate Permanently reduced hours of work may be required for those unable to return to their previous contracted hours. (cid:2) Tolerance of a higher level of sickness absence by the employer might be reasonably expected if there are frequent exacerbations of symptoms. Overlap with other conditions There is considerable overlap between CFS/ME and a number of other conditions for which the precise pathology and etiology are unknown, including \201 bromyalgia and irritable bowel syndrome. For example, 20 \200\22370% of patients with \201 bromyalgia meet the diagnostic de \201 nition for CFS/ME, and 35 \200\22370% of patie nts with CFS/ME could also be de \201 ned as having \201 bromyalgia. Relevant legislatio n The Equality Act 2010 would apply to individuals with CFS/ME and employ- ers would be exp ected to make reasonable adjustments to work. Further information and guidance NHS Plus/Dep artment of Health (2006). Occupational aspects of the man- agement of chronic fatigue syndr ome: a National Guideline , related lea \202 ets for employers and employees. Available at : M http://www.nhsplus.nhs.uk/ providers/clinicaleffectiveness-guidelines.asp 23_Smedley_Chap23.indd 461 1/2/2013 12:36:35 PM CHAPTER 23 Generic \201 tness for work and disorders 462 Diabetes mellitus Terminology and diagnostic criteria \200 Type 1 usually develops in chi ldhood and adolescence. \200 Type 2 predominantly occurs in adults and accounts for 90% o f cases. WHO criteria for diagnosis Depends on symptoms of diabetes (polydypsia, polyuria and weight loss) plus: \200 a random venous plasma glucose \200 11.1mmol/L or \200 a fasting pl asma glucose concentration \200 7.0mmol/L (whole blood \200 6.1mmol/L) or plasma glucose concentration \200 11.1mmol/L 2h after 75g anhydrous glucose in an oral glucose tolerance test. If asymptomatic the diagnosis requires at least one additional glucose test result on anoth er day. General occupational health considerations Fitness to work should be based on an individual risk assessment taking into account the nature of the work, the health status of the worke r and how well their diabetes is controlled. A report from the individual \200\231s spe- ci alist or GP may be useful. Employers must make reasonable adjustments to employee \200\231s duties as required by the Equality Act 2010. From an occupational aspect, the most important clinical complications of diabetes are: \200 Hypoglycaemia: premonitory warning signs include hunger, sweating a nd dizziness, but these may be reduced or absent. Risk factors for hypoglycaemia are: \200 treatment with insulin or sulphonylureas \200 poor compliance with medication or diet \200 excessive exercise \200 alcohol \200 renal failure \200 intensi \201 cation of treatment. Impaired visual acuity: proliferative retinopathy, maculopathy and pan-retinal laser photocoagulation may bring individuals below DVLA standards for Group 1 d riving Neuropathy: this may lead to a reduction in \201 ne motor skills, reduced positional awar eness and postural hypotension. Sensory loss leads to an increased risk of accidental damag e to peripheral tissues. Sickness absence Studies of sickness absence in employees with diabetes show increases in a bsence rates (estimates between 50 \200\223100% increase compared with non-diabetics). Howe ver, the better controlled the diabetes, the less likely the person is to take sick leave. 23_Smedley_Chap23.indd 462 1/2/2013 12:36:35 PM DIABETES MELLITUS 463 Shiftwork In theory, timing of insulin and meals can be dif \201 cult with rotating shifts . However, modern insulin treatments have made shift work less problem- atic than previousl y and most diabetics cope well. Safety critical jobs In the UK, people on insulin are barre d from some jobs e.g. airline pilot, the Armed Forces. The jobs for which there is a blanke t ban are frequently reviewed and the latest list is available from Diabetes UK. Since Octo ber 2011, insulin-treated diabetics have been able to apply for a group 2 driving license, subject to strict DVLA qualifying criteria. A careful risk assessment needs to be done to assess the suitability of people with insulin -treated diabetes for employment where there may be a risk of injury or harm to the individ ual or the public, for example \201 re- \201 ghting. Suitability for such employment sh ould be assessed annually by an occupational health professional in consultation with a dia betes specialist; and should be based on the following criteria: \200 Be physically and m entally \201 t in accordance with non-diabetic standards Be under regular (at least annual) specialist review and their diabetic control must be stable Be well motivated and be able to self-monitor their glucose levels at least bd Have full awareness of hypoglycaemic symptoms \200 Be able to demonstrate an understandin g of the risks of hypoglycaemia. Further information and guidance DVLA. At a glance guide to the current medical standards o f \201 tness to drive . Available at: M http:// Diabetes, UK. Meet our new Peer Support N etwork . Available at: M http://www.diabetes.org.uk/ www.dft.gov.uk/dvla/medical/ataglance.aspx 23_Smedley_Chap23.indd 463 1/2/2013 12:36:35 PM CHAPTER 23 Generic \201 tness for work and disorders 464 Epilepsy De \201 ned by the International League Against Epilepsy (ILEA) as two or more ep ileptic seizures unprovoked by any immediate identi \201 able cause. Epidemiology Depends on de \201 nition, but the most commonly quoted statistics are: \200 Prevalence 5 \200\22310 per 1000 population \200 Incidence 50 (range 40 \200\22370) \201 rst \201 ts per 100,000 population/yr. Clinical classi \201 cation of seizures Partial seizures \200 Simple partial seizures (n o loss of consciousness) \200 Complex partial seizures: with impairment of consciousness at onset \200 simple partial onset followed by impairmen t of consciousness \200 partial seizures evolving to generalized tonic \200\223clonic (GT C) seizures. Generalized seizures Convulsive or non-convulsive with bilateral discharges involving subco rti- cal structures: \200 Absence \200 Myoclonic \200 Clonic \200 Tonic \200 Toni c \200\223clonic \200 Atonic. Unclassi \201 ed epileptic seizures Usually used when an a dequate description is not available. Treatment and prognosis Treatment Treatment is with a nticonvulsants. Chronic stable treatment rarely affects performance signi \201 cantly. Acu te drug over-dosage can cause serious impairment, but is rapidly reversible. Prognosis The risk of further seizures depends on the clinical situation: \200 First seizure (see Fig. 23.2): 67% have a second seizure within 12mths \200 if seizure-free for 6mths, 30% have a furthe r seizure within 12mths Established epilepsy (more than one seizure): most patients who achieve remission (seizure-free for 5yrs) do so within the \201 rst 2yrs; >95% remain seizure-free for 10yrs approximately 20 \200\22330% will have further seizures despite treatment \200 the risk o f further seizures i with i duration of poor control and i frequency, combination of partia l and tonic \200\223clonic seizures, structural cerebral lesions, and impairment of cerebra l function. 23_Smedley_Chap23.indd 464 1/2/2013 12:36:35 PM EPILEPSY 465 80 n o i s s i 60 m e r n 40 i e g a t n e c r e P 20 0 20 5 6 10 15 Years after diagnosis Fig. 23.2 Actuarial percentage recurrences after \201 rst seizure and after 6, 12, and 18 mths without seizures (From Hart YM, Sander JW, Johnson AL, Shorvon SD (1990). National Gen eral Practice Study of Epilepsy. Lancet , 8726, 1271 \200\2234. Reproduced by kind permissi on of Elsevier.) Fitness for work General issues Advice about \201 tness for work should consider the risk to the individual and to others (e.g. passengers). (cid:2) Never base risk assessment on t he label of epilepsy, but on individual clinical and job details. Speci \201 c issues \200 High-risk activities: restrict those with epilepsy from: lone working \200 working at heights \200 swimming or working unprotected near water \200 working with dangerous or unguarded machinery, or \201 re \200 carrying out or as sisting at surgical procedures \200 sole care of dependent (e.g. ventilated or unconsciou s) patients \200 sole manual handling of patients, e.g. carrying infants \200 usually e xcluded: aircrew, armed forces, police, \201 re \201 ghters Driving: see DVLA guidance, but in general: group 1 \200\223 restrict until seizure-free for 1yr (+/ \200\223 treatment), unless seizures only occur during sleep, and the last seizure was >3yrs ago group 2 \200\223 restrict until seizure-free off treatment for 10yrs (5yrs if seizure due to substance abuse and abuse is controlled) advise not to drive during and 6mths after treatment withdrawal \200 provoked seizures (e .g. eclampsia) will be advised on an individual case basis by the DVLA Jobs that are associated with sleep disturbance or fatigue (e.g. shift work) are not contraindicated, but can exacerbate epilepsy \200 Visual display equipment is associated with an extremely low risk of seizure provocation, and it is usually inapprop riate to restrict. Disclosure Individuals are often reluctant to disclose a diagnosis of epilepsy; 50% do not declare it at pre-employment assessment. It can be useful to inform the line manager, but o nly with the individual \200\231s consent. 23_Smedley_Chap23.indd 465 1/2/2013 12:36:35 PM CHAPTER 23 Generic \201 tness for work and disorders 466 Adjustments to work Diagnosis of epilepsy likely to qualify under Disability Discrimination Act 1995/2005. Where practical, employer must provide adjustments/rede- ployment as indica ted by a risk assessment. Further information and guidance DVLA. At a glance guide to the c urrent medical standards of \201 tness to drive . Available at: M http://www.dft.gov.uk/d vla/medical/ataglance.aspx 23_Smedley_Chap23.indd 466 1/2/2013 12:36:35 PM This page intentionally left blank CHAPTER 23 Generic \201 tness for work and disorders 468 Alcohol misuse and \201 tness for work \200 An increasing use of alcohol (especially am ong women) means that more workers are likely to present with alcohol misuse or alcoholism People who are alcohol dependent may not accept that a problem exists, making management challenging be \200\230overlooked \200\231 by well-intentioned c olleagues. Initial signs and symptoms of alcohol misuse may go unrecognized or Guidelines on sensible drinking limits Men Women Daily consumption 3 \200\2234U 2 \200\2233U Weekly consumption Safe drinking 21U 14U Hazardous 22 \200\22350U 15 \200\22335U Harmful >50U >35U 2 Binge drinking is de \201 ned as consuming, in one episode, 8 \200\22310U for men and 6 \200\2238U for women A unit of alcohol is 10mL, by volume, of pure alcohol. Epidemiology \200 22% of UK men drink more than 21U/wk \200 6% of UK men drink more tha n 50U/wk \200 22% of UK women drink more than 14U/wk \200 6% of UK women drink more tha n 36U/wk \200 Alcohol-related deaths doubled from 4023 in 1992 to 8664 in 2009 \200 17% of deaths on UK roads in 2009 were alcohol related \200 5% of road casualties in 2009 in volved someone driving \200\230over the limit \200\231. \200\230Soft \200\231 signs of substance misuse \200 Variable work performance \200 i Accidents \200 i Errors \200 i Complaints \200 i Absenteeism, especially around weeke nds and holidays \200 Poor time-keeping. Clinical assessment and diagnosis Workers may be referred to the OH service because of i si ckness absence, d performance, work attendance while intoxicated, or alcohol consumption at work. Not all will have alcoholism. It is helpful when referring an employee to the OH service if the man- ager gives examples of workplace dif \201 culties. This may alert the occu- pational physician to the possibil ity of alcohol misuse. If suspected, then explore the following: 23_Smedley_Chap23.indd 468 1/2/2013 12:36:35 PM ALCOHOL MISUSE AND FITNESS FOR WORK 469 The employee \200\231s perceptions of their dif \201 culties \200 Medical history, focus ing on illnesses associated with alcohol misuse: dyspepsia \200 jaundice \200 cirrhosis \200 cardiac arrhythmia \200 peripheral neur opathy \200 hypertension \200 Alcohol history \200 Family history of alcohol misuse \200 Accidents or assaults \200 Money problems due to alcohol misuse \200 Legal proble ms, e.g. drink driving convictions \200 Clinical examination, seeking the stigmata of alc oholism \200 Use the Alcohol Use Disorders Identi \201 cation Test (AUDIT) to \200 If cognitive dif \201 culties are suspected, arrange a cognitive assessment. Prognosis \200 The prognosis for a worker with alcoholism is guarded. \200 Some problem drinkers aim fo r \200\230controlled drinking \200\231. In practice, this is rarely achieved and may indic ate a failure to acknowledge the problem. establish severity of misuse Special caution should be exercised in assessing workers in safety critical posts, such as vocational drivers, or key decision-makers. \200 See also b p. 472, Fitness to drive 1; b p. 474, Fitness to drive 2 \200 See also b p. 504, Fitness for safety critical work. Alcohol testing Where supported by an alcohol policy, pre-employment, with cause, or random breath or blood alcohol testing may be undertaken. Medical management \200 Identify a tr eatment provider, usually via the GP \200 In-patient care for assisted alcohol withdrawal is not usually required, but may be required in those; \200 consuming >30U/day \200 with signi \201 cant co-mor bidities \200 history of seizures or delirium tremens Agree a contract with the worker for regular follow-up including, where obtainable, regular reports from treatment agency A sustained period of abstinence is required before any return to work \200 Once at work, monitor time-keeping, performance, and absences \200 Prolonged OH service follow-up (up to 12mths) may be appropriate. Relevant guidance and legislation \200 The Equality Act 2010 \200 Faculty of Occupation al Medicine (2006). Guidance on alcohol and drug misuse in the workplace . FOM, London. 23_Smedley_Chap23.indd 469 1/2/2013 12:36:35 PM CHAPTER 23 Generic \201 tness for work and disorders 470 Further information and guidance \200 NICE (2012). Alcohol dependence and harmful alcohol use . NICE Clinical \200 See also b p. 378, Substance abuse policies. Guidance CG115. Available at: M http://www.nice.org.uk/CG115 23_Smedley_Chap23.indd 470 1/2/2013 12:36:35 PM 471 Chapter 24 Fitness for speci \201 c work Fitness to drive 1 472 Fitness to drive 2 474 Fitness for professional diving 476 Fitness f or work in food handlers 478 Fitness for air passenger travel 1: the physics and physiology of air travel 480 Fitness for air passenger travel 2: speci \201 c medical conditions 482 Fitness for work in professional pilots: commercial pilots/ aircrew 484 Fitness for military service 486 Fitness for work in health care 490 Fitness for exposure p rone procedures 1 494 Fitness for exposure prone procedures 2 496 Fitness to work with chil dren 498 Fitness for work in con \201 ned spaces (or with respirators) 500 Fitness for sea faring 502 Fitness for safety critical work 504 24_Smedley_Chap24.indd 471 1/2/2013 12:38:05 PM CHAPTER 24 Fitness for speci \201 c work 472 Fitness to drive 1 The DVLA is responsible for licensing drivers in the UK. \200 Group 1 drivers are licensed to drive cars and motorbikes \200 Group 2 drivers are licensed to dr ive busses and lorries (passenger-carrying vehicle (PCV) and large goods vehicle (LGV) licenses). Ultimately, it is for the DVLA \200\231s medical advisers to determine an indi- vidual \200 \231s \201 tness to drive. However, if driving is a special requirement of a job, employe rs may make their own assessment of \201 tness. Driving for employment purposes Decisions about \201 tness for vocational driving may be challenged under the Equality Act. Therefore OH professionals should carry out a risk asses s- ment, and be prepared to justify their advice. Examples where Group 2 standards may be a pplied are as follows: \200 Driving in hazardous areas such as quarries or construction s ites \200 Driving emergency response vehicles (ambulances, police cars, \201 re engines): \200 the NHS employing authority determines whether Group 2 standards shall apply to their ambulance drivers (cid:2) Note that insulin-dependent diabetics have been advised by the Medical Advisory Panel on Diabetes and Driving not to drive emergency vehicles. However , this is an extremely contentious issue, and the situation may be subject to change \200 Carrying passengers (see b p. 474, Fitness to drive 2). (cid:2) The Medical Commission on Accident Prevention (now discontinued) recommended that G roup 2 \201 tness standards be applied to taxi drivers, by their local authority, prior t o licensing. More than half of local authorities follow this advice Driving large vehicles (see b p. 474, Fitness to drive 2). General principles \200 It is the duty of the license holder to notify the DVLA of any me dical condition, or change to a medical condition, which may affect his/her \201 tness to drive Drivers need not notify the DVLA if their medical condition is not expected to last >3mths, but they should be guided by medical advice and refrain from drivi ng if advised to do so Any person suffering from a medical condition that is likely to cause sudden incapacity should not drive Any person who is unable to control his/her vehicle safely should not drive. Assessment frequency \200 A Group 1 license is valid until age 70, and thereafter is rene wable every 3yrs License applications must be accompanied by a self-declaration of \201 tness. 24_Smedley_Chap24.indd 472 1/2/2013 12:38:06 PM FITNESS TO DRIVE 1 473 Speci \201 c medical conditions The DVLA publishes extensive guidance on \201 tness to d rive in respect of a range of important medical conditions (see b p. 473, Legislation and g uidance). Ethical issues \200 Where an employee is medically un \201 t to drive, the OH doctor sho uld con \201 rm that the employee understands that his/her condition may impair his/her \201 tness to drive The doctor should advise the employee verbally, and in writing, of his/ her legal duty to n otify the DVLA if he/she is medically un \201 t to drive. This advice should be recorded i n the medical records If an employee who is medically un \201 t to drive refuses to notify the DVLA, then the do ctor should offer to arrange a second medical opinion on the understanding that the employe e does not drive pending reassessment The GMC advises that a doctor should make every reasonable effort to persuade an individual who is un \201 t to drive not to do so If an individual continues to drive despite the advice, then the DVLA medical adviser should be informed in con \201 dence (having \201 rst advised the employ ee in writing of the intention to do so). (cid:2) Always check current GMC guidance before notifying the DVLA in this situation. Adjustments to driving work \200 An OH professional should advise reasonable adjustments to the job (including adaptations to vehicles) if this would enable an employee, whose abil ity to drive is impaired by a medical condition, to work Such adjustments would be a matter of good practice for all employees. However, the employer has a legal obligation if the Equality Act applies Disabled drivers and their advisers can access expert advice and driving assessment through the forum of mobility centers. M http:// www.mobility-centers.or g.uk Legislation/guidance \200 At a Glance Guide to the Current Medical Standards of Fitness t o Drive \200\224A Guide for Medical Practitioners, February 2011. Available online (and upd ated every 6mths) at: M http://www.dft.gov.uk/dvla/ medical/ataglance.aspx General Medical Council Guidance for Doctors. Con \201 dentiality: Protecting and Providing Information FAQs #17. Available at: M http:// www.gmc-uk.org/index .asp Medical Aspects of Fitness to Drive . Medical Commission on Accident Prevention, London, 1995. 24_Smedley_Chap24.indd 473 1/2/2013 12:38:06 PM CHAPTER 24 Fitness for speci \201 c work 474 Fitness to drive 2 LGV/PCV drivers The DVLA sets the \201 tness standards for UK drivers, including drivers of LGVs or PCVs with more than eight seats. General principles The \201 tness standards for HGV or PCV drivers (Group 2 drivers) are more stringent than these for Group 1 drivers. The reasons for this are the higher annual m ileages driven by occupational drivers and the potentially greater consequences of an accid ent involving an HGV or PCV. Assessment frequency A Group 2 license is usually issued at age 21, and is valid until age 45 unless medical \201 tness changes. Thereafter, it is subject to review every 5yrs, or shorter periods depending on medical conditions until age 65. After age 65 licenses are ren ewable annually. Speci \201 c issues \200 It is the duty of the license holder to notify the DVLA of any medical condition that may affect his/her \201 tness to drive Any person suffering from a medical condition likely to cause sudden incapacity should not drive Any person unable to control his/her vehicle safely should not drive \200 A medical pract itioner must prepare a medical report using Form D4. Medical assessment \200 Height \200 Weight \200 Smoking history \200 Alcohol consumption \200 Current medication \200 Corrected visual acuity >6/9 in the better eye and >6/12 in the other eye with uncorrected visual acuity being >3/60 in each eye Visual \201 elds intact \200 Medical history \200 epilepsy \200 other neurological conditions \200 diabetes \200 psychiatric illness \200 cardiovascular disease \200 blood pressure \200 musculoskeletal disease suf \201 cient to interfere with vehicle con trol. The \201 nal decision regarding \201 tness for Group 2 driving lies with the DVLA \200\231s medical adviser and not the examining doctor. Forklift truck operators Task demands Operation of a forklift truck, whether in a factory, on a farm, or on a build- ing site, can be associated with the following hazards: \200 Pr oximity to other vehicles and people 24_Smedley_Chap24.indd 474 1/2/2013 12:38:06 PM FITNESS TO DRIVE 2 475 Noisy environments \200 Relatively con \201 ned spaces \200 Frequent reversing and man euvering. General principles \200 There are no regulations governing \201 tness to oper ate forklifts on private ground. HSE has published useful guidance (see b p. 475, Legislati on and guidance) If the forklift is to be operated on the public highway, the operator must meet current DVLA standards on \201 tness to drive Operators should be 17 or over. Construction workers must be age 18. Agricultural workers should be over school-leaving age The \201 tness required is only that suf \201 cient for the task to be carried out safely and ef \201 ciently. Individuals with a disability should be assessed bearing i n mind good employment practices and disability legislation. Fitness requirements Include good eyesight, adequate hearing, and reasonable head/neck mobi l- ity. The ability to look over the shoulder is important; no condition that predisposes t o sudden loss of consciousness. Assessment frequency \200 Assess at pre-employment \200 Assess at 5-yearly intervals fr om age 40 \200 Over age 65 review annually \200 An operator with a medical condition sh ould be reviewed more frequently if this is indicated. Speci \201 c issues \200 Visual acuity should be 6/12 (corrected) with adequate visual \201 elds \200 Hearing should be suf \201 cient to understand instructions and warnings \200 Alcohol/drug addiction renders a worker un \201 t to operate a lift truck \200 C areful assessment is necessary where there is a history of psychosis \200 Poorly controll ed angina or conditions predisposing to loss of consciousness (arrhythmias, transient ischaemic attack (TIAs)) are a bar to work with lift trucks Epilepsy is acceptable where the criteria for a car license are met \200 Diabetes is perm itted subject to good glycaemic control. Loss of awareness of hypoglycaemia will probably render the diabetic un \201 t \200 Musculoskele tal problems should not signi \201 cantly impair the driver \200\231s ability to look up, sideways, or over the shoulder. Legislation and guidance \200 A guide to vehicle licensing requirements including de \201 nitions of license categories and vehicles is given at: M http://direct.gov.uk/ \200 HSE (2000). Safety in Working with Lift Trucks , HS(G)6. HSE, London. Available at: M http://www.hse.gov.uk/pubns/priced/hsg6.pdf 24_Smedley_Chap24.indd 475 1/2/2013 12:38:06 PM CHAPTER 24 Fitness for speci \201 c work 476 Fitness for professional diving Purpose To establish whether a worker is \201 t to undert ake diving at work and to identify, at an early stage, diving-related illnesses such as dys baric osteonecrosis. Dif \201 culties may arise when individuals undertake diving activity for hire or reward and do so out with (and in breach of) regula- tions (see b p. 544, Divi ng at Work Regulations 1997). General principles \200 Statutory medical assessments can only be carried out by an HSE approved medical examiner of divers. The examiner has to satisfy the HSE that they have the required knowledge of diving medicine to carry out this work. Usually, this knowledge is a cquired by attending a 5-day diving medicine course The initial medical assessment involves the prospective diver completing a medical questionnaire, which is then validated by his/ her GP. The approved me dical examiner then reviews this and advises whether the individual has a medical condition that would disqualify him/her from diving without a full assessment Prior to commencing diver training the prospective diver should undergo a full diving medic al examination. The results of this are recorded on form MA2 which includes the certi \201 cate of \201 tness to dive. The white copy of MA2 is given to the diver and the pink low er copy should be retained by the medical examiner for 7yrs Where a diver is found un \201 t to dive, he/she has the right to appeal this decision to HSE within 28 days. Assessment frequency \200 The medical certi \201 cate is valid for any period stipulated by the examining doctor up to a maximum of 12mths \200 Where a diver is medically un \201 t for work for >14 days or suffers a neurological, cardiorespiratory, or ear disorder, his/her \201 tness to dive must be reassessed by an approved examiner. Speci \201 c issues \200 Female divers should not dive when pregnant \200 CXR and long -bone views are only required where clinically indicated \200 The British Thoracic Societ y has issued guidelines on respiratory aspects of \201 tness for diving Extensive guidance on diving \201 tness standards is provided in the HSE publication MA1 which is available on the HSE website. The underlying principle is that the diver should not be at increased risk of a diving accident because of an existing medical condition. 24_Smedley_Chap24.indd 476 1/2/2013 12:38:06 PM FITNESS FOR PROFESSIONAL DIVING 477 Investigations required at diving medical Initial examination Annual review Exercise testing (step test) Exercise testing (step test) Resting ECG Resting ECG (5-yearly from age 40) Urinalysis Urinalysis Spirometry Spirometry Audiometry Full blood count Relevant legislation and guidance \200 Diving at Work Regulations 1997 \200 HSE The Med ical Examination and Assessment of Divers , MA1. HSE Books, London. Available at: M http://www.hse.gov.uk/diving/ma1.pdf \200 British Thoracic Society (2003). Guidelines on respiratory aspects of \201 tness for diving. Thorax , 58, 3 \200\22313. 24_Smedley_Chap24.indd 477 1/2/2013 12:38:06 PM CHAPTER 24 Fitness for speci \201 c work 478 Fitness for work in food handlers De \201 nition of a food handler A food handler manufact ures, prepares, or transports food, and may come into direct contact with the food or with machines handling unwrapped food. This de \201 nition includes engineers, cleaners, and th ose visiting the premises. The de \201 nition also includes those preparing or serving foo d in canteens and shops. Health screening Fitness for work is assessed by health screening. The screening process ai ms to exclude individuals with medical conditions that may pose a risk of microbiological o r general contamination of food products. The assess- ment should also identify conditions that may be caused or exacerbated by work, or jeopardize employee safety. Therefore, it sho uld identify the following: \200 Those suffering from, or carriers of, infectious disease which can be transmitted to the product, e.g. Norovirus infection of the GI tract \200 T hose suffering from conditions, such as an infected wound or skin condition, which can transmit pathogens