Guidance on standards of

health for clinical health care

workers
C. J. M. Poole*, J. M. Harrington, T. C. Aw, P. S. Burge and
A. C. White||
*Dudley

Priority Health NHS Trust, Health Centre, Cross Street, Dudley DY1 1RN;
of Occupational Health, Edgbaston, Birmingham B15 2TT; Birmingham
Heartlands Hospital, Birmingham B9 5SS; and ||The Queen Elizabeth Hospital,
Mindelsohn Way, Edgbaston, Birmingham B15 2QZ, UK
Institute

Judgements about the health of clinical health care workers in relation to fitness to
practice are made by a variety of doctors. These guidelines have been written to
assist with such judgements and to facilitate equitable decision making in matters
of employment.
Key words: Doctors; fitness to practice; guidelines; health care workers; nurses;
standards of health.
Received 23 October 2000; revised 25 September 2001; accepted 27 September 2001

Introduction
In the nineteenth century, maintenance of personal
health was a fundamental duty and a matter of professional pride for nurses [1]. However, little appears
to have been written about the health of doctors.
Complaints about ill doctors were dealt with by the
General Medical Councils Conduct Committee until
1980, when a health jurisdiction committee was
established on the recommendation of the Merrison
Report [2]. The General Nursing Council (UKCC)
followed with a similar health committee in 1983. More
recently, the health of doctors and nurses has come under
scrutiny with specific recommendations being made
about standards of health for nurses in the Clothier [3]
and Bullock [4] Reports. The Department of Health has
also published guidelines for health care workers
(HCWs) who are infected or may be at risk of being
infected with the human immunodeficiency, hepatitis B
or hepatitis C viruses [57].
This guidance has been written to facilitate openness
and equitable decision making, and to ensure that all
relevant employment issues related to health are taken
into consideration when judgements are being made
about the fitness of a clinical HCW to practice. It is not
intended to cover every medical condition or to be
Correspondence to: Dr C. J. M. Poole, Consultant Occupational
Physician, Dudley Priority Health NHS Trust, Health Centre, Cross
Street, Dudley DY1 1RN, UK. Tel: +44 1384 366416; fax: +44 1384
366422.

proscriptive, and each case will need to be judged on its

merits. We recommend that this guidance is drawn to
the attention of student clinical HCWs before they
enter training so that potential health problems can be
addressed at as early a stage as possible. It has been
formulated by doctors with an interest in fitness to work
from a wide range of specialities. The recommendations
are supported, where possible, by evidence from the
literature and referenced, but where this was not possible,
they are supported by consensus between the authors on
what constitutes good practice. Implementation of the
guidance can be audited internally by occupational health
departments or externally by way of clinical governance.
The term clinical health care worker as used here refers
to a health care worker who treats patients.

Fitness to practice
Judgements about a practitioners health in relation to
fitness to practice are currently made by various groups
of doctors, including professional bodies, three wise
men, managers and occupational physicians. Problems
with performance, conduct or health should in the first
instance be addressed locally, but if this fails and there is
concern that patients are being put at risk, then the
appropriate regulatory body must be informed [8]. On
matters of health and safety, risk assessments should be
made by competent persons [9]. At the local level,
we believe that specialist risk assessments of fitness to

Occup. Med. Vol. 52 No. 1, pp. 1724, 2002

Copyright Society of Occupational Medicine. Printed in Great Britain. All rights reserved. 0962-7480/02

18

Occup. Med. Vol. 52, 2002

practice should be undertaken by accredited specialists in

occupational medicine, with advice from other specialists
as appropriate. Nurses who undertake health assessments
should have a qualification in occupational health and
access to an accredited specialist in occupational
medicine.
All HCWs should be registered with a general practitioner and also have access, either directly or by referral,
to an accredited specialist in occupational medicine
[HSG(94)51]. National services, such as the National
Counselling Service for Sick Doctors, the British Medical
Association [10] and the Royal College of Nursing
counselling services, are also available to doctors or
nurses. Model health questionnaires to assist with job
placement and risk assessment have been published
(HSC1994/064). For doctors in training, their health is
currently screened at the start of each new job. This need
not, however, be more often than at the start of the first
pre-registration house job and thereafter at 3-yearly
intervals up to and including their first appointment to
a permanent post, whether consultant, staff grade or
clinical assistant. A smart card is being developed to
facilitate the recording of occupational health data for this
process. Although this guidance was initially developed
for doctors in training, the standards contained within it
could be applied to all doctors as part of the 5-yearly
revalidation process proposed by the General Medical
Council.
Illnesses or conditions that are relatively common
in clinical HCWs and that create specific occupational
health problems for them or their patients are discussed
below
Depression
Depression is common amongst clinical HCWs [11]. The
nature of the work, degree of autonomy, absence of supporting factors, conflicts between personal life and career,
and high levels of self-criticism or empathy have all been
implicated in its development [12]. Recognition of the
illness may be difficult for non-psychiatrists, but valid and
reliable instruments have been developed to assist with
diagnosis [1316]. For example, although untested in
any study, a score of seven out of nine on the Goldberg
depression scale and eight out of nine on the anxiety
scale, in the absence of a physical cause for symptoms, is
probably incompatible with safe clinical practice. In
coming to such a judgement, co-morbid factors such as
substance misuse, previous self-harming behaviour and
medication need to be taken into consideration, as does
the type of clinical work that is being undertaken. HCWs
who have been sensitized to particular situations as a
result of traumatic early life experiences, such as child
abuse, may not be suited to certain jobs, e.g. paediatrics,
particularly if there is a history of previous emotional
breakdown whilst working under pressure. An increased

emotional vulnerability to emergency work has been

reported in individuals exposed to major physical trauma
earlier in their lives [17]. Specialist psychiatric advice
should be sought in such situations and individuals
appraised of their increased risk, and if practicable given
appropriate support, but relocated if necessary.
A liability to psychosis, mania, hypomania or major
depressive illness, particularly if the HCW has poor
insight into relapses of their illness, is incompatible with
safe clinical practice. The persons work may need to be
adapted, e.g. by restricting surgical interventions, night
work or the administration of medication, or, if practicable, by increased supervision. The potential effects of any
therapeutic or prophylactic psychotropic medication on
cognition or motor performance should also be taken into
consideration.
Substance misuse
Alcohol or psychoactive drug misuse is incompatible
with safe clinical practice. Employers should have a policy
on substance misuse that has been agreed with staff
representatives. Employers should also formalize arrangements for detoxification and rehabilitation, if necessary
by making provision for extra-contractual referrals. We
recommend that HCWs in whom alcohol consumption
has led to problems with performance, the authorities or
social life should, according to their degree of dependence, either abstain from or control their drinking [18]
and that biological markers (e.g. gamma-glutamyl
transferase, mean corpuscular volume and carbohydratedeficient transferrin) be normalized before returning to
work. For illicit drug misuse, abstinence and satisfactory
witnessed urinary drug screening are essential before
returning to work. Because of the risk of relapse, regular
follow-up may be necessary. For individuals whose
job allows unwitnessed access to controlled substances
such as anaesthetics, a change in occupation may be
advisable.
Anorexia and bulimia
These illnesses are relatively common in a mild form,
from which most people make a full recovery. Occasional
out-patient psychiatric support for someone with good
insight into their illness need not be of concern when
judgements about fitness to practice are being made.
Individuals who are of particular concern are those with
continuing symptoms of anorexia, particularly if their
weight is unstable, they have a body mass index of
<17 kg/m2 or intense dysfunctional beliefs of body
image, or there is co-morbidity with addictive or selfharming behaviour. Bulimia with frequent vomiting and
hypokalaemia is incompatible with safe clinical practice.
Anorexia and bulimia may co-exist, and may be associated with psychosocial dysfunction or serious psycho-

C. J. M. Poole et al.: Guidance on standards of health for clinical health care workers 19

pathology, such as a personality disorder. It has been

recommended that applicants for nurse training with
a history of self-harming behaviour, excessive use of
medical facilities or counselling should not be accepted
for training if they show more than one of these patterns
of behaviour, until they have shown an ability to live an
independent life without professional support and have
been in stable employment for at least 2 years [3]. We
believe that this is a reasonable precaution for all clinical
HCWs, but each case should be assessed on its merits
and specialist psychiatric advice sought to assist with risk
assessment [19].
Personality disorders
Individuals may be attracted to health care work because
of personal experience of serious illness in their families,
neurotic drives or unresolved psychological problems
from childhood [20]. Problems with emotions, interpersonal relationships and self-control will often adversely
affect functioning in the workplace. Transient abnormal
behaviour at times of stress is amenable to treatment,
but repetitive problematic behaviour, such as recurrent
self-harm or recurrent somatization, is indicative of a
personality disorder and such an individual is not suited
to clinical work.
Severe personality disorders of the paranoid, schizoid,
antisocial, borderline, histrionic or narcissistic type are
incompatible with safe clinical practice. A HCW who has
been convicted (cautioned or conditionally discharged)
for a serious sexual offence will have to disclose that
conviction to their employer or prospective employer.
Such a conviction is exempt from The Rehabilitation of
Offenders Act 1974 (exemptions) Orders 1975 and 1986,
and is incompatible with clinical practice. In addition,
employers may seek information on pending prosecutions, cautions and bind overs through procedures agreed
with their local police force. HCWs with substantial
access to children may be subjected to a pre-placement
criminal record check [HSG(94)43] or in due course
asked to provide a criminal record certificate.
Acute anxiety states, post-traumatic stress
disorder and phobias
Most acute neurotic states are short lived and treatable,
but if they cause significant lapses in concentration or
impair functional ability at work, then restriction of
practice or relocation may be necessary until normal
functional ability returns.
Visual impairment
Good visual acuity is necessary for most clinical work;
however, adaptive computer technology, such as closecircuit television, voice recognition software and speech
synthesizers, have greatly assisted the visually impaired.

Severely impaired central vision or markedly restricted

visual fields, which cannot be accommodated by reasonable adaptations, are incompatible with tasks that require
detailed vision, such as reading drug charts, microscopy
or surgery; however, some clinical work, such as
psychotherapy or physiotherapy, may be permissible.
Binocular vision is not essential for most clinical work,
but stereopsis (three-dimensional vision) is essential
for work that requires input from both eyes, such as
microsurgery or stereotactic surgery. Diplopia that
cannot be controlled is inconsistent with most clinical
practice. If driving is a requirement of the job, then the
DVLA standards will also apply [21].
There is both qualitative [22] and experimental [23]
evidence that severe protan (red) or deutan (green)
colour-deficient vision may disadvantage doctors in
microscopy. We recommend that medical students and
trainee doctors in selected specialities are screened for
colour-deficient vision, together with tests for severity,
so that individuals can be made aware of potential
limitations in their powers of observation, be guided
in their choice of career and adopt safe systems of work so
as to avoid potential harm to patients. We recommend
that if a doctor has a severe colour deficiency, then he
or she should not work in histopathology, endoscopy or
ophthalmology unless able to adopt a safe system of
working.

Hearing impairment
Mild-to-moderate hearing loss should not create problems with clinical practice, provided the HCW has been
appropriately rehabilitated with adaptive technology.
Such technology includes a hearing aid, loop system,
telephone amplifier, vibrating bleep, transmitter and
visual alarms. In the absence of a functional test or
relevant research, it would seem prudent to recommend
that a clinical HCW who undertakes auscultation as part
of their job, with a mean hearing threshold loss of >35 dB
in the frequency range of 5004000 Hz, should use an
electronic stethoscope.
Severe hearing loss will create difficulty with tasks such
as taking a history from a young child, communicating
with a very ill or infirm patient or auscultation, even
with an electronic stethoscope. Emergency situations,
intensive therapy units, areas where there is a lot of
background noise and operating theatres where masks
have to be worn are areas of practice where patient care is
likely to be compromised. A successful cochlear implant
may re-establish safe clinical practice in these situations.
Someone whose primary mode of communication is sign
language is unlikely to be suited to training as a clinical
HCW except in a very specialized area such as a school
for the deaf.

20

Occup. Med. Vol. 52, 2002

Eczema and psoriasis

Because of the need for regular hand washing and
frequent changes of gloves, contact irritant and contact
allergic dermatitis are relatively common in clinical
HCWs. Careful choice of antiseptic hand washes, correct
hand washing techniques and regular use of emollients
will prevent most irritant contact dermatitis. Patch testing
may be required to identify contact allergic dermatitis,
and specific IgE measurements or skin prick testing
to identify latex allergy. Staff with latex allergy should
work in latex-free areas. Such individuals should not be
excluded from clinical work or be recommended for early
retirement. Good infection control requires that staff with
a rash or broken skin that cannot be satisfactorily covered
should not undertake clinical procedures [24].
Individuals who have had severe eczema in childhoodparticularly if it involved the handsare more
susceptible to contact irritants. Eczematous lesions are
frequently colonized in high concentrations by staphylococci or streptococci. We recommend that staff with
active eczema or broken skin on their hands should not
undertake high-risk clinical procedures such as those
involved with wounds, immunocompromised patients or
neonates. HCWs with endogenous eczema of the hands
that has responded poorly to treatment are not suited to
work that requires repeated hand washing.
Psoriasis is associated with increased shedding of scales
and the dispersal of skin organisms. Mild psoriasis can
probably be safely ignored as a cross-infection risk.
However, extensively distributed psoriatic plaques or
plaques affecting the hands or scalp are associated with
high bacterial counts, which will be dispersed on scales
shed into the environment and thereby pose an increased
risk of infection to vulnerable patients. A severe outbreak
of surgical sepsis has been reported from a HCW with
widespread psoriasis [25]. Clinical HCWs infected or
colonized with methicillin-resistant Staphylococcus aureus
(MRSA) should be suspended from work and treated in
accordance with previously published guidelines [26].
Individuals with a skin condition which makes them
vulnerable to repeated infection or colonization with
MRSA are not suited to clinical work.

Tuberculosis
Clinical HCWs in the UK, especially nurses and those
working in mortuaries or microbiology laboratories, are at
an increased risk of catching tuberculosis (TB) compared
with the general population [27,28]. Such staff should be
advised of their increased risk, told the symptoms of TB
and told to report relevant symptoms to the occupational
health department. The risk of infection with TB is
reduced by BCG vaccination [29], which is recommended in the UK for non-immune clinical HCWs
[30,31]. Pre-placement health screening should include

questions for symptoms of TB, as well as BCG scar

inspection and, for those who do not have an adequate
BCG scar or validated BCG vaccination, a Heaf test.
Clinical HCWs from countries where TB is endemic
(annual incidence >40 per 100 000 of the population)
should be screened for symptoms of TB, given a Heaf
test if there is no BCG scar (unless there is a past history
of TB) and a chest X-ray [31]. Those with relevant
symptoms, a grade 34 Heaf test or an abnormal chest
X-ray should be referred to a respiratory physician.
A HCW who refuses to have a Heaf test should have a
chest X-ray. If this is normal, it should be recorded in
their occupational health notes that their immunity to TB
could not be assessed as they declined tuberculin skin
testing. If the Heaf test is grade 01, the HCW should be
offered BCG vaccination unless there is a contraindication to vaccination, such as pregnancy or immunosuppression [30]. A HCW who is immunosuppressed,
or who refuses BCG vaccination, should not work in
areas where the risk of catching TB or transmitting it to
vulnerable patients is high [32]. In practice, such areas
vary geographically, but probably encompass general
medicine, paediatrics, obstetrics, mortuaries and microbiology laboratories. The HCW should have his or her
practice restricted, their manager advised in writing of
the recommended restrictions and a note to this effect
entered in the occupational health records. A HCW who
is non-immune to TB but chooses not to undergo a BCG
vaccination should sign a Form of Acknowledgement (to
be kept in the occupational health records) that they are
aware of their increased risk of catching TB but have
declined an offer of vaccination. An alternative practice is
for the HCW to have regular (annual) health surveillance
with tuberculin skin tests and chemoprophylaxis or treatment as appropriate if skin reactivity increases by two or
more grades. A Form of Acknowledgement to this effect
should also be signed.
Transmission of TB from HCW to patient is
uncommon [3336]; however, HCWs with infectious TB
should not work with patients. The risk of transmission
of pulmonary TB is low after 2 weeks of chemotherapy
unless the mycobacteria are multidrug resistant, in which
case the HCW should not work until they have completed
a course of treatment and remain culture negative from
sputum. HCWs with positive cultures for environmental
mycobacteria pose no risk to patients.
Asthma
HCWs with current asthma may have impaired lung
function and, if also sensitized by way of their work to, for
example, aldehydes, latex, enzymes, ispagula or acrylates,
then their disability will be enhanced. Workplace control
of the hazard or, where this is not possible, relocation of
the asthmatic HCW away from the sensitizing agent
should be feasible in most health care settings.

C. J. M. Poole et al.: Guidance on standards of health for clinical health care workers 21

Bronchiectasis and cystic fibrosis

HCWs with bronchiectasis or cystic fibrosis and significant production of daily sputum may be colonized or
infected with Pseudomonas sp. or MRSA. There is
evidence of patient-to-patient spread of Pseudomonas sp.
in health care settings [3739], but no published report of
spread from HCW to patient or from patient to HCW.
It would seem prudent, however, for reasons of good
infection control, to restrict HCWs with diseased lungs
and chronic sputum production who have been colonized
with MRSA, Pseudomonas aeruginosa, Burkholderia cepacia
complex or Stenothrophomonas multifilia from working
with neonates or immunocompromised patients. It would
also seem prudent for HCWs with bronchiectasis or
cystic fibrosis to avoid treating patients with Pseudomonas
sp. or MRSA so as to reduce the risk of cross-infection
and further damage to their own lungs.

Blood-borne viruses
The regulatory bodies for doctors, dentists and nurses
have advised on the professional responsibilities of practitioners infected or who have placed themselves at risk
of infection with the hepatitis B virus (HBV) or human
immunodeficiency virus (HIV). HCWs undertaking
exposure-prone procedures (EPPs) should have evidence
of immunity or non-infectivity to HBV [6]. All nonimmune clinical HCWs should be vaccinated against
HBV, and following successful immunization, it is
recommended that one single booster of vaccine only
should be given after 5 years [30]. HCWs who are
non-responders to vaccine and who are non-immune
should be advised in writing of their immune status and
the need for post-exposure prophylaxis with specific
hepatitis B immunoglobulin after a high-risk inoculation
incident. Because of recent reports of transmission from
doctor to patient [40], it is now a requirement of the
Department of Health that HCWs who are hepatitis B
e antigen-negative carriers of the virus and who undertake EPPs or work in renal dialysis units must have
<103 genome equivalents/ml viral DNA (HSC 2000/20).
Current Department of Health guidelines still permit
HCWs who are hepatitis C antibody positive to perform
EPPs although transmission from doctor to patient has
been recorded in these circumstances [4144]. Affected
clinicians should, if appropriate, be offered treatment, but
advised that these guidelines are under review and may
change. Those in training should be advised to consider
changing to work that does not involve EPPs.
Transmission of HIV from HCW to patient has been
recorded now on two separate occasions [45,46]. Clinical
HCWs who are HIV antibody positive, confirmed in two
independent laboratories, must not perform EPPs [5]. As
with other immunosuppressed patients, clinical HCWs
who are HIV seropositive, or at high risk of being positive,

should not be vaccinated with BCG. This is because

the efficacy of the vaccine is unknown in this situation
and there is a risk of inducing disseminated TB in the
vaccinee. A clinical HCW who is Heaf test grade 01 but
who has a past history of TB, immunity to TB, or is from
a country where TB is endemic, should be counselled
about the possibility of HIV infection and, if appropriate,
tested with consent for HIV antibodies. If consent is not
given, the HCW should be restricted as if immunosuppressed (see section on TB). HCWs who are HIV
seropositive or who have the acquired immune deficiency
syndrome are at increased risk of catching TB and may
therefore pose a risk of cross-infection [47]. It would seem
prudent to restrict their practice from high-risk situations.
Influenza and other infections
Clinical HCWs who are febrile, with symptoms of cough,
sneezing, diarrhoea or vomiting, should not be in contact
with neonates or immunocompromised patients. There
is increasing evidence that vaccinating HCWs who work
with elderly patients against influenza is associated with
significantly reduced patient mortality [48,49], probably
by the prevention of nosocomial transmission. We
recommend therefore that HCWs at high risk [30], or
who work with the elderly (>70 years) or immunocompromised patients or in nursing homes, should be
vaccinated against influenza. To avoid the risk of
transmitting rubella to non-immune pregnant patients,
seronegative clinical HCWs (both male and female)
should be vaccinated with rubella vaccine [30]. HCWs
who work with pregnant women, neonates or immunocompromised patients should have their immunity to
varicella ascertained and those who are seronegative must
follow infection control guidelines when in contact with a
case of chicken pox [30]. Staff who are in contact with
varicella specimens in laboratories or mortuaries should
also know their varicella status.
Epilepsy
A liability to epileptic fits or attacks of altered consciousness is not normally a bar to clinical workunless the
attacks occur without warning or in a way which might
put the patient or HCW at risk. Such a situation may
arise when the HCW has sole charge of a patient or is
performing an invasive procedure, e.g. during surgery,
giving an anaesthetic or nursing a baby.
A continuing liability to further seizures by reason of a
structural lesion or electroencephalogram suggesting
subclinical seizures increases the risk of recurrent attacks.
Co-morbid factors, such as substance abuse or depression, need to be taken into consideration, as does compliance with treatment and the side-effects of medication.
If driving is a requirement of the job, then the medical
standards of the DVLA will apply [21]. Once reasonable

22

Occup. Med. Vol. 52, 2002

control of seizures has been achieved, epilepsy should

not prevent training as a clinical HCW, although night
work which leads to sleep deprivation may cause a
deterioration in seizure control [50]. HCWs with seizures
that have occurred only during sleep should not be
restricted in their work unless the HCW is on call that
night or if the symptoms persist during the following day.
A HCW liable to uncontrolled attacks of narcolepsy,
cataplexy or disabling vertigo should be restricted in
the same way as a HCW with epilepsy. Untreated sleep
apnoea will also interfere with concentration and performance, and is not therefore compatible with safe
clinical practice.
Disabling neurological conditions
Occupational problems may occur with any chronic
degenerative neurological condition that impairs motor,
sensory or cognitive functions, such as multiple sclerosis,
dementia or Parkinsons disease. Because much of the
work of a clinical HCW is safety critical, the functional
ability of an affected individual should be kept under
review by an occupational physician, in liaison, when
necessary, with the general practitioner and treating
specialist. A particluar problem occurs with cognitive
deficit that may not be appreciated by the affected HCW;
in which case, additional information from a third party
such as a colleague or spouse may be helpful.
Obesity
A body mass index of >30 kg/m2 is associated with
increased mortality [51], increased morbidity [52] and
more disability pensions [53]. Severe obesity in certain
circumstances may create difficulties with manual
handling and also with health education, which may need
to be taken into consideration at job placement.

employers make suitable and reasonable adjustments to

the workplace to accommodate an employee who has
substantial and long-term physical or mental impairment
that prevents that person from carrying out normal and
everyday activities [55]. Financial help for employers is
available from the Employment Service via the Disability
Employment Advisor.
An employer can only make adaptations if they are
aware that a HCW has a disability or medical condition
relevant to employment, and pre-placement health
screening or periodic health surveillance is one way in
which this can be facilitated. In most situations, safe
clinical practice can be achieved by workplace adaptations, safe systems of work, careful rehabilitation or
redeployment, and openness by both the clinical HCW
and the employer.

Acknowledgements
We thank the following for their contributions: Dr Ian Foulds,
Birmingham Skin Centre, City Hospital, Birmingham;
Professor John Govan, University of Edinburgh, Glasgow;
Professor Linda Luxon, National Hospital for Nervous
Diseases, London; Mr Tim Lang, Mills & Reeve Solicitors,
Birmingham; Professor Philip Murray, Birmingham and
Midland Eye Centre, City Hospital, Birmingham; Mr David
Proops, Department of Otolaryngology, The Queen Elizabeth
Hospital, Birmingham; Dr Alistair Robertson, Department of
Occupational Health, University Hospital of Birmingham
NHS Trust; Dr Peter Verow, Department of Occupational
Health, Sandwell Healthcare NHS Trust; and Dr John
Winer, Neuroscience Centre, The Queen Elizabeth Hospital,
Birmingham.

References
Employment law
HCWs who are at increased risk of illness or injury as a
result of their work must be given information, instruction and training on how to reduce such risks. Clinical
HCWs who contract an illness or who suffer an injury as
a result of their work are entitled to NHS Injury Benefit
(form AW13) and may be entitled to Industrial Injury
Benefit from the Benefits Agency. Doctors who are asked
to provide information about patients for the purpose of
employment should release information in accordance
with the Access to Medical Reports Act (1988) [54]. The
provision of such information falls within category 1 of
the Terms and Conditions of Service of Hospital Medical
and Dental Staff (appendix 3, sections 36 and 37) for
which no fee is payable.
The Disability Discrimination Act (1995) requires that

1. Bunker JWM. Personal Hygiene for Nurses. London:

Clair Elsmere Turner, 1924.
2. Merrison AW. The Report of the Committee of Inquiry into the
Regulation of the Medical Profession. London: HMSO, 1975.
3. Clothier C. The Allitt Inquiry. London: HMSO, 1991.
4. Bullock R. The Jenkinson Inquiry. Mansfield: North
Nottinghamshire Health Authority, 1997.
5. UK Health Departments. AIDS/HIV Infected Health Care
Workers: Guidance on the Management of Infected Health Care
Workers and Patient Notification. London: UK Health
Departments, 1998.
6. UK Health Departments. Protecting Health Care Workers and
Patients from Hepatitis B. Recommendations of the Advisory
Group on Hepatitis. London: UK Health Departments,
1993.
7. Advisory Group on Hepatitis. Hepatitis C Infected HealthcareWorkers. London: Advisory Group on Hepatitis, 96/15.

C. J. M. Poole et al.: Guidance on standards of health for clinical health care workers 23

8. GMC. Maintaining Good Medical Practice. General Medical

Council, 1998.
9. HMSO. Management of Health and Safety at Work Regulations 1992, Approved Code of Practice. London: HMSO,
1992.
10. Oxley J, Brandon S. Getting help for sick doctors (career
focus). Br Med J 1997; 314: 17 May, classified section.
11. Williams S, Hickie S, Pattani S. Improving the Health of the
NHSWorkforce. London: Nuffield Trust, 1998.
12. Firth-Cozens J. Depression in doctors. In Robertson MM,
Katona CLE, eds. Depression and Physical Illness.
Chichester: Wiley, 1997.
13. Goldberg DP, Bridges K, Duncan-Jones P, Grayson D.
Detecting anxiety and depression in general medical
settings. Br Med J 1988; 297: 897899.
14. Goldberg DP, Creed F, Benjamin S. Psychiatry in Medical
Practice. London: Routledge, 1992.
15. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J.
An inventory for measuring depression. Arch Gen Psychiatr
1965; 4: 561576.
16. Zigmond AS, Snaith RP. The hospital anxiety and
depression scale. Acta Psychiatr Scand 1983; 67: 361370.
17. Firth-Cozens J, Midgley SJ, Burges C. Questionnaire
survey of post-traumatic stress disorder in doctors involved
in Omagh bombing. Br Med J 1999; 319: 1609.
18. Heather N, Robertson I, eds. Problem Drinking. Oxford:
Oxford University Press, 1997.
19. Lacey JH, Mitchell-Heggs NA. Anorexia and Bulimia.
ABC of Mental Health. London: Faculty of Occupational
Medicine.
20. Maxwell H, ed. Clinical Psychotherapy for Health Professionals. London: Whurr Publishers Ltd, 2000.
21. DVLA. At a Glance Guide to the Current Medical Standards
of Fitness to Drive. Swansea: DVLA, 1999.
22. Spalding JAB. Medical students and congenital colour
vision deficiency: unnoticed problems and the case for
screening. Occup Med 1999; 49: 247252.
23. Poole CJM, Hill DJ, Christie JL, Birch J. Deficient colour
vision and interpretation of histopathology slides: cross
sectional study. Br Med J 1997; 315: 12791281.
24. Ayliffe GAJ, Fraise AP, Geddes AM, Mitchell K, eds.
Control of Hospital Infection. A Practical Handbook, 4th edn.
London: Arnold, 2000.
25. Payne RW. Severe outbreak of surgical sepsis due to
Staphylococcus aureus of unusual type and origin. Br Med J
1967; 4: 1720.
26. Duckworth G, Cookson H, Humphreys H, Heathcock R.
Revised guidelines for the control of methicillin-resistant
Staphylococcus aureus infection in hospitals. J Hosp Infect
1998; 39: 253290.
27. Meredith S, Watson JM, Citron KM, Cockcroft A,
Darbyshire J. Are healthcare workers in England and Wales
at increased risk of tuberculosis? Br Med J 1996; 313:
522525.
28. Hill A, Burge A, Skinner C. Tuberculosis in National
Health Service staff in the West Midland, region of
England, 19925. Thorax 1997; 52: 994997.
29. Kolditz GA, Brewer TF, Berkey CS, et al. Efficacy of BCG
vaccine in the prevention of tuberculosis. J Am Med Assoc
1994; 271: 698702.

30. UK Health Departments. Immunisation against Infectious

Disease. London: HMSO, 1996.
31. Ormerod LP, et al. for the Joint Tuberculosis Committee of
the British Thoracic Society. Control and prevention of
tuberculosis in the United Kingdom: Code of Practice
2000. Thorax 2000; 55: 887901.
32. The Interdepartmental Working Group on Tuberculosis.
The Prevention and Control of Tuberculosis in the United
Kingdom: Recommendations for the Prevention and Control of
Tuberculosis at Local Level. London: Department of Health
and Welsh Office, 1996.
33. Stewart CJ. Tuberculosis infection in a paediatric department. Br Med J 1976; 1: 3032.
34. Smith WH, David D, Mason KD, Onions JP. Intraoral and
pulmonary tuberculosis following dental treatment. Lancet
1982; 1: 842844.
35. George RH, Gully PR, Gill ON, Innes JA, Bakhshi SS,
Connolly M. An outbreak of tuberculosis in a childrens
hospital. J Hosp Infect 1986; 8: 129142.
36. Askew GL, Finelli L, Hutton M, et al. Mycobacterium
tuberculosis transmission from a paediatrician to patients.
Paediatrics 1997; 100: 1923.
37. Cheng K, Smyth RL, Govan JRW, et al. Spread of -lactam
resistant Pseudomonas aeruginosa in a cystic fibrosis clinic.
Lancet 1996; 348: 639642.
38. Govan JRW, Brown PH, Maddison J, et al. Evidence for
transmission of Pseudomonas cepacia by social contact in
cystic fibrosis. Lancet 1993; 342: 1519.
39. Jones AM, Goven JRW, Doherty CJ, et al. Spread of
multiresistant strain of Pseudomonas aeruginosa in an adult
cystic fibrosis clinic. Lancet 2001; 358: 557558.
40. Heptonstall J. Transmission of hepatitis B to patients
from four infected surgeons without hepatitis B e antigen.
N Engl J Med 1997; 336: 178184.
41. Esteban JI, Gomez J, Martell M, et al. Transmission of
hepatitis C virus by a cardiac surgeon. N Engl J Med 1996;
334: 555560.
42. Hepatitis C virus transmission from healthcare worker to
patient. Commun Dis Rep CDR Wkly 1995; 5: 30 June.
43. Two hepatitis C lookback exercisesnational and in
London. Commun Dis Rep CDR Wkly 200; 10: 125128.
44. Ross RS, Viazov S, Gross T, et al. Transmission of hepatitis
C virus from a patient to an anaesthesiology assistant to
five patients. N Engl J Med 2000; 343: 18511854.
45. Ciesielski C, Marianos D, Ou CY, et al. Transmission of
HIV in a dental practice. Ann Intern Med 1992; 116:
798805.
46. Transmission of HIV from an infected surgeon to a patient
in France. Commun Dis Rep CDR Wkly 1997; 7: 17.
47. Breathnach AS, de Ruiter A, Holdsworth GMC, et al. An
outbreak of multi-drug resistant tuberculosis in a London
teaching hospital. J Hosp Infect 1998; 39: 111117.
48. Carman WF, Elder AG, Wallis LA, et al. Effects of influenza
vaccination of health-care workers on mortality of elderly
people in long-term care: a randomised controlled trial.
Lancet 2000; 355: 9398.
49. Potter J, Stott BJ, Roberts MA, et al. Influenza vaccination
of health care workers in long-term-care in hospitals
reduces the mortality of elderly patients. J Infect Dis 1997;
175: 16.

24

Occup. Med. Vol. 52, 2002

50. Laidlaw J, Richens A, Oxley J, eds. A Textbook of Epilepsy,

3rd edn. Edinburgh: Churchill Livingstone, 1988.
51. Calle EE, Michael TJ, Petrelli JM, Rodriguez C, Clark HW.
Body-mass index and mortality in a prospective cohort of
U.S. adults. N Engl J Med 1999; 341: 10971105.
52. Jung RT. Obesity as a disease. Br Med Bull 1997; 53:
307321.

53. Rissanen A, Heliovaara M, Knekt P, et al. Risk of disability

and mortality due to overweight in a Finnish population.
Br Med J 1990; 301: 835837.
54. HMSO. Access to Medical Reports Act 1988. London:
HMSO.
55. Department for Education & Employment. Disability
Discrimination Act 1995. Code of Practice. London: HMSO.