Fitness for work : the medical aspects

A general framework for assessing fitness for work Health problems and employment Impairment, disability, and handicap Prevalence of disability and its impact on employment The Equality Act 2010 The 'fit note'The ageing worker Occupational health services Contacts between the patient's medical advisers and the workplace Confidentiality Medical reports Assessing fitness for work: general considerations Why an assessment may be needed When an assessment of medical fitness is needed Recruitment medicals Recruitment and the company pension scheme Special groups Young people Severely disabled people The assessment of medical fitness for work A general framework Functional assessment Requirements of the job Factors influencing work performance Objective tests Matching the individual with the job Presentation of the assessment Recommendations following assessment Work accommodation Alternative work Early medical retirement Recent developments and trends Governmental initiatives Maintaining fitness for work Conclusions References Legal aspects of fitness for work Common law Common law duties of employers Standard of care of occupational physicians Duty to inform and warn of risks to health and safety Balancing the risk The state of the art Greater duty of care: 'eggshell skull' principle Duty owed in mental illness Employees' duties Statute law Health and Safety at Work etc. Act 1974 Employers' statutory duties Employees' statutory duties The institutions Employment protection legislation Grounds for dismissal Right of representation 'Capability': ill health cases Lying about previous health conditions Medical evidence and medical reports Status of statements of fitness Not all duties are suspended when an employee is off sick Need for an up-to-date medical report Data Protection Act 1998 Access to Medical Reports Act 1988 Conflicting medical advice Consultation with the employee Seeking suitable alternative employment Permanent health insurance benefits Early retirement on medical grounds Management's role in sickness decisions Pre-placement medical assessments Duty of care in writing pre-employment reports Duty to be honest Confidentiality Expert evidence Pregnancy, discrimination, and the law European law Working Time Directive Other health and safety directives References Disability and equality law 'Medical' model of disability Court judgments The Codes of Practice and Guidance Different forms of disability discrimination Role of the occupational physician Ethical considerations Disability considerations Protected characteristics EqA S4 Definition of 'disability' EqA S6 Normal day-to-day activities Determination of disability Showing an impairment Covert surveillance What is an 'impairment'? EqA Sch1 S1 & 6 Long-term effects EqA Sch1 Part 1, S 2 Severe disfigurement EqA Sch1 S3 'Substantial' EqA Sch1 S4 Effect of medical treatment EqA Sch1S5 Progressive conditions EqA Sch1 S8 Direct discrimination EqA S13 Positive discrimination Combined discrimination EqA S14 Discrimination 'arising from disability' EqA S15 Justification Indirect discrimination EqA S19 Duty to make reasonable adjustments EqA S20 What is reasonable?What is unreasonable?Sickness absence Redeployment and relocation Lifestyle reasons for disability Irrelevance of alleged discriminator's characteristics EqA S24 Harassment EqA S26 Victimization EqA S 27 Employees and job applicants EqA S39 Employees and job applicants: harassment by a third party EqA S40 Enquiries about disability and health EqA S60 Positive action EqA SS158-9 Lack of knowledge of disability EqA Sch 8 S20 Health and Safety Law EqA Sch 22 A right to work?Exemption certificates and 'disability clashes'Fitness standards Arguments of fitness in dismissal cases Working abroad Policies References Support, rehabilitation, and interventions in restoring fitness for work Challenging conventional assumptions: health problems, sickness, and disability The relationship between work and health Common health problems Disability benefits and common health problems Models of disability The medical model The social model of disability The economic model Individual perceptions Organizational policy, process, and practice The biopsychosocial model The contemporary biopsychosocial model Workplace management Vocational rehabilitation Concepts of rehabilitation The evidence for vocational rehabilitation Cognitive-behavioural and talking therapies Social and occupational interventions Educational interventions—the role of health services and healthcare professionals 'Pathways to Work' pilots Summary and conclusions References Ethics in occupational health Governance Professional standards Commercial occupational health Protecting health and promoting well-being Organizational health Health promotion Pre-employment assessment Hazard control Immunization Health screening Health surveillance Drug and alcohol testing Genetic testing and monitoring Health and work Supporting the sick worker Recommending adjustments Termination of employment Health-related pension benefits Information Collection of information Storage Retention and transfer of records Disclosure Consent Social media Covert surveillance Working with others Clinical and non-clinical teams Other health professionals Others in the workplace Others outside the workplace Occupational health research References Neurological disorders Size of the problem Occupational causes of neurological impairment Clinical assessment The impact of prognosis and rehabilitation on work How neurological illnesses may influence work Higher cerebral functions Cognitive function and psychometrics Behaviour and impulse control Disturbances of arousal and consciousness Sleep Pain disorders Speech, language, and communication Emotional state Symptoms related to cranial nerves Motor symptoms related to the trunk and limbs Upper motor neurone lesions, extrapyramidal disorders, and hypertonia Ataxia and incoordination Lower motor neurone lesions Disorders affecting the neuromuscular junctions Somatosensory impairments Loss of sphincter control Fatigue Drug management Driving Factors affecting neurological function Temperature and humidity Light Chemical factors Toxic neuropathies Heavy metal toxicity and organic solvents Organophosphate pesticides and sheep dips Identification and prevention of occupational neurotoxicity Assistive technology Specific neurological disorders Headache disorders Disorders of awareness and sleep Risk factors Risk of recurrence/incapacitation Medication Functional deficits Cerebral tumours Parkinson's disease Environmental neurotoxicity hypotheses Occupational considerations Essential tremor Dystonia Return to work after traumatic head and brain injuries Approving return to work after concussion and minor brain injury Symptoms Signs Cognitive functioning Vocational rehabilitation after moderate-severe brain injury Meningitis and encephalitis Alzheimer's disease and other pre-senile dementias Neurological disorders of childhood Spinal cord injury and disease Multiple sclerosis Miscellaneous genetic disorders Motor neurone diseases Peripheral neuropathy Neuromuscular junction disease Muscle diseases Entrapment neuropathies Chronic fatigue syndrome References Mental health and psychiatric disorders The extent of the problem The economic burden of mental illness Some definitions Primary prevention of mental health disorder Secondary prevention of mental health disorders Tertiary prevention How mental health problems might interfere with work Impaired concentration and attention Impaired motor skills Impaired communication and social skills Risk to self and others The effects of abnormal illness behaviour Why work matters: the psychosocial benefits Obstacles to employment Fit for work? Assessment for employment Back to work: reintegration into the workplace Recovery and return to work Work schemes and sheltered employment Models User employment programmes Common psychiatric disorders Adjustment disorders Depression Post-traumatic disorders including post-traumatic stress disorder Chronic fatigue syndrome Chronic mixed anxiety and depression Bipolar affective disorder (also known as manic depression)Schizophrenia Acute psychotic disorders Personality disorders Conclusions References Epilepsy Definitions Epileptic seizures Epilepsy Classification of epilepsy Focal seizures Generalized seizures Incidence and prevalence Causes of epilepsy Recurrence of seizures Chances of remission Withdrawal of antiepileptic drug treatment Prevention of epilepsy in the workplace Primary and secondary prevention Shift work Stress Photosensitivity and visual display equipment Other types of reflex epilepsy Alcohol and drugs Responsibility of the physician in the workplace Consideration of potential new employees Sensible restrictions on the work of people with epilepsy Lifting of restrictions Effect of antiepileptic drugs on work performance Special work problems Disclosure of epilepsy to employers Accident and absence records of those with epilepsy Current employment practices Getting employers to understand about epilepsy Medical services and opportunities for sheltered work NHS medical services Residential care Epilepsy charities Residential centres and schools for people with epilepsy Special assessment centres Relationship between the occupational physician, neurologist, and general practitioner Existing legislation and guidelines for employment The driving licence regulations and their effects Conclusions and recommendations References Vision and eye disorders Introduction—vision, perception, and work The effect of vision on work The effect of work on vision Perception and ergonomics Matching visual capability to the task required Vision and driving Aims of this chapter Symptoms and signs of visual dysfunction Disturbed visual acuity Disturbed colour vision Disturbed visual fields Disturbances in binocularity Visual discomfort or glare Somatosensory discomfort or pain Common eye disorders and their effects on visual function Refractive errors and their correction Refractive surgery External eye diseases Ocular hypertension Primary open-angle glaucoma Normal tension glaucoma Angle-closure glaucoma Retinal disorders Retinal vein occlusion Posterior ciliary artery occlusion Time off work after surgery Visual ergonomics—lighting, display screens, visual fatigue, and employment of people with visual impairment Lighting and visibility Lighting in the workplace Display screen equipment Visual fatigue Employment of people with visual impairment Ocular hazards, toxicology, and eye protection Heat Light Lasers Radiation Electrical shock Chemicals, particles, fibres, allergens, and irritants Occupational injuries and eye protection Corneal abrasion Corneal foreign bodies Subtarsal foreign bodies Chemical burns Blunt injury Penetrating injury Intra-ocular foreign body Compressed air injuries Eye protection Ocular first aid at work Planning Assessment Irrigation Eye shields Medications References Hearing and vestibular disorders Epidemiology of hearing loss and tinnitus Methods of assessing hearing disability Clinical aspects affecting work capacity including accidents Management: hearing aids and other assistive technology Epidemiology of balance disorders Methods of assessing balance problems Management: vestibular disorders Clinical aspects of vestibular disorders affecting work capacity Summary References Spinal disorders Non-specific low back pain Prevalence and natural history Disability and sickness absence Time trends Risk factors Assessing back pain and disability Triage assessment and investigation Other issues in assessment Managing the worker with a fresh episode of low-back pain Keeping active Keeping active at work Managing the worker who still has problems after 1-3 months Active rehabilitation Pre-placement assessment Investigations and clinical tests Other guidelines Prevention and risk management Neck pain Prevalence and natural history Occupational and personal risk factors Assessing and managing the patient with neck pain Spinal surgery Surgery for lumbar nerve root compression Prolapsed lumbar intervertebral disc Conservative management Surgical management Lumbar spinal stenosis Surgery for low back pain Spinal fusion Total disc replacement The cervical spine Other spinal conditions Ankylosing spondylitis Scheuermann's disease Fractures The thoracolumbar spine The cervical spine Spinal cord injury References Orthopaedics and trauma of the limbs The principles of managing musculoskeletal problems at work Ergonomic principles Psychosocial factors Return to driving post musculoskeletal surgery Work-related musculoskeletal diseases The size of the problem Occupational musculoskeletal disorders Musculoskeletal disorders of the upper limbs Disorders of the shoulder Steroid injections Subacromial decompression Acromioclavicular joint pain Glenohumeral joint stabilization Disorders of the elbow Elbow replacement Epicondylitis Disorders of the wrist and hand Tenosynovitis of the finger flexor and extensor tendons Ulno-carpal abutment Scaphoid non-union Scapho-lunate ligament insufficiency Disorders of the hand Digital arthritis Dupuytren's disease Trigger digit Disorders of the nerves Carpal tunnel syndrome Pronator syndrome Cubital tunnel syndrome Musculoskeletal disorders of the lower limbs General workplace adaptations for lower limb problems Conditions of the hip Hip osteoarthritis Hip replacement Conditions of the knee Knee osteoarthritis Surgery for knee osteoarthritis Knee replacement Meniscal tears Knee arthroscopy The anterior cruciate ligament Conditions of the foot Ankle osteoarthritis Achilles tendinitis (non-insertional)Plantar fasciitis Tibialis posterior tendon dysfunction Bunions/hallux valgus Hallux rigidus Metatarsophalangeal fusion Morton's neuroma Trauma Fractures Removing metalwork Avascular necrosis Pathological fractures Dislocations Ligament injuries Tendon injuries Nerve damage Cold intolerance Ankle sprain Achilles tendon rupture Fractured calcaneus Amputation Lower limb amputation Upper limb amputation Return to work References Rheumatological disorders Work-related upper limb disorders Disorders of the neck and upper limb Cervical spondylosis Disorders of the shoulder Prevention Epicondylitis of the elbow Carpal tunnel syndrome Tenosynovitis of the wrist Non-specific diffuse forearm pain Other management pointers in upper limb disorder Osteoarthritis Risk factors for osteoarthritis Occupational risk factors for osteoarthritis Assessment of osteoarthritis Management of osteoarthritis Management of osteoarthritis in the workplace Inflammatory arthritis Rheumatoid arthritis Management of rheumatoid arthritis Management of rheumatoid arthritis in the workplace Ankylosing spondylitis Seronegative arthritides Reactive arthritis Psoriatic arthritis Connective tissue diseases Systemic lupus erythematosus Risk factors for systemic lupus erythematosus Systemic lupus erythematosus in the workplace Management of systemic lupus erythematosus Management of systemic lupus erythematosus in the workplace Chronic widespread pain and fibromyalgia syndrome Risk factors for fibromyalgia syndrome Management of fibromyalgia syndrome Management of fibromyalgia syndrome in the workplace Conclusion References Gastrointestinal and liver disorders Inflammatory bowel disease Ulcerative colitis Crohn's disease Extra-intestinal manifestations of inflammatory bowel disease Functional limitations Adjustments at work Employment issues for workers with intestinal stomas Irritable bowel syndrome Definition, prevalence, and natural history Management Functional limitations Adjustments at work Gastrointestinal infections Distinguishing infectious and non-infectious diarrhoea Functional assessment and exclusion from work Food handlers Prevention of microbiological contamination of food Exclusion from work Infections with special occupational implications Salmonella infections Hepatitis A Viral hepatitis Hepatitis B Hepatitis C Cirrhosis of the liver Prevalence and prognosis Management and functional assessment Adjustments at work Liver transplantation Guidelines for employees handling hepatotoxins Obesity Prevalence and definitions Treatment Prevention and treatment of obesity in the workplace Functional limitations Adjustments at work References Diabetes mellitus and other endocrine disorders Classification Recent advances in diabetes Insulin-infusion therapy ('insulin-pumps')Islet cell transplantation Diabetes diagnosis by HbA1c Type 2 diabetes and the incretin system Diabetes and employment Prevalence, morbidity, and mortality Diabetes epidemiology Mortality and morbidity Diabetes treatment Type 2 diabetes Type 1 diabetes Control monitoring Glycaemic and risk factor control Glycaemic targets Risk factor targets Special work problems caused by diabetes The work record of people with diabetes Working patterns and diabetic treatment Complications of diabetes Chronic complications Acute complications Diabetic hypoglycaemia Diabetes, pregnancy, and employment Pensions, insurance, advisory services, etc.Pension schemes Diabetes in employer-sponsored health insurance Advisory services Guidelines for employment Conclusions and recommendations Endocrine disorders Hyperthyroidism Hypothyroidism Thyroid eye disease Pituitary disease References Haematological disorders Haemoglobinopathies Sickle cell disease Thalassaemia Immune cytopaenias (AIHA, ITP)Coagulation disorders Therapeutic anticoagulation Inherited clotting disorders: haemophilia and von Willebrand's disease Thrombophilia Malignant haematological disorders Epidemiology Clinical features and recent advances Adjustments to work in malignant haematological diseases Generic issues Immunity and infection risk Stem cell transplantation Indications for stem cell transplantation and survival Fitness for work in stem cell donors Splenectomy and hyposplenism Repeated transfusion Anaemia Fatigue Bleeding Psychosocial aspects Conclusions References Further reading Cardiovascular disorders Epidemiology Clinical features Assessment Management strategies: medical Coronary angioplasty and stenting (percutaneous coronary intervention)Coronary artery bypass grafting Return to work after developing coronary heart disease Cardiac rehabilitation Return to work Psychological factors Screening for coronary disease Congenital and valvular disease Cardiac arrhythmias Syncope Pacemakers and implantable devices Pacemakers Implantable cardioverter defibrillators Hypertension Other circulatory disorders Special work issues Physical activity Lifting weights Driving Work stress Shift work Hazardous substances Hot conditions Cold conditions Travel Electromagnetic fields Physical hazards The future of work Legal aspects References Respiratory disorders Methods of assessing respiratory disability General considerations Measurements of lung function Screening questionnaires Chest radiography Clinical conditions and capacity for work Asthma Statements and strength of evidence Chronic obstructive pulmonary disease Interstitial lung disease Respiratory infections Neoplastic disease Other diseases of the pleura Smoking Special work problems and restrictions References Renal and urological disease Prevalence and morbidity Mortality Presentation Guidelines for identification of kidney disease Diabetes Complications and sequelae of renal disease Hypertension Cardiovascular disease Renal failure End-stage renal disease Dialysis Haemodialysis Peritoneal dialysis Work and dialysis Transplantation Haemodialysis Peritoneal dialysis Renal failure and employment Renal failure and fitness for work Restrictions and contraindications Holidays Shiftwork Drivers Urinary tract infections Urinary incontinence and retention Prostatic cancer Urinary tract calculi Tumours of the renal tract Existing legislation: seafarers Conclusions and recommendations References Women at work Demographics Conception and fertility issues Early diagnosis of pregnancy Miscarriage Declaration of pregnancy to employer Workplace hazards to the pregnant worker Pregnancy changes that affect fitness to work Gynaecological problems Fertility issues Working women: other issues Work-life balance Ergonomic issues Physical fitness and injury Conclusion References Fitness for work after surgery or critical illness What do patients do in the absence of any advice?Does advice from clinicians have an impact on patients' beliefs and behaviours?The evidence base What do we mean by 'fit for work'?Evidence from wound healing studies Evidence from use of different closure methods and internal support Diabetes Obesity Smoking Age The nature of the operation Psychology and surgery Time to return to work following surgery Advice to employees Specific operation sites and procedures Abdominal surgery Cardiothoracic surgery Vascular surgery Head, neck and ENT surgery Urological surgery Breast surgery Gynaecological surgery Orthopaedic surgery Returning to work after critical care treatment References Dermatological disorders Prevalence At pre-employment Eczema Other non-cancerous skin disorders Skin cancer Skin and the psyche Investigations Rehabilitation Skin care Legal considerations Final comments References Human immunodeficiency virus Epidemiology of HIV in the UK Natural history of HIV infection Factors influencing the rate of progression to AIDS Markers of HIV infection and their clinical relevance Symptoms Primary HIV infection Latent period Opportunistic infections Lung manifestations Gastrointestinal manifestations Neurological presentations Eye manifestations Tumours Psychiatric morbidity Treatment of HIV infection5*6 Commonly used drugs Current consensus guidelines relating to HIV treatment Complications of HAART Adherence issues Drug interactions Second-line regimens 'Salvage therapy'Employment status and barriers to employment Vocational support and rehabilitation UK AIDS charities Legal and ethical framework for assessing work fitness Reasonable adjustments Pre-employment screening, HIV testing, and the Equality Act Exposure-prone procedures Ethical framework Healthcare workers Occupational risks for HIV-infected workers Potential occupational exposures to opportunistic infection Working overseas Occupational immunizations Risk of transmitting HIV at work Transmission from worker to client/patient Occupational restrictions placed on HIV-infected healthcare workers HIV testing and healthcare workers Patient notification exercise Care of the HIV-infected healthcare worker Confidentiality Risk of acquiring HIV through work Post-exposure prophylaxis RIDDOR reporting Compensation for HIV infection contracted at work Prevention of occupational HIV transmission Control of Substances Hazardous to Health Regulations Standard precautions Summary References Drugs and alcohol in the workplace Prevalence Impact Alcohol Drugs Accidents Absenteeism Belief Drug and alcohol at work policies Implementation of a new policy Training for managers Referral to occupational health Assessment for drug or alcohol misuse and dependency Features of denial Assessment of fitness to work Fitness to drive Treatment of dependence Return to work Drug and alcohol testing at work Evidence that testing is effective When to test?Types of test Alcohol screening Drug testing Role of occupational health departments in a drug and alcohol testing programme Testing for impairment Conclusions Useful websites References Medication and health in the workplace Epidemiology of medication use Medication prevalence in the workplace Classification of medications Reclassification Harms from medications Classification of adverse drug reactions Frequencies of adverse drug reactions in the workplace Patient information Clinical pharmacology relevant to harms Drug elimination Drug interactions Abuse of medications Influence of legislation/guidance The Equality Act 2010 (see also Chapter 3)SEQOHS standards Effects of medications on performance Performance testing Circadian rhythms Occupational exposures and medications Effects of medications on specific occupations Drivers DVLA Group 2 drivers Shift workers Physicians Occupational travellers Management of clinical conditions Central nervous system Antidepressants Hypnotics and sedatives Antipsychotic drugs Lithium Antiepileptic drugs Antihistamines Antimigraine drugs Drugs for Parkinson's disease Medications for multiple sclerosis Stimulants and appetite suppressants Autonomic nervous system Anaesthetics Cardiovascular medications Antihypertensive drugs Anticoagulants Analgesics and non-steroidal anti-inflammatory drugs Hypoglycaemic drugs (see also Chapter 28)Anticancer medications Anti-infective agents Travel medications Good occupational health practice Workplace solutions and adjustments Prescribing in occupational health Summary References The older worker The demographic background The United Kingdom General age-associated changes Ageing Differences between younger and older people Is the pattern of ageing changing?How old is an 'older worker'?Age-associated changes in function Specific age-associated problems Drug problems Health maintenance and service issues Nutrition, diet, and exercise Health surveillance Links with primary care Workability and employability Ageing and recovery from illness or injury Retraining and redeployment Ethical issues and retirement: duties to employers, responsibilities to employees Organizational issues Management and social aspects Shift work Hours of work Upstream ergonomics: input into the design of processes Older workers and younger managers Possible actions and solutions References Further reading III health retirement Demographics State pensions Occupational and personal pensions The Pensions Advisory Service Defined benefit and defined contribution schemes Criteria Evidence Conflicts of interest Competence Appeals and complaints Guidelines Audit Medico-legal aspects Injury awards Limited life expectancy Conclusions References Health and transport safety: fitness to drive Safety critical tasks Impairing disabilities and medical conditions Occupational driving: public highways Occupational driving: off-road Medical aspects of licensing Specific medical conditions Cardiac events and strokes Seizures Diabetes Vision Sleep disorders Psychiatric illness, drugs, and alcohol Fixed disabilities The role of the occupational health professional References Health screening Characteristics of a screening test Sensitivity, specificity, and predictive value Likelihood ratios Receiver operating characteristic curves Practical and ethical aspects of screening Scope of the screening examination Frequency of examination Advantages and disadvantages of health screening Ethical considerations Screening in occupational health practice Pre-placement examination Health screening prior to job transfers Health screening for return to work after illness Specific screening tests Executive health screening Genetic screening Screening for drugs and alcohol Biological monitoring and biological effect monitoring Health surveillance Evaluation of screening programmes Conclusions References Managing and avoiding sickness absence Epidemiology of sickness absence Theoretical models of sickness absence management Promoting attendance Engagement Manager attitudes and behaviour What is good work?Measuring and monitoring absence Trigger points Policy and procedure Policy statement Key principles Notification of absence Evidence of incapacity 'May be fit for some work'Return to work discussions Formal review Absence due to disability/maternity Prerequisites to interventions Managing short- and medium-term absence Predicting future absence Long-term absence Initial enquiries Detailed assessment Coordinating and delivering interventions and services Timeliness Occupational health reports Communication with other specialists Occupational rehabilitation Presenteeism and productivity References Health promotion in the workplace Defining health promotion Health promotion and public health Health promotion in the workplace Workplace health promotion examples National campaigns Communication techniques Examples of health promotion in the workplace Summary References Cancer survivorship and work Cancer, cancer treatment, and work capability Diagnosis and treatment of cancer: functional prognosis and occupational risk assessment Lymphoedema Fatigue Immunosuppression Radiotherapy Hormonal adjuvant treatment Pain Organ effects Musculoskeletal Psychological impact of cancer Vocational rehabilitation Fitness to drive Follow-up Health promotion Epidemiology of cancer References Further reading