10. In 2001, an expert group was set up to carry out an assessment of the potential health risk posed to patients by healthcare workers who are new to the NHS and who are infected with tuberculosis ( TB), hepatitis B, hepatitis C or HIV. This decision was prompted by the convergence of three issues:
- The recruitment of staff to the NHS from overseas who were subsequently found to be infected with blood-borne viruses ( BBVs);
- Individuals infected with BBVs who were seeking to enter medical, dental, midwifery and nursing schools and to qualify and practise as registered practitioners; and
- The burden of patient notification ('look-back') exercises, in terms of widespread anxiety for patients and high costs to the NHS.
11. In its report, the expert group made a number of recommendations designed to both reinforce and extend existing measures to reduce the risk of healthcare worker to patient transmission of blood-borne viruses and TB. Those recommendations were accepted by Ministers and form the basis of this guidance. Screening arrangements for existing NHS staff were explicitly excluded from the expert group's remit, as were measures to protect against other infectious disease risks (e.g. varicella). Following consultation on draft guidance in 2003, this final version has been produced.
12. This Scottish version of UK guidance describes health clearance measures for new healthcare workers. Its primary purpose is to provide further protection for patients from exposure, in the clinical care setting, to tuberculosis ( TB), hepatitis B, hepatitis C and HIV. The new measures are not intended to prevent those infected with blood-borne viruses from working in the NHS, but rather to restrict them from working in those clinical areas where their infection may pose a risk to patients in their care. This is consistent with existing policy, which imposes restrictions on the working practices of those healthcare workers who are known to be infectious carriers of HIV, hepatitis B and hepatitis C.
13. Healthcare workers may also benefit from these new health clearance arrangements both personally (e.g. earlier diagnosis may lead to curative or life-prolonging treatment and prevention of onward transmission), and professionally (e.g. avoiding work activities that may pose a risk to their own health and making career choices appropriate to their infection status).
14. The action recommended by this guidance forms a necessary part of implementation of NHS Circular GEN (1995) 4: Occupational Health and Safety Services for NHSScotland Staff and Towards a Safer Healthier Workplace, in relation to occupational health assessment for substantive NHS employees as well as temporary staff.
15. The UK Health Departments' guidance, Immunisation Against Infectious Disease (the 'Green Book') includes advice on the immunisation of healthcare workers and this is included at Annex A.
New Healthcare Workers
16. For the purposes of this guidance, a new healthcare worker is defined as:
- an individual having direct clinical contact (as opposed to casual or social contact - see paragraph 19 below) with NHS patients, whether as an employee of an NHS Board or with the NHS Board's agreement (e.g. student placements, visiting fellows) for the first time; and
- existing healthcare workers moving to a post or training that involves exposure-prone procedures ( EPPs) for the first time in their career are also considered as 'new' (see paras 17 and 39).
- returning healthcare workers may also be regarded as 'new', depending on what activities they have engaged in while away from the health service (see paragraphs 40 and 41).
17. The guidance does not apply to healthcare workers who are already employed in the NHS, with the exception of those moving to a post requiring the performance of EPPs for the first time in their career (see also para 39). Equally the guidance does not apply to staff who do not have direct clinical contact with patients (i.e. receptionists, administrators etc).
18. Further detail on categories of new health care worker, including locum, agency and independent healthcare service staff, is given in paras 31-45 below.
Direct Clinical Contact
19. The advice from the Green Book, included at Annex A, describes staff involved in direct patient care as:
' staff who have regular clinical contact with patients and who are directly involved in patient care. This includes doctors, dentists, midwives and nurses, paramedics and ambulance drivers, occupational therapists, physiotherapists, and radiographers. Students and trainees in these disciplines and volunteers who are working with patients must also be included.'
However this list should not be considered exhaustive and there may be workers from allied health professions or other fields such as clinical support where an assessment of risk would suggest standard or additional health checks should be undertaken. It will be for Health Boards and Medical Schools to consider in individual circumstances. (The list of example Exposure Prone Procedures at Annex B will be of use.)
20. The Green Book specifies non-clinical staff (i.e. those for whom immunisation is not normally required) as:
'non-clinical ancillary staff who may have social contact with patients but are not directly involved in patient care. This group includes receptionists, ward clerks, porters and cleaners'.