Health Clearance For Serious Communicable Diseases: New Health Care Workers Draft Guidance for Consultation

UNISON Scotland's response to Scottish Executive Consultation on Health Clearance for Serious Communicable Diseases: New Health Care Workers Draft Guidance for Consultation

October 2003

Executive Summary

• UNISON welcomes the opportunity to respond to the consultation, Health Clearance for Serious Communicable Diseases: New Health Care Workers Draft Guidance for Consultation.

• UNISON Scotland is opposed to the proposals in the Consultation and is disappointed with the Scottish Executive's willingness to so readily adopt Westminster's original consultation on the same subject.

• We believe that the need for all new staff to have standard health clearance for serious communicable diseases and additional health clearance for staff performing EPPs could be construed as racist and in breach of the Human Rights Act 1998 (Article 8).

• UNISON Scotland recommends that the NHS employers work in partnership with trade unions on the development of health and safety procedures and model policies to ensure there is no risk of accidental contamination from HIV/AIDS and other infections.
• As a means to educate and de-stigmatise myths surrounding serious communicable diseases such as HIV/AIDS, we believe that there is a need for a new public education campaign.
• Given the Joint Future agenda, and the joint working done between the health service and local government, there should be discussions on improving the health and safety of patients and health service workers.

Introduction

UNISON is Scotland's largest trade union representing 150,000 members delivering public services in Local Government, Health, further and higher education, energy (gas and electricity), water, transport and the voluntary and community sector. We represent the majority of the employees of the National Health Service in Scotland.

This paper constitutes UNISON Scotland's response to the consultation document issued by the Scottish Executive on Health Clearance for Serious Communicable Diseases: New Health Care Workers Draft Guidance for Consultation.

Response

Health Clearance Measures for New Health Care Workers

UNISON Scotland is concerned with the Scottish Executive's proposal to introduce health clearance measures for new health care workers being employed or starting training in a clinical care setting either for the first time or, in certain circumstances, returning to work in the NHS. As the document states, this consultation is a Scottish version of the English guidance. There is no attempt however, to analyse, criticise or change the English version. This is disappointing considering that the English version of the consultation is based on extremely thin evidence. The English consultation is based on a report from an expert group, set up at the request of CMO and Ministers. The Ad hoc risk assessment group was given the task,

" to consider the risk posed to patients by health care workers infected with serious communicable diseases… who were new to the NHS. Considerations for existing staff were specifically excluded." (1)

Racist

UNISON Scotland believes that the consultation could be construed as racist. The expert group was asked to assess the potential risks posed to patients by new staff in particular. It is highly likely that this was due to fears that new foreign nurses and medical staff could pose a greater risk to patients than those from the UK. This could be viewed as scaremongering, thinly veiled as a health and safety precaution. This point is reinforced in group's report. In the section summarising one of their meetings, it states that one of the outcomes,

"Reviewed current UK policy on screening for and restricting health care workers with BBVs. Followed-up with investigation of other countries' policies, especially those countries contributing significantly to the NHS workforce or where recruitment is ongoing/planned." (1)

As a union representing national health service workers from many different origins, we would argue that this approach has a racist foundation. The expert group was also concerned with this, but ultimately felt they would be able to justify their decision. The group,

"Reviewed the legal issues with potential bearing on the policy (e.g. Human Rights, European Community, Race Discrimination, Disability Discrimination, Negligence (duty of care) and Health and Safety) to inform discussion of options. It was felt that, should any indirect discrimination occur unintentionally, this would be justifiable and proportionate in the circumstances." (1)

Unison Scotland does not believe that there can ever be justification for any kind of discrimination or racism. We will therefore strongly resist any attempt to test new staff. The whole idea of testing certain staff over others, and treating those that decline as if they were infected, is not acceptable. The group recommended that those who decline testing (for posts or careers involving exposure-prone procedures [EPPs]),

"…will be treated as if infected and their practice restricted accordingly." (1)

This is one step away from compulsory health tests for all workers, which UNISON Scotland is against. The expert group actually considered,

"Stratified testing of new entrants according to prevalence of the disease in country of birth or membership of a high-risk group (e.g. HIV in gay men); effectively testing for HIV and hepatitis C virus (HCV) since universal hepatitis B (HBV) and TB policies already in place."

To even consider testing entrants according to what prevalence band they fit within, in a country-by-country comparison, is impractical and pointless. Just because someone might come from a country where there is a higher percentage of HIV or hepatitis does not indicate that this employee has a disease. The chances of someone having a communicable disease, are so low, that it still would not justify testing. How would employers separate out those who may have a disease? Potential employees would have to be asked questions such whether they were gay or black?

We would point out that this kind of testing may infringe on workers' civil liberties and be in breach of the Human Rights Act 1998 (Article 8). A far better approach to improving health and safety risks is to generate a culture of openness and transparency. Employers' occupational health and safety personnel and trade unions need to work together to create a blame-free atmosphere. Compulsory testing of certain staff will only create an atmosphere of suspicion.

No Hard Evidence

The expert group used vague evidence to back their recommendations. They claim to have used "the best available evidence", however this is not backed up with any hard evidence or raw data. The report makes a poor attempt at backing up their reasoning, which is surprising considering the long list of experts including many medical and legal professionals. Their report states that,

"Using the best available evidence on the current prevalence and transmission rates in the UK it was estimated that, for the four infections combined, around 30 or fewer transmissions per year might be expected from infected health care workers to patients." (1)

The expert group gave absolutely no indication on where this "best available evidence" came from. Whereas in other government publications on related subjects there is plenty of detailed statistics and raw data to back up whatever argument an expert group may be putting forward.

For example, in one related Scottish Executive Publication on needlestick awareness entitled, Needlestick Awareness: Sharpen Your Awareness, published in 29/05/01, the report of the Short Life Working Group looked at needlestick injuries in the NHSScotland. The Report addressed the need to consider the introduction of safer devices and recommended that all NHS employers carry out a full risk assessment when deciding whether or not to introduce safer devices.

The Needlestick publication however, was packed full of statistics and raw evidence. For example,

"In September 1999, all NHSScotland Trusts and Health Boards were asked by the Scottish Executive Health Department to provide information relating to the incidence of needlestick injuries in their area, 23 out of 28 Trusts and 15 out of 21 Health Boards (including Special Health Boards and the CSA) responded. The data, in general, covered the time period 1996-99 and have been extrapolated to represent all 28 Trusts in Scotland." (2)

The report also attempts to look at other world-wide reports on the same subject, such as in one case where the group are looking at when needlestick injury occurs,

"These data are similar to those of a larger American study (CDC, 1999) where only one quarter of the procedures undertaken when a needlestick injury occurred was during the clinical procedure." (2)

Nevertheless, even they admitted that,

"One of the main barriers to the work of the group has been the lack of adequate information. Data pertaining to needlestick injuries are not collected consistently across the NHSScotland." (2)

This is a far more honest approach to introducing new proposals with taxpayers money. The group studying needlestick injuries and debating whether or not it was worth it to pay for safer needles, at least admitted that the available information was poor, but made some attempt at examining raw evidence. They also presented a risk assessment to help employers make decisions. UNISON is not claiming that this report is correct or for that matter incorrect. What we are trying to demonstrate, is that when expert groups are asked to present an argument by the government, they use information when it suits them, and when it does not, they do not.

Ironically the expert group who were reporting on using safer needles, did not recommend that safer needlesticks should be used (something that would protect the staff). They only offered a risk assessment to help employers. Whereas the expert group who are reporting on testing staff, recommend that testing should go ahead (something that would protect patients). There seems to be a discrepancy in policy here. Considering that all the evidence available shows that health care workers are far more likely to contract a disease from patients than the other way around, the recommendations should if anything be reversed. If the Executive and the public demand that health care workers are to be tested then we would demand that all patients are tested.

Low Risk of Infection

UNISON Scotland believes that the Scottish Executive are going along with the English version of the consultation for political reasons rather than for real health risks. If they had properly examined the origins of the consultation they would have found the reasoning flawed. Even the information that the expert group base their findings on, shows a very low risk factor involved. See page 16, Annex 3, table entitled, "Risk of transmission of serious communicable diseases by prevalence band of country of origin of health worker". (1) The table shows percentages of risks of transmission by prevalence band of country of origin of health care worker. The percentage of risk shown however, is extremely low for all the diseases. For example, for the HIV transmission risk estimate during EPP is 0.02 %,

"HIV transmission risk estimate is based on global published literature and modelling work. Patient notification exercises conducted in the UK (in which no transmissions were found) estimate the risk to be <0.02%. until further evidence becomes available, this estimate seems more realistic than the lower US figure of 0.00024-0.0024%." (1)

Not only is the evidence practically non-existent for risk of transmission, but the low percentage of risk is not even based on "real" evidence. It is based on globally published literature and modelling work. The table divides and compares the risks according to prevalence bands, which are far from an exact science. The actual UK evidence then explicitly states that no transmissions were found in the UK. The US evidence shows an even lower risk of transmission compared to the global and modelling evidence. This is significant, as there are far more immigrants in the USA compared to many other countries. If one were to believe the scaremongering, racist beliefs that AIDS/HIV and other infectious diseases were being brought into the (UK) country by infected foreigners, then there should be a higher risk of disease/infection in the USA.

So not only is the evidence very weak, but the evidence that they do use, does not back up their argument. They are therefore making recommendations to test new staff, even though the evidence shows it would not be worthwhile. So why are these recommendations being made? If every decision taken in the NHS was based on such flimsy evidence, the NHS would go bust. This further goes to prove that the decision to test health workers comes from a political decision, not one based on careful evidence-based research and an occupational risk assessment.

Media-fuelled Fears

Whilst UNISON understands the need to have clear guidelines and procedures for protecting patients against infection from AIDS/HIV health workers, we are not aware of any reported cases of patients dying following contact with AIDS/HIV infected health care workers. It is more likely that Ministers want the testing to be carried out based on the well-publicised cases of thousands of patients being checked for possible HIV infection following contact with infected healthcare workers. There have been around two dozen such cases in Britain in 14 years, but in no case has cross-infection been found. Only in two cases worldwide has there been any suggestion this has happened - involving an orthopaedic surgeon in France and a dentist in Florida. (4)

It is vital that both patients and health care workers are protected from the risks of infection. A far more valuable use of resources would be to concentrate on the health and safety of both patients and health care workers. Proper staff training, more open communication and the introduction of better working practices such as the use of safety needles would be a step in the right direction. We believe that trade unions have a clear role in the management of health and safety for health care workers and patients. We would like to see this role developed so that trade unions work in partnership with employers.

Impractical

UNISON Scotland is not advocating that infected workers, who acknowledge their disease, work in EPPs. It is, however wrong to suggest that health clearance testing for new staff is the best way to manage communicable disease control. The British Medical Association questioned whether the measures would be effective. Vivienne Nathanson, head of science, said:

"We must not be reliant on simple testing before commencing employment. Nor is regular testing the answer, as it does not provide the right levels of security." (4)

One does not, however, need to be a medical expert to know that testing for a communicable disease once means that someone is safe from disease forever. You could be free of a communicable disease today, and depending on how you spent the evening, by tomorrow, you could have acquired a communicable disease. Is the government therefore advocating that we should be testing health care workers on a regular basis? If not, then the whole exercise is pointless.

The Role of Trade Unions

UNISON Scotland is disappointed that the consultation does not include a greater role for trade unions working in real partnership with employers. Trade unions should be involved in supporting and representing health workers. We believe the document should put the onus on the NHS or employer to work with trade unions in managing health and safety risks posed by communicable diseases.

Conclusion

UNISON Scotland is opposed to the Scottish Executive's consultation on health clearance testing for health care workers. We believe that this is the wrong strategy to take concerning the potential infection of serious communicable diseases between health care workers and patients. We believe that testing new health care workers is morally wrong. There is no evidence to show that it is worthwhile in terms of costs, health and safety and human resource management. It will create a negative atmosphere of suspicion and blame in the workplace. Instead we recommend a more open and communicative atmosphere. The NHS and employers should work in partnership with trade unions on improving health and safety for patients and staff, including workers performing exposure prone procedures.

We question why Ministers in England (and now Scotland) would want to introduce health clearances for new staff. Given the consultation's reasoning (or lack of it), we believe that these proposals could be construed as racist and could be in breach of the Human Rights Act 1998 (Article 8). UNISON Scotland urges the Scottish Executive to examine the evidence behind the original expert group's recommendations more closely. It would appear that the Executive have accepted the English consultation without fully analysing the evidence. If they had, they would have found that the evidence used to back the group's report is very weak. This leads us to seriously question the motives behind the proposals. The evidence that does exist, all points towards an extremely low chance of infection from health care worker to patient, therefore making the exercise of testing staff an costly and inefficient. It is also extremely impractical. One does not need to be a medical expert to know that testing someone for a serious communicable disease one day, necessarily means that they would be free of disease the next day. As there have not been any cases of health care workers infecting patients, so far, we must lead to the conclusion that this proposal is politically motivated and is seriously flawed. A far more positive and useful proposal would be to use precious funds for health and safety training, for setting up a nation-wide campaign to educate and de-stigmatise myths surrounding communicable diseases, and for introducing safer working practices across the board, such as the use of safety needles.

References:

(1) Health Clearance for Serious Communicable Diseases Report from the Ad hoc Risk Assessment Expert Group. Department of Health. Revised December 2002.

(2) Needlestick Awareness: Sharpen Your Awareness, Towards a Safer Healthier Workplace Needlestick Injuries in the NHSScotland, 29/05/01

(3) Health care workers, AIDS and Prevention, Avert.org, http://www.avert.org/needlestick.htm

(4) Health Recruits to Face Compulsory HIV Tests, The Guardian, January 3, 2003

For Further Information Please Contact:

Matt Smith, Scottish Secretary
UNISONScotland
UNISON House
14, West Campbell Street,
Glasgow G2 6RX

Tel 0141-332 0006 Fax 0141 342 2835

e-mail matt.smith@unison.co.uk