Pre-employment examinations & Pre-employment examinations & fitness standardsfitness standards

Professor T.C. AwMBBS, PhD, FRCP, FRCPC, FFOM, FFPHM

Head, Division of Occupational Health

University of Kent

Pre-employment examinationsPre-employment examinations

Purpose:• Detect clinical abnormalities that indicate a

mismatch between state of health and proposed job

• Enable necessary adjustments to be made

Pre-employment examinationsPre-employment examinations

Implications

Risk of ill-health or injury to– Individual– Co-workers– Customers– Patients– Visitors

Pre-employment examinationsPre-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

Pre-employment examinationsPre-employment examinations

Employee ‘reasons’Inform individual of hazards & preventative

measuresEstablishes health status before starting workAdjustments to job to fit the manHealth status at the time

Pre-employment examinationsPre-employment examinations

Occupational health ‘reasons’Assess the match between person & jobObtain baseline informationCheck on immunisation status & updateOpportunity for health promotion & adviceAllows effective follow up for clinical conditions

detected – continuity of care

Pre-employment examinationsPre-employment examinations

Practical reasons:Employer requirementGovernment requirementEvidence-based reason

Pre-employment assessments in Pre-employment assessments in the NHSthe 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

Pre-employment assessmentsPre-employment assessments

30% random sample of 217 occupational health units40 participating units 3-month period

Pre-employment assessmentsPre-employment assessments

Methods used:Self-administered questionnaire 4517Quest. + nurse interview 3116Quest. +/- nurse interview 688Quest. + nurse interview +/- Dr. exam 390Quest. + nurse interview + Dr. exam 196Nurse-administered Quest. 41

Pre-employment assessmentsPre-employment assessments

Decision: Nos. %Fit 8954 98Restriction 120 1.3Rejection 65 0.7

Total9139

Findings:Findings:

What were the main reasons for Rejection & Restriction?

Pre-employment assessmentsPre-employment assessments

Reasons for rejection: BMI (Kg/m2) 26 40% Skin conditions 14 21.5% Psychiatric conditions 7 10.8% Musculo-skeletal conditions 4 6.2% Raised BP 2 3.1% Others 12 18.5%

TOTAL 65

Findings:Findings:

Which staff groups had the highest rejection/restriction?

Pre-employment assessmentPre-employment assessment

Rejection by occupational group: Technician 3/88 3.4% Student nurse 17/1000 1.7% Catering staff 4/235 1.7% Nursing assts. 14/949 1.5% Qualified nurse 7/2159 0.3% Administrative staff 1/422 0.2% Doctor 1/1127 0.1%

Pre-employment examinationsPre-employment examinations

217 questionnaires

Pre-employment examinationsPre-employment examinations

Question:

Necessity or unwarranted?

Is it necessary? Is it necessary? YESYESEnsure man is fit to do the jobAdjustments of job to fit the manCost-effectiveness depends on the consequences of

the abnormality detected– Munchausen by proxy (Allitt)– Hepatitis B carriers– Shipman

Is it necessary? Is it necessary? NONO

Low pick-up rate Poor predictor of state of health Costs Logistics Disability Discrimination

‘‘ShipmanShipman’’

Pre-employment examinationsPre-employment examinations

OPTIONS:

1. Scrap them altogether

2. Retain in limited &/or modified form

3. Carry on as at present

Pre-employment examinationsPre-employment examinations

Practical considerations:Limit pre-employment assessment to ‘high-risk

groups’Agree standard questionnaire for specific

occupational groupsQuestionnaire for all, examination and tests for

someComputer-administered or computer scanned

questionnaire

Pre-employment examinationsPre-employment examinations

CRITERIA: Jobs requiring PEE Job has implications for 3rd parties Recognised uncontrollable hazards of the job

– PHYSICAL: noise– CHEMICAL: asthmagens– MECHANICAL: manual handling– BIOLOGICAL: body fluids – PSYCHO-SOCIAL: stress

Liability for employer?

Pre-employment examinationsPre-employment examinations

Questionnaire– Self-administered– Nurse-administered

Examination– Nurse– Physician (GP)– Occupational physician

Investigations– X-rays, blood tests, urinalysis, etc

Pre-employment examinations & Pre-employment examinations & Fitness standardsFitness standards

PROCESSEstablish Fitness standardsQUESTIONNAIRE + staged referral

Nurse interview + assessment +/-medical examination

Consideration: Cost-effectiveness?

Fitness standardsFitness standards

Job categoriesPilotsDrivers (Public service vehicles & heavy goods

vehicles)Food-handlersSea-farersUniformed services (police, army, fire-fighters,

ambulance crew)

Medical standards for fitness - Medical standards for fitness - DriversDrivers

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.

Medical standards for fitness - Medical standards for fitness - DriversDrivers

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).

Medical standards for fitness - Medical standards for fitness - DriversDrivers

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.

Medical standards for fitnessMedical standards for fitness

TRANSIENT ISCHAEMIC ATTACKSPatients 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.

ReferencesReferences

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 4th edition. Oxford University press, Oxford.

Pre-employment Pre-employment QUESTIONNAIRESQUESTIONNAIRES

Limit number of questions:Retain useful questions – reasonRemove ‘not useful’ questions

– Varicose veins, piles– Dysmenorrhoea vs. periodic pain

Details of proposed jobDetails of proposed job

No informationJob titleJob title, department and location of postJob specificationImmediate supervisorOHD walk-through

OTHER DATA:OTHER DATA:

Reports on previous health Reports on present treatmentRecords of sickness absence

Decision & adviceDecision & 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

QuestionQuestion

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

ConclusionsConclusions

Pre-employment assessments:Focused / selected groupsUniformity in methodAgreed criteria / fitness standardsBased on job requirementsPeriodic audit

Occupational Health [at Work] Occupational Health [at Work] 2006;3(3):18-252006;3(3):18-25

Ballard J (2006)

‘Pre-employment health screening: Part 1 – pre-employment questionnaires’

 

t.c.aw@kent.ac.uk