Oxford Handbook of Occupational Health (2 edn)
Annotate
Cite
General principles of fitness for work assessments
Purpose
The purpose of undertaking fitness for work assessments is to try to achieve the best possible job–person fit. Knowledge of workplace hazards and job demands should inform the assessment. The objective should be to be inclusive and, where practicable, to make reasonable adjustments to accommodate those with disabilities. Such assessments may be carried out pre-placement, prior to promotion or job transfer, or following sickness absence or work-related injury. Other reasons for carrying out a fitness for work assessment include:
Legislative compliance: for example, medical assessments under the Control of Asbestos Regulations 2012, Diving at Work Regulations 1997
Infection control:
food industry (product safety)
health services (patient safety)
Baseline data for health surveillance: e.g. audiometry, spirometry.
Routine periodic medicals, unless subject to rigorous assessment, may generate activity but fail to achieve any useful purpose. Employers may be under the mistaken impression that a ‘rigorous’ medical will reduce or eliminate sickness absence.
The rationale for the fitness assessment should be clear to all parties, as should the procedures to be followed where an individual is deemed unfit following assessment.
Key information
Knowledge of workplace hazards and task demands
Special requirements, e.g. emergency response duties, working in isolation, driving
Current job description
The assessor should be familiar with the workplace, or should specifically visit the workplace to ensure appropriate knowledge of the job. This is especially important where the post makes unusual demands of employees
Any legislative fitness standards should be observed
Company or industry sector guidance, where available, is helpful in identifying relative and absolute medical contraindications to work.
Reports to employer
The employer should be informed in writing of the individual’s fitness for his/her designated post
Any restrictions on fitness should be clearly stated
Identify any adjustments the employer may wish to consider under the Equality Act 2010
No information regarding underlying medical conditions should be disclosed except with the employee’s consent and where disclosure is necessary for health and safety reasons or for the employer to comply with legislation.
Record keeping
Clear legible contemporaneous notes should be kept (see 
p.
748, Recording an occupational health consultation)
Entries in the employee’s OH record should be signed and dated
Health questionnaires and records of any medical assessment should be filed in the employee’s medical record
All OH files should be securely stored in the OH department. It is illegal and unethical for sensitive health records to be stored where others may have access to them (see p.
350, Managing occupational health records 2: security, transfer and the archiving of records p.
362, Confidentiality, consent, and communication, p.
578, Data Protection Act 1998).
Relevant legislation and guidance
Faculty of Occupational Medicine (2012). Fitness for work, 5th edn. Oxford University Press, Oxford.
Equality Act 2010.
Faculty of Occupational Medicine (2012). Guidance on ethics for occupational physicians, 7th edn. Faculty of Occupational Medicine, London.
Occupational history
Purpose
Identify occupational risk factors for disease
Understand job demands
Advise on fitness for work
Inform efforts at rehabilitation or redeployment
It is not sufficient to ask ‘What is your job?’ although even that may be overlooked by some doctors. Job names vary and may mislead. It is much more useful to know what an employee actually does at work, or has done in his/her previous main job. This should be followed by enquiry about the main workplace hazards, the likely intensity and route of any exposures, and any control measures in place (including personal protective equipment).
• Ask about concurrent jobs (paid or unpaid) as otherwise these may not be declared. This includes second jobs, evening or weekend work, participation in family businesses, such as farms or shops, and moonlighting, i.e. work not declared for tax purposes.
Some jobs place workers at high risk of certain occupational diseases. For example, spray painters are at risk of occupational asthma (due to isocyanates in ‘two-pack’ paints). Such a work history should prompt the physician to consider whether the patient may have that disease.
What do you do at your work?
Do you have another job?
Does anyone else at work have this problem?
Does it get better away from work?
and sometimes:
Have you ever worked with …?
What are your hobbies?
Diseases of long latency
Some diseases, such as bladder cancer or pneumoconiosis have a long latent interval between exposure and presentation. To establish an occupational cause in that situation requires a lifetime occupational history. Sometimes, it is more efficient to ask if the patient has ever worked with the suspected agent, e.g. for mesothelioma ask about asbestos exposure.
Hobbies
Pastimes can lead to significant non-occupational exposures especially in those whose hobby occupies many hours per week. Prolonged exposure may be compounded by a lack of health and safety knowledge and inadequate control measures. As a result hobbies may cause occupational-type illness.
Pre-placement assessment
Purpose
The purpose of a pre-placement health assessment is to establish a prospective employee’s fitness for employment, including his/her ability to offer regular effective attendance. Consider relevant previous and current health problems and significant workplace risks.
Process (see Fig. 23.1)
•Prospective employees should be advised not to submit their resignation to their current employer until their fitness is confirmed (including results of drug screen where relevant).
The Equality Act 2010 requires that only the successful applicant should be offered a pre-placement assessment. It is crucial that assessment is undertaken after selection or outcome should not be known to employer at the time of selection. Thus, the term pre-placement is often used, rather than the previously common term ‘pre-employment assessment’.
Flow chart showing the process for pre-placement assessment.
Where there is high turnover (e.g. service industries) a rapid access scheme (same-day clinical assessment, where indicated, by rapid screening questionnaires) reduces costs, while managing the associated risk.
Key information
Current job description, including special job requirements
Knowledge of workplace risks and task demands
Sickness absence record for last 2yrs
Any legislative fitness standards
Industry sector guidance, where available.
Clinical investigations
Depending on the post, these may include tests listed in Table 23.1.
| Test | Example |
|---|---|
Spirometry | Animal house technicians |
CXR | Commercial divers |
Audiometry | Call centre workers, pipe fitters |
Visual acuity and visual fields | Occupational drivers |
Colour vision | Seafarers, electricians |
Exercise test | Firefighters |
Full blood count | Divers, lead workers |
Immunity to infectious diseases (rubella, varicella, hepatitis B) | Health care workers ( |
Drug screening | Safety critical jobs |
| Test | Example |
|---|---|
Spirometry | Animal house technicians |
CXR | Commercial divers |
Audiometry | Call centre workers, pipe fitters |
Visual acuity and visual fields | Occupational drivers |
Colour vision | Seafarers, electricians |
Exercise test | Firefighters |
Full blood count | Divers, lead workers |
Immunity to infectious diseases (rubella, varicella, hepatitis B) | Health care workers ( |
Drug screening | Safety critical jobs |
This list is not exhaustive.
Legislation and guidance
Faculty of Occupational Medicine (2007). Fitness for Work, 4th edn. Oxford, Oxford University Press.
Equality Act 2010. Available at: 
http://www.legislation.gov.uk/ukpga/2010/15/contents
Guidance on Ethics for Occupational Physicians (6th edn). Faculty of Occupational Medicine, London, 2006.
Psychosocial factors and fitness for work
Psychosocial factors have been recognized increasingly over the past 10yrs as having an important impact on work capacity and the risk of work-related ill health.
The factors listed here increase the risk of occurrence or recurrence of psychological morbidity and musculoskeletal disorders. However, they should also be taken into consideration when advising about fitness for work, likelihood of absence, and adjustments required, thus facilitating rehabilitation and reducing risk.
Personal psychosocial factors
Personality type: type A personality, and perfectionist and obsessional traits
Pre-existing psychiatric morbidity:
depression and anxiety
psychotic disorders
Health beliefs
Somatizing tendency
Conflicting family responsibilities
Poor work–life balance.
Workplace psychosocial factors
These factors and their control are covered in detail on p.134, Organizational psychosocial factors. However, the most important are:
Job demands
Excessive or insufficient workload
Control over work:
lack of control over the volume or rate of work, or achievement of targets
low decision latitude
Monotonous or repetitive work: intellectual demands mismatched with the individual’s ability or professional background
Low job satisfaction
Low perceived value by service users or colleagues
Poor relationships with others:
managers
colleagues
customers
Bullying and harassment.
Control of psychosocial hazards at work
Ageing and fitness for work
Epidemiology and workforce demographics
The demographics of populations are changing. The proportion of the UK population who are in the 50–64-yr age group is increasing.
Changes in UK pension arrangements are likely to increase retirement age, with more individuals working beyond the age of 65yrs.
It is predicted that within the next 25yrs, 30% of the workforce in Europe will be >50yrs old.
Physiological changes with age
There is some evidence that certain physiological and cognitive parameters change with ↑ age.
Physical
↓ Cardiovascular capacity (measured by VO2 max)
↓ Musculoskeletal capacity.
↓ Heat tolerance: unclear whether this is simply a function of age, or whether it reflects a higher incidence of cardiovascular disease
↑ Sleep disturbance.
• There is wide individual variation in the baseline level and rate of decline of physiological parameters. A physically fit 50-yr-old can have a greater physical capacity than an unfit 20-yr-old.
Cognitive
↓ Precision
↓ Speed of perception and cognitive processing
↑ Control of language
↑ Ability to process complex information in difficult situations.
Overall function in ageing workers
There is good evidence that job performance does not weaken markedly with age; indeed, it can improve.
‘Workability’ is a concept that assumes that overall performance derives from a portfolio of skills and attributes. The relative contribution of various attributes changes with age; overall performance is preserved. Motivation, loyalty, and experience all generally improve with age, and these factors tend to compensate for physiological decline. If better use is made of enhanced attributes in older workers (e.g. using their experience to train and mentor others), their work potential is maximized.
Sickness absence
Long-term absence is more common in older employees as a group because of the higher incidence of serious or degenerative diseases. However, short-term absence is lower in this group because of a combination of factors including lack of immediate dependents (e.g. time off to look after children) and higher levels of motivation.
As with overall function, there is a wide individual variation in absence-taking, and generalization is unwise in decision-making about individuals.
Risks for older workers
The following factors are associated with ↓ work ability and ↑ risk of ill health, and it is particularly important to be aware of them in older workers:
Role conflict
Fear of error
Poor control over work
Lack of professional development
Lack of feedback and appreciation
High speed of decision-making.
Interventions to manage an ageing workforce
There is little direct evidence of benefit from the scientific literature because of a lack of intervention studies. However, these adjustments are based on enhancing ‘workability’ as described here.
Careful management of change:
tailored re-training for new technology
flexible career development initiatives for older workers.
Train supervisors to be aware of age management
Apply age ergonomics:
special attention to ergonomics solutions for manual handling tasks and avoiding extremely heavy physical work
adaptations to man–machine interfaces for long-sightedness (clear controls, large visual displays) and slower reaction times
avoiding extremely hot working environments
Health promotion and facilitation of exercise programmes to promote general physical fitness. This is clearly a matter of personal choice for employees, but the effect of physical fitness on overall work capacity with increasing age is often not appreciated
Adopt a generally positive approach and supportive culture for older employees; value their experienced input.
Relevant legislation
The Equality Act 2010 ( p.
562, Equality Act 2010, b p. 572, Age discrimination) puts an onus on employers not to discriminate in employment on the grounds of age. Because of the wide variation in fitness in older people, it will be necessary to carry out a careful individual assessment of capacity, and make adjustments where these are practicable.
Obesity
Definition ‘A disorder in which excess fat has accumulated to an extent that health may be adversely affected’. (Royal College of Physicians)
Epidemiology
According to the World Health Organization (WHO) there is an epidemic of obesity. In the UK obesity (body mass index > 30kg/m2) affects
22% of ♂ population
24% of ♀ population.
Risk factors
Predisposing factors for obesity include:
Age (obesity rises with age)
Gender (females>males)
Social class (risk increases with lower social class)
Genetic
Marital status (married>single).
It can be precipitated by:
Smoking cessation (e.g. by substituting food for cigarettes)
Physical inactivity (e.g. due to ill health, work and family pressures)
Increased dietary calorie intake (e.g. holidays, psychological distress)
Rarely, sympatho-adrenal or other endocrine disorders
Drugs e.g. anti epileptics, anti-psychotics, anti-depressants, and insulin.
Classification
WHO classifies weight as in Table 23.2).
| BMI (Caucasians) Kg/m 2 | BMI (South Asians) Kg/m 2 | |
|---|---|---|
Overweight | 25.0–29.9 | >23.0 |
Obese (class 1) | 30.0–34.9 | >25.0 |
Obese (class 2) | 35.0–39.9 | |
Obese (class 3) (morbid obesity) | >40 |
| BMI (Caucasians) Kg/m 2 | BMI (South Asians) Kg/m 2 | |
|---|---|---|
Overweight | 25.0–29.9 | >23.0 |
Obese (class 1) | 30.0–34.9 | >25.0 |
Obese (class 2) | 35.0–39.9 | |
Obese (class 3) (morbid obesity) | >40 |
Waist circumference is important because abdominal fat deposition dictates risk of medical complications. Risk is increased with increasing waist circumference:
Europeans/Caucasians: men > 102 cm, women > 88cm
South Asians: men >90 cm, women > 80 cm.
Clinical features
Obesity is important because is associated with an increased risk of:
Type 2 diabetes
Cardiovascular disease (hypertension, angina, myocardial infarction, cerebrovascular accidents)
Respiratory complications, e.g. sleep apnoea
Cancers, e.g. of breast, colon, uterus, kidney, and oesophagus.
Other conditions, e.g. gout, varicose veins, gallstones, fatty liver, menorrhagia.
Sickness absence
Obesity is a predictor of:
Short-term sickness absence in men and women
Long-term sickness absence in men and women.
Overweight is a predictor of:
Short-term absence on men
Long-term absence on women.
Obesity can accelerate physical disorders (e.g. osteoarthritis of the knees). In terms of work limitations, the effects of obesity are estimated to be the equivalent of the worker being 20yrs older.
Other potential occupational issues
Increased travel costs due to the need to use two seats (air, rail travel)
Impaired fit of personal protective equipment, e.g. face masks, clothing
Costs of adapted furniture
Special arrangements for evacuation during emergencies
Inability to mount an emergency response.
Prevention
The workplace is an important opportunity for the prevention of overweight and obesity. See p.
368, Health and safety policies.
Clinical management
Dietary advice
Physical activity management
National Institute for Health and Clinical Excellence (NICE) (SIGN in Scotland) have produced guidelines on the use of drugs and surgery.
Orlistat, lipase inhibitor: improves weight loss if taken with a low fat diet
Surgical interventions:
laparoscopic banding (least invasive)
gastric bypass (effective weight loss, but significant complications).
Compensation/legal aspects
Obesity is recognized as a clinical condition and appears in ICD-10. It is associated with frequent reports of disability both in mobility and activities of daily living, and may be covered by the Equalities Act 2010. Any adjustments/adaptations should be consistent with the medical advice on the importance of physical activity.
Further information
Nerys W (2008). Managing obesity in the workplace. Radcliffe Publishing Oxford.
Cognitive impairment and fitness for work
Causes of cognitive impairment
Dementia
Pseudo-dementia in those with severe depression
Space-occupying lesions, e.g. subdural haematoma
Brain injury
Alcohol or substance misuse
Hypothyroidism
Vitamin B12 or folate deficiency
Vasculitis.
Epidemiology
Alzheimer’s disease (AD) and vascular dementia are the most common forms of dementia
There are ~17,000 dementia sufferers under age 65 in the UK
5% of people over the age of 65yrs have dementia, rising to 20% over the age of 80yrs
Evidence that work is a risk factor for AD is conflicting. Some evidence that blue-collar work ↑ risk, but this may be confounded by premorbid ability and/or socio-economic status
Exposures to organic solvents, lead, mercury, aluminium, or pesticides have all been implicated, but the evidence is inconclusive.
Symptoms and practical problems at work
Impairment of:
memory
reasoning
personality
communication (word finding difficulties)
Workers may be referred to the OH service owing to concerns regarding their memory, decision-making, time-keeping, communication, interpersonal relationships, attendance, or overall performance
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 specific examples of workplace difficulties as this may alert the assessing physician to the possibility of cognitive impairment. If suspected then explore the following;
The employee’s perceptions of their difficulties
Family history of dementia
Past medical history: history of head injury, brain tumour, etc.
Drug/alcohol history
Educational history
Occupational history (exposure to occupational neurotoxins).
Consider treatable causes of dementia:
pseudo-dementia in those with severe depression
space-occupying lesions
alcohol misuse
hypothyroidism
vitamin B12 or folate deficiency
vasculitis.
Investigation
If cognitive difficulties are suspected then tests to screen for cognitive impairment such as the Addenbrooke’s Cognitive Examination – Revised (ACE-R) or the widely used, but less sensitive Mini-Mental State Examination (MMSE)1 may be helpful. An MMSE score of <29–30 in a person of working age is unusual (anxiety may compromise performance). An MMSE score <24 indicates significant cognitive difficulties
Referral to a psychologist for formal cognitive assessment.
Prognosis
Prognosis depends on cause and the outcome of treatment
The prognosis of dementia is one of declining cognitive function, and employment cannot usually be sustained in the medium term
Workplace adjustments:
highly structured/routine work
regular supportive supervision
predictable workload.
Factors that reduce the feasibility of remaining at work:
highly variable work pattern
high decision latitude
multi-tasking
time pressures
cognitively demanding work
behavioural problems.
Caution should be exercised in assessing workers in safety critical posts or key decision-makers.
Medical management
Identify reasonably practicable workplace adjustments
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.
Depression
Types The most common type of depression is unipolar depression; bipolar disorder (manic depression) affects around 1%.
Prevalence
Major depressive episode: males – 1.9%. females – 2.8%
Mixed anxiety and depression: males – 6.9%, females – 11.0%
Lifetime risk of depression: 10–12% in men, 20–26% in women.
Causation
Predisposing factors
Genetic (> ×2 increased risk if first degree relative affected)
Adverse childhood experiences
Previous history of depression
Underlying physical illness.
Precipitating factors
Major adverse life events
Physical illness, e.g. onset, worsening of symptoms
Drug therapy, e.g. corticosteroids
Work-related difficulties, especially bullying.
Perpetuating factors
Lack of confiding relationship with partner
Misuse of alcohol or drugs
Combination of work and domestic problems
Isolation and lack of adequate support.
Diagnostic assessment
Classification:
DSM-IV (APA) – ‘Major depressive disorder’
ICD10 (WHO) – ‘Depressive episode’/’Recurrent depressive disorder’
both sets of criteria require impairment of social, occupational or other important areas of functioning.
Clinical treatment
Psychological:
CBT – linking thoughts, feeling and behaviours to challenge negative patterns of thinking
Pharmacological:
SSRIs most commonly used, e.g fluoxetine, sertraline, citalopram
Other drugs include, e.g. mirtazapine, venlafaxine, agomelatine
Maintain treatment for at least 6mths from point of maximum recovery (2yrs if recurrent depression)
Relapse rate of major depression: 60% in 5yrs if untreated.
Occupational health input
Facilitate early referral for psychiatric assessment/psychological treatment.
Fitness for work
Performance:
poor motivation
reduced concentration and poor decision-making
lack of confidence
impaired communication, withdrawal and/or irritability
lack of energy
antidepressant medication.
Sickness absence:
significant impairment of performance
non-compliance with medication
side effects of medication
premature reduction of dose.
Fitness to attend disciplinary hearing
Legal fitness to plead criteria relate mainly to capacity. Main question is whether the employee understands the allegations and their significance—can they take part in the decision making process?
Useful guide to cognitive ability is the employee’s 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’s home would be intrusive. Therefore a neutral location, e.g. hotel suite, might be more acceptable.
Time off work
Rehabilitation and reasonable adjustments at work
‘Round-table’ discussions can be helpful:
shared problem-solving approach
OH, HR, employee, manager +/– treating psychiatrist/psychologist
realistic goal setting, job definition, and work routine
agreed hours and days of work, and how these change over time
manager’s involvement
preparation of work colleagues for employee’s return.
Further information
Workplace intervention for people with common mental health problems: Evidence review and recommendations. British Occupational Health Research Foundation, available at: http://www.bohrf.org.uk/downloads/cmh_rev.pdf
Chronic fatigue syndrome/myalgic encephalomyelitis
There is a broad range of disability among patients with CFS. Some at the mild end of the spectrum manage to work normally, while others will need protracted adjustments to work.
Intervention studies have shown that ~30–60% 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 benefits
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 maintain some employment (even after adjustment for severity)
Low likelihood of a good treatment outcome in CFS/ME predicted by:
severe symptoms
psychiatric co-morbidity
long duration of symptoms.
The prediction of return to work might be assumed for practical purposes to reflect these factors, although, because few studies look at work outcomes, 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 influenced by psychosocial factors including illness beliefs, personal experience, personality, and coping skills. Treatment includes:
A multidisciplinary approach to rehabilitation, including the input of physicians, pain specialists, psychologists, dieticians, physiotherapists, and sometimes alternative therapists
Medical control of symptoms (e.g. treating pain and sleep disturbance)
Management of comorbid conditions (e.g. depression)
Of the specific treatment modalities, CBT and graded exercise therapy (GET) have been shown to be effective for CFS/ME, although GET 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 difficult for an employer to implement or sustain prolonged adjustments to work. Therefore, it is important that there is close liaison between treating physicians and allied specialists, OH advisers, managers, and HR advisers in supporting a return to work. In CFS/ME it is best if a work rehabilitation can be coordinated as part of an overall graded activity programme.
A protracted phasing up of working hours with a low baseline (e.g. 2–3h, 2–3 days/week) and very gradual increase may be necessary. It may take many months (or even more than a year in some cases) to reach premorbid working hours
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 avoid peak traffic times
Frequent rest breaks should be built in to the work schedule
Reduction in heavy physical 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.
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 aetiology are unknown, including fibromyalgia and irritable bowel syndrome. For example, 20–70% of patients with fibromyalgia meet the diagnostic definition for CFS/ME, and 35–70% of patients with CFS/ME could also be defined as having fibromyalgia.
Relevant legislation
The Equality Act 2010 would apply to individuals with CFS/ME and employers would be expected to make reasonable adjustments to work.
Further information and guidance
NHS Plus/Department of Health (2006). Occupational
aspects of the management of chronic fatigue syndrome: a
National Guideline, related leaflets for employers and employees. Available at: http://www.nhsplus.nhs.uk/providers/clinicaleffectiveness-guidelines.asp
Diabetes mellitus
Terminology and diagnostic criteria
Type 1 usually develops in childhood and adolescence.
Type 2 predominantly occurs in adults and accounts for 90% of cases.
Depends on symptoms of diabetes (polydypsia, polyuria and weight loss) plus:
a random venous plasma glucose ›11.1mmol/L or
a fasting plasma glucose concentration ›7.0mmol/L (whole blood ›6.1mmol/L) or
plasma glucose concentration ›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 another 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 worker and how well their diabetes is controlled. A report from the individual’s specialist or GP may be useful. Employers must make reasonable adjustments to employee’s duties as required by the Equality Act 2010.
From an occupational aspect, the most important clinical complications of diabetes are:
Hypoglycaemia: premonitory warning signs include hunger, sweating and dizziness, but these may be reduced or absent. Risk factors for hypoglycaemia are:
treatment with insulin or sulphonylureas
poor compliance with medication or diet
excessive exercise
alcohol
renal failure
intensification of treatment.
Impaired visual acuity: proliferative retinopathy, maculopathy and pan-retinal laser photocoagulation may bring individuals below DVLA standards for Group 1 driving
Neuropathy: this may lead to a reduction in fine motor skills, reduced positional awareness and postural hypotension. Sensory loss leads to an increased risk of accidental damage to peripheral tissues.
Sickness absence
Studies of sickness absence in employees with diabetes show increases in absence rates (estimates between 50–100% increase compared with non-diabetics). However, the better controlled the diabetes, the less likely the person is to take sick leave.
Shiftwork
In theory, timing of insulin and meals can be difficult with rotating shifts. However, modern insulin treatments have made shift work less problematic than previously and most diabetics cope well.
Safety critical jobs
In the UK, people on insulin are barred from some jobs e.g. airline pilot, the Armed Forces. The jobs for which there is a blanket ban are frequently reviewed and the latest list is available from Diabetes UK. Since October 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 individual or the public, for example firefighting. Suitability for such employment should be assessed annually by an occupational health professional in consultation with a diabetes specialist; and should be based on the following criteria:
Be physically and mentally fit 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
Be able to demonstrate an understanding of the risks of hypoglycaemia.
Further information and guidance
DVLA. At a glance guide to the current medical
standards of fitness to drive. Available at: http://www.dft.gov.uk/dvla/medical/ataglance.aspx
Diabetes, UK. Meet our new Peer Support Network. Available at: http://www.diabetes.org.uk/
Epilepsy
Defined by the International League Against Epilepsy (ILEA) as two or more epileptic seizures unprovoked by any immediate identifiable cause.
Epidemiology
Depends on definition, but the most commonly quoted statistics are:
Prevalence 5–10 per 1000 population
Incidence 50 (range 40–70) first fits per 100,000 population/yr.
Clinical classification of seizures
Partial seizures
Simple partial seizures (no loss of consciousness)
Complex partial seizures:
with impairment of consciousness at onset
simple partial onset followed by impairment of consciousness
partial seizures evolving to generalized tonic–clonic (GTC) seizures.
Generalized seizures
Convulsive or non-convulsive with bilateral discharges involving subcortical structures:
Absence
Myoclonic
Clonic
Tonic
Tonic–clonic
Atonic.
Unclassified epileptic seizures
Usually used when an adequate description is not available.
Treatment and prognosis
Treatment
Treatment is with anticonvulsants. Chronic stable treatment rarely affects performance significantly. Acute drug over-dosage can cause serious impairment, but is rapidly reversible.
Prognosis
The risk of further seizures depends on the clinical situation:
First seizure (see Fig. 23.2):
67% have a second seizure within 12mths
if seizure-free for 6mths, 30% have a further seizure within 12mths
Established epilepsy (more than one seizure):
most patients who achieve remission (seizure-free for 5yrs) do so within the first 2yrs; >95% remain seizure-free for 10yrs
approximately 20–30% will have further seizures despite treatment
the risk of further seizures ↑ with ↑ duration of poor control and ↑ frequency, combination of partial and tonic–clonic seizures, structural cerebral lesions, and impairment of cerebral function.
Actuarial percentage recurrences after first seizure and after 6, 12, and 18mths without seizures (From Hart YM, Sander JW, Johnson AL, Shorvon SD (1990). National General Practice Study of Epilepsy. Lancet, 8726, 1271–4. Reproduced by kind permission of Elsevier.)
Fitness for work
General issues
Advice about fitness for work should consider the risk to the individual and to others (e.g. passengers). Never base risk assessment on the label of epilepsy, but on individual clinical and job details.
Specific issues
High-risk activities: restrict those with epilepsy from:
lone working
working at heights
swimming or working unprotected near water
working with dangerous or unguarded machinery, or fire
carrying out or assisting at surgical procedures
sole care of dependent (e.g. ventilated or unconscious) patients
sole manual handling of patients, e.g. carrying infants
usually excluded: aircrew, armed forces, police, firefighters
Driving: see DVLA guidance, but in general:
group 1 – restrict until seizure-free for 1yr (+/– treatment), unless seizures only occur during sleep, and the last seizure was >3yrs ago
group 2 – 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
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
Visual display equipment is associated with an extremely low risk of seizure provocation, and it is usually inappropriate 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 only with the individual’s consent.
Adjustments to work
Diagnosis of epilepsy likely to qualify under Disability Discrimination Act 1995/2005. Where practical, employer must provide adjustments/redeployment as indicated by a risk assessment.
Further information and guidance
DVLA. At a glance guide to the current medical
standards of fitness to drive. Available at: http://www.dft.gov.uk/dvla/medical/ataglance.aspx
Alcohol misuse and fitness for work
An increasing use of alcohol (especially among 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
Initial signs and symptoms of alcohol misuse may go unrecognized or be ‘overlooked’ by well-intentioned colleagues.
| Men | Women | |
|---|---|---|
Daily consumption | 3–4U | 2–3U |
Weekly consumption | ||
Safe drinking | 21U | 14U |
Hazardous | 22–50U | 15–35U |
Harmful | >50U | >35U |
| Men | Women | |
|---|---|---|
Daily consumption | 3–4U | 2–3U |
Weekly consumption | ||
Safe drinking | 21U | 14U |
Hazardous | 22–50U | 15–35U |
Harmful | >50U | >35U |
Binge drinking is defined as consuming, in one episode, 8–10U for men and 6–8U for women
A unit of alcohol is 10mL, by volume, of pure alcohol.
Epidemiology
22% of UK men drink more than 21U/wk
6% of UK men drink more than 50U/wk
22% of UK women drink more than 14U/wk
6% of UK women drink more than 36U/wk
Alcohol-related deaths doubled from 4023 in 1992 to 8664 in 2009
17% of deaths on UK roads in 2009 were alcohol related
5% of road casualties in 2009 involved someone driving ‘over the limit’.
‘Soft’ signs of substance misuse
Variable work performance
↑ Accidents
↑ Errors
↑ Complaints
↑ Absenteeism, especially around weekends and holidays
Poor time-keeping.
Clinical assessment and diagnosis
Workers may be referred to the OH service because of ↑ sickness absence, ↓ 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 manager gives examples of workplace difficulties. This may alert the occupational physician to the possibility of alcohol misuse. If suspected, then explore the following:
The employee’s perceptions of their difficulties
Medical history, focusing on illnesses associated with alcohol misuse:
dyspepsia
jaundice
cirrhosis
cardiac arrhythmia
peripheral neuropathy
hypertension
Alcohol history
Family history of alcohol misuse
Accidents or assaults
Money problems due to alcohol misuse
Legal problems, e.g. drink driving convictions
Clinical examination, seeking the stigmata of alcoholism
Use the Alcohol Use Disorders Identification Test (AUDIT) to establish severity of misuse
If cognitive difficulties are suspected, arrange a cognitive assessment.
Prognosis
The prognosis for a worker with alcoholism is guarded.
Some problem drinkers aim for ‘controlled drinking’. In practice, this is rarely achieved and may indicate a failure to acknowledge the problem.
Alcohol testing
Where supported by an alcohol policy, pre-employment, with cause, or random breath or blood alcohol testing may be undertaken.
Medical management
Identify a treatment provider, usually via the GP
In-patient care for assisted alcohol withdrawal is not usually required, but may be required in those;
consuming >30U/day
with significant co-morbidities
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
Once at work, monitor time-keeping, performance, and absences
Prolonged OH service follow-up (up to 12mths) may be appropriate.
Relevant guidance and legislation
The Equality Act 2010
Faculty of Occupational Medicine (2006). Guidance on alcohol and drug misuse in the workplace. FOM, London.
Further information and guidance
NICE (2012). Alcohol
dependence and harmful alcohol use. NICE Clinical Guidance CG115. Available at: http://www.nice.org.uk/CG115
See also p.
378, Substance abuse policies.
Folstein MF, Folstein SE, McHugh PR (1975). ‘Mini-mental State’: a practical method for grading the cognitive state of patients for the clinician. Psychiatry Res, 12, 189–98.
