CIVIL NUCLEAR CONSTABULARY MEDICAL CRITERIA – Version three – May 2014 This document brings together the guidance that must be followed in carrying out medical examinations on CNC employees who require a mandatory medical examination, broken down by type of medical. The guidance has originated from a number of sources (and each point records the origin for audit purposes) including: 1 2 3 4 5 6 7 8 9 10

HOC 25/2003 – Eyesight standards for police recruitment – 1st April 2003 ACPO Firearms Guidance 2004 HOC 59/2004 – National Recruitment Standards – Medical Standards for Police Recruitment Control of Noise at Work Regulations 2006 HSE guidance ACPO Medical standards for AFO’s and eyesight standards for STU Taser Officers 14/10/13 – which refers to DVLA Group 2 guidance – www.dft.gov.uk/dvla/medical/ataglance.aspx IRR 1999 requirements Justification for CNC medical standards document NICE – Hypertension: Quick Reference Guide Medical report on activity after hip and knee replacement – 26th October 2014 – Prof A Hart

This document should be used in conjunction with the Civil Nuclear Constabulary medical specification which details the elements which should be tested in each medical examination. This guidance should be considered carefully on a case by case basis and any conditions noted should be highlighted to the CNC CMO and referred to CNC Risk Assessment Panel for consideration for suitability for employment. NB the OH Departments are not expected to make decisions on suitability for employment but act in an advisory capacity. The medical specification details which member of Occupational Health staff should carry out the medical examination. Occupational Health staff carrying out the assessment should be made aware of any medication being taken by the individual so that an accurate review can be made of the potential effects of the treatment on the ability of that person to carry out their role (for example handling Firearms safely). As well as police officers, CNC Police staff in high risk roles who also require medical examinations are detailed separately and are: Firearms Instructor Armourer Kennel Assistant Staff Control Room Operator Staff PST instructor NB whilst Senior Officers require annual medicals, their medical assessment should be undertaken on a case by case basis commensurate with their individual role. As such, individual Job Descriptions will be provided prior to the medical to ensure that the OHD is able to carry out an appropriate assessment of suitability for work. In all cases where any area of concern is discovered at the medicals, the relevant HR Representative / Line Manager should be informed for consideration at Risk Assessment panel. For conditions that have been identified at pre-employment, during routine medical examination or other Occupational Health intervention, and the individual joins the CNC/remains in their role/is placed on recuperative/restricted duties, it is expected that this will be monitored at

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the routine medical examinations or via separate Occupational Health intervention. In these circumstances further Risk Assessments are only necessary where the condition has deteriorated. Applicants to these roles will be expected to complete a Declaration of Health which should be signed by the individual’s GP once complete and prior to submission at pre-employment and six-yearly intervals. Any medical condition should be highlighted to CNC CMO / via CNC Occupational Health for consideration at CNC RAP by emailing: [email protected] or telephone 01235 466220.

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Mandatory standard

Visual Field

Normal Vision fields (checked by confrontation unless detailed assessment clinically indicated), namely a field of view of at least 160 degrees horizontally by 100 degrees vertically is required. The field of view should be free of any large defective areas, particularly in the fovea. Single defects smaller than the physiological blind spot, and multiple defects that add to an area smaller than the psychological blind spot, should be acceptable – Screening by taking a history of confrontation is acceptable (do not rely on a keystone or similar screening tool, an optician’s report is acceptable).

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Spectacles and contact lenses Eye surgery

Corrective spectacles and contact lenses are acceptable (nb for AFO spectacles cannot be worn to reach the unaided standards, however for contact lens wearers, unaided standard not applicable provided the aided standard can be corrected to 6/7.5 in each eye and binocularly and the lenses are well tolerated) LIKELY TO BE SUITABLE - PRK, LASIK, LASEK, ICRS, cataract surgery: There is no significant weakening of the cornea. A period of at least 6 weeks after surgery should be allowed before applications are accepted. There may be a reduction in low light level visual performance; Test visual performance under low illuminance conditions. UNLIKELY TO BE SUITABLE - Radial Keratotomy (RK), Arcuate Keratotomy (AK), corneal grafts. Any other surgical procedures that result in a significant weakening of the cornea. There is a measurable risk of corneal rupture if the eye is struck.

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Eyesight

UNLIKELY TO BE SUITABLE – Squint, History of detached retina, History of Glaucoma, Photorefractive Keratotomy LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – Latent squint, Lens implant, Corneal graft with good uncorrected visual acuity. Pre-employment Because AFO role requires use of non-dominant eye, eyesight should be 6/7.5 6/7.5 aided or unaided in each eye and binocularly Existing employees Binocular vision: If AFO achieves less than pre-employment requirement but reaches 6/7.5 aided or unaided (6/12 or better worst eye) Unaided 6/36, risk assess on a case by case basis. (nb When successful correction has been achieved using soft contact lenses unaided standard need not apply). Dichromats and severe anomalous trichromats unsuitable for firearms roles. If colour vision status has not already been established by previous testing. Ishihara as screening test – if abnormal then confirm with either – 2nd edition City University Test (fail if 5 or more total errors Or 2 errors on the large circle plates) Using Farnsworth DI5 (fail if 2 or more major crossings). Other equivalent or additional tests should be used but generally unless clinically indicated colour vision needs checked only once.

EYESIGHT

Visual Acuity

Colour Vision

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Mandatory standard

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Hearing

UNLIKELY TO BE SUITABLE Existing employees: sum of hearing loss > 84db over 0.5, 1, 2 KHz frequencies. Sum of hearing loss > 123db over 3, 4, 6 KHz frequencies.

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EARS UNLIKELY TO BE SUITABLE On recruitment: more than average of 20dB loss over range 500 – 4000 Hz when audiogram is taken using a sound proof booth, Unilateral hearing loss of a similar magnitude. For applicants who achieve less than the recruitment standards but more than the Existing employee standards, risk assess on an individual basis to inform opinion on impact on ongoing employment

External ear

Tympanic membrane and middle ear NOSE

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THROAT

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Use of hearing aids (including implanted devices) to achieve this standard would not be compatible with firearms use LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – More severe recurrent otitis externa (impedes function, balance and use of communications equipment), Atresia or stenosis of ear canal (unless excluded on audiometric criteria) LIKELY TO BE SUITABLE – Mild occasional otitis externa

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LIKELY TO BE SUITABLE – Healed perforation, Healed Chronic otitis media, successful myringoplasty / tympanoplasty LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – Chronic perforation, Ventilation tubes (grommets), Inactive Chronic otitis media, Active Chronic otitis media, Chronic serous otitis media, Post-mastoid surgery (unless audiometric standards are not met. If active chronic disease – unlikely to be suitable), Otosclerosis, Facial palsy with loss of function LIKELY TO BE SUITABLE – Allergic vasomotor rhinitis, recurrent nasal polyps where there isn’t a significant history, persistent chronic sinusitis where there isn’t a significant history LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT - recurrent nasal polyps where there is a significant history, persistent chronic sinusitis where there is a significant history

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LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – Chronic laryngitis, Other laryngeal disease, Severe speech impediment, Balance disorders and vertigo (Usually a symptom of another condition which may make the individual unsuitable) UNLIKELY TO BE SUITABLE ON RECRUITMENT, RISK ASSESS ON INDIVIDUAL BASIS IF IDENTIFIED AT ANNUAL MEDICAL – Tracheostomy, Severe speech impediment where the individual cannot communicate effectively (unable effectively to perform vital task of radio and voice communication)

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n/a Cardiovascular

Hypertension Recruitment if blood pressure exceeds 140/90, refer to GP for assessment and consideration of medication. Allow continuation of recruitment activities once blood pressure stabilised with no side effects from medication. Existing employees: if blood pressure exceeds 140/90, refer to GP for assessment and medication as appropriate, if BP exceeds 140/90 but does not exceed 160/100 where there is no evidence of end organ damage following the process as defined on page 10 of the NICE guidelines, officer may remain operational. Review in OHD in 4-6 weeks. OH should not declare them as 'fit' until the GP investigations are concluded and the BP concern resolved as appropriate. Officers who have Blood Pressure in excess of 160/100 and those in excess of 140/90 with evidence of end organ damage must be removed from operational duties immediately whilst GP examinations are concluded.

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For all other conditions, refer to DVLA Group 2 Neurological

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Refer to DVLA Group 2 guidance

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Endocrine system

TEST

Mandatory standard

Metabolic

LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – History of thyroid disorder/disease (likely to be suitable where successful treatment has been completed), history of any other metabolic disorder,

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Weight Body fat

On recruitment, BMI below 19 / above 30 (where percentage body fat greater than Male – 25%, Female – 32%), defer to later course to enable appropriate timescale to increase / reduce. For existing employees, refer to the appropriate CNC Health, Well-being and Fitness Advisor using appended referral form for lifestyle advice. Unless medical symptoms are present, low / raised BMI / body fat percentage for existing employees does not affect operational deployability. Insulin-Treated Not suitable for employment as a CNC AFO, other roles RAP on case by case basis Potential hypoglycaemia inducing tablets Unlikely to be suitable, RAP on individual basis Other tablets (non-insulin medication) Unlikely to be suitable, RAP on individual basis Diet managed Pre-employment – unlikely to be suitable, Existing employees - Likely to be suitable, carry out RAP in all circumstances Hypoglycaemia for any other cause than diabetes, pancreas transplant, pancreatic islet cell transplant – RAP on individual basis. Refer to DVLA Group 2

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Diabetes

Hypoglyca emia

Alimentary system

Respiratory

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UNLIKELY TO BE SUITABLE ON RECRUITMENT, RISK ASSESS ON INDIVIDUAL BASIS IF IDENTIFIED AT ANNUAL MEDICAL– Inflammatory bowel disease (Crohn’s disease, Ulcerative Colitis (further investigation required if treatment has been successful) – chronic conditions with unpredictable course and relatively high surgical intervention rates), chronic liver disease, Chronic biliary tree disorder, chronic pancreatitis, Stoma (CBRN user) LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – Peptic ulceration or dyspepsia (chronic pain may interfere with role), not mild IBS (investigate – require close proximity to toilet, codeine for control, stress associated), Hernia (defer until treated > 3 months after treatment – training and operational role will be compromised due to local weakness in abdominal musculature. Hernia is likely to increase in severity), Gallstone disease, single episode of pancreatitis, Anal and perianal conditions – where chronic (persistent perianal sepsis will cause significant absence LIKELY TO BE SUITABLE – mild IBS Conditions will limit working ability most commonly from the sensation of breathlessness LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – Sinusitis, Chronic URTI, Past history of asthma, FEV 1% less than 75, Non Asthmatic Chronic Respiratory disorders, Asthma currently in treatment including inhalers, FEVI of FVC more than two standard deviations below predicted norm LIKELY TO BE SUITABLE – Treated hay fever without history of wheezing, Spontaneous Pneumothorax on one occasion, UNLIKELY TO BE SUITABLE – Any persistent respiratory disease impairing exercise capacity, Chronic Obstructive Pulmonary Disease (COPD) affecting exercise capacity (the loss of normal respiratory function will limit exercise capacity even in the absence of superadded chest infections, active tuberculosis (unacceptable risk of transmission) LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – Asthma (note the CBRN requirements of the role), Hay Fever, Recurrent pneumothoraces (reassess after treatment aimed at preventing further occurrences), history of tuberculosis, Sarcoidosis refer to DVLA Group 2 guidance - Cough syncope / carcinoma of lung

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TEST

Mandatory standard

Nephrourogenital system

Genito Urinary

UNLIKELY TO BE SUITABLE – Chronic genito-urinary disorders, persistent major urethral abnormality (treatment is likely to be protracted),

Effects ability to attend and safety. Complications pain, hypertension and renal failure

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LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – Haematuria / Proteinuria (GP to investigate in the first instance), recurrent urinary tract infections, minor urethral abnormality, urinary incontinence, benign scrotal swellings, testicular tumours, Renal disorders

UNLIKELY TO BE SUITABLE History of nephritis and ongoing impairment, polycystic kidney disease (progression to end stage kidney failure), Irreversible renal failure (associated fatigue, anemia and therapy effects not compatible with operational Police Constable role), Renal dialysis (Haemo/CAPD) (associated fatigue, anemia and therapy effects not compatible with operational Police Constable role) LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT Major congenital renal abnormality, established renal stone disease LIKELY TO BE SUITABLE - Congenital renal abnormality with normal renal function, unilateral kidney (with remaining kidney functioning well) Refer to DVLA Group 2 guidance for other conditions

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Musculoskeletal, orthopedic and soft tissue conditions Dexterity, mobility and good spinal function are essential physical requirements for an individual to undertake the role of police officer

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LIKELY TO BE SUITABLE – Resolved whiplash (may be exacerbated by physical activities and driving), controlled gout without complications UNLIKELY TO BE SUITABLE –, History of laminectomy, History of major joint surgery, Recurrent dislocation of major joint, Major foot deformities, Muscle wasting – effects of Cerebral Palsy, Chronic orthopaedic problems, Endoprosthetic replacement (used in osteosarcoma surgery. Unacceptable risk of prosthesis failure or fracture around site), Osteochrondritis dissecans (risk of severe knee joint damage), cervical discectomy (+/- fusion) (cervical discectomy will often not improve neck pain. Also there may be persisting neurological disability in the upper limbs), Multiple level lumbar disease, UNSUITABLE – at recruitment stage reject applicants who have undergone any key joint replacement surgery (eg Hip or knee) LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT History of Back disorder requiring hospital treatment, History of minor back disorder, History of arthroscopy including partial meniscectomy, Isolated dislocation of any joint, Rheumatoid arthritis (progressive joint damage with degrading of operational capacity), Ankylosing Spondylitis, History of knee injuries NOT requiring surgery, Significant fracture, Major soft tissue injury, Chondromalacia patellae, Any previous injury (fracture, soft tissue injury) or congenital deformity, causing long term reduction in function of a joint or limb, internally fixed fractures ‘metal work’ (risk of re-fracture at site of metal work when returning to more energetic activities), Medial meniscectomy, Lateral meniscectomy (risk of early osteoarthritis with associated disability), Ligamentous injury requiring surgery or causing instability (risk of re-injury in operational role), foot disorders, amputations (total or partial) of upper or lower limb, Single level resolved lumbar disk disease +/- discectomy (low back pain +/- lower limb symptoms can be disabling. Exacerbated by driving, standing for long periods, other physical tasks), Recurrent low back pain / persistent sciatica, Reiter’s diseases / reactive arthropathy, Connective tissue diseases / other arthritis (can cause diagnostic difficulties and often unpredictable course. Potential for severe incapacitation), for existing employees risk assess individuals with joint replacements on a case by case basis applying the criteria contained within the document: ‘medical report on activity after knee and hip replacement’ At recruitment stage risk assess applicants with non key joint replacement on a case by case basis ( e.g silastic implants for fingers and toes)

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Mandatory standard

Psychiatric

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Minor/Short-lived Anxiety and Depression Existing employees - consider return to full duties once symptoms disappear, subject to approval from RAP. On recruitment, consider as fit for employment when 6 months elapsed from becoming well and stable after incident More severe Anxiety and Depression (without significant memory or concentration problems, agitation, behavioural disturbance or suicidal thoughts) – RAP required. Consider as fit for employment / return to full duties when 6 months elapsed from becoming well and stable after incident (for existing employees, they may remain on medication, for new recruits, 6 months must have elapsed post completion of medication). More Severe Anxiety States or depressive illnesses (with significant memory or concentration problems, agitation, behavioural disturbances or suicidal thoughts) – RAP required. For existing employees Consider as fit for employment / return to full duties when 6 months elapsed from becoming well and stable after incident (they may remain on medication) For new recruits, 2 years must have elapsed from becoming well and stable after incident, 6 months must have elapsed post completion of medication. Acute psychotic disorders of any type A person must be free from such episode for a minimum of three years before they could be considered – unlikely to be suitable pre-employment, RAP on all occasions, for existing employees – RAP to determine continuation of employment. All other psychiatric disorders – Refer to DVLA Group 2 guidance and RAP in all circumstances.

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In view of the possible consequences of having firearms possession following mental health issues, contact with the GP would be considered essential in such cases not least to inform the GP that access to firearms is an issue. (Appropriate consent should be sought from the officer unless there is a significant risk of harm to self or others). Skin

Haematological disorders

Possible radioactive exposure, investigate any skin condition or abrasion on exposed areas UNLIKELY TO BE SUITABLE – Extensive skin disease with chronic discomfort or disruption of dermal integrity, widespread eczema/dermatitis, severe psoriasis LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT Pustular Acne, Other chronic skin conditions, Mild eczema (not on exposed areas), Malignant Melanoma, following excision (exposure to irritants or inhospitable environments will result in frequent exacerbations – consider IRR requirements and CBRN usage) LIKELY TO BE SUITABLE – Mild psoriasis UNLIKELY TO BE SUITABLE – Polycythaemia (Haematocrit >0.55) (Unacceptable risk of disabling complications), Thalassaemia major with severe chronic anemia (unable to safely perform required exertion), Sickle cell disease (anaemia and crises), Mild symptomatic haemophilia (physical tasks and risk of injury may precipitate hemorrhage), Anticoagulation therapy including warfarin (reject - pre-employment, RAP on employment) LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – Previously undetected iron deficiency anaemia (refer to GP), Other anaemia (many of the underlying conditions causing anaemia will preclude suitability), G6PD deficiency, Mild Asymptomatic haemophilia, Leukaemia / lymphoma with complete remission, Anticoagulation therapy including warfarin (reject - pre-employment, RAP on employment) LIKELY TO BE SUITABLE – Sickle cell disease trait (usually asymptomatic)

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LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT –Hepatitis B Carriers, Hepatitis C and D, Glandular fever LIKELY TO BE SUITABLE – Resolved Hepatitis E infection, Resolved Hepatitis B infection without carrier status

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Mandatory standard

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Infectious disease

LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT genetic disease, chronic pelvic inflammatory disease (PID) with chronic pain, incapacitating menorrhagia, incapacitating dysmenorrhoea, endometriosis, fibroids and ovarian cysts, cervical dysplasia CIN 3, polycystic ovary disease LIKELY TO BE SUITABLE – Cervical dysplasia CIN 1/2, pregnancy (3 months following delivery), termination of pregnancy (after 4 weeks where no complications) LIKELY TO REQUIRE FURTHER INFORMATION, INVESTIGATION AND ASSESSMENT – All indications of SLD’s including dyslexia, dyscalculia, dyspraxia, dysgraphia, ADD, ADHD, Asberger’s Syndrome must be referred to CNC OH for an individual Risk Assessment Panel to be conducted. Please ensure that individual has a full adult diagnostic report (CNC will consider funding for existing employees).

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Drug and alchohol misuse and dependency

Refer to CNC Substance Misuse Procedure and security vetting procedures for existing employees and CNC Substance Misuse Procedure and security vetting procedures and DVLA Group 2 guidance on recruitment

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Excessive sleepiness

Refer to DVLA Group 2 guidance

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HIV / AIDS Transplant not already covered Devices or implants not covered in earlier sections

Risk assess on individual basis (refer to DVLA Group 2 guidance) Risk assess on individual basis (refer to DVLA Group 2 guidance)

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Risk assess on individual basis (refer to DVLA Group 2 guidance) – Unlikely to be suitable on recruitment

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Miscellaneous

Specific Learning Difficulties

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Police staff roles subject to medical assessment Police staff roles which will require a full medical pre-employment and on an annual basis are detailed below. In all cases a full medical should be carried out based on AFO standards and any areas where these are not met should be subject to consideration by Risk Assessment Panel for agreement regarding suitability of appointment / reasonable adjustments required. In doing so, particular attention must be paid to the areas indicated below (nb psychiatric illness must be considered carefully in all circumstances): Police staff firearms instructor Hearing CNC AFO standards apply in all circumstances Eyesight

CNC AFO standards apply in all circumstances

Skin

CNC AFO standards apply in all circumstances where police staff member is expected to be involved in on-site emergency exercises

Respiratory

CNC AFO standards may apply where police staff member is expected to be involved in on-site emergency exercises

Diabetes

CNC AFO standards may apply where police staff member is expected to be involved in on-site emergency exercises

Mental Health

CNC AFO standards apply in all circumstances

Armourer and Kennel Assistant Hearing / Ears Consider AFO standards, RAP incidences where these are not met on a case by case basis. Hearing conversation programme required to monitor changes in hearing including baseline assessment. Vision Consider AFO standards, RAP incidences where these are not met on a case by case basis, practical Risk Assessment may be required. Respiratory

Consider AFO standards, RAP incidences where these are not met on a case by case basis.

Skin

Consider AFO standards, RAP incidences where these are not met on a case by case basis.

Mental Health

CNC AFO standards apply in all circumstances

Staff Control Room Operator Ears Consider national police recruitment standards, RAP incidences where these are not met on a case by case basis. Must have the ability to understand conversational voice, hearing conversation programme required to monitor changes in hearing including baseline assessment Speech

UNLIKELY TO BE SUITABLE - Severe speech impediment where the individual cannot communicate effectively (unable effectively to perform vital task of radio and voice communication)

Vision

Consider national police recruitment standards, RAP incidences where these are not met on a case by case basis, practical Risk Assessment may be required.

Police staff PST Instructor, Health, Wellbeing and Fitness Advisor Cardiovascular Consider AFO standards, RAP incidences where these are not met on a case by case basis

Respiratory

Consider AFO standards, RAP incidences where these are not met on a case by case basis

Musculoskeletal

Consider AFO standards, RAP incidences where these are not met on a case by case basis