1. Pre-employment examinations & fitness standards Professor T.C. Aw MBBS, PhD, FRCP, FRCPC, FFOM, FFPHM Head, Division of Occupational Health University of Kent

2. Pre-employment examinations Purpose: Detect clinical abnormalities that indicate a mismatch between state of health and proposed job Enable necessary adjustments to be made

3. Pre-employment examinations Implications Risk of ill-health or injury to – Individual – Co-workers – Customers – Patients – Visitors

4. Pre-employment examinations Employer ‘reasons’ Shows a caring employer Reduces costs to organisation – Sickness absence – Staff time – Hospital bills Establishes health status before starting Inform individuals of hazards & prevention Fit man to job

5. Pre-employment examinations Employee ‘reasons’ Inform individual of hazards & preventative measures Establishes health status before starting work Adjustments to job to fit the man Health status at the time

6. Pre-employment examinations Occupational health ‘reasons’ Assess the match between person & job Obtain baseline information Check on immunisation status & update Opportunity for health promotion & advice Allows effective follow up for clinical conditions detected – continuity of care

7. Pre-employment examinations Practical reasons: Employer requirement Government requirement Evidence-based reason

8. Pre-employment assessments in the NHS Whitaker S, Aw T-C Occupational Medicine 1995;45(2):75-80 Braddick MR, Atwell CP, Aw T-C Occupational Medicine 1992;42:36-38

9. Pre-employment assessments 30% random sample of 217 occupational health units 40 participating units 3-month period

10. Pre-employment assessments Methods used: Self-administered questionnaire4517 Quest. + nurse interview3116 Quest. +/- nurse interview 688 Quest. + nurse interview +/- Dr. exam 390 Quest. + nurse interview + Dr. exam 196 Nurse-administered Quest. 41

11. Pre-employment assessments Decision:Nos.% Fit895498 Restriction 1201.3 Rejection 650.7 Total9139

12. Findings: What were the main reasons for Rejection & Restriction?

13. Pre-employment assessments Reasons for rejection: BMI (Kg/m 2 )2640% Skin conditions1421.5% Psychiatric conditions 710.8% Musculo-skeletal conditions 46.2% Raised BP 23.1% Others1218.5% TOTAL65

14. Findings: Which staff groups had the highest rejection/restriction?

15. Pre-employment assessment Rejection by occupational group: Technician3/883.4% Student nurse17/10001.7% Catering staff4/2351.7% Nursing assts.14/9491.5% Qualified nurse7/21590.3% Administrative staff1/4220.2% Doctor1/11270.1%

16. Pre-employment examinations 217 questionnaires

17. Pre-employment examinations Question: Necessity or unwarranted?

18. Is it necessary? YES Ensure man is fit to do the job Adjustments of job to fit the man Cost-effectiveness depends on the consequences of the abnormality detected – Munchausen by proxy (Allitt) – Hepatitis B carriers – Shipman

19. Is it necessary? NO Low pick-up rate Poor predictor of state of health Costs Logistics Disability Discrimination

20. ‘Shipman’

21. Pre-employment examinations OPTIONS: 1. Scrap them altogether 2. Retain in limited &/or modified form 3. Carry on as at present

22. Pre-employment examinations Practical considerations: Limit pre-employment assessment to ‘high-risk groups’ Agree standard questionnaire for specific occupational groups Questionnaire for all, examination and tests for some Computer-administered or computer scanned questionnaire

23. Pre-employment examinations CRITERIA: Jobs requiring PEE Job has implications for 3 rd parties Recognised uncontrollable hazards of the job – PHYSICAL: noise – CHEMICAL: asthmagens – MECHANICAL: manual handling – BIOLOGICAL: body fluids – PSYCHO-SOCIAL: stress Liability for employer?

24. Pre-employment examinations Questionnaire – Self-administered – Nurse-administered Examination – Nurse – Physician (GP) – Occupational physician Investigations – X-rays, blood tests, urinalysis, etc

25. Pre-employment examinations & Fitness standards PROCESS Establish Fitness standards QUESTIONNAIRE + staged referral Nurse interview + assessment +/-medical examination Consideration: Cost-effectiveness?

26. Fitness standards Job categories Pilots Drivers (Public service vehicles & heavy goods vehicles) Food-handlers Sea-farers Uniformed services (police, army, fire-fighters, ambulance crew)

27. Medical standards for fitness - Drivers Vision (new drivers) should be 6/9 on the Snellen scale in the better eye and 6/12 on the Snellen scale in the other eye (wearing glasses or contact lenses if needed) and 3/60 in each eye without glasses or contact lenses.

28. Medical standards for fitness - Drivers DIABETES All on oral hypoglycaemics or insulin must inform DVLA (in general, stop driving for 1 month after starting insulin, to get stable; drivers must demonstrate satisfactory control, and must recognize hypoglycaemia). Check that vision conforms to required standard. Advise avoid driving if hypoglycaemic risk á (eg meal delay; or after excess exercise).

29. Medical standards for fitness - Drivers EPILEPSY A person who has an epileptic attack whilst awake must not drive for one year from the date of the attack. A person who has an attack whilst asleep must also refrain from driving for one year from the date of the attack, unless they have had an attack whilst asleep more than three years ago and have not had any awake attacks since that asleep attack. In any event, they should not drive if they are likely to cause danger to the public or themselves.

30. Medical standards for fitness TRANSIENT ISCHAEMIC ATTACKS Patients with TIA or stroke should not drive for at least one month. If TIAs have been recurrent and frequent, a 3 month period free of attacks may be required. Patients who have had a single episode of loss of consciousness (no cause found) still need to have at least one year off driving.

31. References DVLA (2006). At-a-glance guide to the medical standards for fitness to drive. DVLA, Swansea [www.patient.co.uk/showdoc/40000803/] Palmer K, Cox R, Brown I. eds. (2006) Fitness for work – the medical aspects 4 th edition. Oxford University press, Oxford.

32. Pre-employment QUESTIONNAIRES Limit number of questions: Retain useful questions – reason Remove ‘not useful’ questions – Varicose veins, piles – Dysmenorrhoea vs. periodic pain

33. Details of proposed job No information Job title Job title, department and location of post Job specification Immediate supervisor OHD walk-through

34. OTHER DATA: Reports on previous health Reports on present treatment Records of sickness absence

35. Decision & advice Fit / suitable Fit with restriction, e.g. – Review as patient is under treatment – Shift work – Work at heights – Moving machinery – Driving – Lifting Unfit / unsuitable

36. Question What should you advise if: A blind person wants to fly a plane A diabetic wants to row across the Atlantic An amputee wants to climb Mt Everest

37. Conclusions Pre-employment assessments: Focused / selected groups Uniformity in method Agreed criteria / fitness standards Based on job requirements Periodic audit

38. Occupational Health [at Work] 2006;3(3):18-25 Ballard J (2006) ‘Pre-employment health screening: Part 1 – pre- employment questionnaires’

40. t.c.aw@kent.ac.uk