JSP 950 MEDICAL POLICY
LEAFLET 6-7-7
JOINT
SERVICE MANUAL OF MEDICAL FITNESS
JSP 950 Lft 6-7-7 (v3.0 Aug 24)
Effective from 1000Z 15 Aug 24
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JSP 950 Lft 6-7-7 (V3.0 Aug 24)
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Contents
Page Number
Amendments table
1
Section One: Description of the PULHHEEMS System
1-1
Section Two: The Joint Medical Employment Standard
2-1
Annex A Medical Deployment Standard
2-A-1
Annex B Medical Employment Standard
2-B-1
Annex C Medical Limitations
2-C-1
Section Three: Occupational Health Assessments
3-1
Annex A Functional Interpretation of Grades for each Quality
3-A-1
Annex B Guidelines for the Conduct of the Pre-Service Medical Assessment
3-B-1
Annex C Assessment of Body Mass Index
3-C-1
Annex D Assessment of hearing acuity (H)
3-D-1
Annex E Assessment of distant visual acuity (E)
3-E-1
Annex F Evaluation of Mental Capacity (M) and Emotional Stability (S)
2-F-1
Annex G Assessment of Red/Green Colour Perception (CP)
3-G-1
Annex H Health declaration - example for use at demobilisation
3-H-1
Annex I Guidelines for Undertaking Screening Pure Tone Audiometry
3-I-1
Section Four: The Influence of Particular Conditions on Medical Fitness for Entry 4-
1
Annex A Eyes Pre-entry
4-A-1
Annex B Ear Nose and Throat Pre-entry
4-B-1
Annex C Cardiovascular Pre-entry
4-C-1
Annex D Respiratory Pre-entry
4-D-1
Annex E Gastrointestinal Pre-entry
4-E-1
Annex F Renal and Urological Pre-entry
4-F-1
Annex G Neurological Pre-entry
4-G-1
Annex H Endocrine Pre-entry
4-H-1
Annex I Dermatological Pre-entry
4-I-1
Annex J Gender Health Pre-entry
4-J-1
Annex K Musculoskeletal Pre-entry
4-K-1
Annex L Psychiatry Pre-entry
4-L-1
Annex M Dental and Oro-Maxillofacial Pre-entry
4-M-1
Annex N Other Conditions Pre-Entry
4-N-1
Section Five: The Influence of Particular Conditions on Medical Fitness During
Service
5-1 to 5-3
Annex A Eyes In-Service
5-A-1
Annex B Ear Nose and Throat In-Service
5-B-1
Annex C Cardiovascular In-Service
5-C-1
Annex D Respiratory In-Service
5-D-1
Annex E Gastrointestinal In-Service
5-E-1
Annex F Renal and Urological In-Service
5-F-1
Annex G Neurological In-Service
5-G-1
Annex H Endocrine In-Service
5-H-1
Annex I Dermatological In-Service
5-I-1
Annex J Reproductive In-Service
5-J-1
Annex K Musculoskeletal In-Service
5-K-1
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Annex L Psychiatry In-Service
5-L-1
Annex M Dental and Oro-Maxillofacial In-Service
5-M-1
Annex N Other Conditions In-Service
5-N-1
Section Six: Harmonisation of Medical Boards Leading to Discharge 6-1
Annex A FMed 23 Revised 04/07
6-A-1
Annex B FMed 23 Completion Instructions
6-B-1
Annex C Consent to Disclosure of Medical and Administrative Records and
Information following Naval Service Board of Survey (NSMBOS) – In accordance with
Data Protection and Access to Medical Reports Legislation
6-C-2
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Amendments table
Date and
Summary of amendments/remarks
Version
JSP 950 Part 1 Leaflet 6-7-7
1 Aug 16 1.0
New JSP format to comply with DRU JSP review. Merged leaflets 6-7-1 to 6-7-6 (inclusive).
Section 1 Description of the PULHHEEMS system
1 Aug 16 1.0
Content unchanged. Last reviewed Jun 07.
3 Jun 19 1.5
Policy content unchanged. Minor amendments to paragraph 19 approved by MES MJP.
Section 2 The Joint Medical Employment Standard
1 Aug 16 1.0
Major review.
15 Dec 17 1.2
Major review.
3 Jun 19 1.5
Amendment to paragraph 7 a (3) regarding sS rules for temporary JMES approved by MES MJP.
17 Nov 21 2.0 Addition to Para 7(3): Permanency
17 Nov 21 2.0 Additions to Annex B: Medical Employment Standards (table page 2-B-5)
20 Jun 22 2.2 Addition to Annex B: E2 - Medical Employment Standards (table page 2-B-7)
Section 3 Annex C Medical Limitations
12 Mar 21 1.9 Amendment to Hearing/Vision 2200 medical limitation.
Amendment to Hearing/Vision 2201 medical limitation.
Section 3 Occupational Health Assessments
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
29 Jul 19 1.6
Section title change only.
6 Apr 20 1.7
Minor amendment to paras 3 b (1) and 11 only.
Section 3 Annex A Functional Interpretation of Grades for each Quality
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 3 Annex B Guidelines for the Conduct of the Pre-Service Medical Assessment
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 3 Annex C Assessment of Body Mass Index
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 3 Annex D Assessment of hearing acuity (H)
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 3 Annex E Assessment of distant visual acuity (E)
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 3 Annex F Evaluation of Mental Capacity (M) and Emotional Stability (S)
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 3 Annex G Assessment of Red/Green Colour Perception (CP)
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
12 Mar 21 1.9 Major review.
Section 3 Annex H Health declaration - example for use at demobilisation
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 4 The influence of particular conditions on medical fitness for entry
1 Aug 16 1.0
Content unchanged. Last reviewed Apr 14.
8 Sep 18 1.3
Update of paragraph 4.2 General Requirements.
29 Aug 19 1.6 Major review.
17 Nov 21 2.0 New paragraph 10 inserted and footnote 7: Robustness / resilience / vulnerability to military
service
Section 4 Annex A Eyes pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed 1 Feb 16.
29 Jul 19 1.6
Minor amendment to add Appendix 1 ‘Calculation of Spherical Equivalent’.
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Amendments table
Date and
Summary of amendments/remarks
Version
6 Apr 20 1.7
Deletion of footnote 3 from para 2 a (3).
17 Nov 21 2.0 Amendment to 2. a. (3) : Refractive errors.
Section 4 Annex B Ear, nose and throat pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed 1 Feb 16.
12 Mar 21 1.9 Amendment to paragraph 2d: removed footnote 2.
Section 4 Annex C Cardiovascular pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed 1 Feb 16.
6 Apr 20 1.7
Amendments of paras 6-8.
12 Mar 21 1.9 New paragraphs 16 & 17 inserted: Pericarditis.
Section 4 Annex D Respiratory pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 4 Annex E Gastrointestinal pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
12 Mar 21 1.9 Amendment to paragraph 12c: Bariatric Surgery.
Section 4 Annex F Renal and urological pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 4 Annex G Neurological pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed 1 Feb 16.
Section 4 Annex H Endocrine pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 4 Annex I Dermatological pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed Jun 07.
15 Dec 17 1.2 Major review.
Section 4 Annex J Reproductive pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 06.
Section 4 Annex K Musculoskeletal pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed 1 Feb 16.
29 Aug 19 1.6 Major review.
Section 4 Annex L Psychiatry pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
24 Sep18 1.4 Major review.
12 Mar 21 1.9 Removal of wording in paragraph 7.
Amendment to paragraph 38: replaced reference to Lft 6-7-4 with the correct section of Lft 6-7-7.
Section 4 Annex M Dental and oro-maxillo-facial pre-entry
1 Aug 16 1.0
Major review.
Section 4 Annex N Other conditions pre-entry
1 Aug 16 1.0
Content unchanged. Last reviewed Apr 14.
2 Sep 16 1.1
Major review.
3 Jun 19 1.5
New footnote 10 to paragraph 11.
Update of Table 1 ‘Recommended allergy and immunology clinics for military referrals’.
29 Jul 19 1.6
Amendment to paragraph 10a Huntingdon’s Disease agreed by MES MJP.
6 Apr 20 1.7
Amendment para 10 f Suxamethonium sensitivity.
24 Aug 20 1.8 Amendment to paragraph on Sickle Cell Trait. Addition of paragraphs on anticoagulation therapy
and COVID-19 infection.
12 Mar 21 1.9 Amendment to paragraphs 21-24: Immune System Disorders.
1 Dec 21 2.1
New Paragraph 5: PrEP
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Amendments table
Date and
Summary of amendments/remarks
Version
20 Jun 22 2.2 Addition to Paragraph 4 (a) HIV
Section 5 The influence of particular conditions on Medical Fitness during Service
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
6 Apr 20 1.7
Update of title.
12 Mar 21 1.9 Amendment to paragraph 1: update to footnote 1.
Section 5 Annex A Eyes in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
29 Jul 19 1.6
Minor amendment to paragraph 5a to refer to new Appendix 1 to Annex A Section 4.
Section 5 Annex B Ear, nose and throat in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 5 Annex C Cardiovascular in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Mar 14.
12 Mar 21 1.9 Amendment to paragraph 3: Hypertension.
Section 5 Annex D Respiratory in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
3 Jun 19 1.5
Major Review.
Section 5 Annex E Gastrointestinal in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Apr 14.
12 Mar 21 1.9 Amendment to paragraph 11: replaced reference to Lft 6-7-5 with the correct section of Lft 6-7-7.
Amendments to paragraph 12 – 13: Bariatric Surgery.
02 Aug 2022
Amendment to Para 12: additional paragraphs added 12-17.
Section 5 Annex F Renal and urological in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
12 Mar 21 1.9 Amendment to paragraph 1b: removed reference to Lft 6-7-5.
Section 5 Annex G Neurological in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 5 Annex H Endocrine in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
Section 5 Annex I Dermatological in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Apr 08.
12 Mar 21 1.9 Amendment to paragraph 1: replaced reference to Lft 6-7-5 with the correct section of Lft 6-7-7
and replaced ‘medical y invalided’ with ‘medically discharged’.
Section 5 Annex J Reproductive in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Apr 07.
12 Mar 21 1.9 Amendment to paragraph 1: replaced reference to Lft 6-7-5 with the correct section of Lft 6-7-7.
Amendment to paragraph 2a: removed reference to Lft 6-7-5.
Section 5 Annex K Musculoskeletal in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Feb 15.
Section 5 Annex L Psychiatry in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Jan 16.
3 Jun 19 1.5
Major Review.
Section 5 Annex M Dental and oro-maxillo-facial in-service
1 Aug 16 1.0
Content unchanged. Last reviewed Oct 13.
15 Dec 17 1.2 Major review.
6 Apr 20 1.7
Update of OMFS consultant contact details (removal of Table 1).
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Amendments table
Date and
Summary of amendments/remarks
Version
Section 5 Annex N Other conditions in-service
1 Aug 16 1.0
Content unchanged. Last reviewed 1 Feb 16.
3 Jun 19 1.5
Update of Table 1 ‘Recommended allergy and immunology clinics for military referrals’.
29 Aug 19 1.6 Minor amendment to paragraph 5 line 3.
24 Aug 20 1.8 Amendment to paragraph on Sickle Cell Trait. Addition of paragraphs on anticoagulation therapy
and COVID-19 infection.
12 Mar 21 1.9 Amendment to paragraph 4: replaced reference to Lft 6-7-4 with the correct section of Lft 6-7-7.
1 Dec 21 2.1
New Paragraph 7: PrEP
20 Jun 22 2.2 Ammendment to Paragraph 5: HIV
Section 6 Harmonisation of Medical Boards leading to discharge
1 Aug 16 1.0
Content unchanged. Last reviewed Apr 07
3 Jun 19 1.5
Minor amendment to paragraph 10c and Annex B paragraph 1 regarding FMed 23 approved by
MES MJP.
6 Apr 20 1.7
Amendment of Annex C title only.
12 Mar 21 1.9 Amendment to paragraph 7a: removed reference to Lft 6-7-5.
Section 6 Annex A FMed 23 Revised 04/07
12 Mar 21 1.9 Content unchanged. Added to amendment table.
Section 6 Annex B FMed 23 Completion Instructions
12 Mar 21 1.9 Content unchanged. Added to amendment table.
Section 6 Annex C Consent to Disclosure of Medical and Administrative Records and Information following
Naval Service Board of Survey (NSMBOS) – In accordance with Data Protection and Access to Medical
Reports Legislation
12 Mar 21 1.9 Content unchanged. Added to amendment table.
29 Jul 24
Full review and re-write of all annexes within Section 4.
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SECTION ONE: DESCRIPTION OF THE PULHHEEMS SYSTEM
General
1.
These medical standards are designed to provide a framework for the medical
assessment of functional capacity of potential recruits and serving personnel from which
can be derived a determination of fitness for service. They are to be applied by Service
Medical Officers (MOs), Civilian Medical Practitioners (CMPs) and doctors carrying out
assessments on behalf of the Service recruiting organisations. The award of an
appropriate single-Service medical employment standard should be based on a sound
knowledge of the individual’s intended or present job and a thorough clinical assessment.
MOs and CMPs may draw on the expertise of specialist clinicians to evaluate diagnosis or
prognosis and on the expertise of specialists in occupational medicine in the determination
of fitness for work. In all cases, care should be taken to ensure that the PULHHEEMS
profile awarded truly reflects the individual’s functional capacity and the medical
employment standard awarded truly reflects medical employability.
Purpose
2.
The PULHHEEMS system has been developed to provide a method for standardising
and recording the medical functional assessment. It is used as a tool from which medical
employability criteria can be derived and communicated to the Executive branches.
The system
3.
In the United Kingdom Armed Forces, the classification system that leads to the
award of the employment standard is the PULHHEEMS System of Medical Classification.
The decision to award a particular employment standard must be based on function and
the ability to perform the tasks involved in a given job. The presence of certain medical
conditions will influence the PULHHEEMS profile; these are detailed in 3 and 4. The code
letters in this acronym refer to a sub-division of physical and mental function as follows:
P
Physical Capacity
U
Upper Limbs
L
Locomotion
HH Hearing Acuity (right and left)
EE Visual Acuity (right and left, uncorrected and corrected)
M
Mental Capacity
S
Stability (Emotional)
4.
These subdivisions are known as qualities. The combined assessment of the group
of qualities forms the PULHHEEMS profile. From this profile, each of the sSs can then
award a medical employment standard appropriate to the individual that will ensure that he
or she is not employed on duties for which he or she is medically unfit. Since medical
employment standard systems are Service specific, they will not be discussed further here;
clarification is provided in Section 5.
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The qualities in more detail
5.
The following list clarifies the factors to be considered when assessing each of the
qualities:
a.
P – Physical capacity. This quality is used to indicate an individual’s overall
physical and mental development, his or her potential for physical training and
suitability for employment worldwide (i.e. the overall functional capacity). The ‘P’
grading is affected by other qualities in the PULHHEEMS profile, namely the ‘U’, ‘L’,
‘HH’, ‘EE’ ‘M’ and ‘S’ gradings.
b.
U – Upper limbs. This indicates the functionality of the hands, arms, shoulder
girdle and cervical and thoracic spine. A reduced ‘U’ grading will also affect the ‘P’
grading.
c.
L – Locomotion. The ‘L’ grading refers to the functional efficiency of the
locomotor system. This quality must therefore take into account assessment of the
lumbar spine, pelvis, hips, legs, knees, ankles and feet. Observation of gait and
mobility are also important. Any conditions affecting the function of the locomotor
system will result in a reduced ‘L’ grading which will in turn be reflected in the ‘P’
grading.
d.
HH – Hearing. This quality assesses auditory acuity only. Diseases of the ear
such as otitis externa are assessed under the ‘P’ quality. However, severe loss of
hearing will affect the ‘P’ grading.
e.
EE – Visual acuity. This quality assesses visual acuity only. Diseases of the
eye such as glaucoma are assessed under the ‘P’ quality. However, severe loss of
visual acuity will affect the ‘P’ grading.
f.
M – Mental capacity. Mental capacity is not subject to formal medical
assessment at recruitment. However, the recruit selection procedure, including
interviews, and the individual’s academic record will allow judgement to be made on
this quality. Subject changes are only likely to occur as a result of neurological
disease or head injury.
g.
S – Stability (emotional). The ‘S’ quality indicates emotional stability which
grades the individual’s ability to withstand the psychological stress of military life
(especially operations). Amendments to the ‘S’ grade are usually required in cases
of psychiatric illness but are not restricted to these circumstances.
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Grades of each quality
6.
Each quality has the potential to be awarded a grade of 1 to 8. However, only the ‘E’
quality uses all 8 possible gradings. The permitted gradings are tabulated as follows:
P
U
L
H
H
E
E
M
S
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
4
4
4
4
4
5
5
6
6
7
7
7
7
7
7
7
8
8
8
8
8
8
8
8
8
Additionally, the grading of P0 is used in the circumstances outlined in paragraphs 7 and
15.
Functional interpretation of each grade
7.
Specific definitions for the grades of the P, U, L, M and S qualities are:
Quality
Definition
0
Medically unfit for duty and under medical care (P quality only)
2
Medically fit for unrestricted service worldwide
3
Medically fit for duty with minor employment limitations
4
Medically fit for duty within the limitations of pregnancy
7
Medically fit for duty with major employment limitations
8
Medically unfit for service
Employability includes functional capacity to deploy on operations. The following matrix
should be used to provide guidance on the functional capacity of each grading under the
U, L, M and S qualities:
Degree Functional capacity
Service capacity
2
Average
Full
3
Below Average
Restricted
7
Very limited
Restricted
8
Severely limited
Unfit for any form of service
0
Unfit for duty: under medical care
Unfit for duty: under medical care
8.
The degrees of quality of HH and EE reflect discrete levels of performance under
audiometric testing and testing of visual acuity. The standard in the RIGHT eye or ear is
graded first, the LEFT side second.
9.
The audiometric standards with their corresponding gradings are detailed in Section
2, along with details of the audiometric examination and examination of the ears.
10. The system of grading visual acuity along with the ophthalmic examination and
recording of the results are in Section 2.
Assessments of functional capacity
11. On entry to the Armed Forces individuals are awarded a PULHHEEMS profile which
is deemed permanent. The letter P signifying ‘Permanent’ may be inserted after the
degree of P quality or after the single-Service Medical Employment Standard. Subsequent
re-gradings are referred to as medical boarding, whether carried out at unit level or by a
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formally constituted Medical Board. Individuals who remain on duty with medical conditions
that do not require immediate in-patient treatment are classified according to their
functional capacities, but no lower than a grading of 7. Where a condition is expected to
resolve, the letter R (signifying remediable) may be inserted after the degree of P quality or
other quality, for example P3R L3 or P3R L3R. Non-remediable conditions do not require
the R suffix. These gradings may be held in a temporary capacity indicated by a T suffix
after the degree of P quality or after the single-Service Medical Employment Standard. The
maximum period for which an individual may hold such a temporary grading is subject to
single-Service regulations but should not normally exceed 18 months. Where a condition
persists beyond 18 months, or it can be predicted that this will be the case at an earlier
stage, a definitive standard (permanent) is to be awarded, without the letter R for remedial
conditions. Reference is to be made in the medical board report on the likely duration of
time before recovery might be expected if there remains a possibility of continuing
improvement.
12. Personnel who are due to exit the Service, but who hold a temporary medical
employment standard, may leave and a medical board may be held dependent upon
single-Service employment regulations. An individual would not normally be given an
extension of Service solely to allow assignation of a definitive (permanent) medical
employment standard. Where an individual has a condition that would result in invaliding,
but whose discharge date precedes medical board assessment, the case is to be
discussed with the single-Service President of the medical board to determine the most
suitable course of action.
13. The medical employment standard of an individual admitted to a hospital is not to be
changed purely for this purpose unless the in-patient period exceeds or is expected to
exceed one month. If this is the case, the award of a P0 grading is appropriate. Medical
boarding prior to admission and after discharge is to make a functional assessment with
respect to the PULHHEEMS profile and award an appropriate single-Service category in
the normal way.
14. Individuals who are discharged from hospital and are fit for limited duty only, but
whose full recovery is expected within a total period of 18 months of downgrading, are to
be awarded R and T annotations as appropriate (see para 11). If their condition is
expected to remain extant beyond 18 months or is not remediable, a permanent category
is to be awarded by a Medical Board. In all remediable cases, an expectation of the
recovery period is to be recorded in the medical board record. Those discharged from
hospital directly to a short period of sick leave need not be re-assessed until the end of the
period of sick leave, but before return to work.
15. Individuals who are discharged from hospital but are expected to remain unfit for duty
for a prolonged period (greater than one month) are to be awarded a P0 grading. If it
becomes apparent that a return to work is unlikely for medical reasons, P8 medical
boarding is to be considered. Alternatively, an appropriate working medical category is to
be awarded on return to duty. An individual should not normally be discharged from the
Service with a P0 grading. Medical discharge will attract a grading of P8; administrative
discharge associated with medical conditions may occur in those graded P7 or higher.
16. Pregnant serving women who are fit for duty are to be graded P4 with appropriate
single-Service medical employability limitations. Where other clinical conditions occur
during or after pregnancy which merit re-grading in their own right, medical boarding is to
take account of these and reflect them in the normal way.
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Assessment of the individual
17. Medical assessment is carried out under the PULHHEEMS system at entry and
discharge, and at intervals during service (see Section 3).
18. All PULHHEEMS qualities and gradings should be governed by their functional
assessment definitions found in Section 3. The P quality takes account of deployability and
is affected by the ability to carry out the duties required within the individual’s employment
group.
Recording of assessments
19. The PULHHEEMS assessment is to be recorded on medical forms and electronic
medical templates where boxes or drop-downs are provided for this purpose1. When a
change is made through medical boarding, the new profile is to be recorded on the
medical record. Medical board reports are to include the review date of the medical
standard awarded if necessary.
20. Illustrative examples of medical board PULHHEEMS assessment for a number of
conditions are given below:
a.
Year of birth
P
U
L
H
H
E
E
M
S
1
1
1979
3R
2
2
1
2
2
2
-
-
Relevant clinical details
Ht…..…..180…..…..cm
P
U
Left inguinal hernia awaiting operation.
CP………..2…………..
L
S
Wt……….89……….kg
This individual has a left inguinal hernia, which is considered remediable. The grading P3R will be
retained until he is ready to be awarded a permanent grade. This may be P2, assuming full
recovery.
1 Appropriate FMed Forms (paper or electronic), or within the Grading Templates in the electronic medical record system.
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b.
Year of birth
P
U
L
H
H
E
E
M
S
4
5
1969
3
2
2
3
4
2
2
2
2
Relevant clinical details
Ht…..…..179…..…..cm
P
U
Severe noise-induced hearing loss L>R.
CP………..2…………..
L
S
Wt……….77……….kg
This individual has marked noise induced hearing loss in both ears. Note that in this case
the HH gradings affect his physical capacity and thus his permanent P grading; a grade of
P3 has been awarded.
c.
Year of birth
P
U
L
H
H
E
E
M
S
1
1
1966
7R
2
2
2
2
2
7
-
-
Relevant clinical details
Ht…..…..185…..…..cm
P
U
Chronic depressive illness.
CP………..3…………..
L
S
Wt……….62……….kg
This individual has a chronic depressive illness and has been awarded a grading of 7
under the ‘S’ quality. Note that the illness will also affect the individual’s physical capacity
and deployability, so the ‘P’ grading has also been reduced to 7.
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SECTION TWO: THE JOINT MEDICAL EMPLOYMENT STANDARD
Background
1.
Prior to Nov 09 the single-Services used variations on a common theme to describe
medical employability of service personnel. However, because no common denominator
existed, direct comparisons could not be made. To resolve this, the Joint Medical
Employment Standard (JMES) system of classification was introduced. However, following
its introduction differences in the extent of single-Service adoption meant that only some
data (Medical Deployment Standard) was available for reporting to the Defence People
and Training Board (DPTB) and the Defence Board (DB), and this data lacked sufficient
granularity for useful reporting purposes (such as numbers fit for deployment to specific
locations or environment) and manpower planning.
2.
In Feb 15, the JMES Harmonisation Working Group recommended modifications to
the existing JMES system to promote consistency of use across the single-Services to
provide better information for Executive decision-making purposes and the ability to offer
more accurate information to the DPTB and the DB.
3.
This Leaflet describes the harmonised JMES system.
Introduction
4.
The JMES is awarded by medical staff in order to inform commanders and career
managers of the deployability and employability of Service Personnel. It describes the
deployability, functional and geographical employability and specific medical limitations.
5.
Employment or deployment of a Service Person outwith their JMES must not be
done lightly. The Chain of Command retains the authority to employ or deploy the Service
Person outwith their JMES, but only in exceptional circumstances and after conducting a
risk assessment. ‘Exceptional’ is defined as:
In an emergency; in extremis; where there is no other choice and not using that
Service Person would result in very serious consequences. Financial reasons or
standard manning difficulties would not necessarily be regarded as reasonable
considerations. Unless life is
at stake, it would be considered unreasonable to task a
Service Person with a duty outwith their JMES.
In this case, the risk of employment or deployment of the Service Person lies with the
Chain of Command and medical advice from a consultant occupational physician must be
sought. A Service Person’s JMES should not be altered to comply with Chain of Command
requirements unless it is appropriate to do so and the patient has provided consent.
Further direction for the Chain of Command can be found in Joint and single Service
Employment Policy.
6.
Changes to the entry JMES and any subsequent changes will require a medical
grading review in accordance with single-Service policy.
a.
BRd 1750A Handbook of Naval Medical Standards.
b.
AGAI 78 Army Medical Employment Policy PULHHEEMS Administrative
Pamphlet (PAP).
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c.
AP 1269A Royal Air Force Manual of Medical Fitness.
JMES elements
7.
The JMES classification system is divided into 4 x Primary Elements and 2 x Detailed
Elements:
a.
Primary elements:
(1)
Date of award. This is the date the JMES assessment took place or the
date when the medical assessment was last reviewed.
(2)
Date of review. The next review must take place in accordance with
single-Service policy by this date.
(3)
Permanency. When a Board awards a JMES a decision should be made
as to whether the JMES is temporary (Temp), permanent (Perm) or not
applicable (NA). The maximum period of validity of a temporary JMES is
(except where an extension is approved under single Service rules):
(a) 12 months for the Army.
(b) 12 months before referral to RNMBOS / regional OH Board for the
RN.
(c) 18 months for the RAF.
A permanent JMES may be awarded at any time if clinically indicated. When a
temporary JMES is to become permanent, a formal Medical Board will be
convened in accordance with single-Service policy. Permanent does not imply
that the JMES can never change but serves to distinguish for personnel staff
the longer-term health problems affecting function from the relatively short term,
in order to assist with employment decisions.
The default review period for Perm JMES (MFD(E2)), MLD and MND is annual.
Where a Service consultant in Occupational Medicine deems that a named
individual has an underlying condition which is stable and the impact on function
is well understood, they may recommend an appropriate frequency for JMES
reviews greater than one year (up to a maximum of five years).
(4)
Medical Deployment Standard (MDS). This is an overall deployability
summary coding with the sub-categories of Medically Fully Deployable (MFD),
Medically Limited Deployability (MLD) and Medically Not Deployable (MND).
Further details are at Annex A.
b.
Detailed elements:
(1)
Medical Employment Standard (MES). This is an alphanumeric code
reflecting an individual’s fitness to be employed in the Air (A), Land (L) and
Maritime (M) environments together with any additional specific Environment
and Medical Support (E) considerations e.g. A4 L3 M4 E3. On DMICP the suffix
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‘Legacy’ distinguishes between legacy and harmonised JMES awards. On JPA
the inclusion of a hyphen, for example ‘A-1’, distinguishes between legacy and
harmonised JMES awards. Further details are at Annex B.
(2)
Medical Limitations (MedLims). MedLims are applied as necessary and
are visible on JPA e.g. 1206 Unfit to work in confined spaces. Further details
are at Annex C.
8.
A typical JMES might read:
Date of Award
Date of Review
Permanency
MDS
MES
MedLim
10 Aug 16
10 Feb 17
TEMP
MLD
A4 L3 M4 E3
1206
9.
Communication of occupational medicine advice to the Chain of Command.
JMES is communicated to the Chain of Command through JPA via a direct feed from
DMICP. In addition, the single-Services utilise the following to provide additional
information:
a.
RN - JMES Electronic Signal.
b.
Army - PAP Appendix 9 document.
c.
RAF - Reassessment of Employment Standard – Patient Advice Notice.
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Annex A
MEDICAL DEPLOYMENT STANDARD
1.
The Medical Deployment Standard (MDS) describes the medical capacity for
deployment.
2.
Table 1 details the MDS codes and their meaning.
Table 1 Medical Deployment Standard codes
MDS code
Description
MFD
1.
Fit to deploy to all parts of the world on contingent or follow-on operations
Medically Fully
without any limitations or requirements for routine medical support beyond deployed
Deployable
Primary Healthcare.
2.
Deployment limited due to:
a.
A medical condition.
b.
Medical treatment needs.
c.
Medical support requirements.
MLD
d.
Risk arising from exposure to specific climates e.g. heat or cold.
Medically
Limited
e.
The need to avoid specific exposures e.g. noise or chemicals.
Deployability
3.
A grade of MLD requires a medical risk assessment (MRA) to be carried out
for deployment. The decision on that deployment will depend on the medical
condition, individual function, the proposed employment, length of the deployment
and the medical support available.
4.
MLD personnel may vary from those with minimal limitations who can be used
in a wide range of roles and situations to those who can only undertake a limited
role or Career Employment Group (CEG) within a specific, well supported setting.
5.
Not deployable outside the United Kingdom.
MND
Medically Not
6.
May be admitted to or under the care of a Medical Facility (MF) or awaiting
Deployable
medical discharge (A6 L6 M6 E5 or 6).
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Annex B
MEDICAL EMPLOYMENT STANDARD
1.
The Medical Employment Standard (MES) relates to an individual’s employment in
their branch/trade duties and is expressed as numerical degrees in four functional areas
(detailed elements), indicated by the letters A, L, M and E. These reflect medical fitness for
duties in the
Air,
Land and
Maritime environments and any additional specific
Environment
and Medical Support considerations. All detailed elements of the MES are to be allocated
for each individual.
2.
Distinguishing between legacy and harmonised JMES awards. On DMICP the
suffix ‘Legacy’ distinguishes between legacy and harmonised JMES awards. On JPA the
inclusion of a hyphen, for example ‘A-1’, distinguishes between legacy and harmonised
JMES awards.
3.
Where single-Service supplementary guidance is not present, information contained in
the ‘Description’ and ‘Guidance’ columns apply.
4.
Table 1 details the MES codes and their meaning.
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Table 1 Medical Employment Standard codes
AIR
MES
Single-Service Supplementary Guidance
Description
Guidance
Code
RN
Army
RAF
Fit for flying duties without
A1
Only for aircrew.
restriction.
Fit for flying duties but has
A2
Only for aircrew.
reduced hearing or eyesight.
May be used for:
Remotely Piloted Air
Fit for duties in the air within
Systems Operators2,
A3
the stated employment or
Aircrew1.
Gliding Instructors3, Flight
MedLims.
Medical Officers, Air
Stewards.
Fit to be flown in a passenger
A4
aircraft.
Except as aeromedical evacuation
A5
Unfit to be taken into the air.
patients.
Duties in the aviation environment include,
Personnel will usually be
but not limited to, air traffic control,
non-effective or given a
Unfit for any duties in the
A6
baggage handling, aircraft towing, aircraft
medical board
aviation environment.
maintenance, airfield driving and duties on
recommendation for
a flying station/base.
discharge.
1 Including other Career Employments Groups defined in
AP 1269A Royal Air Force Manual of Medical Fitness
2 RPAS Operators AP1269A Lft 4-02 para 20
d AP 1269A Royal Air Force Manual of Medical Fitness
3 VGS Gliding Instructors AP1269A Lft 4-02 para 1
6 AP 1269A Royal Air Force Manual of Medical Fitness
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LAND
MES
Single-Service Supplementary Guidance
Description
Guidance
Code
RN
Army
RAF
L1
Fit for unrestricted duty.
May undertake
Must have appropriate level of
Operational Fitness Tests
musculoskeletal fitness to undertake role
RN5 / RM6 unfit for
(OFTs)7 with appropriate
and all expected duties in austere
defined aspects of
build-up training. Must be
environments. Must be able to undertake
mandatory fitness
fit PJ
HQ4 Global Low to
Pre-Employment Training (PET) and
testing or modifications
Medium Threat
Fit for high readiness roles with
Individual Pre-Deployment Training (IPDT)
Minor limitations but fit for
L2
to command courses
environments.
minor limitations.
to deliver the minimum personal military
high-readiness roles.
required but fully
Operational deployments
skills to allow an individual to carry out the employable and
are subject to Deployed
requirements of their job specification
deployable in
MRA only if MDS is MLD.
while maintaining their own Force
branch/trade.
No limitation on exposure
Protection (FP) and positively contributing
to weapons noise. Must
to the FP of those around them.4
be E1 or E2.
Operational deployments
Should not impose a significant and/or
require deployed MRA
constant demand on the medical services
(PAP App 26) to be
if deployed, on exercise or deployments.
Able to undertake all
completed by Unit CoC.
The individual may deploy on operations
branch/trade duties but has
Fit for limited duties but with
ROHT input to deployed
L3
or overseas exercises following
difficulty with specified
some restriction subject to MRA.
MRA will not be required
completion of a MRA. Have no limitations
general Service activities
unless annotated on App
in their ability to function wearing personal
eg running.
9. Routine activities (as
equipment demanded of the environment,
defined in PAP Chapter 5)
branch/trade and rank.
are covered by App 9.
4 Joint Operational IPDT Policy. IPDT requirements are set against the overall risk to deployed personnel within an individual theatre. This assessment takes into account the identified risk from terrorism, armed
attack, criminality and environmental factors including Road Traffic Accidents. Whilst there may be variations in IPDT requirements for personnel deployed on certain operations given their role and exposure to risk,
the nature of certain Global operations require all personnel to be trained to a single standard to mitigate the expected threat.
Global Low Threat. Environments where the identified threats or risks to deployed
personnel may not require FP restrictions to be imposed. This category also includes personnel deployed within Medium and High threat environments where the nature of their deployment does not expose them to
the threat
. Global Medium Threat. Environments where there is an identified threat from terrorism, armed attack or high risk of environmental hazards to personnel operating in remote or isolated locations.
Personnel deployed on Global Medium Threat deployments are required to complete enhanced training as defined by the JTRs, relevant to role or specific risks.
Global High Threat. Environments where there is an
identified high threat from terrorism, armed attacks, Insider Threat or violent criminality. Personnel deployed on Global High Threat deployments are required to complete enhanced training as defined by the JTRs,
relevant to role or specific risks.
5 BRd 51 (2) Physical Education and Executive Health Manual - RNFT Policy and Protocols
6 Royal Marines Fitness Test Annex A Feb 16
7 MATT 2 Fitness Issue 11 Apr 19
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LAND
MES
Single-Service Supplementary Guidance
Description
Guidance
Code
RN
Army
RAF
Operational deployments
Individuals whose medical conditions have
require deployed MRA
Not able to undertake all
the potential to pose a significant risk on
(PAP App 26) completed branch/trade duties. May
Fit for certain deployed roles into deployment in the land environment. May
by Unit CoC. ROHT input only deploy if accepted by
Likely to be restricted to
well-established MOB locations
be reliant on an uninterrupted supply of
to deployed MRA
deployed location SMO
L4
Major Overseas Bases
subject to Consultant
medication and/or a reliable cold chain.
required in all
and cleared by a
only.
Occupational Physician MRA.
Must be able to function wearing a helmet
circumstances. Routine
Consultant Occupational
and the minimum theatre entry standard
activities (as defined in
Physician or Manning
body armour.
PAP Chapter 5) are
Medical Casework.
covered by App 9.
Individuals who are unable to deploy due
May be employed within
to significant MedLims. May be fit limited
Must be fit for branch /
their branch/trade and
Unfit deployment. Fit for
UK operations. Able to provide regular
trade subject to allowable
are fit for UK internal
L5
branch/trade and limited UK
and effective service in the non-deployed
limitations as defined in
operations within the
operations.
land environment subject to meeting the
PAP Table 6 (Functional
bounds of their
minimum requirements as specified in
Interpretation of JMES).
MedLims.
single-Service employment policy.
L6 temp requires ROHT
Personnel will usually be
sanction to extend > 6
non-effective or given a
Unfit for service in the land
L6
Unfit for any duties.
months and DM(A)
medical board
environment.
sanction to extend >12
recommendation for
months.
discharge.
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MARITIME
MES
Single-Service Supplementary Guidance
Description
Guidance
Code
RN
Army8
RAF
RAF personnel who are
May be employed and deployed worldwide
augmentees or fit to be
M1
Fit for unrestricted duties.
in the maritime environment.
borne as augmentees9 to a
ship’s company.
Fit for duties at sea but may be restricted
RAF personnel who are
to specific size or type of vessel, have
To be employed or
augmentees or fit to be
Fit for restricted duties afloat
M2
medical support needs or environmental
deployed within the
borne as augmentees to a
within the limitations as stated.
limitations as indicated by the MES and
MedLims specified.
ship’s company with
MedLims.
specific MedLims.
Unfit to serve in a
Able to safely move around a ship
vessel at sea but may
alongside or within the confines of a
Augmentees able to move
serve within the
harbour including the ability to evacuate
safely around a ship
Fit for restricted duties in a vessel
confines of a port or
from the vessel and take intial emergency
alongside or within the
M3
in harbour or alongside with the
harbour. Does NOT
action (e.g. first Aid, firefighting and
confines of a harbour.
limitations as stated.
automatically imply fit
damage control*) without assistance.*
Able to evacuate and take
for full firefighting and
defined as the initial actions to be taken on
emergency action.
damage control duties
discovering the fire or other emergency.
ot training.
Fit to move safely around a ship at sea, in
harbour or alongside including using
ladders and stairs, opening heavy hatches,
stepping over hatch combings and
RN personnel should
tolerating a moving/rolling platform.10 Not
not be graded M4.
Commando and Port and
Fit to be carried as embarked
to be part of the firefighting or damage
Maritime personnel
Fit to travel by sea as a
M4
forces in transit.
control organisation but must be able to
RM personnel should
should not normally be
passenger.
take emergency response and evacuation
not normally be graded graded M4.
actions unaided.
M4.
Usual grading for Army and RAF
personnel who do not have a regular
maritime role.
8 Army personnel employed in the maritime environment should follow RN single-Service guidance.
9 Augmentees are personnel who will work as part of or alongside the ship’s personnel as part of their role and may be expected to undertake damage control of firefighting duties.
10 Ladders may be vertical or sloping, hatch combings are up to 30 cm above the deck, hatches may weigh ≥100 Kg and require up to 8 clips (rotating metal handles) to be moved to allow opening and
closing the hatch. Some hatches are horizontal and require to be lifted open. The ability to complete these tasks whilst the platform is rolling or being subject to the motion of the seas should be considered.
The ability to hear alarms and move around in poor lighting or smoke are essential to the ability to safely evacuate from the vessel unaided in case of an emergency.
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MARITIME
MES
Single-Service Supplementary Guidance
Description
Guidance
Code
RN
Army8
RAF
Embedded RAF personnel
Not to work on ships/submarines alongside
with severe seasickness or
Fit for restricted duties ashore
M5
and may not be able to complete all duties
other medical condition(s)
within the limitations as stated.
required of their branch/trade ashore.
incompatible with being on
board a ship.
Long-term sick or in a MTF for >28 days or
Unfit for any duties in the
M6
given a medical board recommendation for
maritime environment.
discharge.
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ENVIRONMENT AND MEDICAL SUPPORT
MES
Single-Service Supplementary Guidance
Code
Description
Guidance
RN
Army
RAF
Fit to deploy on contingent and enduring
operations with no requirement for medical
Fit for worldwide service in all
E1
care within the deployed location beyond
environments.
deployed Primary Healthcare (or
equivalent).
Has a specific medical condition, which
does not currently affect employability or
deployability but may do so in future. Has
no climatic restriction and no requirement
for medical support bar adequate supply of
medication. The medical condition is stable
with treatment. Should loss of medication
Examples of medical
occur for ≤ 1 week this should not lead to
Excludes any medical
risk markers are early
No functional limitation but
condition that would
Fit for unrestricted duties but with clinical deterioration in the condition or
noise induced hearing
has a stable controlled
E2
require review by a MO
a medical risk marker.
functional degradation during that time.
loss, stable chronic
condition such as high
before authorising
condition requiring
blood pressure.
deployment.
Due to the operational limitations of the
medical monitoring.
structure of Healthcare Delivery in different
deployed environments and differences in
force generation processes, sS Regulations
MAY require additional medical review
before deployment.
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ENVIRONMENT AND MEDICAL SUPPORT
MES
Single-Service Supplementary Guidance
Code
Description
Guidance
RN
Army
RAF
Environmental limitations
or the individual requires
Personnel may be
access to additional
employed in locations
medical provision, but not
Fit subject to limitations as will require
with reduced health care full UK care level (e.g.
Personnel may require
access to enhanced medical support, or
provision. When advising access to a
guaranteed access to
has specific medication requirements
on employment or
physiotherapist, dentist,
Restricted employment outside
an MO outside UK
unlikely to be compatible with contingent
deployment away from
Mental Health Nurse, GP
E3
UK due to medical support or
waters or only be
operations. Fit to be in areas within
the firm base the MO
or a general hospital
environmental requirements.
deployable where
limitations e.g. climatic injuries, hearing
must ensure that in-
doctor). Requires basic
access to Secondary
loss, susceptibility to environmental
theatre medical provision MRA by station MO.
Healthcare is possible.
exposure.
can meet the individual’s Confirmation of the
routine and emergency
adequacy of medical
needs.
support by receiving
medical authority is
required.11
Individual must have
access to significant
additional medical
When advising on
provision to full UK care
Only to be employed out of the
employment outside the
Has a medical condition requiring access
Limited to major
level. Requires enhanced
UK where there is access to
UK the MO must ensure
either routinely or as an emergency to
Overseas Bases only
MRA by Consultant in OM,
E4
established, ‘NHS equivalent or
that in-theatre medical
better’ Primary and Secondary
medical care at a level available equivalent (excludes Falklands
normally Manning (Medical
provision can meet the
to that provided in the UK.
and Diego Garcia).
Casework). Confirmation
Healthcare.
individual’s routine and
of the adequacy of medical
emergency needs.
support by receiving
medical authority is
required.
Personnel with on-going
Personnel for example
See M grade for ability
health care needs, which requiring medical
May be employed within the UK
To be employed appropriately to their
E5
to be employed on a
would be adversely
treatment or follow-up
only.
MedLims within the UK.
ship.
affected by employment
more frequent than 6
outside of the UK.
monthly.
11 An MRA may be enduring for a period of up to of 3 years across short-term deployments to a specified location. It should be reviewed by an MO if the risk assessment changes during this time (i.e.
change in medical condition, treatment, follow-up requirements, JMES or medical support).
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ENVIRONMENT AND MEDICAL SUPPORT
MES
Single-Service Supplementary Guidance
Code
Description
Guidance
RN
Army
RAF
Pregnancy/Maternity.
Only to be used when the woman has
Prior to formal
formally informed her employer of her
declaration, to be
pregnancy (e.g. using Mat B1)
and she
graded MND A4 L4 M3
has given her consent in writing for MES to E5.
be displayed as E6 or a contemporaneous
E6
record has been made in the clinical notes
confirming permission granted. E6 is to be
maintained until the Service woman has
successfully completed a return-to-work
medical post pregnancy and/or maternity
leave.
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Annex C
MEDICAL LIMITATIONS
1.
The JMES provides sufficient information to the Executive and line management to
enable them to understand employability and deployability but does not give sufficient
information to allow a precise understanding of how an individual may be employed. This
is achieved by the use of Medical Limitations (MedLims) and their accompanying codes.
2.
In DMICP MedLims are listed in the order they are applied. More than 12 MedLims
can be applied in DMICP but only 12 will be visible to personnel staff on JPA. If >12
MedLims are applied, MedLim ‘000’ will automatically appear on JPA. This MedLim directs
the CoC to seek further medical advice on employability.
3.
Medical Officers must only apply MedLims if they are fully conversant with the
implications of doing so. If required, advice must be sought from suitably qualified and
experienced medical personnel.
4.
Where sub-domains are annotated ‘(App 9)’, additional Appendix 9-specific MedLims
are available, but only within DMICP Appendix 9 template drop-down menus.
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Table 1 Medical Limitation codes
1000 Series - Miscellaneous Domain
MedLim
Sub-domain
Description
Code
> 12 MedLims allocated – CoC to seek further medical advice on
MedLims (>12)
000
employability
Restrictions on Service duties and employment not specified by a
Not otherwise specified
1100
MedLim (details in med docs)
Working conditions
1200
Unfit shift work
Working conditions
1201
Unfit for night work
Working conditions
1202
Unfit for lone working
Working conditions
1203
Unfit to work at height
Working conditions
1204
Unfit to work on gantries
Working conditions
1205
Unfit to work underground
Working conditions
1206
Unfit to work in confined spaces
Working conditions
1207
Unfit to work without direct supervision
Fit limited duties in trade or branch (type will be specified in Med
Working conditions
1208
Docs)
Working conditions
1209
Office duties only
Working conditions
1210
Fit limited working hours agreed between MO and Line Manager
Working conditions
1211
Unfit to conduct EPPs
Working conditions
1212
Passenger - land vehicles restriction
(App 9)
Working conditions
1213
Workplace restrictions
(App 9)
Employment
1300
Medical marker (no functional limitation)1
Employment
1301
Employment subject to single-Service manning restriction
Employment
1302
Enlisted below entry standards
Employment (App 9)
1303
Refer to Appendix 9
Safety critical duties
1400
Unfit to conduct safety critical duties
Safety critical duties
1401
Unfit to undertake service driving
Safety critical duties
1402
Unfit to undertake service driving with passengers
Safety critical duties
1403
Unfit to drive specific vehicle (type will be specified in Med Docs)
Safety critical duties
1404
Not to be responsible for operating machinery
Safety critical duties
1405
Unfit for work with unguarded machinery
Below required colour perception standard requires supervision for
Safety critical duties
1406
colour discrimination tasks
Food handling
1500
Unfit food handling
Food handling
1501
Unfit for galley / kitchen duties
Diet
1600
Must have opportunity for regular meals
Diet
1601
To have access to a gluten free diet at all times
Diet
1602
To have access to specialist diet (type will be specified in Med Docs)
1 Or additional medical condition(s) requiring a medical marker (no functional limitation).
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2000 Series - Aviation Domain
MedLim
Sub-domain
Description
Code
Flying
2000
Unfit solo pilot - must fly with a pilot suitably qualified on type
Flying
2001
Unfit solo (aircrew category will be specified in Med Docs)
Flying
2002
Unfit specific aircraft (type(s) to be specified in Med Docs)
Flying
2003
Fit (details to be specified in Med Docs) flying duties only
Flying
2004
Unfit (conditions of flight to be specified in Med Docs)
Flying
2005
Permanently unfit flying duties
Flying
2006
Unfit to climb on aircraft
Flying
2007
Unfit ejection seat aircraft
Flying
2008
Restricted employability because of anthropometric limitations
Controlling
2100
Unfit aircraft controlling duties
Fit to control only when another qualified controller is on duty and in
Controlling
2101
close proximity
Aircrew assessed as hearing standard <H2 but with a satisfactory
Hearing / Vision
2200
functional hearing test iaw AP1269A
Must wear approved visual correction when flying or controlling
Hearing / Vision
2201
aircraft and carry a spare pair of spectacles
Must carry approved corrective flying spectacles when flying or
Hearing / Vision
2203
controlling aircraft
Respirators
2300
Unfit aircrew respirators
STASS
2400
Fit dry/poolside STASS training only
STASS
2401
Unfit any STASS training
Parachuting
2500
Unfit land parachuting
Parachuting
2501
Unfit sea parachuting
3000 Series - Land Domain
MedLim
Sub-domain
Description
Code
Limited operational land deployments. Employable within the confines
Deployment
3000
of a rear echelon only
No operational land deployments. Must not deploy to any operational
Deployment
3001
arena
Deployment (App 9)
3002
Fit for short land deployments subject to Medical Risk Assessment
Deployment
3003
Fit detachments in worldwide areas not exceeding 30 days
Mobility (App 9)
3100
Infantry activities (including digging) restrictions
Mobility (App 9)
3101
Travel on foot across rough terrain restrictions
Mobility (App 9)
3102
Move tactically and adopting fire positions restrictions
Field conditions (App
3200
Living in field conditions restrictions
9)
4000 Series - Maritime Domain
MedLim
Sub-domain
Description
Code
Ships / submarines
4000
Fit to serve in frigates and above only
Ships / submarines
4001
Fit for short visits to a ships / submarine alongside only
Ships / submarines
4002
Fit to serve in ships or submarines at sea in UK waters only
Fit to serve in ships or submarines at sea in UK and Northern
Ships / submarines
4003
European waters only
Fit for submarines in UK and US fleet exercise areas within medevac
Ships / submarines
4004
range
Ships / submarines
4005
Temporarily unfit submarine service
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Ships / submarines
4006
Permanently unfit submarine service
Permanently unfit service on a submarine at sea (fit SM duties
Ships / submarines
4007
alongside / ashore)
Permanently unfit service on a submarine at sea or alongside (fit SM
Ships / submarines
4008
duties ashore only)
Marine Craft
4100
Unfit fast boat transits and boat operations in rough sea states
Royal Marines
4200
Permanently unfit for Royal Marines General Service
Diving
4300
Temporarily unfit diving
Diving
4301
Permanently unfit diving
Fit to dive, with restrictions assigned by SMO Underwater
Diving
4302
Med/NSMBOS. DW MO for medical restrictor
Unfit mixed gas diving, navigation and watch keeping duties – (for
Diving
4303
CP4 divers i
aw BR1750A 1219b)
Sea survival / fire
4400
Unfit for BSSC or ISSC
fighting
Sea survival / fire
4401
Unfit BSSC / ISSC but fit Embarked Forces Fire Fighting Training
fighting
Sea survival / fire
4402
Unfit firefighting training and duties
fighting
Dockyard
4500
Unfit to work on dockyard edges
Medical review
4600
Fit for short embarked deployments subject to MRA
Fit to serve in ships, submarines or RM Units with a permanent MO
Medical support
4601
borne only
Needs access to a MO within 24 hours when deployed outside UK
Medical support
4602
waters
Needs access to a MO within 2 days when deployed outside UK
Medical support
4603
waters
Needs access to a MO within 3 days when deployed outside UK
Medical support
4604
waters
Needs access to a MO within 5 days when deployed outside UK
Medical support
4605
waters
Needs access to a MO within 7 days when deployed outside UK
Medical support
4606
waters
5000 Series - Environment and Medical Support Domain
MedLim
Sub-domain
Description
Code
Geographical/Regional assignment restrictions (details specified in
Geographical
5000
medical documents)
Geographical
5001
Unfit to deploy, travel or reside in malarious areas
Unfit Service outside base areas. Not to be used for RN/RM
Geographical
5002
personnel
Climatic restrictions - To be employed in appropriate thermal
Climatic (App 9)
5100
environment
Climatic
5101
Unfit for work outdoors
Unfit exposure to hot environments (including within the UK) seek
Climatic
5102
guidance from medical staff
Unfit exposure to cold environments (including within the UK) seek
Climatic
5103
guidance from medical staff
Climatic
5104
Unfit exposure to excessively wet environments
Climatic
5105
Unfit exposure bright light / strong sunlight
To wear Service / civilian PPE to ensure hands and feet are kept
Climatic
5106
warm
Climatic
5107
Fit to be employed in temperate climates only
Unfit exposure skin irritants / sensitizers (type will be specified in Med
Environmental hazards
5200
Docs)
Unfit exposure to dusts, fumes and vapours (type will be specified in
Environmental hazards
5201
Med Docs)
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Has (or may have) been exposed to environ hazard, avoid further
Environmental hazards
5202
exposure, refer to med docs/JPA
Climatic
5101
Unfit for work outdoors
Unfit exposure to hot environments (including within the UK) seek
Climatic
5102
guidance from medical staff
Unfit exposure to cold environments (including within the UK) seek
Climatic
5103
guidance from medical staff
Climatic
5104
Unfit exposure to excessively wet environments
Climatic
5105
Unfit exposure bright light / strong sunlight
To wear Service / civilian PPE to ensure hands and feet are kept
Climatic
5106
warm
Climatic
5107
Fit to be employed in temperate climates only
Unfit exposure skin irritants / sensitizers (type will be specified in Med
Environmental hazards
5200
Docs)
Unfit exposure to dusts, fumes and vapours (type will be specified in
Environmental hazards
5201
Med Docs)
Has (or may have) been exposed to environ hazard, avoid further
Environmental hazards
5202
exposure, refer to med docs/JPA
Not to conduct safety critical duties if medical support device(s)
Med support
5300
unavailable
Med support
5301
To have access to appropriate power supply for medical equipment
Med support
5302
Requires access to irradiated Blood Products
ROHC auto-upgrade: if not upgraded MFD within 12 mths is to return
Auto-upgrade
5400
to NSMBOS/FMB
ROHC upgrade: if not upgraded MFD or MFD (8001 + or - 5504)
Auto-upgrade
5401
within 12 mths return to NSMBOS/FMB2
PMO/SMO upgrade: if not upgraded MFD or MFD (8001 + or - 5504)
Auto-upgrade
5402
within 12 mths return to NSMBOS/FMB
Must have MRA undertaken by ROHC prior to Exercise / IPDT /
Medical review
5500
deployment
Medical review
5501
To be made available for regular medical reviews
Medical review
5502
For annual review by PMO / SMO
Medical review
5503
For annual review by Regional OH Consultant
Medical review
5504
Requires MRA prior to attendance on Command Course
JCC / SCC
5600
Fit for modified JCC or SCC / JCC or SCC (RM Band) only
6000 Series - Locomotion, Lifting and Carrying Domain
MedLim
Sub-domain
Description
Code
Locomotion
6000
Unfit strenuous physical exertion
Locomotion
6001
Requires to be seated at place of work
Locomotion
6002
Fit sedentary duties only
Locomotion
6003
Unable to sit for long periods
Locomotion
6004
Unable to stand for long periods
Locomotion
6005
Unfit for work kneeling down
Locomotion
6006
Unfit marching / drill
Locomotion
6007
Able to walk short distances only
Locomotion
6008
Unable to climb stairs regularly in course of duty
Locomotion
6009
Unable to climb vertical ladders
Fit limited use of one hand / arm (details will be specified in Med
Upper Limbs
6100
Docs)
Lifting/Carrying
6200
Unfit heavy lifting
2 To be revised at next template revision to: “5401: ROHC auto-upgrade: if not upgraded MFD or MLD (iaw current policy) within 12
mths return to NSMBOS”.
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Lifting/Carrying
6201
No load carrying
7000 Series Hearing and Vision Domain
MedLim
Description
Description
Code
Hearing
7000
To have annual audiograms with subsequent review by PMO / SMO
To ensure correct use of hearing personal protective equipment iaw
Hearing
7001
Hearing Conservation Programme
Hearing
7002
To avoid unprotected exposure to loud noise
Hearing
7003
Unfit exposure to noise above (to be specified) level
Hearing
7004
Unfit wearing of headsets
Hearing
7005
Unfit split headsets
To wear appropriate eye protection including specialist or tinted
Vision
7100
eyewear
8000 Series - Physical Fitness and Rehabilitation Domain
MedLim
Sub-domain
Description
Code
Fitness testing
8000
Medically exempt from all requirements of RNFT / RAFFT / PFA
Fit for Alternative Aerobic Assessment or Rockport Walk element of
Fitness testing
8001
RNFT / RAFFT
Fitness testing
8002
Unfit upper body / strength test element of the RNFT
Fitness testing
8003
Unfit RM BFT / CFT / ACFT / speed marches
Fitness testing
8004
Unfit AFT / OFT / speed marches
Fitness testing (App 9)
8005
Unfit to walk 3.2km carrying 15kg
Fitness testing
8006
Unfit OFT
Fitness testing
8007
Unfit Alternative Aerobic Assessment
Fitness testing
8008
Unfit press-ups
Fitness testing
8009
Alternative press-up hand position allowed
Fitness testing
8010
Unfit sit-ups
PT
8100
Unfit running
PT
8101
Unfit impact activity
PT
8102
Unfit organised physical training; fit individual PT programme only
PT
8103
Unfit Upper body PT
PT
8104
Restricted lower limb non-impact physical training
Rehabilitation
8200
Individual to be made available to follow rehabilitation PT programme
Rehabilitation
8201
Graduated Rehabilitation as directed by Clinical Lead
Graduated rehab including supervised phased return to limited sea
Rehabilitation
8202
duties as directed by Clin Lead
Fit travel outside UK on duty for adaptive sport/adventurous
Rehabilitation
8203
trg/represent the Service following MRA
Rehabilitation
8204
Unfit Multi Activity Course
Rehabilitation
8205
Unfit Core Recovery Event 1
Rehabilitation
8206
Unfit Core Recovery Event 2
Rehabilitation
8207
Unfit Core Recovery Event 3
Sport
8300
Unfit sport (to be specified in Med Docs)
Sport
8301
Unfit contact sports
Sport
8302
Unfit solo swimming
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9000 Series - Military Tasks Domain
MedLim
Sub-domain
Description
Code
Weapon handling
9000
Unfit handling live arms3
Weapon handling
9001
Unfit live weapons / fit simulation
Weapon handling
9002
Unfit APWT
Weapon handling
9003
Ranges restrictions
(App 9)
Weapon handling
9004
Weapon handling restrictions
(App 9)
Guard / Ceremonial
9200
Unfit guard duties
Guard / Ceremonial
9201
Unfit for ceremonial duties
Personal Kit and
9300
Clothing restrictions / military PPE (to be specified in med docs)
Equipment
Personal Kit and
9301
Unfit wearing Service footwear (to be specified in Med Docs)
Equipment
Personal Kit and
9302
Unfit non-aircrew respirators
Equipment
Dog handling
9400
Unfit for dog handling
Unfit CBRN threat areas, unable to tolerate CBRN protection and / or
CBRN
9500
prophylactic measures
Unit
9600
Unfit to return to original unit
UKSF
9700
Permanently unfit UKSF Selection
3 Unable to bear arms whether through psychiatric or physical reasons. Individuals are still fit to undertake weapons handling without live
ammunition.
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SECTION THREE: OCCUPATIONAL HEALTH ASSESSMENTS
Aim 1.
The aim of this Section is to describe the requirements and processes of medical
assessment for Armed Forces personnel. It applies to both regular and reserve forces.
General 2.
Medical assessment including both history and examination where appropriate must
be systematic and thorough. The medical assessment should produce not only an
accurate picture of the person’s health, but also their functional capacity with regard to
their current and likely future employment (including deployment). Careful assessment for
age-related decrement of functional capacity or ill health is required. Any change in
employment may require a further assessment. In all cases the medical assessment is to
be carried out by medical personnel with sufficient training to recognise abnormal results in
the screening tests used and to be able to deal with any health concerns raised, by
onward referral if necessary. This Section does not cover statutory health examinations
(e.g. isocyanate workers) for which reference should be made to the appropriate policy,
guidelines and single-Service publications.
3.
Medical assessments are to be conducted on the following occasions for the
purposes stated. Guidelines on the conduct of each assessment are provided in the
following paragraphs. At each assessment a PULHHEEMS grade1 is to be recorded on
the medical record and (with the individual’s consent) the result passed to the appropriate
administrative office2. Each quality and the factors that affect it are described in Section 1
and the functional interpretation of grades for each quality are summarised at Annex A.
Further guidance for the allocation of a grading by medical condition is given in the
annexes to Sections 4 and 5.
a.
Pre-Service. The purpose of the pre-service medical examination is to
determine medical fitness for employment (with respect to the period of
engagement). Comprehensive guidelines are provided in paragraphs 5-7 and at
Annex B.
b.
In-Service. In-Service assessments may be routine, for a specific requirement3
or on occasions when a medical board is required. Their purpose is to confirm
continued fitness for present employment and they provide an opportunity for health
promotion (activities in this latter respect are outwith the remit of this JSP). Further
guidelines are provided in Paragraphs 8-10.
(1) Routine medical assessments remain appropriate where legislation
demands enhanced health surveillance. Thus, specialist trade groups require
more frequent medical assessment in line with regulatory frameworks such as
the Diving at Work Regulations or MAA Regulatory Articles (as non-exhaustive
examples applicable to divers and aviators respectively).
1 Including suffixes to the grading in accordance with single Service guidelines.
2 In accordance with single Service policy.
3 E.g. change of commission or re-engagement.
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(2) Service Medical Boards4 are conducted to re-grade personnel following
changes in their functional capacity and medical employability resulting from
illness and/or injury, either on a temporary or permanent basis.
c.
Mobilisation and demobilisation (Reserve forces only). The purpose of the
mobilisation medical assessment is to confirm fitness for mobilisation and/or
deployment. The aim of the demobilisation medical is to identify any changes in
health status that have occurred during mobilisation and to confirm fitness for future
reserve service. Further guidelines are provided in paragraphs 11-13.
d.
Discharge. The discharge medical assessment is conducted at the termination
of employment. Its purpose is to assess and record the medical status and functional
capacity at the time of discharge including an appropriate PULHHEEMS grade.
Further guidelines are provided in paragraph 14.
4.
Annexes C-G are provided to assist the assessment of Body Mass Index and the
H,
E,
M,
S and
CP qualities respectively.
Guidelines for the pre-Service medical assessment 5.
General. The aim of pre-service medical assessment is to determine fitness for
employment for the terms of initial engagement and (implicitly) fitness to join the Armed
Forces Pension Scheme. Because the pre-service medical assessment must be
particularly thorough, comprehensive guidelines are provided at Annex B. Section 3
provides specific details of conditions of relevance for entry to service. The requirements
for assessment for special employments (e.g. aircrew, divers) are not included in this
Section and for which reference should be made to single-Service guidelines.
6.
History. Although a pre-employment health questionnaire may have been reviewed
prior to personal assessment of the candidate, the guidelines are restricted to general
principles and the verification of the history at the time of the examination. For guidelines
on the evaluation of the
M and
S qualities, see Annex F.
7.
Physical Examination. Functional fitness must be determined and therefore the
physical examination must be comprehensive in all cases.
Guidelines for in-Service medical assessments 8.
General. The aim of the in-service medical assessment is to confirm continued
fitness for present employment. It may also provide an opportunity for health promotion
although a full description of activities in this respect is outwith the remit of this JSP.
Reference may be made to the guidelines for assessment at Annex B but the assessment
need not in all cases be as comprehensive. Section 5 provides specific details of
conditions of relevance during Service.
9.
History. There is more to be gained from a comprehensive review of medical history
(since the last examination) than there is through physical examination. Episodes of ill
health should be reviewed and in particular, an assessment made and recorded on
whether there has been any interaction between health and work5. For guidelines on the
evaluation of the
M and
S qualities, see Annex F.
4 Refer to single Service guidelines for further instructions.
5 Elucidation of all biopsychosocial factors is recommended.
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10.
Physical examination. Any mandatory health surveillance examinations must be
conducted (e.g. audiometry for those on Hearing Conservation programmes). The
examination may be targeted but sufficient evidence is to be gained from the examination
to enable an accurate assessment for each PULHHEEMS quality. If there has been a
significant decrement of functional capacity, adjustment to the P quality may be required.
Audiometry and measurement of distant visual acuity, height, weight, blood pressure and
urinalysis are to be recorded at each assessment.
Guidelines for the assessment at mobilisation and de-mobilisation of Reserves 11.
Mobilisation. The aim of the mobilisation medical assessment is to determine fitness
for a reservist’s mobilised and/or deployed role(s). Reservists will already have had a pre-
service medical assessment and may have had in-service assessments. The assessment
must be thorough in order to detect conditions that may constrain performance in their
role. This may include a request for focused and specific information from the Reservist’s
GP with respect to function. Additionally, experience has shown that reservists tend to be
older than regulars. It is therefore recommended that the assessment should be as
comprehensive as that described at Annex B.
a.
History. All aspects of the medical history since the last medical assessment
should be explored and any intended deployed role6 determined to inform the
decision on fitness for mobilisation. For additional guidelines on the evaluation of
mental health, see Annex F.
b.
Physical examination. Sufficient evidence is to be gained from a targeted
medical assessment to enable an accurate JMES. Audiometry and measurement of
distant visual acuity, height, weight, blood pressure and urinalysis are to be recorded.
12.
Demobilisation of Reservists. The following procedures apply:
a.
The purpose of the demobilisation medical is to identify any changes in health
status that have occurred during mobilisation and to confirm fitness for future reserve
service.
b.
A Health Declaration by the individual is to be completed, indicating whether or
not there has been any change in health status during the period of mobilised
service. Where there has been a change, the declaration is to include any known
causes for the change and action taken as a result. An example of such a health
declaration is at Annex H.
c.
All personnel are to be offered the opportunity for a consultation with a doctor.
d.
Appropriate disposal of the F Med 965 theatre medical record is to be
confirmed.
Guidelines for the discharge medical assessment 13.
General. The aim of the discharge medical assessment is to assess and record the
medical status and functional capacity at the time of discharge including an appropriate
6 Both geographic and activity aspects are to be determined.
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PULHHEEMS profile. This assessment may be required as evidence of illness or injury
attributed to service7and to inform any decision for re-enlistment. The results of the
assessment must therefore be recorded meticulously. In particular, known exposures to
hazards (physical, biological, chemical, psychological) that have potential adverse health
effects (such as disease vectors or environmental and industrial hazards) must be listed.
Reference may be made to the guidelines for assessment at Annex B but the assessment
need not in all cases be as comprehensive. For discharges from Service for medical
reasons, these instructions are complementary to Section 6 Harmonisation of Medical
Boards Leading to Discharge. The FMed 133 is normally completed at this assessment.
14.
History. All episodes of ill health during service should be reviewed and in particular,
an assessment made and recorded on whether there has been any interaction between
health and work8. For guidelines on the evaluation of the
M and
S qualities, see Annex F.
15.
Physical Examination. The examination may be targeted but sufficient evidence is
to be gained from the examination to enable an accurate assessment for each
PULHHEEMS quality. If there has been a significant age-related decrement of functional
capacity, adjustment to the P grade may be required. Audiometry and measurement of
distant visual acuity, height, weight, blood pressure and urinalysis are to be recorded.
Annexes A.
Functional Interpretation of Grades for each Quality.
B.
Guidelines for the Conduct of the Pre-Service Medical Assessment.
C.
Assessment of Body Mass Index.
D.
Assessment of hearing acuity (H).
E.
Assessment of distant visual acuity (E).
F.
Evaluation of Mental Capacity (M) and Emotional Stability (S).
G.
Assessment of Red/Green Colour Perception (CP).
H.
Health declaration - example for use at demobilisation.
I.
Guidelines for undertaking screening Pure Tone Audiometry.
7 The examining medical officer is not required to determine attributability.
8 Elucidation of all biopsychosocial factors is recommended.
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Annex A
FUNCTIONAL INTERPRETATION OF GRADES FOR EACH QUALITY
Grade
P
U
L
HH
EE
M
S
Factors to Age, build
Strength, range Strength, range Audiometrically
Visual
Mental capacity.
Emotional stability.
considered strength and of movement
of movement
assessed acuity
acuity.
stamina
and general
and efficiency
of hearing. The
efficiency of
of feet, legs
sum of the
upper arm,
pelvic girdle
hearing loss at:
shoulder girdle
and lower back.
and back
FREQUENCIES
Lower
Upper
1
45dB or 45 dB
Not less
less
or less
than 6/6.
Good hearing
*(RN only: Level
not to be more
than 30 dB at 6
kHz or 20 dB at
any other
frequency)
2
Medically fit
Muscle power
Can run, jump,
84dB
123dB
Not less
Ability under
The absence of a
for
average. Able
climb crawl and or less
or less
than 6/9. service conditions
medical condition
unrestricted
to handle arms
perform all
Acceptable
to learn to perform
affecting normal
service
and do heavy
kinds of manual practical hearing
successfully all
emotional stability.
worldwide.
manual work.
labour.
for Service
Service duties.
purposes
Includes capability
to be trained as
tradesperson or
specialist
3
Medically fit
Must be able to Capable of
150dB
210dB
Not less
Ability under
The presence of a
for duty with use personal
walking at least or less
or less
than
Service
minor limitation to
minor
weapon
5 miles and
Impaired hearing. 6/12.
conditions to learn
emotional stability
employment and be capable able to stand for The hearing level
to perform simple
likely to affect
limitations
of wearing
periods of at
at which most
unskilled duties.
the individual’s
protective
least 2 hours
.
personnel are
ability to perform
clothing.
unfit for entry to
their normal military
the Service.
duty and general
military skills.
Limitations to
employment are to
be stated (e.g.
working patterns)
preferably following
discussion between
clinicians and the
individual’s line-
manager (following
consent). Fit to
handle live arms
and perform
mandatory military
training but must be
reviewed by a
service-appointed
medical officer prior
to deployment.
4
Medically fit
More
More
Not less
for duty
than
than
than
within the
150DB 210dB 6/18.
limitations of
Very poor
pregnancy.
hearing. Below
entry standard for
the Services.
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Grade
P
U
L
HH
EE
M
S
5
Not
less
than
6/24.
6
Not
.
less
than
6/36.
7
Medically fit
Capable of
Able to walk
Not
Capable of
The presence
for duty with
sedentary
2 miles at
less
performing
of a major
major
and routine
own pace.
than
simple duties
limitation to
employment
work of a
Can stand
6/60.
under
emotional
limitations.
lighter type. for a
supervision. Not
stability likely to
moderate
able to bear
significantly
period.
arms. Fit for
affect the
restricted
individual’s
service only.
ability to
perform their
normal military
duty and
general military
skills. Able to
function within
a military work
environment.
However, unfit
to handle live
arms or be
deployed.
8
Medically
Medically
Medically
Medically unfit
Less
Medically unfit
Defect of
unfit for
unfit for
unfit for
for service.
than
for service.
emotional
service.
service.
service.
6/60.
stability such
that the
individual is
below P7
criteria.
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Annex B
GUIDELINES FOR THE CONDUCT OF PRE-SERVICE MEDICAL
ASSESSMENT
1.
Introduction. This Annex describes the pre-service medical assessment process. It
includes an element of screening to assess an individual’s fitness for service, including the
likelihood of developing a condition during service.
2.
Documentation. A pre-employment health questionnaire is to be completed in
accordance with single-Service guidelines. The date and details of the pre-service medical
assessment are to be recorded on the appropriate single-Service form, whether paper1 or
electronic and, with the individual’s consent, the result passed to the appropriate
administrative office.
Preliminary assessments 3.
Appropriately trained medical staff may conduct and record the following preliminary
assessments before a medical officer conducts the examination.
a.
The NHS Number is to be recorded (if not already recorded on the health
questionnaire).
b.
Height, weight, BMI2 and, when applicable3, body fat percentage.
c.
Blood pressure4 (sitting). Two additional measurements are to be taken if the
first recording is abnormal.
d.
Urinalysis (blood, protein and glucose). Two additional samples are to be tested
if the first recording is abnormal5.
e.
Peak Expiratory Flow Rate (PEFR). The predicted PEFR is to be calculated and
the actual PEFR measured. Two additional measurements are to be taken if the first
recording is abnormal. Forced Expiratory Volume (FEV1) and Forced Vital capacity
(FVC) are to be measured if indicated6.
f.
Audiometry. See Annex D for further guidance on assessment and recording.
g.
Distant Visual Acuity (
EE) and Red/Green Colour Perception
(CP). See
Annexes E and G for further guidance on assessment and recording.
4.
It is good practice for the examining medical officer to collect the individual from the
waiting area and this is an ideal time for gait to be observed. Personal identity is to be
verified, and completeness of medical documentation (health questionnaire and a record
of preliminary assessments) confirmed.
History
1 The individual’s name is to be recorded on each sheet of the paper record.
2 See Annex C for Body Mass Index Guidelines.
3 In accordance with single Service instructions.
4 In accordance wit
h British Hypertension Society guidelines. 5 See Chapter 3, Leaflet 7, Paragraph 3.7.1.
6 See Chapter 3, Leaflet 5, Paragraphs 3.5.2 – 3.5.6.
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5.
Although the pre-employment health questionnaire will have been reviewed prior to
personal assessment of the candidate, these guidelines are restricted to general principles
and the verification of the history at the time of examination. It must be confirmed that
there is no history of any conditions incompatible with service. Section 4 provides specific
details of the influence of conditions on PULHHEEMS assessment at entry. At this stage of
the assessment, an evaluation of both the
M (intelligence or ability to learn) and
S
(emotional stability) qualities should commence in order for an appropriate grade to be
allocated at the end of the assessment. Further guidance on assessment of these qualities
is provided at Annex F.
6.
The examining medical officer is to carefully review and verify the history. A summary
of pertinent information e.g. significant illness/operations and dates is to be entered on the
assessment record. In particular, the examining medical officer is to ensure that the
individual is asked specifically, and expand where appropriate on a history of the following
conditions:
a.
Asthma, wheezing, inhaler use.
b.
Mental ill-health issues, deliberate self-harm.
c.
Migraine.
d.
Skin conditions.
e.
Musculoskeletal conditions.
f.
A family history of disease, in particular if there is a history of sudden death
particularly at an early age (<40 years) or lipid disorder.
g.
Use of tobacco, alcohol and any substance misuse.
h.
Specific dietary requirements/sensitivities.
7.
The following details should also be recorded on the assessment record:
a.
Occupational history.
b.
Current sporting and physical activity levels.
c.
Current medical problems together with medication (including oral
contraception).
d.
Women are to be asked for the date of their last menstrual period, the date and
result of their last cervical smear and any abnormal cervical smear results.
8.
Following a review of the history, the individual is to read, sign and date the
verification declaration, and the examining medical officer is to countersign as a witness.
Examination
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9.
Introduction. A comprehensive clinical examination as set out below is to be
performed and all systems are to be assessed. Medical Officers should use their clinical
judgement in interpreting these guidelines to determine the depth and detail of
examination required in each case. If abnormalities are suspected, further information may
be sought from the individual’s normal providers of primary and secondary care. Any
abnormality discovered by the examiner should be pursued to a level sufficient to make a
PULHHEEMS grading. The functional interpretation of grades for each quality is given at
Annex A. Specific medical conditions which affect entry and employment when serving are
detailed in Sections 4 and 5 respectively.
10.
Caveats. Chaperones are to be used in accordance with best practice7 and the name
of the chaperone should be recorded. If a chaperone is declined, this must also be
recorded. The routine pre-service assessment does not require examination of the female
breasts or genitalia. Inspection of the anus is not necessary in either male or female
candidates.
11.
General considerations. The nature of the medical examination should be
explained to the candidate together with the reasons for examination of particular systems
throughout the examination. At appropriate stages during the physical examination,
individuals should be asked to undress down to their underwear to facilitate a full
inspection and also to gain an overall impression of their physique8. The candidate’s
speech, general appearance and any external signs of systemic disease should be noted
throughout the interview and examination. Similarly, the skin appearance can be assessed
throughout the examination although the examining doctor should specifically examine the
scalp. If necessary, confirmation of the nature and location of declared tattoos are to be
recorded9. The recommended procedure for examination in a logical order is set out
below. A record of the findings is to be made against each element.
12.
Head and neck. The inspection of the head and neck is to include:
a.
General: observation of faces and facial movements.
b.
Visual examination and function: external examination, pupil reaction to light
and accommodation, ocular movements in all directions of gaze, visual fields by
confrontation and fundoscopy10.
c.
Ears: Tympanic membranes, Valsalva manoeuvre.
d.
Nose: deformity, patency of nasal passages.
e.
Mouth: teeth, tongue, palate, speech.
f.
Cervical lymph nodes.
g.
Thyroid.
h.
Scalp: to exclude skin disease.
7 https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/intimate-examinations-and-chaperones
8 Physically immature candidates may not be acceptable.
9 In accordance with single Service procedures.
10 With the examination room darkened.
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i.
Other cranial nerves and special senses. The sense of smell need not be
tested.
13.
Chest. Examination of the chest is to be performed with upper body clothing
removed but there is no routine requirement for females to remove the bra. If it is
necessary to move the bra in order to listen to heart sounds an explanation should be
given to the patient. Examination should include:
a. Pulse (rate and rhythm). Peripheral pulses and radiofemoral delay if indicated.
b. Confirmation of blood pressure recording (by reference to previous clinical
measurement). Repeat if indicated.
c. Location of apex beat, cardiac thrills and auscultation of the heart sounds.
Carotid auscultation.
d. Respiratory rate, symmetry of chest, expansion, percussion and auscultation of
breath sounds.
e. Axillary lymph nodes.
14.
Abdomen. Upper body clothing may now be replaced. The candidate should be
asked to lie on their back on the couch to facilitate examination of the abdomen. Formal
examination of the liver, spleen, kidneys, inguinal lymph nodes and testes is to be
performed, and the absence of any herniae confirmed.
Examination of female genitalia is
not to be undertaken. 15.
Examination of the musculoskeletal system. A formal and comprehensive clinical
and functional examination11 of the musculoskeletal system is essential. Where relevant,
movements should be conducted against resistance to determine muscle strength and
neurological examination performed if indicated. For convenience, the assessment is
described below by region.
16.
Upper limbs. The upper limbs may be examined with the candidate standing, or
sitting on the edge of the examination couch:
a.
Shoulder. Confirm symmetry, normal power, full active and passive movement
(abduction, adduction, internal and external rotation).
b.
Elbow. Confirm symmetry, normal power, full active and passive movement
(flexion, extension, pronation and supination). Tendon reflexes.
c.
Wrist. Confirm symmetry, normal power, and full active and passive movement
(flexion and extension). Tendon reflexes.
d.
Hands. Confirm full function of fingers and thumb, dexterity and grip strength.
e.
Coordination. Confirm normal upper limb coordination.
11 A DVD titled: The Functional Orthopaedic Examination of the Potential Recruit is available from BDFL (Catalogue Number
C52127/07).
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17.
Lower limbs. Examination of the lower limbs should be performed with the candidate
lying or reclined on the examination couch for hips and knees, and with the legs hanging
over the couch for ankles and feet.
a.
General. Confirm equal length of the legs.
b.
Hips. Confirm normal power, normal and symmetrical flexion, extension,
adduction and straight leg raise, and with the knee and hip flexed at 90°, normal
internal and external rotation.
c.
Knees.
(1)
Inspection. Confirm symmetrical quadriceps muscle mass.
(2)
Palpation. Confirm the absence of effusion and joint line and tibial
tubercle tenderness.
(3)
Movement. Confirm normal power, symmetrical and normal flexion and
extension and absence of crepitus. With the leg in extension confirm the
integrity of the medial and lateral collateral ligaments. Confirm the integrity of
the anterior and posterior cruciate ligaments (posterior sag, anterior drawer test,
Lachman’s test), and of the menisci by McMurray’s test. Finally, patellar
apprehension testing should be performed.
(4)
Tendon reflexes.
d.
Ankle. Confirm the absence of Achilles tendon tenderness or thickening.
Confirm normal power, full and symmetrical movement: dorsiflexion, plantar flexion,
inversion and eversion (both passively and actively). Perform the ankle anterior
drawer test to demonstrate integrity of the anterior talo-fibular ligament. Tendon
reflexes.
e.
Feet and toes. Confirm normal power, normal and symmetrical movement of
the midfoot and forefoot joints. Confirm normal movement of all toes and exclude the
presence of deformities (club feet, flat feet, claw toes, scars and hard corns).
18.
Spine. The spine is best examined with the candidate standing.
a.
Cervical spine. Confirm normal and symmetrical flexion, extension, lateral
flexion and rotation.
b.
Thoracic spine. Exclude kyphosis and scoliosis and confirm full thoracic
rotation.
c.
Lumbo-sacral spine. Confirm flexion and a smooth spinal curve without
bending the knees12, extension, lateral flexion and rotation.
d.
Coordination. Confirm normal spinal and lower limb coordination.
12 Ideal: touch the floor. Minimum acceptable: reach the level of the ankle.
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19.
Dynamic functional assessment. Performance of the following exercises will further
inform the assessment of the
U and
L qualities:
a.
Press-ups. The candidates should be asked to perform 3 or 4 press-ups: males
– knees off floor, straight back, at shoulder width with the palms flat on the floor. The
rise must be from nose-on-floor to elbows fully extended. Observation must ensure
that the elbows are at the same level on each side and that there is no asymmetry of
the upper limbs or thorax. If necessary, females may perform the exercise using the
knees as the fulcrum point.
b.
Normal gait. Gait will already have been observed as the candidate enters the
examination room but should be confirmed by taking normal steps across the room.
c.
Toe walking. The candidate should walk across the room on the tips of their
toes with the feet fully extended.
d.
Heel walking. The candidate should walk across the room on the heels of their
feet.
e.
Walking on the outer border of the feet. The candidate should walk across
the room on the outer borders of the feet.
f.
Duck walking. The candidate takes 5-6 steps whilst squatting with the knees
and hips flexed and the ankles fully dorsiflexed.
g.
Heel raises. 5 single heel raises should be performed with both arms
outstretched and fingertips only in contact with the wall. The other leg is held with the
knee flexed to 90°.
h.
Further dynamic functional assessment. Medical officers may request
physical selection staff to further assess dynamic qualities during physical selection
tests (e.g. gait during running tests, shoulder performance during chin-ups).
20.
Summary. The examining medical officer is to ensure that a record of findings
against each element has been made, provide a summary of the medical examination,
provide the candidate with a PULHHEEMS grading together with a Pass / Fail / Deferral
statement and then sign and date the record, with a note of their name in block capitals. If
appropriate, the medical officer must also indicate if the candidate may undertake physical
selection tests. Any attachments to the examination record must be indicated.
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Annex C
ASSESSMENT OF BODY MASS INDEX
1.
Introduction. The height – weight tables published in previous versions of JSP 346
Section 2 are no longer relevant. It is recommended that the relationship between height
and weight should be assessed with reference to Body Mass Index (BMI). Although BMI
does not measure body fat directly, research has shown that BMI correlates well with
direct measures of body fat. It is an inexpensive and easy-to-perform method of
assessment of weight categories that correlate with health problems and is accepted by
health authorities (including WHO) as a valid indicator of obesity for health risk
assessment. Of particular importance are the relationships between BMI and (a) the risk of
injury during military training and (b) cardiovascular risk. Body Mass Index is measured as
follows: mass in kilograms divided by height in metres, squared, and therefore has the
units kg/m2.
2.
A classification of cardiovascular disease risk based on both BMI and waist
circumference has been adopted by the National Institute for Health and Clinical
Effectiveness (NICE). The NICE classification of BMI and waist circumference is shown in
tables below. A recent INM report1 has recommended that the latest guidance from NICE2,
that BMI and waist circumference should be recorded. In addition, the INM report
recommends that the disease risk criteria within the NICE guidelines be modified to
provide statements on suitability for entry to the Armed Forces.
Table C1: NICE classification of BMI.
Classification
BMI (kg/m2)
Underweight
≤18.5
Healthy weight
18.5-24.9
Overweight
25.0-29.9
Obesity Class 1
30.0-34.9
Obesity Class 2
35.0-39.9
Obesity Class 3
≥40
Table C2: NICE classification of risk for waist circumference(cm).
Waist Circumference Risk
Men
Women
Low
<94
<80
High
94-102
80-88
Very High
>102
>88
3.
Pre-service assessment. Although sSs may have their own policies for entry for
absolute height and weight3, the recommended BMI guidelines for entry into service are as
follows:
Table C3: Upper and lower BMI limits for entry.
Age
Male and
Male and female Male maximum
Female
(years)
female
maximum
with additional
maximum with
minimum
assessment
additional
assessment
18+
18
28
32
30
16 to <18
17
27
27
27
1 INM Report No. 2007.026 dated Jun 07.
2 https://www.nice.org.uk/guidance/cg43
3 Based on anthropometric and other considerations.
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4.
The additional assessments required are measurement of waist circumference and
satisfactory aerobic fitness4. For males waist circumference must be less than 94cm; for
females waist circumference must be less than 80cm.
5.
These requirements are based upon both research into risk of and type of training
injuries and the health effects of the extremes of BMI. It is generally considered that health
becomes an issue when the BMI is outside of a range of 18-30 and the health effects of
being underweight or overweight are well known. However, the overall fitness and
functional capacity of the individual should also be considered. For example, some
individuals, such as body builders, who are lean but have a high BMI due to a high lean
body mass, may be suitable for service. However, there is clear evidence that there is a
significantly increased risk of musculoskeletal injury (particularly during military training
and in females) in those with a low BMI5. Similarly, there is evidence that in individuals
with a high BMI there is decreased muscle endurance and an associated increase in
fatigue6.
6.
In-service, mobilisation and discharge assessments. BMI should not be used
alone as a reason to change the
P quality but should be used as part of a comprehensive
functional assessment to determine suitability for employment.
7.
Specialist employment groups. Single-Service height and weight standards will
apply for entry into specialist employment groups, such as aircrew, parachutists, Royal
Marines and submariners. These standards can be found in the relevant single-Service
publications.
8.
Protocol for the assessment of waist circumference. The following protocol
should be followed to ensure consistency in the assessment of waist circumference78:
a. The candidate’s waist should be exposed, sufficient for the relevant bony
landmarks to be identified.
b. The candidate should be standing with the feet together, weight evenly
distributed and with a relaxed arm position.
c. The candidate should breathe normally and the waist measurement is to be
taken at the end of normal expiration.
d. The correct position is midway between the bottom of the ribcage and the
uppermost border of the iliac crest.
e. The tape should be snug but not compress the skin.
f. If there is difficulty locating the bony landmarks the tape is to be placed at the
level of the umbilicus.
4 As assessed by pre-employment physical selection tests and subject to single Service requirements.
5 Identifying Risk Factors for the Development of Training Injuries among Female Army Recruits. Greeves J, Leamon S, Bunting A,
Panchel R, Mansfield H. QinetiQ Report 05/01990. Jul 2006.
6 Fitness, performance and anthropometric characteristics of 19,195 Canadian Forces personnel, classified according to body mass
index. Jette M, Sidney K, Lewis W. Mill Med. 1990;155:120-6.
7 Garrow J, Summerbell C. Obesity [online]. Available fro
m: https://www.birmingham.ac.uk/Documents/college-
mds/haps/projects/HCNA/06HCNA3D2.pdf
8 World Health Organization.
Measuring obesity—classification and description of anthropometric data. Report on a WHO consultation
on the epidemiology of obesity. Geneva: World Health Organization, 1987.
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ANNEX D
ASSESSMENT OF HEARING ACUITY (H)
1.
Personnel working in noisy working environments are at risk of hearing damage,
which may result in deafness and/or tinnitus. Audiometry is the standard health
surveillance tool for the assessment of noise-induced hearing loss and all new entrants
must have their hearing acuity assessed by pure tone audiometry. This requirement will
provide a baseline against which future audiometry can be compared and will also
highlight any disorder of hearing at recruitment. The standards of hearing acuity required
by individual trade groups are a single-Service issue and the relevant single-Service
publications contain detailed information on these standards. For detailed information on
health surveillance once in service see the Surgeon General’s Policy Letter 12/061.
2.
Audiometric basis of assessment. The basis of audiometric assessment is the
summing of high and low frequency levels in decibels (dB) over six frequencies. The
frequencies used are 0.5, 1, 2, 3, 4 and 6 kilohertz (kHz); the low frequencies being 0.5, 1
and 2 kHz and the high frequencies 3, 4 and 6 kHz. The hearing in each ear is assessed
and recorded separately. The assessment is recorded under the first H for the right ear,
and under the second H for the left ear. The higher value digit, representing the worst
frequency group, determines the individual's overall hearing category for each ear.
3.
Audiometric standards. There are five grades of hearing acuity: 1, 2, 3, 4 and 8,
described in the following table:
Table D1: Grades of hearing acuity.
Grades Sum of hearing level at
Sum of hearing level at high
General description
low frequencies in dB
frequencies in dB
1
Not more than 45. (RN
Not more than 45. (RN only:
Good hearing
only: No single level to be
Level not to be more than 30
more than 20dB)
dB at 6 kHz or 20 dB at any
other frequency)
2
Not more than 84
Not more than123
Acceptable hearing
3
Not more than 150
Not more than 210
Impaired hearing.
4
More than 150
More than 210
Poor hearing where continuing
employment is subject to
specialist assessment.
8
More than 150
More than 210
Poor hearing that has been
assessed as being incompatible
with continued service.
4.
During service any change in the H degree, other than a fall from H1 to H2, must be
referred for an ENT opinion. Unilateral hearing loss also requires specialist assessment,
with investigation as necessary. Those with unilateral or bilateral hearing loss who are
considered suitable for continued employment in the Services must be subject to
appropriate controls and education (both of the individual and their managers) to ensure
appropriate protection from exposure to noise and to reduce the risk of any further
deterioration in hearing.
1 SGPL 12/06: Noise at work health surveillance.
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5.
It is important to remember that hearing acuity does not necessarily correlate closely
with hearing function or ability to undertake effectively and safely any particular
employment role. Any functional impairment that is found to be due to impaired hearing
should be reflected in the P quality. Restrictions on employment that are as a direct result
of impaired hearing should also be reflected in the P quality. In both these cases the
impaired hearing acuity will be reflected in the H quality for each ear.
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Annex E
ASSESSMENT OF DISTANT VISUAL ACUITY (E)
1.
This Annex provides details of distant visual acuity (VA) assessment only. Other
ophthalmological examination requirements are detailed in Annex B and Annex G
(red/green colour vision perception).
Pre-Service assessment
2.
Accurate assessment of distant visual acuity (VA) is essential, as specified visual
standards are critical in many Service trades. Failure to meet the standards is a cause of
premature discharge and examiners must be wary of potential pit-falls in testing.
Examining medical officers are to be aware of the potential for long term wear contact lens
users to forget to declare their use of visual correction.
3.
Before being given an appointment for a pre-Service medical examination, the
candidate is to be questioned as to whether he or she wears spectacles or contact lenses
and one of the following procedures applied. All candidates who wear spectacles or
contact lenses are to provide a visual correction prescription dated in the previous 6
months which may be requested prior to the pre-service assessment. However, if there is
a discrepancy between VA measured at an optician and that recorded at the pre-service
assessment, the latter should take precedence.
a.
New entrants who wear spectacles only are to be instructed to bring their
spectacles with them when attending the medical examination.
b.
Contact lenses alter the curvature of the cornea and VA assessment
immediately following their removal functionally improves VA. New entrants who wear
contact lenses (hard or soft) and already have spectacles are therefore:
(1) To be instructed not to wear their soft contact lenses for at least a period
of 48 hours prior to their medical examination, or 10 days in the case of hard
contact lenses.
(2) To be instructed to bring their spectacles with them when attending the
medical examination.
(3) To be given an appointment at a date which will allow (1) above.
b.
New entrants who wear contact lenses but do not have spectacles are:
(1) To be instructed not to wear their soft contact lenses for at least a period
of 48 hours prior to their medical examination, or 10 days in the case of hard
contact lenses. They must however, bring them to the examination.
(2) To be given an appointment at a date which will allow (1) above.
(3) To have their VA assessed and recorded
unaided first, and then to fit their
contact lenses and have their
aided VA assessed and recorded.
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(4) At the pre-service medical examination, to be warned that if in all other
respects their selection is successful, they will be required to be in possession
of spectacles and an appropriate prescription at their initial medical examination
(5) To have the medical examination record1 annotated “corrected VA
assessed with contact lenses only.”
In-Service assessment 4.
Distant visual acuity (both uncorrected and corrected) is to be measured and
recorded at each assessment.
Distant visual acuity testing and recording 5.
Snellen chart. The following instructions should be observed to ensure accuracy in
the use of distant vision test charts. A standard 6 metre Snellen chart is to be used,
adequately illuminated, and set at exactly 6 metres2 from the candidate.
a.
Commencing with the right eye, each eye is tested separately. The eye not
under examination is to be properly occluded, be directed towards the chart and the
candidate must not be allowed to turn their head.
b.
The candidate may not screw up the eyes during testing; this includes the eye
under cover.
c.
Since it is easy to memorise the top three letters of the chart, a prior view of the
chart invalidates the test. The chart must be changed and the examination repeated.
6.
Near visual acuity testing. Near visual acuity testing is required for certain branches
and trades. Single-Service guidance provides details of the testing procedures required
and standards to be achieved.
7.
PULHHEEMS equivalents for visual acuity. The PULHHEEMS equivalents for
corrected and uncorrected visual acuity are as follows:
Visual acuity
PULHHEEMS ‘E’
grade
Not less than 6/6
1
Not less than 6/9
2
Not less than 6/12
3
Not less than 6/18
4
Not less than 6/24
5
Not less than 6/36
6
Not less than 6/60
7
Less than 6/60
8
1 For example, serial 89 of FMed 1.
2 If space is limited, an optician’s mirror may be used to double the distance of a 3m test lane, but the 6m chart must be used in all
cases (i.e. the 3m un-reflected version is not to be used).
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8.
Recording. The recording of visual acuity under EE shows the uncorrected and
corrected vision in each eye separately, the first E representing the RIGHT eye, the
second the LEFT eye. Under EE the upper numbers denote the uncorrected visual acuity
and the lower numbers the corrected visual acuity. For example, a person with
uncorrected vision R = 6/12, L = 6/18, corrected vision R = 6/6, L = 6/9 is recorded as:
P
U
L
H
H
E
E
M
S
3
4
1
2
Period of validity of MES
A person whose unaided vision is R = 6/6, L = 6/6 is recorded as:
P
U
L
H
H
E
E
M
S
1
1
Period of validity of MES
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Annex F
EVALUATION OF MENTAL CAPACITY (M) AND EMOTIONAL STABILITY
(S)
General 1.
The physician is not expected to perform an exhaustive psychiatric examination;
however, a limited enquiry should always be made. The most effective method is one of
professional interest coupled with a respect for the candidate’s personality and feelings.
Questioning should begin with points relevant to the situation but of low emotional content.
This can lead onto a more general discussion of social background, work history and
emotional relationships.
Pre-Service assessment 2.
M quality. The
M quality is assessed in the recruit selection process by intelligence
testing.
3.
S quality. Emotional stability (
S) must be assessed by the examining medical officer.
There is no adequate group test for temperament or personality and reliance must be
placed on history. Contact with psychiatric services, substance abuse, eating disorders
and contact with police and social services should all be elicited. Any history of self-harm
or post-traumatic stress must be sought.
4.
Further guidance. The medical examiner should follow the specific psychiatric
guidance for entry as detailed in Section 4.
In-Service assessment 5.
M quality. The
M quality for serving personnel is not equivalent to that applied in the
pre-service assessment. It is a clinical classification distinguishing those whose mental
capacity makes them suitable for normal employment or deployment from those whose
limited capacity may affect employability. Although the examining medical officer may
make a recommendation, permanent re-grading of the
M quality must always be made
following assessment by a Service neurologist or clinical psychologist.
6.
S quality. Although the examining medical officer may make a recommendation,
permanent re-grading of the
S quality must always be made following assessment from
Service mental health specialists1.
7.
Further guidance. The medical examiner should follow the specific psychiatric
guidelines for serving personnel as detailed in Section 5. Those who are below M2 and S2
will exhibit a reduction in their overall functional capacity, and this should be reflected in a
reduced P quality.
1 Normally a psychiatrist but on occasions a community psychiatric nurse or clinical psychologist.
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Annex G
ASSESSMENT OF RED/GREEN COLOUR PERCEPTION (CP)
1.
Apart from certain uncommon cases of injury, disease, or a small number of drugs,
colour perception (CP) alters little during Service life. The test on entry is regarded as final,
and re-testing is only performed when a work-process risk assessment requires a review
(in support of risk mitigation measures, i.e. where a level of colour perception is critical to
the safe operation of new equipment introduced to Service) or for medical reasons.
2.
Testing of all candidates at entry is to comprise of a screen using Ishihara plates at
the fitness for service medical. Further assessment using the City University Colour
Assessment and Diagnosis (CAD1) test may be conducted in certain career employment
groups, as defined by the single Services, if the candidate fails the Ishihara test or if a
CAD score (otherwise known as a “colour vision” or CV category) is mandated as part of
enhanced health surveillance2.
3.
Service standards for CP are as follows:
a.
CP 1 (functionally normal CP). Attainment of CV-2 on CAD test (see table 1).
b.
CP 2 (normal CP). The correct recognition of the first 17 plates of the Ishihara
test OR attainment of CV-0 or CV-1 on CAD test (see table 1).
c.
CP 3 (defective but safe CP). Attainment of CV-3 on CAD test.
d.
CP4 (poor to severely deficient CP).
(1)
Army and RAF. Unable to pass Ishihara test AND / OR attainment of CV-
4 or CV-5 on CAD test.
(2)
RN. Unable to pass Ishihara test AND / OR attainment of CV-4 or CV-5 on
CAD test BUT able to correctly recognise the colours used in relevant trade
situations as assessed by an appropriate trade test (where offered – specific
trades only). The test normally used is matched paired wires. Other tests may
be used in specific situations.
e.
CP 5 (severely deficient CP). RN only: unable to pass any of the above tests.
1 The CAD test has replaced the Holmes-Wright Lantern (HWL) test due to obsolescence of replacement parts. Research b
y Barbur et
al has shown that the CAD test may have 100% sensitivity and 100% specificity for the assessment of colour vision deficiency, providing
an enhanced test for the diagnosis of CP deficiencies / assessment of CP functionality in specific trade groups. For reference, the CAD
test offers a significant improvement on the DMS use of the Ishihara 24 plate test with zero errors which will fail 9.2% of colour normals
and pass 1.7% of deutans, some of whom will have a severe CV deficiency; 0.6% of protans will also pass. While use of the HWL-A test
on high intensity improves these figures some deutans and protans are still able to pass this test (22% and 1.4% respectively). As a
result, CAD has been adopted as an industry standard across several sectors including aviation and maritime.
2 Refer to sS policy on enhanced health surveillance.
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Procedures for CP testing
Ishihara Testing
4.
Examination method. The Ishihara pseudoisochromatic plates are to be used for
colour vision testing in the first instance (where sS policy may stipulate appropriate use of
either the 24 or 38-plate edition depending on specific trade/regulatory requirements). The
procedures below are to be followed.
a.
The test is conducted using only good diffused daylight direct onto the test
plates or the alternative illuminant (fluorescent daylight lamp to BS 950 Part 1; 1967
[1980], all other light being excluded).
b.
The test plates are shown to the candidate at a distance of 50 to 100 cm for not
more than 5 seconds. The candidate may wear spectacles or contact lenses3 if
appropriate. The ‘winding line’ plates do not normally need to be presented.
c.
Each number is read aloud by the candidate. They must not trace or handle the
plates.
d.
The number of plates miscalled is recorded on the examination form (not
applicable to the RAF).
5.
Assessment. If no errors are made the candidate is graded CP2: colour vision
normal. Certain numbers might be miscalled by those with normal colour vision,
particularly when under stress. If no more than 3 plates are miscalled those plates are
shown again. If no errors are made on the second presentation a grading of CP2 may be
given. For candidates failing the test (more than 3 mistakes on the first presentation and
any errors on a second presentation), the candidate is assessed as CP4 pending
supplementary testing with CAD if required.
CAD Testing
6.
Examination method. CAD is a computer-based test in which the candidate sees a
coloured stimulus moving across the centre of the computer screen. The candidate must
press a button to indicate the direction the stimulus has moved. It is not possible to identify
the direction of movement if the colour is below the candidate’s chromatic detection
threshold or is one of the colours that they confuse if colour vision deficient. The colour
and intensity of the stimulus is changed until the candidate’s threshold for detecting each
colour (red/green(RG)) is found4. CAD testing is performed only by suitably qualified and
experienced assessors at designated single Service establishments (currently the RAF
Centre of Aviation Medicine, Recruiting and Selection Department of Occupational
Medicine at RAF Cranwell and the Institute of Naval Medicine).
7.
Assessment. The testing process provides a CAD Unit Threshold that equates to a
CV-category5. The screening programme will identify those candidates who have normal
(CP2) or abnormal red/green colour vision (the full red/green programme must then be run
3 Where contact lenses are used, the examiner is to check that these are not X-Chrom lenses. X-Chrom are not permitted to be used
during the assessment (in such circumstances appropriate glasses should be worn).
4 There is a separate programme to test for blue/yellow deficiencies which are normally acquired rather than congenital.
5 CV categories have been set to provide an equivalent standard to those given by the HWL test (see footnote 1).
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to categorise further categorise CP1, CP3 and CP4). Table 1 provides how CV-categories
map to CP standards (note that the CV and CP numbers do not directly correspond).
CV
Equivalent
CAD Unit Threshold (RG)
Description
Category
CP standard
Normal trichromats (could be used for
individuals required to undertake
CV-0
<= the mean for age
CP2
extremely demanding colour related
tasks).
<= the upper normal limit for
CV-16
Normal trichromats.
CP2
age
<= 2.35 CAD Units but not
Functionally normal trichromatic
CV-2
CP1
CV1
vision.
CV-37
<=4.00 CAD Units but not CV2
Safe trichromatic vision.
CP3
<=12.00 CAD Units but not
CV-4
Poor RG colour vision.
CP4
CV3
CV-5
>12.00 CAD Units but not CV4
Severe RG colour vision deficiency.
CP4
Table 1: CV Categories
6 CV-1 equates to a HWL pass on the dim B setting.
7 CV-3 equates to a HWL pass on the bright A setting.
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Annex H
DEMOBILISATION HEALTH DECLARATION EXAMPLE
1.
The requirement for and minimum content of medical assessments for Reserve
Forces on demobilisation are mandated by the Surgeon General1. The health declaration
that follows is an example that is currently used at RTMC Chilwell.
1 D/DMSD/3202/2 dated 28 Apr 03.
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OFFICIAL SENSITIVE PERSONAL
Medical in Confidence
(when completed)
Health declaration (to be attached to FMed 4 on demobilisation)
Service Number
Rank/Rate
Surname
Forename(s)
DOB
Maritime Reserves
Army Reserves
RAF Reserves
Unit
1a.
Have you suffered any illness or injury, consulted your doctor or received any medication
Yes
No
during your deployment?
1b.
Have you attended the dentist in theatre during your deployment?
Yes
No
1c.
Have you attended the physiotherapist in theatre during your deployment?
Yes
No
1d.
If you have answered yes to question 1a-c. or believe that your health has changed in any way during your
deployment, please give details below:
2a.
Are you aware of any environmental exposure during your deployment (e.g. depleted
Yes
No
uranium, noise, vibration or infectious disease)? If yes, please give details below:
2b.
Do you require antimalarials for the next four weeks?
Yes
No
2c.
Have you been issued malaria/Leishmaniasis/depleted uranium warning cards?
Yes
No
3.
Do you want to see a Medical Officer?
Yes
No
4.
Do you want to see a mental health worker?
Yes
No
Signature
Date
Investigations
Urinalysis
Peak Flow
BP
Pulse Hearing
Eyesight
Protein
R
L
R
L
Blood
Glucose
R (corrected)
L (corrected)
Signature of medical staff
Date
NB Patient will need to see a medical officer if there has been any significant change in medical/health condition
during deployment.
Summary of medical examination
Disposal
Fit
Referred to GP
Referred to NHS specialist
Referred to other hospital specialist
Signature of medical officer
Date
OFFICIAL SENSITIVE PERSONAL
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Annex I
GUIDELINES FOR UNDERTAKING SCREENING PURE TONE
AUDIOMETRY
1.
Pure tone audiometry is the standard health surveillance tool for hearing loss,
including Noise Induced Hearing Loss (NIHL). Audiometry is undertaken in medical
centres using automated pure tone audiometry. In this form it is equivalent to industrial
screening audiometry. More accurate clinical audiometry is available in Service approved
audiology departments, such as the Defence Audiology Service (DAS) based at Institute of
Naval Medicine.
2.
This leaflet deals with screening audiometry. It should be carried out in accordance
with the guidelines below and at a frequency determined by appropriate risk assessment in
line with JSP 950 Lft 6-4-4, and as directed by single-Service and other relevant hearing
conservation policy, e.g. operational mounting orders.
Environment 3
For screening audiometry to be as accurate as possible, it is necessary to minimise
extraneous noise, in case this masks the test tones and gives a false result. Criteria are
laid down for test rooms and should be adhered to1. The frequencies most sensitive to
environmental interference are the low frequencies of 1 kHz and below. These frequencies
may result from people walking through or past a testing area – this should be taken into
consideration when siting the test room. The requirements for audiometry should be
considered during all new building work or contracts for facilities where audiometry will
take place.
4.
In all but exceptional circumstances, it is necessary to use an audiometric
soundproof booth to achieve acceptable testing conditions. Testing within MoD should be
undertaken in an appropriate booth, which must be serviced and maintained to the correct
standard2. A minority of people find audiometric booths claustrophobic and need to be
tested outside the booth. Noise excluding headsets are not deemed suitable for MOD
purposes, and so personnel should be referred for clinical audiometry in this scenario.
Equipment 5.
Screening audiograms may be performed using an automatic screening audiometer.
The audiometer is to be set to record in 5 dB increments, and not used in Bekesy mode.
The currently approved audiometer is the Amplivox CA850 4A, although units with
previous models3 which comply with requirements may continue to use them. The CA850
is available from MG&S Abbey Wood (NSN 6515-99-773-4626 Audiometer Screening
CA850-4A Automatic Screening Incorporating Internal Database & Integrated Graphics
c/w Audiocups+Designated Printer).
6.
Each audiometer should only be used with the earphones supplied with it. Earphones
are calibrated to a particular audiometer, and it is not acceptable to swap earphones
between audiometers. If earphones need to be changed, the audiometer must be sent for
recalibration with the new earphones as laid out in Paras 8-10 below.
1 BS EN ISO 8253-1:2010 Acoustics. Audiometric test methods Pure-tone air and bone conduction audiometry Jan 11.
2 BS EN 60645-1 (IEC 60645-1) and the relevant BS EN ISO 389 (ISO 389) series standards.
3 e.g. Microlab series.
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7.
Manual pure tone audiometry is the gold-standard of hearing threshold
measurement. Manual audiograms are only to be conducted by personnel trained, as a
minimum, to current British Society of Audiology Education Committee Guideline on The
Training of Industrial Audiometricians standard. This is to ensure that manual audiometry
is carried out in a repeatable and accurate manner. Where manual audiometry is required
a request for testing should be sent to an appropriate clinical audiology department such
as DAS.
Equipment maintenance, calibration and daily checks4 8.
Screening audiometers should comply with BS EN IEC 60645-1:2001, and are to be
calibrated in accordance with BS EN ISO 389-1:2000.
9.
All equipment should be maintained, calibrated and used according to the
recommendations of BS 6655:1986 EN 26189:1991 ISO 6189:1983 Specification for pure
tone air conduction threshold audiometry for hearing conservation purposes. A basic
calibration of each audiometer is to be performed by a competent laboratory annually. It is
acceptable to use the manufacturer for this check.
10. The annual check must incorporate calibration of the earphones used with the
audiometer. This is important, as the earphones are often the weakest link in the
calibration chain, being easily damaged in use.
11. A listening check should be undertaken daily before use. An experienced and trained
individual with good hearing5 should listen at each frequency and at 3 sound intensities to
ensure that no extraneous noise is generated by the apparatus.
Training for those carrying out audiometry 12. In order to ensure that screening audiometry is as accurate as possible, and does not
miss early changes in hearing acuity, the test must be performed in a consistent manner
with care. Personnel undertaking screening automatic audiometry should be trained in the
procedure. Some training in audiometry is currently provided in Phase 2 at DMSTC and
this will be expanded in early 2014. In addition an e-learning package is being developed
for use for update and refresher training in medical centres. Personnel newly arrived on a
unit are to be supervised until they have demonstrated a satisfactory standard. All
personnel undertaking audiometry are to be checked annually to ensure understanding of
the procedure by a senior member of staff nominated by the senior MO - this check is to
include independent validation of an entire audiometric screening test. This check may be
undertaken locally, but should be recorded in local training documentation in a manner that
is available to Healthcare Governance Assurance Visit teams. Any individual who has not
performed audiometry within the past year is to undergo the local refresher training before
performing unsupervised audiometric testing.
Quality Control 13. It is important that audiometry is undertaken under standardised test conditions with
close attention to quality control procedures. Quality control is important to improve the
4 To be conducted in accordance with single-Service policy (AP 1269 11-04, APHCS Infrastructure and Equipment Policy) until replaced
by DPHC Instructions.
5 Preferably a Senior NCO or Practice Nurse with hearing no worse that H2 H2.
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repeatability and reliability of the data produced. Comparisons between audiometric results
taken over a period of time on one individual are an important part of interpretation in an
on-going and effective audiometric programme. To ensure that results are comparable it is
essential that standardised method of testing is used. Careful explanation to the subject of
the procedure and familiarisation with the test tones before the test begins are also
essential for the collection of reliable data. The criteria used to determine the accuracy
with which results are obtained include:
a.
Whether repeat audiometry on the same individual and same day is consistent6,
b.
Appropriate and timely equipment calibration, and
c.
The presence of background noise in the test environment.
Procedure 14. An aide memoire for the procedure below is detailed in the protocol for performing
screening audiometry flow-diagram.
15. It is civilian best practice that before undertaking an audiogram the identity of the
individual should be checked against a photographic identity document (e.g. MOD 90, a
photographic driving licence, or passport) to confirm their identity; this should be followed
in DMS facilities7. If they had not had an audiogram before, the initial noise and health
questionnaire at Appendix 2 should be completed. For subsequent audiograms, the
previous medical records including last audiogram(s) should be available. Any significant
changes to personal details, job or noise exposure should be noted, and if necessary the
questionnaire at Appendix 2 should be completed again.
16. Specific enquiry should be made about current problems, to include subjective
hearing loss, Upper Respiratory Tract Infection (URTI) symptoms, earache, discharge from
the ear, tinnitus or balance problems. With the exception of subjective hearing loss,
individuals with any problems should be referred to an appropriate clinician8 before the test
proceeds. The clinician should decide if audiometry can be performed same day or
deferred.
17. The ear should be examined using an otoscope. If significant amounts of wax are
present (here defined as obscuring more than 80% of the view of the tympanic
membrane), the wax should be removed by somebody trained in the procedure. If ear
drops or ear syringing are used, at least 48 hours should be allowed post treatment before
audiometry. If otoscopy reveals abnormalities, such as inflammation, fluid behind the
tympanic membrane, perforation, blood or discharge) the individual should be referred to
an appropriate clinician before the test proceeds. The clinician should decide if audiometry
can be performed same day or deferred.
18. An explanation of the test procedure should be provided to the individual. They
should be seated in the booth, and the tester should fit the earphones in the correct
orientation (red right ear, blue left ear), ensuring they are properly seated and positioned
over each ear, lining the speaker up with the ear canal. The individual should be observed
6 Only required if there are clinical concerns over an audiometric result, or more general concerns about the quality of audiometry at a
unit.
7 Any attempt at impersonation should be dealt with as a disciplinary matter.
8 This will normally be a medical officer but could include an appropriately trained nurse or audiologist.
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throughout the test to ensure that they do not attempt to falsify the test (e.g. swapping
headphones over halfway through, watching the light on the audiometer or rhythmically
pressing the response button). The test should be completed using automatic computer
mode, not Bekesy or manual mode. The frequencies 500 Hz, 1 kHz, 2 kHz, 3 kHz, 4 kHz,
6 kHz and 8 kHz are to be recorded on every occasion for both ears. If automatic mode
fails to record a valid result at any frequency, these should be repeated and added using
manual mode.
19. When the audiogram is complete the tester should remove the headphones for the
patient to reduce the likelihood of damage to the headphones. On completion of the test,
results should be compared with the most recent previous audiogram (unless this is the
initial test). If there is a difference of 15 dB or more9 at any frequency from the previous
result, the test should be repeated on the following day10. Until the test has been repeated,
the individual should be protected from further noise exposure. If a change of 15dB or
more is confirmed on repeat testing, this may be regarded as reliable. Further action is
detailed in the following paragraphs.
20. Inspect the audiogram for any obvious problems. See JSP 950 Lft 6-4-2 for guidance
on inspection of audiometry. If urgent concerns are identified, the individual should be
referred to an appropriate clinician immediately.
21. If no urgent concerns are identified, the audiogram should be referred for routine
review by an appropriate clinician. The individual should be booked for repeat audiometry
at the appropriate frequency, and a diary entry made on DMICP
Documentation 22. The audiogram is to be handled under a “Protect – Medical” caveat. The result is to
be entered onto DMICP via the audiometry template, and the audiogram itself scanned
onto DMICP as part of the patient record for medico-legal reasons. Once the audiogram
has been successfully scanned into the patient record, the original audiogram can be
shredded under normal arrangements for clinical records. Where there is no DMICP
record (e.g. Civil Servants), the audiogram is to be stored in the individuals Medical File for
a minimum of forty years.
23. When recording audiograms on DMICP, negative values are to be recorded as
negative values, and not set to 0. Similarly, negative values are to be summed as
negative, and not rounded up to 0. This is to ensure that the audiogram permits
subsequent changes to be detected. For example look at the following audiogram:
9 Changes up to and including 10dB at a single frequency between screening audiograms may not be reliable and may occur without ear
disease being present.
10 A minimum of 16 hours should be allowed between tests, ideally 24 hours. If there are no appointments available in an appropriate
timescale, the test should be repeated within a maximum of 2 weeks.
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-10
0
10
20
30
dB
HL
40
50
60
70
80
90
100
500 1k 2k 3k 4k 6k 8
k
Frequency (Hz)
This should be recorded as:
Frequency
dB
500
-5
1kHz
-5
2kHz
5
3kHz
10
4kHz
5
6kHz
5
8kHz
10
sum low tones
-5
sum high tones
20
24. Policy on interpretation of audiograms can be found in
JSP 950 Lft 6-4-2 ‘Assessing
Audiograms - Guidance for Medical Staff’.
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Protocol for performing screening audiometry
Baseline/Initial Test
Subsequent Tests
Initial noise and health
Obtain records for the patient
questionnaire – personal details,
including last audiogram(s). Note
job, previous exposures, medical
significant changes to personal
history
details, job or noise exposure.
Current problems?
Subjective hearing loss
earache, discharge
yes
tinnitus and/or balance problems
no
Re-book:
Abnormal:
Following wax
Inflamed
Conduct otoscopic
removal
Fluid
examination
Perforation
Blood
wax
no
wax
Book for
retest the
Refer to: MO/OH
Conduct test:
following
Nurse/Practice Nurse1
Use computer mode, not Beksey of Manual
day4:
Monitor individual throughout test to ensure
Protect from
it is valid2
further noise
exposure
pending retest
Yes:
Change confirmed
Compare with last test3
by repeat test
Yes:
Test not yet
repeated
Urgent concerns
Is there a difference
≥ 15 dB at any frequency from the previous test3
no
Inspect the audiogram for any obvious problems5
no concerns
Notes:
1. Clinicians should decide if audiometry
can be performed same day (e.g.
subjective hearing loss, tinnitus) or
deferred (e.g. otitis media).
2. E.g. swapping headphones.
3. Unless this is baseline entry
Advise patient
audiometry.
of results:
4. Audiometry should be repeated once
Send audiogram
to confirm result. If a difference ≥ 15 dB
for routine review
at any frequency is confirmed refer to
by MO/OH
MO/OH Nurse/Practice Nurse.
5. See Section two for guidance on
Nurse/Practice
inspection of audiometry.
Nurse
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AUDIOMETRY HEALTH QUESTIONNAIRE
Service Number
Rank/Rate
Surname
Forename(s)
DOB
RN/RM
Army
RAF
Unit
Initial/Entry
Pre-Deployment
Repeat Initial/Entry
Repeat Pre-
Deployment
Periodic/Routine
Post-Deployment
Repeat
Repeat Post-
Periodic/Routine
Deployment
Special
Clinical
Repeat Special
Repeat Clinical
Date of audiogram
Ear Nose and Throat
If yes, please give details
Have you noticed any change in your hearing?
Yes
No
1.
Do you have trouble hearing or understanding
Yes
No
2.
normal conversation?
Do other people complain about your hearing and/or
Yes
No
3.
the loudness at which you listen to radio/TV?
Have any of your immediate blood relatives (mother,
Yes
No
4.
father, sister(s) and brother(s)) had hearing loss prior
to the age of 50?
Do you experience frequent earaches, ear infections,
Yes
No
5.
excessive earwax or discharge from the ear?
Do you experience ringing or buzzing in the ear?
Yes
No
6.
Have you ever had a perforated/burst ear drum? If
Yes
No
7.
yes, when and reason?
Have you consulted an Ear Nose & Throat specialist
Yes
No
8.
in the last year? If yes, when?
Have you had ear surgery recommended or
Yes
No
9.
performed?
Do you use a hearing aid, or have you ever been
Yes
No
10.
fitted for one?
Past Medical History
Have you had a cold, flu or sinus problem in the past
Yes
No
11.
7 days?
Have you suffered any head injuries or loss of
Yes
No
12.
consciousness? If yes, when and reason?
Occupational Health
What is your present occupation?
Yes
No
13.
Reserves only: What is your civilian occupation?
Does your current role (including civilian occupation
Yes
No
for Reserves) involve regular exposure to any loud
14.
noise? (e.g. firearms, artillery fire, power tools,
aircraft, motor boats, heavy machinery).
Do you regularly use an i-Pod, MP3 player or
Yes
No
15.
equivalent device?
Do you have any noisy hobbies e.g. shooting?
Yes
No
16.
Have you had a past exposure to explosion or blast? Yes
No
17.
In the past 48 hours have you been exposed to loud
Yes
No
18.
noise?
Post-Deployment Testing Only
Have you noticed any change e.g. loss of sensitivity
Yes
No
1.
or ringing in the ears, in your hearing since your last
test?
Were you exposed to any explosions or blasts when
Yes
No
2.
on operations?
Did you wear hearing protection when exposed to
Yes
No
3.
noise? What did you use?
Were the potential noise hazards that may be
Yes
No
encountered in the operational theatre and their
4.
control measures covered during your PDT and
RSOI training?
Signature
Date
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SECTION FOUR: THE INFLUENCE OF PARTICULAR CONDITIONS ON
MEDICAL FITNESS FOR ENTRY
1.
Introduction. These standards represent the agreed tri-Service minimum medical
standards for entry. The single Services may apply a higher standard, particularly in
relation to branches or trade groups where there are specific occupational fitness
requirements e.g. aircrew, divers, marines, parachutists and submariners. Specific
regulations on these groups are found in single Service publications1 and referenced as
appropriate in the annexes to this Section.
2.
General requirements. New entrants to the Armed Forces must be medically fit to
meet the various challenges of Service roles in which they will be expected to deploy;
potentially anywhere in the world, at short notice, in locations remote from established
medical care. Those with pre-existing conditions requiring periodic medical care or review,
or with a requirement for long term medication, must be appropriately screened according
to Section 3, in conjunction with the medical condition annexes.
3.
Physical activity. Prior to their application, potential recruits should be capable of
undertaking regular and substantial levels of exercise comparable with military training
without experiencing adverse effects (e.g. symptoms of lower limb pain). This is to ensure
that applicants can achieve levels of exercise that will be encountered during initial military
training and Service. The following activities may be considered representative of the type
of activities required:
a.
Running 30 – 40 minutes a minimum of 3 x weekly.
b.
Hill walking with 10 kg load (backpack) for 90 – 120 minutes (6 – 8 miles)
weekly.
4.
It is this level of activity that is implied when the phrase “activity comparable with
military service/training” is used in relevant annexes. Demonstrable evidence of said
activity should be considered and highlighted in any specialist referral (if indicated).
5.
Note: the potential candidate can only be advised to achieve an appropriate level of
activity. Care must be taken to ensure that an “order” (and thus responsibility to the MOD)
is not implied.
6.
Medical assessment.
a.
The recruitment medical assessment is to be based upon a functional
assessment of the physical and mental potential to undertake military training, all
general Service duties and serve in any environment worldwide for the period of the
initial engagement being offered. Many conditions which may not limit civilian
employment or sporting/recreational pursuits may be incompatible with military
service.
b.
Potential recruits are normally only accepted where they meet the standard for
full deployability.
1 Current versions of BRd 1750A (RN), AGAI 78 (Army), AP1269A (RAF) and any associated DINs or single Service Policy Letters.
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c.
Candidates with a lesser grading will not normally be accepted unless formal
authority has been granted by the relevant Personnel or Executive Branch following
medical advice2.
7.
Definitions. The following definitions apply throughout this section:
a.
FIT - Meets the Medical Entry Standard. Fit to undertake entry training and
Service without restriction.
b.
UNFIT - Not fit to undertake entry training and Service without additional
medical risk.
c.
Normally UNFIT - The expectation is that the candidate is UNFIT, but in
exceptional circumstances an experienced clinician may determine that the
candidate is FIT3.
8.
Determining a candidate as FIT for Entry. The annexes to this section give policy
on when a candidate can be found FIT. There are 3 scenarios where a candidate may be
found FIT:
a.
In the absence of conditions that are listed as excluding entry. Candidates
who meet the standard may be found FIT by examining clinicians.
b.
When candidates have a condition that determines they are ‘Normally
UNFIT’. An examining clinician may determine that a candidate does not meet a
medical standard and the Annex defines their condition as “are normally UNFIT”. In
such a scenario, after taking into account medical history, examination and function
(in the context of the proposed Career Employment Group (CEG)), such candidates
may be found FIT. The decision that these candidates are FIT may only be made by
single Service Medical Entry Staff4 (SSMES) or their delegated authority. The clinical
justification for such decisions must be documented in the pre-employment medical
assessment healthcare record. These candidates will still be fit to undertake entry
training and Service without restriction.
c.
When candidates have a condition that determines they are ‘UNFIT’.
Candidates who fulfil the criteria in the Annexes that would normally fulfil the
definition of “are UNFIT” can, in some limited situations, after detailed consideration
of medical history, examination and function and CEG be determined FIT in
accordance with paragraph 9. Paragraph 9 gives single Service Occupational
Physicians, responsible for Service Entry, discretion to use their clinical
judgement. Such candidates will still be fit to undertake entry training and Service
without restriction. The clinical justification for such decisions must be documented in
the pre-employment medical assessment healthcare record.
9.
Determining a candidate UNFIT for Entry. The annexes to this section give
guidance on when a candidate is UNFIT.
a.
These candidates will not normally be recruited.
2 BRd 1750A (RN), AGAI 78 (Army), AP 3391 Vol 3 Part B Lflt 220 (RAF).
3 See paragraph 6b.
4 SSMES must have appropriate oversight from a Consultant in Occupational Medicine.
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b.
Exceptionally candidates who are determined to be medically UNFIT may enter
service through a single Service Executive/Personnel ‘waiver’5. Advice must be
sought by the Executive/Personnel from an Occupational Physician from the SSMES
on restrictions which may be needed in training and in Service to inform the
Executive decision. The responsibility for the final decision to accept a candidate into
service and the recruiting risk lie solely with the Executive/Personnel function6.
c.
When a JMES is allocated, these candidates are to have Med Lim 1302
allocated to facilitate longitudinal analysis and inform review of standards in future.
10.
Seeking additional guidance. While this section and its annexes provide general
direction, each case must be assessed on merit, with the intention to facilitate decision-
making by examining clinicians. In addition, advice can be sought from SSMES on any
candidate and in particular for those conditions not covered in the appropriate section.
11.
Discretion for single-Service Occupational Physicians responsible for Service
Entry. Occasionally, exclusion of a candidate in particular circumstances may be
considered unreasonable. In such cases some discretion, consistent with single Service
policies or on advice from the SSMES, may be appropriate and would normally require an
Occupational Medicine Consultant opinion. Such candidates will be determined to be
medically FIT. Candidates who the SSMES declare UNFIT can still enter if supported by
the Executive through the waiver system (see paragraph 7).
12. Occasionally a candidate may have a number of conditions which, when taken
together in their entirety either clinically or temporally, make it reasonable to find them
UNFIT7. This is because they have not demonstrated sufficient resilience or robustness
over a sustained period and / or they are considered to be vulnerable to the demands of
military service. This would normally require an Occupational Medicine Consultant opinion.
13. It may be appropriate to seek clinical opinion from civilian consultants, Service-
appointed consultants or single Service or Defence Consultant Advisers through the
SSMES (as required by single Service recruiting policy). In these cases, it is important for
the referring medical officer to ask for an opinion about the nature and prognosis of a
condition including likely requirements for treatment/medication and follow-up. The effect
on function and fitness for service can then be determined by discussion with SSMES. In
many cases an opinion rather than a formal consultation with the candidate will satisfy this
requirement.
14.
Incidental findings. Where previously undiagnosed conditions are discovered by
examining clinicians, candidates are to be informed and their permission sought for their
usual general practitioner (GP) to be notified. When such permission is not obtained,
candidates should be encouraged to report the circumstances to their own GP. Agreement
to notify or not is to be recorded in the entry medical assessment paperwork. A letter to the
GP is to be given to the candidate and a copy of the letter is to be retained in the
applicant’s entry medical examination record.
5 See Paragraph 4. Detail is included in single Service publications listed at Footnote 1.
6 The Army’s waiver use relates to special enlistment (specialist Knowledge, Skills & Experience). It is not a route open to most
candidates who are rejected as UNFIT as it is not another level of appeal.
7 For example, a candidate may have experienced anxiety, alcohol missue, drug missue, self-harm, eating disorders and depression as
separate discrete episodes which may be within the entry standards if considered individually, yet may be considered UNFIT when
considering the totality of their mental health issues.
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15.
Specific conditions. Annexes A – N contain guidance on the effects of specific
conditions on the fitness of a potential recruit to enter initial military training. The annexes
are laid out by system, except for Annex N which contains a mixture of conditions that do
not sit in the other annexes. Where the candidate presents with a condition not listed in the
annexes, the opinion of the SSMES must be sought.
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Annex A
EYES PRE-ENTRY
1.
General principles for assessing Candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry, with respect to their
eyes, are:
a.
Function. A Candidate must have the visual function, in all military
environments, to safely and effectively:
(1) Perform their military role.
(2) Operate their personal weapon.
b.
Prognosis. Where a candidate is found to have a resolved or current
ophthalmic condition, the following general criteria should be met in addition to the
relevant specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated by military service (in particular blunt /
penetrating trauma, extremes of heat / cold, atmospheric pressure, UV light or
environmental conditions [e.g. dust]).
(2) Pose a significant risk of future temporary or permanent loss of function (in
one or both eyes).
(3) Pose a risk of sudden deterioration / incapacitation without reasonable
warning.
c.
Medical support requirements. Where a candidate has a pre-existing or is at
increased risk of an ophthalmic condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication occur for ≤ 1 week this should not lead to
clinical deterioration in the condition or functional degradation during that time. In the
deployed environment the condition should not foreseeably impact military medical
resource.
2.
Exceptional considerations. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the Single Service Medical Entry Staff (sSMES).
3.
The role of P and EE qualities. Conditions of the eye, orbit and eyesight are
assessed and recorded under P. The entries under EE are records of distance visual
acuity only (see Section 3). The minimum standards for both uncorrected and corrected
visual acuity on recruitment are determined by single-Service authorities. These standards
are dependent upon the proposed employment and trade group; irrespective of this, the
minimum standard is subject to the magnitude of correction required stated below.
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Conditions affecting visual acuity and field
4.
Absence of a functioning eye. Candidates with monocular (or uniocular) vision1; or
reduction of corrected vision in one eye to below either entry EE standard are UNFIT. This
is due to the elevated risk of blindness and incapacitation if the functioning eye is
damaged by ballistic or blunt trauma on operations.
5.
Visual field defects. Candidates with scotoma or limitation of binocular visual field
(from any cause) which precludes holding Group 1 driving licence2 or affects the central 15
degrees of right monocular vision3 are UNFIT. Candidates require adequate visual fields to
keep effective ‘lookout’ and operate a personal weapon safely.
6.
Double vision (diplopia). Candidates with double vision are UNFIT. Candidates
require the visual function required to perform their role safely and efficiently.
7.
Binocular Vision (stereopsis). Binocular vision is not a requirement for Service
Entry. Candidates may not meet the higher eyesight standards for certain trades. All cases
should be referred for sSMES opinion on fitness.
8.
Night blindness (nyctalopia). Candidates with night blindness, whether congenital
or acquired, are UNFIT. Candidates need to be able to work in low light and tactical
conditions.
9.
Refractive errors. Candidates with refractive errors outside the limits stated below
are UNFIT as the eyes are likely to be structurally abnormal. Patients with high myopia
have a higher risk of traumatic or spontaneous retinal detachment which if not diagnosed
and treated promptly may lead to permanent visual loss. Candidates with high
hypermetropia have a higher risk of glaucoma, a sight-threatening condition.
a.
Equivalent Spherical Error (ESE) greater than +5.00 -6.004 dioptres.
b.
Cylindrical error greater than +3.00 or -3.00 dioptres in any meridian. Where the
cylindrical error is greater than +/- 3.00 but less then +/- 5.00 dioptres, refer to
footnote5.
c.
To calculate the ESE and for further guidance on the application of this
Standard see Appendix 1.
10.
Refractive Surgery. The following methods of surgical correction of myopia or
hypermetropia are suitable for entry subject to single-Service requirements:
a.
Photorefractive keratectomy (PRK).
b.
Laser epithelial keratomileusis (LASEK).
1 Uniocular: When one eye is normal and the other eye is either absent or is blind. Blind Eye: An eye possessing a best attainable
corrected Snellen visual acuity (VA) of 6/60 or worse. Monocular: When an individual has two seeing eyes, one eye with normal vision
but the other eye possessing a best corrected VA between 6/60 and 6/24.
2 The latest edition of the DVLA publication ‘Assessing fitness to drive: a guide for medical professionals’ provides guidance under
‘Minimum standards for field of vision – all drivers’.
3 Essential for safe weapon handling.
4 Correspondence DCA Ophthalmology 16 Jun 21 to align with RCOpth definition of high myopia.
5 Where the Cylindrical Error is greater than 3 dioptres (but less than 5D) then corneal topography along with Service Ophthalmology
review is required to rule out keratoconus.
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c.
Laser in-situ keratomileusis (LASIK).
d.
Small Incision Lenticule Extraction (SMILE).
e.
Implantable Collamer Lens (ICL) with a central aqueous port.
11. Entry will not be considered for radial keratotomy (RK), or astigmatic keratotomy
(AK), or any other form of incisional corneal refractive surgery, other than those
procedures listed above. All invasive intraocular surgical procedures other than ICL
implants will remain a bar to entry, as there is a higher risk of sight and non-sight
threatening complications in the short and long term and the quality of vision can fluctuate.
Candidates require the visual function required to perform their role safely and efficiently.
12. To be considered, the prospective entry candidate must provide appropriate
documentary evidence that they fulfil all the following criteria:
a.
The total preoperative refractive error was not outside the limits for selection.
Refractive surgery does not change the underlying risks associated with high
hypermetropia or myopia,
b.
The preoperative best spectacle corrected visual acuity was within selection
limits, as the refractive surgery outcomes for high myopia and high hypermetropia are
less favourable, and refractive surgery does not change the underlying risks
associated with high hypermetropia or myopia,
c.
At least six months have elapsed since the date of the last surgery or
enhancement (to be extended to a period of one year if the candidate was aged 21 or
younger at the time of the surgery). This is to allow healing and stability of vision,
d.
There have been no significant visual side effects secondary to the surgery
affecting daily activities or night vision (such as glare, haloes), persistent discomfort,
requirement for topical eye medication) beyond 180 days post procedure,
e.
Stability of refraction post-procedure: no more than 0.50 dioptre difference in
the spherical equivalent or cylindrical correction of either eye should be
demonstrated by two separate refractions at least 90 days apart.
13. A single revision of corneal refractive surgery is acceptable, subject to the candidate
meeting all the criteria as above, including the preoperative limits before the first corneal
refractive surgery.
Conditions affecting eye movements (ocular motility)
14.
Involuntary eye movements (nystagmus). Candidates with involuntary eye
movements which impair visual function are UNFIT unless mild, long-standing,
asymptomatic, and not impairing visual function. Candidates require the visual function
required to perform their role safely and efficiently.
15.
Squint. Candidates with a squint are often hypermetropic and may be amblyopic
(total or partial) and may therefore fail to correct to a reasonable level of Visual Acuity.
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They will also have poor binocular vision (stereopsis).6 This may affect suitability for some
roles (e.g. aircrew) although the ability to fire a standard weapon is unlikely to be
compromised. Candidates with a squint and acceptable Visual Acuity are normally FIT.
Candidates with a history of incomitant squint7 are UNFIT. An incomitant squint is change
in the degree of squint in different positions of gaze and is associated with blurred or
double vision. Most squints do not fall into this category. Candidates require the visual
function required to perform their role safely and efficiently.
16.
Squint correction surgery. Candidates who had squint correction surgery within
preceding 6 months are UNFIT. This is to allow for adequate healing and adaptation of
eyesight. Candidates require the visual function required to perform their role safely and
efficiently. See para 12c and 12b (above).
17.
Orbital fractures and reconstruction. Candidates with a history of orbital fractures
and reconstruction causing chronic pain or restriction of ocular motility8 sufficient to impair
performance in role are UNFIT. Candidates require the visual function required to perform
their role safely and efficiently. The presence of metalwork, provided ocular function and
mobility are normal, is not a bar to entry.
Conditions affecting eyelids
18.
Eyelid inflammation (blepharitis). Candidates with eyelid inflammation are UNFIT
until it is controlled without the requirement for regular prescription only medication.9 This
is foreseeably exacerbated by military service in variable environmental conditions (e.g.
temperature, humidity, wind, dust) leading to reduced visual function. Candidates require
the visual function required to perform their role safely and efficiently.
19.
Uncontrollable closure of the eyelids (blepharospasm). Candidates with
uncontrollable closure of the eyelids that impairs visual function are UNFIT. Candidates
require the visual function required to perform their role safely and efficiently.
20.
Damage to the eyelids or eyelid movement. Candidates with damage to the
eyelids or eyelid movement (including ptosis) sufficient to impair protection of the eye or
affecting the visual fields are UNFIT. This poses a significant risk of future temporary or
permanent loss of function (in one or both eyes).
21.
Turning in or out of the eyelids (entropion or ectropion). Candidates with turning
in or out of the eyelids are UNFIT until surgically repaired.as these are foreseeably
exacerbated by military service in variable environmental conditions (e.g. temperature,
humidity, wind, dust). Candidates require the visual function required to perform their role
safely and efficiently.
Conditions affecting tear system (lacrimal apparatus)
22.
Persistent watery eyes (chronic epiphora). Candidates with persistent watery eyes
which impairs visual function are UNFIT. Candidates require the visual function to perform
their role and operate personal weapon safely and efficiently. Chronic epiphora is
disabling, causing discomfort and impairing visual function.
6 See Para 7 (binocular vision).
7 For example, Duane Syndrome.
8 See Para 15 (incomitant squint).
9 The use of over-the-counter (non-presciption) medications is acceptable.
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23.
Inflammation of the tear sac (dacryocystitis) as an adult.10 Candidates with
inflammation of the tear sac are UNFIT. Dacryocystitis is usually associated with blocked
tear drainage, epiphora (as above) and is often recurrent. Candidates require the visual
function required to perform their role safely and efficiently.
24.
Dry eye syndrome (keratoconjunctivitis sicca or associated with Sjogren’s
Syndrome)11. Candidates with dry eye syndrome which impairs visual function UNFIT.
Candidates require the visual function required to perform their role safely and efficiently.
Conditions affecting the front of the eye (cornea, conjunctiva, sclera)
25.
Keratitis / ulcer. Candidates are UNFIT until fully resolved. Candidates with more
than one episode are UNFIT. Candidates require the visual function required to perform
their role safely and efficiently. This poses a significant risk of future temporary or
permanent loss of function (in one or both eyes).
26.
Corneal dystrophy. Candidates with corneal dystrophy which impairs visual function
are UNFIT. Candidates require the visual function required to perform their role safely and
efficiently. This poses a significant risk of future temporary or permanent loss of function
(in one or both eyes).
27.
Corneal graft. Candidates with a corneal graft are UNFIT due to risk of eyeball
rupture following minor trauma and graft rejection. This poses a significant risk of future
temporary or permanent loss of function (in one or both eyes).
28.
Corneal vascularisation or opacity. Where visual acuity is below single-Service
entry standards, Candidates are UNFIT. Candidates require the visual function required to
perform their role safely and efficiently.
29.
Conjunctival infection / inflammation (conjunctivitis). Candidates with acute
conjunctivitis are FIT once the condition has resolved. Candidates with chronic
conjunctivitis are UNFIT. Candidates require the visual function required to perform their
role safely and efficiently.
30.
Conjunctival abnormality such as pterygium.12 If threatening the visual axis,
causing irritation or pain, candidates are UNFIT. Candidates require the visual function
required to perform their role safely and efficiently.
31.
Keratoconus (thinning of the cornea). Candidates with keratoconus are FIT
provided they meet all the following criteria.
a.
Candidates with a diagnosis of keratoconus or corneal ectasia may be
considered suitable for service after they have undergone a corneal crosslinking
procedure (CXL) and subsequently demonstrate stability determined by two post-
operative ‘Pentacam’ corneal topography examinations and subjective refractions, to
be conducted not less than 12 months apart. No specific CXL technique (epithelium-
on, epithelium-off) is required. Stability is defined by the following criteria:
10 Childhood dacryocystitis usually affects infants and spontaneously resolves.
11 Candidates with a single episode of episcleritis which has resolved are FIT.
12 Recurrence is 10-30% after surgery, depending on type of surgery.
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(1) No increase in Kmax by greater than or equal to 1.00 dioptres,
(2) No increase in cylinder by greater than or equal to 0.50 dioptres (on
Pentacam or subjective refraction),
(3) No more than 0.50 dioptres myopic shift (decrease in spherical equivalent
as measured by subjective refraction),
(4) Candidates must also meet visual requirements per Service with spectacle
use (no Rigid Gas Permeable contact lenses to be used for one month prior to
exam).
32. Candidates are UNFIT due to the presence of advanced keratoconus if either of the
following post-operative criteria apply:
a.
Central Corneal Thickness < 400 um.
b.
Kmax > 58 dioptres.
33. Candidates with a diagnosis of progressive corneal ectasia or keratoconus who have
not undergone CXL are UNFIT. Candidates require the visual function required to perform
their role safely and efficiently. This poses a significant risk of future temporary or
permanent loss of function (in one or both eyes).
34.
Inflammation (scleritis). Candidates are UNFIT. Any single or recurrent episode.
This poses a significant risk of future temporary or permanent loss of function (in one or
both eyes).
Conditions affecting the lens
35.
Absent lens (aphakia). Candidates are UNFIT. Candidates require the visual
function required to perform their role safely and efficiently.
36.
Intraocular lens implant (pseudophakia). Candidates who are pseudophakic are
UNFIT. Candidates require the visual function required to perform their role safely and
efficiently.13
37.
Lens opacity (including cataracts or past cataract surgery). Service-approved
specialist opinion is required. Candidates require the visual function required to perform
their role safely and efficiently.
38.
Lens dislocation, partial or complete. Candidates are UNFIT. Candidates require
the visual function required to perform their role safely and efficiently.
Conditions affecting the middle eye (iris, uveal tract)
13 With the exception of those who have had Implantable Collamer Lens (ICL) surgery which incorporates a central aqueous port while
retaining the biological lens. These candidates may be acceptable in accordance with Para 10, above.
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39.
Missing tissue to the eye (coloboma) (excluding iris14). Candidates are UNFIT.
This condition is usually associated with abnormal visual function and risk of associated
conditions, such as retinal detachment in the case of retinal coloboma and visual field
defects in the case of optic nerve coloboma. Candidates require the visual function
required to perform their role safely and efficiently. This poses a significant risk of future
temporary or permanent loss of function (in one or both eyes).
40.
Uveitis.15 Candidates with chronic or recurrent (more than once); anterior,
intermediate or posterior (syn-iritis, pars-planitis, vitritis, choroiditis, panuveitis) are
UNFIT. Candidates require the visual function required to perform their role safely and
efficiently. This poses a significant risk of future temporary or permanent loss of function
(in one or both eyes).
Conditions affecting the back of the eye (retina, macula)
41.
Vascular lesions. Coats disease, sickle cell retinopathy, choroidal neovascular
membranes and retinal venous and arterial occlusions are UNFIT, due to being associated
with abnormal visual function and future risk of deterioration. Candidates require the visual
function required to perform their role safely and efficiently.
42.
Retinitis, active or recurrent. Candidates are UNFIT. Retinitis poses a significant
risk of future temporary or permanent loss of function (in one or both eyes). Candidates
require the visual function required to perform their role safely and efficiently. Candidates
with retinitis pigmentosa (not a true retinitis) are UNFIT for the reasons stated above. Non
progressive sectoral Retinitis Pigmentosa may be FIT following service-approved
ophthalmological review.
43.
Retinal detachment. All cases with a history of retinal detachment16 are to be
referred to a service ophthalmologist. This poses a significant risk of future temporary or
permanent loss of function (in one or both eyes).
44.
Macular dystrophies or degenerations. Candidates are UNFIT. This poses a
significant risk of future temporary or permanent loss of function (in one or both eyes).
45.
Central serous retinopathy. Candidates are UNFIT because of the high risk of
recurrence.
Conditions affecting the optic pathways (optic nerve)
46.
Neuritis. Candidates are UNFIT. This condition is associated with systemic disease
such as multiple sclerosis and poses a significant risk of future temporary or permanent
loss of function (in one or both eyes).
47.
Neuropathy. Candidates are UNFIT. This condition results in impairment of visual
function and poses a significant risk of future temporary or permanent loss of function (in
one or both eyes).
14 Iris colobomata are generally benign, unless associated with other systemic syndromes and are normally acceptable.
15 Prognosis after traumatic uveitis, e.g. from intra-ocular foreign body, is good and recurrence uncommon. Candidates may be
determined FIT following a favourable assessment by a specialist.
16 There will be cases that may be acceptable, e.g. if the retina has been adequately reattached and the vision is good, the refraction
stable and within limits, no significant anisometropia, the visual field full and the ocular motility normal.
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48.
Papilloedema. Candidates are UNFIT. This poses a significant risk of future
temporary or permanent loss of function (in one or both eyes). A history of prior self-
limiting papilloedema with low risk of recurrence, such as after meningitis, must be referred
to sSMES.
49.
Glaucoma or history of ocular hypertension. Candidates are UNFIT. This poses a
significant risk of future temporary or permanent loss of function (in one or both eyes).
50.
Calcium aggregates in the optic nerve (Drusen). These are rarely symptomatic
but should be assessed as follows:
a.
Drusen + normal visual field, FIT with no further input required.
b.
Drusen with any reduction in visual field, but within normal vision entry criteria,
refer to Service Ophthalmology.
c.
Drusen not meeting entry criteria for visual function, UNFIT.
Other conditions and procedures
51.
Globe (eyeball) trauma. Candidates with a history of penetrating injury to either eye
resulting in abnormal function are UNFIT. Candidates require the visual function required
to perform their role safely and efficiently. Those with such a history who achieve the
Visual Acuity and other visual functional requirements should be referred for a Service
ophthalmological opinion.
52.
Neoplasm (cancer). Candidates with a history of ocular cancer are UNFIT. Those
with such a history who achieve the Visual Acuity, other visual functional requirements and
have been discharged from routine follow up should be referred for a Service
ophthalmological opinion. This poses a significant risk of future temporary or permanent
loss of function (in one or both eyes).
53.
Ophthalmic migraine. See Annex G Neurological Para 11.
Appendices
1.
Assessing Refractive Error - Supporting Notes and Flow Chart
2.
Cylindrical Error Flowchart
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Appendix 1 to
Annex A
ASSESSING REFRACTIVE ERROR - SUP
PORTING NOTES AND FLOW
CHART
Calculation of Spherical Equivalent (Equivalent Spherical Error (ESE)) 1.
The Equivalent Spherical Error (ESE) is the total refractive error, calculated as the
spherical component of refraction added to HALF of the cylindrical component of
refraction. The unit of measurement is dioptres (D). For example:
a.
Spherical +4.00D with cylindrical +2.00D = (+4.00D) + (2.00D/2) = ESE +5.00D
b.
Spherical +7.00D with cylindrical -3.00D = (+7.00D) + (-3.00D/2) = ESE +5.50D
2.
The Standard refers to the calculated ESE and NOT to the Spherical
Component. The individual spherical component is NOT to be used in isolation. For
example:
a.
Spherical -6.50D with cylindrical +2.00D = (-6.50D) + (+2.00D/2) = ESE -5.50D.
In this example, even though the spherical component is greater than -6.00D, the
calculated spherical equivalent is only -5.50D. The candidate is therefore FIT.
b.
Spherical -5.50D with cylindrical -2.00D = (-5.50D) + (-2.00D/2) = ESE -6.50D.
In this example, even though the spherical component is less than -6.00D, the
spherical equivalent is greater than -6.00D. The candidate is therefore UNFIT.
3.
The standard refers to the cylindrical component which IS to be used in its own right,
as well as to calculate the Spherical Equivalent Error (ESE). For example:
a.
Spherical +4.00D with cylindrical -2.00D = (+4.00D) + (-2.00D/2) = ESE
+3.00D. In this case, the cylindrical component is less than -3.00D and the
calculated ESE is less than +5.00D. The candidate is FIT.
b.
Spherical +5.50D with cylindrical -2.00D = (+5.50D) + (-2.00D/2) = ESE
+4.50D. In this case, the cylindrical component is less than -3.00D and the
calculated ESE is less than +5.00D. The candidate is FIT.
c.
Spherical +4.50D with cylindrical +2.00D = (+4.50D) + (2.00D/2) = ESE
+5.50D. In this case, the cylindrical component is less than -3.00D, but the
calculated ESE is greater than +5.00D. The candidate is UNFIT.
d.
Spherical +2.50D with cylindrical -4.00D = (+2.50D) + (-4.00D/2) = ESE +
0.50D. In this example, even though the calculated ESE is less than +5.00D, the
cylindrical component is greater than -3.00D. The candidate requires corneal
topography and Service Ophthalmology opinion. The Candidate is FIT.
e.
Spherical +2.50D with cylindrical -6.00D = (+2.50D) + (-6.00D/2) = ESE -0.50D.
In this example, even though the calculated ESE is less than -6.00D, the cylindrical
component is greater than -5.00D. The candidate is UNFIT.
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Examples
Sph
Cyl
ESE
Outcome
Reason
+4.00D
-3.00D
+2.50D
FIT
ESE in standard
+4.00D
-5.00D
+1.50D
UNFIT
Excessive Cyl
+4.00D
-4.00D
+2.00D
Corneal
Cyl >3.00D, <5.00D
Topography with
ESE acceptable
Service
Ophthalmology
opinion – possibly
FIT
+4.00D
+2.50D
+5.25D
UNFIT
ESE outside
standard
-5.75D
+2.00D
-4.75D
FIT
ESE in standard
-5.75D
-2.00D
-6.75D
UNFIT
ESE outside
standard
-5.75D
+3.50D
-4.00D
Corneal
Cyl >3.00D, <5.00D
Topography with
ESE acceptable
Service
Ophthalmology
opinion – possibly
FIT
-5.75D
-3.50D
-7.50D
UNFIT
ESE outside
standard
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Appendix 2 to
Annex A
CYLINDRICAL ERROR FLOWCHART
Optometrist report.
Note Sph and Cyl
dioptre values
Calculate ESE
ESE = Sph + (Cyl/2)
Is ESE
between
No
Yes
+5.00D &
6.00D?
Cyl
Cyl ≥ 5.00D
Cyl ≤ 3.00D
Value?
Cyl value >3.00D
and <5.00D
F2F Medical
Corneal
Topography
UNFIT
FIT
then refer to
Opth SpecMed
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Annex B
EAR, NOSE AND THROAT PRE-ENTRY
1.
General principles for assessing candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry, with respect to their
ears, nose and throat (ENT) are:
a.
Function. A candidate must have an adequate level of auditory, respiratory,
vestibular (balance) function in all military environments to:
(1) Safely perform their military role.
(2) Accurately hear instructions including radio communications and auditory
warnings.
b.
Prognosis. Where a candidate is found to have a resolved or current ENT
condition, the following general criteria should be met in addition to the relevant
specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated by the demands of military service (for
example noise exposure, extremes of heat / cold, atmospheric pressure, or
environmental conditions such as dust and allergens).
(2) Pose a significant risk of future temporary or permanent loss of function
(for example hearing loss in one or both ears).
(3) Pose a risk of sudden deterioration / incapacitation without reasonable
warning.
c.
Medical support requirements. Where a candidate has a pre-existing or
increased risk of an ENT condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication occur for ≤ 1 week this should not lead to
clinical deterioration in the condition or functional degradation during that time. In the
deployed environment the condition should not foreseeably impact military medical
resource.
2.
Exceptional considerations. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the Single Service Medical Entry Staff (sSMES).1
Hearing function
3.
Candidates are assessed according to their un-aided hearing level. Both ears
are tested and the worse grade on either ear is used as the maximal grade that the
candidate can achieve.
1 Delegated Authority arrangements may apply.
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a.
An audiogram result of H1 will mean the candidate is FIT.
b.
A grade of H2 or within the warning range of the HSE hearing categorisation2
but below referral level needs to be reviewed by sSMES. The candidate may be
subject to additional audiometry screening in-service.
c.
A grade of H3 or low≥er, or above HSE referral level is UNFIT due to the
requirement to hear well to perform in a military environment, especially when
performing safety critical tasks and the increased likelihood of disability arising from
further hearing loss.
d.
Any candidate who needs a hearing aid to restore normal function is UNFIT.
The use of hearing aids is incompatible with military personal protective equipment
and the use of communications headgear.
Conditions affecting the external ear
4.
Deformity of the pinna (outer ear). Candidates with minor deformities of the pinna
which do not interfere with the wearing of hearing protection or communication devices (in
ear, on ear, and integrated) are FIT. Candidates with deformity of the pinna sufficient to
interfere with the wearing of such devices (which are essential for safe and effective
military operations) are UNFIT.
5.
Otitis Externa (inflammation, irritation or Infection of the external ear canal).
Candidates who have had more than one episode of Otitis Externa not requiring specialist
intervention are FIT. Candidates with recurrent or persistent Otitis Externa who have
required specialist treatment are UNFIT. This is because of the risk of recurrence without
reasonable warning, which can cause distracting pain, narrowing of the ear canal and can
affect a candidate’s functional hearing ability. It can also cause issues with wearing
hearing protection or communication devices (in ear, on ear, and integrated), all of which
could impact their ability to safely perform their military role.
Conditions of the middle and inner ear
6.
Perforated tympanic membrane (hole or tear in the ear drum). Candidates are
FIT three months after a complete spontaneous healing or successful surgery
(tympanoplasty) to repair a perforation, provided hearing acuity is within entry limits and, if
tympanoplasty has occurred, tympanometry3 is normal. Candidates with a current
perforation are UNFIT because it affects their ability to hear properly and predisposes to
ear infections.
7.
Acute Otitis Media (AOM) (infection of the middle ear). Candidates who have had
more than one episode of AOM not requiring specialist intervention are FIT. Candidates
with recurrent or persistent AOM, who have required specialist treatment, are UNFIT. This
is because of risk of recurrence without reasonable warning. Recurrent AOM affects a
candidate’s ability to hear properly, which impacts military performance in challenging
environments. Candidates may be determined FIT provided they meet all the following
criteria:
2 The HSE categorisation is age and sex standardised, starting at age 18. Candidates aged lower than 18 at the time of application
should be judged as if aged 18. (DCA ENT/ORL opinion).
3 Tympanometry is a test that shows how well your middle ear is working. It does this by measuring how your eardrum moves
Hearing tests for children - NHS (www.nhs.uk).
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a.
The last episode resolved at least 12 months ago,
b.
The ear drum has healed,
c.
Hearing acuity is within entry limits,
d.
If tympanoplasty was required, tympanometry is normal.
8.
Chronic Otitis Media (COM) (ongoing chronic infection of the middle ear).
Candidates with inactive or healed COM who are no longer under specialist follow-up are
FIT provided they meet all the following criteria:
a.
The last episode resolved at least 12 months ago,
b.
The ear drum has healed,
c.
Hearing acuity is within entry limits,
d.
If tympanoplasty was required, tympanometry is normal.
9.
Candidates with active COM (including cholesteatoma4) are UNFIT because it limits
the ability to hear properly and perform military duties, can suddenly deteriorate without
reasonable warning, predisposes to other infections and place a high demand on medical
services.
10.
Surgical tubes in the ear drum - ventilation tubes (grommets, T- tubes).
Candidates who have had ventilation tubes which are no longer in place are FIT provided
they meet all the following criteria:
a.
The ear drum has healed,
b.
Hearing acuity is within entry limits,
c.
If tympanoplasty was required, tympanometry is normal,
d.
Remained symptom free for at least 6 months, due to the risk of recurrent
middle ear effusion (glue ear).
11. Candidates with ventilation tubes in place are UNFIT. This is because it limits the
ability to hear properly and safely perform their military role, can suddenly deteriorate
without reasonable warning, and predisposes to other infections.
12.
Myringitis (inflammation of the ear drum). Candidates with active or unresolved
myringitis are UNFIT due to the risk of sudden deterioration without reasonable warning.
This is because it affects a candidate’s ability to hear properly and safely perform their
military role.
4 A cholesteatoma is an abnormal collection of skin cells deep inside the ear
- https://www.nhs.uk/conditions/cholesteatoma
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13.
Mastoidectomy (surgical removal of cells from the mastoid bone within the
ear). Candidates are FIT following successful mastoid surgery provided they meet all the
following criteria:
a.
The ear drum has healed,
b.
Hearing acuity is within entry limits,
c.
Tympanometry is normal,
d.
No further specialist input required,
e.
Reviewed by service approved ENT consultant and confirmed the cavity is
stable and the condition is unlikely to give rise to a continuing need for medical
supervision or treatment, which impacts their ability to safely perform their military
role.
14.
Otosclerosis / Ossicular fixation (abnormal hardening of the small bones of the
middle ear). Otosclerosis is a progressive condition resulting in hearing loss. Candidates
with this condition are UNFIT even if hearing acuity is currently within entry limits due to
the risk of deterioration and hearing loss. Hearing loss will impact their ability to safely
perform their military role.
15.
Meniere’s disease (inner ear disorder that affects balance and hearing).
Candidates with a diagnosis of Meniere’s disease are UNFIT. This is because it can
deteriorate without reasonable warning, affecting a candidate’s ability to hear properly and
maintain balance, impacting their ability to safely perform their military role.
16.
Tinnitus (ringing / buzzing in the ears). Candidates with acceptable hearing but
who report mild, non-disabling, non-problematic episodes of tinnitus are FIT. If the
symptoms have impacted the candidate’s function or needed ENT referral, the candidate
is UNFIT, even if the audio-vestibular examination is otherwise normal. This is because
problematic tinnitus may worsen with noise exposure or stressful environments and can be
extremely distracting, impacting their ability to safely perform their military role.
Conditions affecting the Nose and Sinuses
17.
Nasal deformity. Candidates are FIT if able to breathe freely through at least one
nostril. Where there is septal perforation, it must be asymptomatic (no bleeding, crusting or
nasal blockage). Candidates are FIT six months following successful reconstructive
surgery, providing they can breathe freely through at least one nostril. Candidates with
deformity of the nose sufficient to interfere with breathing or the use of face masks,
breathing apparatus and other similar devices are UNFIT because all military personnel
need to be able to wear appropriate facial / respiratory personal protective equipment.
18.
Epistaxis (nose bleeds). Candidates with minor epistaxis (not requiring specialist
treatment or affecting daily function) are FIT. Candidates with recurrent epistaxis which
has been successfully treated are FIT provided they no longer require specialist input.
Candidates with ongoing symptomatic epistaxis or who are undergoing treatment are
UNFIT because of the risk of sudden deterioration and the inability to treat in austere
conditions. Candidates with hereditary haemorrhagic telangiectasia are UNFIT for this
reason.
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19.
Rhinosinusitis (inflammation of nose and sinus). Candidates with mild symptoms
are FIT. Candidates with seasonal rhinosinusitis are FIT if symptoms are controlled only
over the counter treatment and are non-disabling. Candidates with rhinosinusitis requiring
regular prescription medication5 are UNFIT, due to the impact of symptoms on military
performance and risk of sudden deterioration.
20.
Nasal polyposis (painless growths inside the nose). Candidates with
asymptomatic nasal polyposis or with a history of treated polyposis who remain
asymptomatic are FIT. Candidates with symptomatic nasal polyposis are UNFIT due to the
risk of further growth causing airway obstruction and blockage of sinuses, causing sudden
deterioration. This would impact their ability to safely perform their military role.
Conditions affecting the Throat (Pharynx, Larynx and Trachea)
21.
Adenoid hypertrophy (obstructive condition related to increased size of the
adenoids). Candidates are FIT following successful adenoidectomy. Candidates with
symptomatic adenoids are UNFIT, because the symptoms will affect breathing and the
quality of sleep which will affect their ability to safely perform their military role.
22.
Obstructive sleep apnoea / hypopnoea syndrome (intermittent airway blockage
whilst asleep). Candidates with obstructive sleep apnoea / hypopnoea syndrome are
UNFIT due to the requirement to access medical equipment and impact of fatigue which
will affect their ability to safely perform their military role.
23.
Cleft lip / palate. Candidates with no functional deficit are FIT. Candidates with
uncorrected cleft-lip and / or hard / soft palate or any gross abnormalities of the dento-
facial complex and associated soft tissues, must be referred to sSMES, who may refer to a
sS or HQ DPHC Dental Officer. This is because uncorrected conditions pose difficulties to
the candidate for feeding and increase risks of sinus infection. Additionally, if the condition
is likely to affect wearing protective headgear and / or respirators and / or safety
equipment they are UNFIT as it would be impossible to provide suitable and sufficient
Personal Protective Equipment (PPE).
24.
Laryngeal conditions. Candidates with papillomatosis (respiratory wart-like growths)
or a history of respiratory papillomatosis, whether treated or not, are UNFIT. Papillomata in
the larynx have a high risk of reoccurrence and can cause breathing and swallowing
problems. These can place significant limits on a candidate’s ability to safely perform their
military role.
25.
Tracheostomy. Candidates presenting with a healed tracheostomy are FIT provided
the reason for tracheostomy is not associated with other health concerns. Candidates with
an open tracheostomy are UNFIT due to the risk of infection, bleeding, sudden blockage of
the trachea and risk of sudden deterioration which impacts on ability to safely perform their
military role.
General conditions affecting the Ears, Nose and Throat
5 The use of over-the-counter (non-presciption) medications is acceptable.
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26.
Previous or ongoing cancer. Candidates with a current diagnosis and ongoing
treatment of ENT cancer are UNFIT. For candidates with a past history of cancer refer to
Annex N.
27.
Autoimmune conditions. Candidates with Wegener’s Granulomatosis or other
vasculitides are UNFIT because they can cause chronic inflammation and damage to the
nasal passages, sinuses, throat and lungs, which could suddenly deteriorate and impact
on ability to safely perform their military role.
28.
Facial nerve palsy. Candidates are FIT provided they can clearly communicate and
close their eyes fully. Candidates with unresolved palsy and with functional deficit are
UNFIT if it impacts on their ability to use respirators and safely perform their military role.
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Annex C
CARDIOVASCULAR PRE-ENTRY 1.
General principles for assessing candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry, with respect to their
cardiovascular system (heart and blood vessels) are:
a.
Function. A candidate must have the cardiac reserve, in all military
environments, to safely and effectively:
(1) Undertake maximal exercise for the purposes of assessment and trade
specific training.
(2) Perform their military role in the UK firm base and deployed environment.
(3) Operate their personal weapon and other role equipment.
b.
Prognosis. Where a candidate is found to have a resolved or current
cardiovascular disease (CVD), the following general criteria should be met in addition
to the relevant specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated by military service; in particular, extremes of
heat / cold, atmospheric pressure changes, dehydration or strenuous physical
exertion.
(2) Pose a risk of reduced performance, distraction, or sudden incapacitation.
The same applies to any treatment required.
c.
Medical support requirements. Where a candidate has a pre-existing or
increased risk of a cardiological condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication occur for ≤ one week this should not lead to
clinical deterioration in the condition or functional degradation during that time. In the
deployed environment the condition should not foreseeably impact military medical
resource.
2.
Exceptional considerations. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the Single Service Medical Entry Staff (sSMES). The resultant FIT or UNFIT outcome
will be determined by sSMES.
3.
Cardiovascular Risk Factors. Assessment of cardiovascular risk factors is an
important consideration when conducting any cardiovascular assessment in order to
reduce future events. Genetic, environmental, and other factors remain important
contributors to cardiovascular disease throughout a service persons career and it is
essential that these be reduced or avoided wherever possible. Below are specific
conditions known to increase the risk of future cardiovascular disease and must be
considered in candidates. Risk calculators, while helpful, are not validated in a young
population.
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a.
Hyperlipidaemia. Hyperlipidaemia is a risk factor of coronary artery disease
(CAD) which can lead to ischaemic heart disease (IHD). It often requires life-long
treatment. Candidates with untreated hyperlipidaemia are UNFIT. Candidates with
treated hyperlipidaemia are FIT E21 subject to meeting all of the following conditions:
(1) Effective treatment2 with statin monotherapy,
(2) Stable dose requirement for six months,
(3) No side effects from treatment,
(4) No diagnosis of hypertension (treated or untreated).
b.
Candidates with a familial dyslipidaemia, even if on treatment, are UNFIT.
c.
Hypertension (high blood pressure). High blood pressure is a predictor of
cardiovascular disease and is associated with ischaemic heart disease, heart failure,
renal failure and stroke. The higher the blood pressure, the greater the risk of
cardiovascular disease. Candidates with successfully treated hypertension (24h
ABPM <135/85 mmHg) are FIT subject to meeting all the following criteria:
(1) No diagnosis of dyslipidaemia (treated or untreated),
(2) Effective treatment with monotherapy,
(3) No evidence of end organ damage (normal ECG, fundoscopy and renal
function).
Cardiovascular Conditions 4.
Diseases of the coronary arteries.
a.
Coronary artery disease (CAD). Asymptomatic candidates with an incidental
finding of coronary artery calcification should be referred to a service-approved
cardiologist.
All other candidates with CAD are UNFIT. CAD is a progressive and
unpredictable condition. Exercise may precipitate disabling symptoms such as chest
pain. It is the predominant cause of exercise-related cardiac events and primary
cause of sudden death in those over 35 years of age. Approximately 50% of
cardiovascular events cause death with no prior symptoms.
b.
Ischaemic heart disease (IHD). This includes acute coronary syndromes
(ACS), myocardial infarction (heart attack) and stable / unstable angina (chest pain).
Following successful treatment of IHD there is an ongoing annual risk of future
events. Candidates with these conditions are UNFIT due to the risk of incapacitation
and requirement for access to prompt emergency medical intervention. This is
defined as access to specialist coronary intervention within two hours of symptom
onset.
c.
Other coronary artery pathology. Anomalous coronary artery origin,
1 Candidates must undergo annual cardiac risk assessment (BP check, lipid profile).
2 Total chol >5, LDL-chol >4, Triglycerides >2.3 (all mmol/L)
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spontaneous coronary artery dissection (SCAD), coronary artery bridging and
coronary arteritis are rare conditions but can have significant consequences.
Candidates with these conditions must be referred to a service-approved cardiologist.
5.
Arrhythmias (heart rhythm abnormalities). These can vary from benign
normal variants to life threatening abnormalities resulting in a significant risk of sudden
incapacitation or even death. Candidates with any symptomatic rhythm abnormality or
those who require medication to suppress the abnormality are UNFIT because these can
result in a significant risk of sudden incapacitation or even death.
6.
Bradycardia and conduction disease. These associated conditions are outlined
below:
a.
Sinus bradycardia, first degree block and Mobitz Type 1 AV nodal block are
considered normal findings, especially in athletic individuals and these candidates
are FIT.
b.
Partial right bundle branch block, where the QRS duration is <120ms, is a
normal ECG finding and needs no further investigation. These candidates are FIT.
c.
Those with Mobitz type 2 and complete AV nodal block are UNFIT because
these can result in a significant risk of sudden incapacitation or even death.
7.
AV nodal re-entry tachycardia (AVNRT). Candidates with a history of AVNRT
which is untreated, or which requires medication for suppression are UNFIT as AVNRT
usually presents abruptly with symptoms such as palpitations, dizziness, chest pain or loss
of consciousness. Those successfully treated with ablation require referral to a service-
approved cardiologist.
8.
Atrio-ventricular accessory pathway. Candidates known to have an
accessory pathway are UNFIT as they can cause palpitations, breathlessness, chest pain
or syncope.
In rare cases this can cause arrhythmia and sudden death. Those
successfully treated with ablation require referral to a service-approved cardiologist.
9.
Atrial tachycardias. Candidates with a history of atrial tachycardias are UNFIT
as they can be distracting, may incapacitate and are difficult to treat.
10.
Atrial flutter. Candidates with a history of atrial flutter, which has not been
treated with curative ablation are UNFIT as atrial flutter can be distracting, may
incapacitate and is difficult to treat. Candidates with successful ablation and no recurrence
within 6 months must be referred to a service-approved cardiologist.
11.
Atrial fibrillation. Candidates with one previous episode of AF may be
considered FIT subject to all the following:
a.
Due to a known reversible cause.
b.
No structural problem or ongoing metabolic disease.
c.
At least two years have elapsed with no recurrence.
d.
No ongoing treatment.
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12. Candidates with a history of more than one episode of atrial fibrillation are UNFIT as
there is a risk of distraction, reduced exercise tolerance and stroke.
13.
Ventricular tachycardia (VT). Candidates with a past history of VT are UNFIT as it
can cause palpitations, breathlessness, syncope or sudden death. Candidates with
fascicular or outflow tract VT must be referred to a service approved cardiologist and a
final decision made by sSMES.
14.
Inherited arrhythmogenic conditions (channelopathies).3 Candidates with a
confirmed or suspected diagnosis or positive family history of a channelopathy are UNFIT
because these conditions can present unpredictably with symptoms including sudden
cardiac death. Exercise or elevated body temperature can also exacerbate these
conditions.
15.
Implantable cardiac devices. Candidates who have an underlying cardiac
condition which requires treatment with a pacemaker or internal cardiac defibrillator (ICD)
are UNFIT. These devices are associated with a risk of infection and endocarditis and will
require lifelong monitoring.
16.
Implantable loop recorders. Implantable loop recorders are purely monitoring
devices. The suitability of the candidate will depend on the underlying condition. These
individuals must be referred to service approved cardiologist.
17.
Heart failure. Candidates with a diagnosis of heart failure, including those treated
with cardiac transplantation, are UNFIT as it is associated with reduced exercise tolerance
and generally has a poor prognosis.
18.
Cardiomyopathies (heart muscle diseases). Candidates with a confirmed
diagnosis of a cardiomyopathy are UNFIT because complications include heart rhythm
abnormalities, blood clots, mechanical heart failure, pulmonary hypertension, and sudden
cardiac death. Candidates without symptoms who have a positive family history must be
referred to a service approved cardiologist.
19.
Inflammatory cardiac conditions. Cardiac inflammation can occur for multiple
reasons. Symptoms can be painful, distracting and associated with cardiac complications
including death. Recurrent episodes after the initial acute event are common.
a.
Pericarditis. Candidates with a single episode who meet all of the following
criteria are FIT
:
(1) Episode resolved more than two years ago,
(2) Episode lasted no more than six weeks,
(3) Normal ECG and echocardiogram at least three months after resolution of
acute symptoms.
b.
Candidates who do not meet these criteria are UNFIT because inflammation of
the pericardium is painful and associated with pericardial effusion and tamponade
3 Brugada Syndrome, Catecholaminergic polymorphic ventricular tachycardia, Idiopathic ventricular fibrillation and Long and Short QT
Syndromes
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and requires a period of exercise restriction. Risk of recurrence is greatest in the
early years after an initial episode and ranges from 15 – 30%.
c.
Myocarditis (inflammation of the heart muscle). Candidates with a single
episode who meet all the following criteria are FIT:
(1) Episode resolved more than two years ago,
(2) Normal 24 hour ECG, biomarkers (troponin and NT-proBNP), exercise
tolerance test and cardiac MRI, all performed a minimum of six months after the
acute episode.
d.
Candidates who do not meet all of the above criteria are UNFIT because of
increased risk of recurrence, approximately 25% will develop persistent heart
dysfunction and 20% may acutely deteriorate and will either die or require heart
transplantation.
e.
Infective endocarditis (infection of the heart lining or valves). All
candidates with a past history of infective endocarditis are UNFIT because it is
associated with a 30% risk of death over 12 months and a recurrence of 8-12%.
20.
Valvular heart disease. Candidates without symptoms who have a structurally
normal heart and MILD4 regurgitation of a single heart valve are FIT. Candidates with any
degree of valve stenosis (narrowing) or more than mild regurgitation of any valve are
UNFIT (for mild pulmonary stenosis see Para 20 for pulmonary valve stenosis). All valvular
abnormalities can increase the risk of infective endocarditis. Moderate regurgitation of a
valve may be associated with harmful structural changes of the heart and has a tendency
to worsen with exercise. Stenosis of a cardiac valve can reduce cardiac output, limit
exercise capacity, and progression is unpredictable. Certain valves require specific
considerations:
a.
Bicuspid aortic valve disease. Candidates with bicuspid aortic valve disease
are UNFIT because it is associated with earlier deterioration in valve function
(stenosis and / or regurgitation) which can require surgical intervention anywhere
from the third decade onwards. It is also associated with disease of the aorta
including aneurysm and dissection.
b.
Mitral valve prolapse. Candidates with this condition are UNFIT because there
is an association between mitral valve prolapse, infective endocarditis, significant
mitral regurgitation (MR) and ventricular tachyarrhythmias (fast, abnormal heart
rhythm). The tachyarrhythmias are a particular concern where there is a finding of
mitral valve annulus disjunction. Candidates without symptoms with no more than
mild MR and no annular disjunction must be referred to a service approved
cardiologist.
c.
Prosthetic cardiac valves. Candidates who have undergone any cardiac valve
intervention are UNFIT as prosthetic valves, either tissue or mechanical, are
associated with an increased risk of infective endocarditis, valve deterioration over
time, need long term follow up, and may require anticoagulation.
4 Per British Society of Echocardiography agreed data set (or guidelines).
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21.
Congenital heart disease. With the exception of the conditions listed below,
candidates with congenital heart disease are UNFIT due to the risk of arrhythmia, heart
failure, and valve complications:
a.
Pulmonary valve stenosis. Candidates with isolated mild pulmonary valve
stenosis are FIT. This has a good prognosis and a very low risk of progression.
Candidates with supra- or sub-valvular stenosis are UNFIT due to the risk of
progression.
b.
Patent ductus arteriosus (PDA). Candidates without symptoms who have an
isolated PDA, which has been successfully closed more than six months ago, are
FIT. All other candidates are UNFIT.
c.
Muscular ventricular septal defects (VSD). Asymptomatic candidates with an
isolated finding of previous muscular VSD which has closed spontaneously are FIT.
d.
Small Atrial Septic Defect (ASD). This is less than or equal to 6mm who have
no other abnormality on echocardiogram, are asymptomatic with their exercise
training and have no prior history of stroke or TIA are FIT.
e.
Small restrictive VSD. (hole in muscular part of ventricular septum only, less
than or equal to 5mm) those who have an otherwise normal echocardiogram and no
prior history of infective endocarditis are FIT. Candidates with VSDs not meeting
these criteria are UNFIT due to the risk of progression of blood shunting across the
defect leading to pulmonary hypertension, cardiac enlargement and impaired
exercise capacity.
22.
Patent foramen ovale (PFO). PFO is a common variant in the general population
(~25%). Candidates with no cardiovascular complications (stroke or transient ischaemic
attack) are FIT. Candidates without symptoms who have had successful PFO closure must
be referred to a service-approved cardiologist to assess the risk of arrhythmia.
23.
Inherited aortopathies (aortic disease). Candidates with these conditions are
UNFIT. Inherited aortopathies and connective tissue diseases5 have high risks of
complications including aortic dissection, valve dysfunction, aneurysm / rupture, and
unpredictable rates of progression.
24.
Anticoagulation.
See Annex N Para 8.
25.
Cardiotoxic drugs. See Annex N Para 12b footnote 10.
Peripheral vascular diseases. 26.
Raynaud’s phenomenon or vasospastic disease. See Annex N.
27.
Congenital arterio-venous malformations (AVMs). Candidates with small,
symptom-free congenital AVMs are FIT. Those with AVMs affecting function are UNFIT
due to interference with military duty and equipment.
5 Including but not limited to Marfan syndrome, Ehlers Danlos, and Loeys-Dietz.
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28.
Congenital lymphoedema. All candidates with congenital lymphoedema are
UNFIT due to functional limitation and risk of infection.
29.
Deep venous thrombosis (DVT). See Annex N Para 6.
30.
Varicose veins. Candidates with symptom-free minor varicose veins or who have
undergone successful treatment are FIT. Candidates with symptomatic varicose veins
(skin changes or ulceration around the ankle) affecting lower limb function are UNFIT.
31.
Vascular trauma. Candidates with a history of vascular trauma require a referral to
a service-approved vascular surgeon.
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Annex D
RESPIRATORY PRE-ENTRY
1.
General principles for assessing Candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry, with respect to their
respiratory system are:
a.
Function. A candidate must have the respiratory reserve, in all military
environments, to safely and effectively:
(1) Undertake maximal exercise for the purposes of assessment and trade
specific training.
(2) Perform their military role in the UK firm base and deployed environment.
(3) Operate their personal weapon and other role equipment.
b.
Prognosis. Where a candidate is found to have a resolved or current
respiratory condition the following general criteria should be met in addition to the
relevant specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated by military service, in particular have risk of
being made worse or brought on by extremes of heat or cold, atmospheric
pressure or environmental conditions, e.g. dust or fumes.
(2) Pose a significant risk of future temporary or permanent loss of function.
(3) Pose a risk of sudden deterioration or incapacitation without reasonable
warning.
c.
Medical Support Requirements. Where a candidate has a pre-existing or
increased risk of a Respiratory condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication occur for ≤ one week this should not lead to
clinical deterioration in the condition or functional degradation during that time. In the
deployed environment the condition should not foreseeably impact military medical
resource.
2.
Exceptional considerations. Criteria within each condition have been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the Single Service Medical Entry Staff (sSMES).1 The resultant FIT or UNFIT
outcome will be determined by sSMES.
Conditions affecting the respiratory system
1 Delegated Authority arrangements may apply.
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3.
Candidates with active or previous history of clinician-diagnosed respiratory disease
with a spirometry which is currently below the Lower Limit of Normal (LLN)2 (standardised
for age, birth sex, height, and ethnicity) from whatever cause are UNFIT. These
candidates would need access to routine specialist medical services unavailable in austere
locations with limited medical support and would lack the respiratory function to safely
perform their military role. Candidates must also be able to safely undertake maximal
exercise for the purposes of assessment and training.
4.
Abnormalities of the chest wall (including pectus excavatum and pectus
carinatum). Candidates with chest wall abnormalities require careful clinical and functional
assessment (to ensure PPE such as combat body armour can be worn). Those without
respiratory symptoms or impaired exercise capacity and who have no other functional
limitations, with a normal clinical examination and ECG are FIT. Those with mild to
moderate impairment or surgical correction will require further assessment to include
normal spirometry, echocardiography and chest x-ray (anterior posterior and lateral views)
and will require referral to sSMES3 for final decision. In some cases, if the candidate is still
growing, deferral until skeletal maturity4 may be required. Those with significant
impairment of function are UNFIT.
Airway disease
5.
Asthma. The diagnosis of asthma is a clinical one (supported by objective tests).
The absence of consistent gold-standard diagnostic criteria means that it is not possible to
make unequivocal evidence-based recommendations on how to make a diagnosis of
asthma and there is no single diagnostic test. However, it is accepted that asthma is a
chronic disease characterised by airway inflammation, typical symptoms and airflow
obstruction, all of which are intermittent and variable. It is important to distinguish a
diagnosis of asthma from other conditions where similar signs and symptoms occur, such
as respiratory tract infections, particularly when trying to establish a diagnosis of asthma
based on historic records in those who are currently symptom-free.
a.
A focussed respiratory medical history is the best tool to help establish the
probability that a candidate has asthma. This must include assessment of:
(1) Any clinician-delivered diagnosis of asthma.
(2) The presence of typical symptoms – wheeze, chest tightness,
breathlessness, and cough (the presence of more than one increases the
probability significantly).
(3) The variability of symptoms over time.
(4) Symptom triggers, such as exercise, change in air temperature, fumes,
dust, allergens.
2 Normal range is between LLN = 5% percentile and Upper Limit of Normal (ULN) = 95th percentile. Use of fixed ratio FEV1/FVC <0.7
and 80% predicted not recommended for defining normal range. Recommendation to use GLI reference equations for spirometry,
biological sex, not gender used to interpret lung function. Stanojevic S, Kaminsky DA, Miller MR, et al. ERS/ATS technical standard on
interpretive strategies for routine lung function tests. Eur Respir J 2022; 60: 2101499 [DOI: 10.1183/13993003.01499-2021].
3 ECHO not normally required for mild chest wall abnormalities but would be required for those where connective tissue conditions are
suspected e.g., Marfans, or more than mild chest wall deformity.
4
Skeletal maturity. Ascertaining whether a candidate has reached skeletal maturity might be relevant in some conditions. In general,
this means being aged 16 years and over for women and 18 years for men.
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(5) A history of exacerbations precipitated by respiratory tract infection.
(6) Prescription of medications usually used for asthma, including inhaled
bronchodilators and inhaled steroids.
(7) A history of requirement for oral steroids, nebulised bronchodilators and /
or hospital treatment (including emergency department attendance).
b.
Factors in the history which increase the probability of a diagnosis of asthma
include:
(1) Documented evidence of wheeze heard by a clinician on auscultation of
the chest.
(2) Documented evidence of airflow obstruction (PEF, FEV1, FEV1 / FVC
ratio below LLN).
(3) A history of atopy (allergic rhinitis, allergic eczema).
(4) Recurrent episodes of typical symptoms after age three years.
6.
Candidates with no symptoms beyond the age of three years5 are FIT as the
probability of developing asthma is no higher than the rest of the population.
7.
Candidates with any of the following features are UNFIT as they have a high
probability of current or future asthma:
a.
Those with current asthma-like symptoms (including exercise-induced).
b.
Those diagnosed with asthma who have experienced symptoms and / or have
been prescribed any treatment for asthma in the preceding one year.6
c.
Those who have had more than five acute episodes of asthma-like symptoms
requiring primary healthcare intervention after the age of three years.7
d.
Those who have required specialist / secondary healthcare management of
their asthma.8
8.
Where there is Inducible Laryngeal Obstruction (ILO) or Breathing Pattern Disorder
(BPD) is suspected refer to sSMES.
9.
Chronic Obstructive Pulmonary Disease (COPD). Candidates with a confirmed
diagnosis of COPD9 are UNFIT. Candidates require the respiratory function to safely
5 Morgan WI, Stern DA, et al Outcome of Asthma and Wheezing in the First 6 Years of Life.
Am J Respir Crit Care Med. 2005;172;
1253-1258 DOI: 10.1164/rccm.200504.525OC
6 Army entry standards condition based waiver under the 5 point plan has been enabling entry for Candidates 1 year off treatment.
Defence Statistics analysis paper 20231012-Asthma Med Waivers Cohort Analysis found ‘no evidence that personnel granted asthma
med waivers on entry have experienced adverse employment or health outcomes.’
7 Von Mutius E. Paediatric origins of adult lung disease.
Thorax. 2001; 56:153-159. Decline in presence of asthma in adolescent years
may be related to a specific phenotype of wheezing associated with viral respiratory tract infections. Predictors of progression over
puberty into adulthood are severity of illness, presence and severity of atopy and uptake of smoking.
8 Tri-Service Respiratory Specialists consensus.
9 Chronic condition which leads to progressive loss of function over time.
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perform their military role and these candidates would need access to routine specialist
medical services which are unavailable in austere locations.
10.
Bronchiectasis. Candidates with a confirmed diagnosis of bronchiectasis (including
cystic fibrosis) are UNFIT. Candidates require the respiratory function to safely perform
their military role and these candidates would need access to routine specialist medical
services which are unavailable in austere locations.
11.
Alpha-1 Antitrypsin Deficiency. Those with PiMZ or PiMS carrier status are FIT
because the risk of developing lung disease is very low.10 Candidates with a confirmed
diagnosis of Alpha-1 Antitrypsin Deficiency, whether they have evidence of associated
organ dysfunction or not, are UNFIT. This is a progressive disease, candidates require the
respiratory function to safely perform their military role and these candidates would need
access to routine specialist medical services which are unavailable in austere locations.
Pleural Disease
12.
Spontaneous Pneumothorax. Primary spontaneous pneumothorax (PSP) occurs in
otherwise healthy people, usually before the age of 40 years whereas secondary
spontaneous pneumothorax occurs in people with underlying chronic lung disease, most
commonly COPD. Recurrence after PSP is common, mostly within the first year, with rates
as high as 30% after a first occurrence, and 50% following a second.11 Referral for
consideration of surgical management to reduce the risk of recurrence may be
recommended after a second pneumothorax.
13. Candidates who have had a PSP are FIT if either of the following criteria are met:
a.
A period of five years has passed after a single PSP which was not definitively
treated and there have been no recurrences12 and the candidate is functionally
unrestricted.
b.
Candidates with single or recurrent PSP who have had definitive treatment
(normally pleurectomy by open or Video-Assisted Thoracoscopic Surgery (VATS))
after one year13, provided there is no evidence of recurrence and the candidate has
no functional restrictions.14
14. Candidates with either of the following features are UNFIT:
a.
Those who have had a secondary spontaneous pneumothorax (because of the
underlying condition), or
10 Santos G, and Turner AM. Alpha-1 antitrypsin deficiency: an update on clinical aspects of diagnosis and management: an updated
review. Faculty Reviews 2020 9:(1) https://doi.org/10.12703/b/9-1
11 Walker SP, Bibby AC, Halford P, et al. Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-
analysis. Eur Respir J 2018; 52: 1800864 [https://doi.org/10.1183/13993003.00864-2018] After 5 years background risk approximating
same as general population.
12 Walker SP, Bibby AC, Halford P, et al. Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-
analysis. Eur Respir J 2018; 52: 1800864 [https://doi.org/10.1183/13993003.00864-2018] After 5 years background risk approximating
same as general population.
13 Consensus Respiratory Specialist opinion- evidence poor, risk of recurrence varied but general risk of surgical failure is early post
procedure, less than 1 year. Old data suggestive of overall risk of recurrence 4.4%, at 1 year approximately 2%. (Cardillo G, et al.
Videothoracoscopic treatment of primary spontaneous pneumothorax: a 6 year experience.
The annuals of Thoracic Surgery.2000;
69(2);357-361. https://doi.org/10.1016/S0003-4975(99)01299-0.) Risk of recurrence likely less now due to improvement in techniques
and in procedure at specialist thoracic centres.
14 Pleurodesis is not considered definitive treatment for certain occupational groups (e.g. aircrew and divers). VATS is not acceptable
for aircrew.
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b.
Those who have had a second PSP without definitive treatment.
15.
Traumatic pneumothorax. Pneumothorax in which a clear traumatic (or iatrogenic)
cause is identified, does not carry the same high likelihood of recurrence as spontaneous
pneumothorax. Candidates who have made a full clinical recovery, have achieved activity
comparable with military service for a period of at least three months and have normal
spirometry15 are FIT.
Parenchymal lung disease (affecting lung tissue)
16.
Sarcoidosis. Sarcoidosis is an uncommon, multi-system disorder of unknown
aetiology. Acute sarcoidosis is usually self-limiting but even after resolution carries a
lifetime risk of recurrence.16 Chronic disease most commonly affects the lungs and the
lympho-reticular system and may cause long-term, progressive organ dysfunction.
Cardiac, neurological, and ophthalmic sarcoidosis are of particular concern, as are the
treatments for sarcoidosis which may include oral corticosteroids or immunosuppressive
drugs.
17. Candidates with any confirmed history of sarcoidosis are UNFIT because they need
access to routine specialist medical services and pose a risk of sudden deterioration or
incapacitation.
18. Candidates with a history of any parenchymal lung disease, including interstitial
pneumonias and pulmonary fibrosis are UNFIT because they are progressive diseases
and they need access to routine specialist medical services and pose a risk of sudden
deterioration or incapacitation.
Respiratory infection
19.
Tuberculosis. A candidate who has made a complete recovery from TB infection or
has completed appropriate treatment for Latent TB must be referred to sSMES along with
details of treatment received. Candidates with active TB, or untreated Latent TB are
UNFIT. Candidates require respiratory function to safely perform their military role, may
pose an infection risk to others and would need access to routine specialist medical
services which are unavailable in austere locations.
20.
Pneumonia (including COVID-19). Candidates with a history of resolved pneumonia
are FIT, provided there is no evidence of recurrence and they have achieved activity
comparable with military service for a period of at least three months. Candidates with
persistent symptoms are UNFIT (see Annex N for Chronic fatigue syndrome and
associated conditions). Candidates require the respiratory function to safely perform their
military role, may pose an infection risk to others and would need access to routine
specialist medical services which are unavailable in austere locations.
Breathing related sleep disorders
21.
Obstructive sleep apnoea / hypopnoea syndrome (intermittent airway blockage
whilst asleep). Please see Annex B ENT Para 22.
15 Military SME judgement
16 Presenting with acute presentation, organ dysfunction and/ or required treatment there is a >10% risk of recurrence. Grunewald J,
Eklund A. Lofgren’s Syndrome.
Am J Respir Crit Care Med.2009; 179;307-312. DOI:10.1164/rccm.200807-1082OC. Inoue Y, Inui N,
Hashimoto D, Enomoto N,Fujisawa T, Nakamura Y, et al. Cumulative Incidence and Predictors of Progression in Corticosteroid-sNaive
Patients with Sarcoidosis.
PLoS One. 2015; 10(11). DOI:10.1371/jpurnal.pone.0143371 Baughman RP, Judson, MA. Relapse of
sarcoidosis:what are they and can we predict who will get them?
Eur Respi J. 2014; 43:337-339. DOI:10.1183/09031936.00138913
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Pulmonary Embolism (PE)
22. Candidates with a history of PE with a clearly identified provoking factor are FIT17,
provided all the following criteria are met:
a.
A full recovery has been made with no evidence of complications,
b.
The initial provoking factor is no longer present or likely to reoccur,
c.
No previous episodes of Venous Thromboembolism (VTE),
d.
A period of six months has passed after withdrawal of treatment with no
recurrence of Venous Thromboembolism (VTE),
e.
The candidate is functionally unrestricted.
23. Candidates with a history of unprovoked PE are UNFIT because there is an
unacceptably high risk of recurrence.18 These candidates would need access to specialist
medical services and there is a risk of sudden deterioration and incapacitation.
24. Candidates on anticoagulant treatment are UNFIT. Anticoagulant treatment carries
an unacceptably high risk of bleeding, which would compromise the ability to achieve
haemostasis in an operational environment as laid out in Annex N Para 8.
17 Iorio A, Kearon C, Filippucci E, et al. Risk of Recurrence After a First Episode of Symptomatic Venous Thromboembolism Provoked
by a Transient Risk Factor: A Systematic Review.
Arch Intern Med. 2010;170(19):1710–1716. doi:10.1001/archinternmed.2010.367
18 Khan F, Rahman A, et al. Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant
treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis.
BMJ. 2019; 366:4363 DOI:
http://dx.doi.org/10.1136/bmj.l4363
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Annex E
GASTROINTESTINAL PRE-ENTRY
1.
The general principles against which a candidate is assessed as FIT for entry, with
respect to their Gastrointestinal system are:
a.
Function. Candidates must have the physical and cognitive function to operate
in all military environments, to safely and effectively perform their military role.
b.
Prognosis. Where a candidate is found to have a resolved or current
gastrointestinal condition, the following general criteria should be met in addition to
the relevant specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated by military service (in particular, extremes of
cold / heat, changes in atmospheric pressure or environmental conditions, or
inability to access dietary modifications).
(2) Pose a significant risk of future exacerbation or complications of the
condition.
(3) Pose a risk of sudden deterioration / incapacitation without reasonable
warning.
c.
Medical Support Requirements. Where a candidate has a pre-existing, or is at
increased risk of a gastroenterological condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication occur for ≤ one week this should not lead to
clinical deterioration in the condition or functional degradation during that time. In the
deployed environment the condition should not foreseeably impact military medical
resource.
2.
Exceptional considerations. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the Single Service Medical Entry Staff (sSMES).1
Conditions affecting the Upper GI Tract (oesophagus, stomach and duodenum)
3.
Motility disorders. Candidates with oesophageal motility disorders (including, but
not limited to, achalasia) are UNFIT, including those with a good response to surgery. This
is due to the ongoing risk of motility disorders causing choking in an environment where
endoscopic intervention is not available.
4.
Eosinophilic oesophagitis. Candidates are FIT if symptom-free for a period of one-
year post-treatment completion.2 Candidates requiring maintenance therapy are UNFIT
even if symptom free for one year. This is due to the risk of recurrence of symptoms,
including incapacitating food bolus, and serious long-term health risks of the underlying
condition, such as oesophageal stricturing.
1 Delegated Authority arrangements may apply.
2 Eosinophilic Esophagitis: A Review - PMC (nih.gov)
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5.
Unexplained Dysphagia (difficulty swallowing). Candidates with a history of
unexplained dysphagia and / or food bolus obstruction who have been asymptomatic for
five years are FIT because they are unlikely to have a recurrence which needs urgent
access to gastroscopy.
6.
Dyspepsia (indigestion) and / or Gastro Oesophageal Reflux Disease (GORD)
(Heartburn). If symptoms respond to lifestyle changes, such as weight loss and avoidance
of spicy foods, alcohol, and smoking, and do not require regular prescribed medication the
candidate is FIT. Endoscopic review for dyspepsia / GORD prior to entry is not needed.
Those with persistent dyspepsia and / or GORD symptoms requiring regular prescribed
medication to control symptoms are UNFIT because uninterrupted medication supplies
cannot be guaranteed and symptoms can be distracting or incapacitating.
7.
Barrett’s oesophagus. Candidates with Barrett's oesophagus are UNFIT because
daily prescribed medications are essential to reduce the risk of progression to cancer and
uninterrupted medication supplies cannot be guaranteed.
8.
Peptic ulcer disease (ulcers of the oesophagus, stomach or duodenum).
Candidates with medically or endoscopically (as per national guidelines3), resolved peptic
ulcer disease are FIT after 12 months, providing they meet all the following criteria:
a.
Remain asymptomatic,
b.
Do not require regular prescribed medication,
c.
Proof of successful Helicobacter pylori eradication if identified.
9.
Candidates with a history of abdominal surgery for peptic ulceration or perforation are
UNFIT due to the risk of complications, requiring further medical, endoscopic and/or
surgical input.
10.
Anti reflux / hiatus hernia surgery. Candidates who have had anti reflux surgery
are FIT provided they meet all the following criteria:
a.
They are six months post-surgery,
b.
Able to swallow and eat normally,
c.
Do not have any disabling symptoms4,
d.
Are no longer under secondary care follow-up.
11. Candidates with post-operative dysphagia are UNFIT as they may develop
complications which require urgent access to gastroscopy.
Liver, biliary tree and pancreas
3 Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and
Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS)
4 Disabling symptoms include any dysphagia, gas bloat (inability to belch) or the return of dyspeptic symptoms not controlled by
standard PPI therapy.
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12. Candidates with a congenital / developmental, chronic or fibrotic / cirrhotic
disease of the liver, biliary tree or pancreas are UNFIT due to the risk of progression of
disease to cirrhosis and liver failure.
13.
Fatty liver. Candidates with an isolated diagnosis of fatty liver on ultrasound with
normal liver function tests are FIT. Candidates with fatty liver on ultrasound and abnormal
liver function tests should be referred to sSMES.
14.
Viral hepatitis. Refer to Annex N Para 18.
15.
Pancreatitis. Candidates who fully recover from a single episode of acute
pancreatitis, with no evidence of chronic pancreatitis, gastric outlet obstruction or
pancreatic insufficiency or diabetes after 12 months are FIT provided any treatable causes
of the pancreatitis have been addressed. Candidates with previous gallstone pancreatitis
who have undergone cholecystectomy are FIT. Candidates with a history of alcohol-
induced pancreatitis are UNFIT due to likely recurrence of symptoms and functional
impairment.
16.
Cholecystitis (gallbladder inflammation). Candidates who have had procedures to
correct sphincter of Oddi dysfunction more than six months ago and remain asymptomatic
are FIT. Candidates who have had cholecystectomy (removal of gallbladder) more than six
months ago are FIT. Candidates with a current or previous history of symptomatic
cholecystitis, or other disorders of the gallbladder and biliary system are UNFIT until six
months after definitive surgical treatment due to the risk of recurrence and potential
complications.
17.
Metabolic liver disease. Candidates with suspected haemochromatosis who are
subsequently confirmed H63D homozygous state or compound heterozygotes (C282Y /
H63D) are FIT.5 Candidates with a current or previous history of metabolic liver disease,
including, but not limited to C282Y homozygous haemochromatosis, Wilson's disease and
alpha-1 anti-trypsin deficiency, are UNFIT due to the risk of complications, progression to
cirrhosis and liver failure.
18.
Splenomegaly (enlarged spleen). Candidates with splenomegaly are UNFIT as the
underlying condition is incompatible with service due to the risk of splenic rupture from any
abdominal trauma.
19.
Gilbert’s syndrome. Candidates with Gilbert’s syndrome are FIT.
Bowel conditions (small bowel and colon). 20.
Irritable bowel syndrome (IBS). Candidates with symptoms not requiring prescribed
medication (or last issued more than six months ago), who only infrequently use over-the-
counter medications and are able to tolerate a varied diet6 are FIT. Candidates with a
current or previous history of IBS requiring ongoing medical review, or of sufficient severity
to interfere with normal daily activities (for example repeated time off school, work, or
having to change plans due to symptoms) are UNFIT. This is because candidates must be
able to work in challenging environments, in a physically demanding job with limited
5 H63D homozygous state or compound heterozygotes (C282Y/H63D) do not have genetic haemochromatosis and very rarely develop
iron overload.
6 The requirement to tolerate the diet while deployed, at sea or on field rations, should be borne in mind.
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medical support and without immediate access to hygiene facilities where specific diets
cannot be guaranteed.
21.
Inflammatory bowel disease (IBD). Candidates with a history of IBD, including
ulcerative colitis, Crohn’s disease or IBD-unspecified, regardless of treatment or period of
remission are UNFIT. This is due to the risk of increased severity of gastrointestinal
infection7 and / or risk of a flare in an austere environment8,9, where UK gold standard care
cannot be reached within the required timelines. Cold chain storage for medications
cannot be guaranteed on deployments.
22.
Hereditary GI cancer syndromes. A genetic predisposition
to hereditary GI cancer
syndromes is not a bar to entry. All cases should be referred for sSMES opinion with all
available clinical information. Genetic testing should not be undertaken solely to facilitate
application to join the Military. Consideration will be given to risk of progression to cancer,
likely age of onset and if military service could increase the risk to health or impede
surveillance requirements.10
23.
Hirschsprung’s disease. Candidates with Hirschsprung’s Disease are UNFIT
because symptoms are likely to persist and require ongoing medication following surgery.
Candidates must be able to work in challenging environments, in a physically demanding
job with limited medical support and immediate access to hygiene facilities.
Intestinal malabsorption syndromes 24.
Pernicious anaemia. Candidates with pernicious anaemia on an established vitamin
B12 replacement schedule are FIT E2 provided there is no evidence of anaemia and
normal vitamin B12 levels have been demonstrated within six months of application.
Candidates with current anaemia or a low vitamin B12 level are UNFIT until effectively
treated due to the potential impact of symptoms.
25.
Coeliac disease. Candidates with a history of gluten sensitive enteropathy (coeliac
disease) are UNFIT, due to the current inability to provide a sustained gluten-free diet
throughout a service career, causing both short- and long-term illness. Coeliac disease is
a condition with the potential for significant systemic illness if a gluten free diet is not
maintained.11
26.
Lactose, gluten or other food sensitivity / intolerance. Candidates able to tolerate
a varied diet, who infrequently use over-the-counter medications and who have not
required prescribed medication within six months are FIT. Candidates requiring ongoing
medical review, or with symptoms severe enough to interfere with normal daily activities
(for example repeated time off school, work, or having to change plans due to symptoms)
are UNFIT. Candidates must be able to work in challenging environments, in a physically
demanding job with limited medical support and without immediate access to hygiene
facilities, where specific diets cannot be guaranteed.
7 Increased risk of gastrointestinal infections, especially in areas of high diarrhoeal disease rates, due to potential mucosal inflammation
and compromise. This is compounded by the use of immunosuppression.
8 An untreated flare of Crohn risks include stricturing with potential for life threatening small bowel obstruction, fistula or abscess
development.
9Acute severe UC flare requires immediate access to IV steroids, and potentially subsequent rescue therapy and possible colectomy by
a colorectal surgeon if no response to rescue therapy.
10 Guidelines for the management of hereditary colorectal cancer from the British Society of Gastroenterology (BSG)/Association of
Coloproctology of Great Britain and Ireland (ACPGBI)/United Kingdom Cancer Genetics Group (UKCGG)
11 Symptoms may include: anaemia, abdominal pain, nausea, diarrhoea, rash, arthropathy, headaches, fatigue and poor concentration.
Small bowel lymphoma is a rare complication associated with an un-sustained gluten free diet.
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Weight loss surgery
27.
Bariatric surgery. Candidates who have had a sleeve gastrectomy > two years ago
are FIT provided they can reach and maintain entry standard BMI, have no further
symptoms or associated conditions12 and require no further supplementation (except
multivitamins13). Candidates who have undergone bariatric surgery within the last two
years are UNFIT because their physiology is still adapting to the surgery. Candidates
whose surgery has included gastrointestinal anastomosis formation14 are permanently
UNFIT because of the risk of major complications such as internal herniation and
hypoglycaemia. Candidates who have a gastric band in place are UNFIT due to the risk of
complications requiring surgical intervention. Candidates who have had a gastric band
removed and recovered without problem are FIT provided other selection criteria are met.
Abdominal and Bowel Surgery 28.
Splenectomy. See Annex N Para 41.
Herniae (bulging of organ or tissue through an abnormal opening) 29.
Abdominal wall hernia. Candidates with an easily reducible umbilical hernia that
does not affect physical activity or interfere with wearing military clothing or equipment are
FIT. Candidates with repaired hernia who are six months post-surgery and have no clinical
suspicion of recurrence are FIT if they can tolerate activities comparable with military
training / Service over a minimum period of three months. Candidates are UNFIT if any
other abdominal wall hernia (inguinal, epigastric, spigelian or incisional) is present. Any
candidate awaiting surgery to repair any hernia is UNFIT. This is to allow the abdominal
muscles to repair and allow time for the candidate to return to fitness standards needed to
successfully complete military training.
Other abdominal Surgical procedures 30. Provided the original reason for abdominal surgery is not a bar to entry, candidates
with a history of abdominal surgery should be assessed following the guidance below.
a.
Open abdominal Surgery. Candidates who have undergone abdominal
surgery during the preceding six months are UNFIT. This is to allow the abdominal
muscles to repair and allow time for the candidate to return to fitness standards
needed to successfully complete military training.
b.
Laparoscopy. Candidates who have had diagnostic laparoscopy and or other
simple procedures such as appendicectomy or laparoscopic sterilisation are FIT once
able to return to full physical activity. They must be able to conduct activities
12 such as arthritis, hypertension and diabetes. NICE criteria only offers surgery to patients with a BMI over 35 with associated
comorbidities, or a BMI over 40. Of note:
1.
Comorbidities do improve/resolve.
2.
As a rule of thumb, 65+% T2DM cases go into remission,
3.
At least 33% with hypertension become normotensive and off meds.
13 Current recommendations are B12 injections every 3 months (some people may be taking high doses oral vitamin B12 instead), iron
supplements, AdCalD3 and multivitamins
14 these procedures include: roux-en-Y and one anastomosis, duodenal switch (DS) operations, and single anastomosis duodeno-ileal
(SADI) procedures. As new procedures are being developed, any procedure outwith this list, must be discussed with sSMES
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comparable with military training / service over a minimum period of three months
without symptoms.
Bowel, anal and perianal conditions which may require surgery. 31.
Stomas. Candidates who have a history of a stoma for trauma, which has been
successfully reversed, are FIT once recovered from surgery, provided there is no evidence
of incisional hernia or disqualifying associated injuries.
Candidates who have had
successful reversal of a stoma formed for other reasons must be referred to sSMES.
Candidates with a current colostomy or ileostomy are UNFIT. Candidates must be able to
work in challenging environments, in a physically demanding job, including austere
locations with limited access to medical support and hygiene facilities.
32.
Pouch surgery. Candidates who have undergone colectomy and pouch surgery are
UNFIT as they require prolonged medical specialist follow-up and significant long-term
sequelae / complications are expected.15 Candidates must be able to work in challenging
environments, in a physically demanding job, including in austere locations with limited
access to medical support and hygiene facilities.
33.
Pilonidal sinus (cyst). A previous history of acute abscess drainage is not a bar to
Service. Candidates with “off midline”16 excision and closure techniques are FIT following
complete healing. Those who have had wide excision with healing by secondary intention
are UNFIT until 12 months have elapsed since complete healing of the wound, because
early recurrence of pilonidal sinus is common. Candidates with active disease or a history
of more than two planned, definitive surgical procedures for pilonidal sinus are UNFIT due
to the high risk of further recurrence.17
34.
Haemorrhoids (piles). Candidates with treated haemorrhoids who are asymptomatic
and have no post-treatment complications are FIT. Candidates with active haemorrhoids
(internal or external), which are symptomatic and causing significant functional limitation
(including school, workplaces, or exercise adjustments) are UNFIT. Candidates must be
able to work in challenging environments including extremes of heat and cold, in a
physically demanding job with limited access to medical support and hygiene facilities.
15 A “well-functioning” ileoanal pouch will see the patient opening their bowels, on average, six times per day and twice at night.
Pouchitis is common, with an incidence of 20-50%. (increased frequency, urgency, abdominal cramping, incontinence).
Initial treatment is with antibiotics (metronidazole or cipro), but second-line and subsequent treatments may include dual antibiotic
therapy or biologics.
30% of patients who have one episode of pouchitis will progress to chronic pouchitis, while up to 90% will experience further episodes.
Up to 20% of pouches “fail” (5-10% early, 10% late), requiring ileostomy or pouch excision.
16 “Off midline” excision and closure techniques (Karydakis Flap, Bascom Cleft-Lift, or Limburg (Rhomboid) Flap, other flap techniques)
flatten the natal cleft and have markedly higher success rates (90%+) and would be FIT once healing complete.
17 Wide excision and healing by secondary intention” is an attempt at definitive treatment, but may require prolonged healing of
potentially wide, deep open wounds. Excision and healing by secondary intention is associated with a high rates of recurrence as it does
not address the anatomical contribution of the natal cleft to pilonidal disease.
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Annex F
RENAL AND UROLOGICAL PRE-ENTRY
Introduction
1.
General principles for assessing candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry, with respect to the renal
and urological system are:
a.
Function. A candidate must have stable renal and urinary tract function in all
military environments to perform their military role safely and effectively including in
austere locations with limited medical support.
b.
Prognosis. Where a candidate is found to have a resolved or current renal
and/or urological condition, the following general criteria should be met in addition to
the relevant specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated or precipitated by military service (in particular
extremes of heat/strenuous exercise/dehydration).
(2) Pose a significant risk of future temporary or permanent loss of function.
(3) Pose a risk of sudden deterioration/incapacitation without reasonable
warning.
c.
Medical Support Requirements. Where a candidate has a pre-existing or
increased risk of a renal or urological condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication occur for ≤ 1 week this should not lead to
clinical deterioration in the condition or functional degradation during that time. In the
deployed environment the condition should not foreseeably impact military medical
resource.
2.
Exceptional considerations. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the Single Service Medical Entry Staff (sSMES).1 The resultant FIT or UNFIT
outcome will be determined by sSMES.
3.
Examination. Examination of the genitalia is
not required at the recruit medical
examination and should
not be performed. There are no indications for such examinations
during an occupational health assessment.
Abnormalities of Urinalysis
4.
Haematuria (blood in the urine).2
Whilst the sensitivity of urine dipsticks may vary
from one manufacturer to another, trace haematuria should be considered negative and
significant haematuria is considered to be 1+ or greater. There is no distinction in
1 Delegated Authority arrangements may apply.
2 Based on British Association of Urological Surgeons (BAUS), NICE and UK Renal Association guidelines.
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significance between non-haemolysed and haemolysed dipstick-positive haematuria. 1+
positive for either should be considered of equal significance.
a.
Visible haematuria. Candidates with visible haematuria obviously related to
menstruation are FIT. Other candidates with a single episode of visible haematuria
are FIT E2 (for annual monitoring) if they meet all the following criteria
(1) Blood pressure estimated Glomular Filtration Rate (eGFR) and urine
Albumin to Creatinine Ration (ACR) or Protein to Creatinine Ratio (PCR) are
within normal parameters.
(2) Other causes of transient haematuria (inc. Urine Tract Infection (UTI)) are
excluded.
(3) Normal urology assessment including cystoscopy and relevant imaging (if
renal impairment, proteinuria or hypertension consider simultaneous referral to
nephrology).
b.
Candidates with visible haematuria who do not meet the above criteria are
UNFIT due to the likelihood of underlying disease and the requirement for medical
support.
c.
Asymptomatic non-visible haematuria. Candidates with non-visible
haematuria obviously related to menstruation are FIT. Candidates with
uninvestigated asymptomatic non-visible haematuria (more than a trace of blood), on
two of three dipsticks, two weeks between tests are UNFIT as this may signify an
underlying undiagnosed renal or urological condition that may affect their ability to
safely and effectively perform their military role and requires further specialist
investigation. If a suitable urological and/or renal assessment excludes an underlying
medical condition3,4,5 as the cause for the blood in the urine, the candidate is FIT E2
(for annual monitoring)
d.
Symptomatic non-visible haematuria. Candidates with a single episode of
symptomatic (dysuria, abdominal pain, urgency) non-visible haematuria (i.e., more
than a trace of blood on dipstick) are FIT E2 (for annual monitoring) if they meet all
the following criteria:
(1) Blood pressure, eGFR and urine ACR or PCR are within normal
parameters.
(2) Other causes of transient haematuria (inc. UTI) are excluded.
(3) Normal urology assessment including cystoscopy and relevant imaging (if
renal impairment, proteinuria or hypertension consider simultaneous referral to
nephrology).
e.
Candidates who do not meet the above criteria are UNFIT due to the likelihood
of underlying disease and the requirement for medical support.
3 candidates who are aged 40 years and over require urological assessment including cystoscopy and imaging to exclude both benign
and malignant urological conditions.
4 Candidates who are under 40 years of age, with any of the following blood pressure ≥140/90 mmHg or eGFR <60ml/min or ACR>3 or
PCR >5, will require a nephrology assessment.
5 Candidates who are under 40 years of age and do not require renal assessment should be referred to sSMES to determine FIT E2.
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5.
Glycosuria (Sugar in the urine). If sugar is found on urinalysis, this may indicate an
underlying diagnosis of diabetes and requires further specialist investigation. Further
assessment is required before the candidate can be accepted as per JSP 950 section 4, 6-
7-7 Annex H para 17 Endocrinology pre-entry.
6.
Proteinuria (Protein in urine). If protein is found on urinalysis (more than trace on
two of three dipstick tests, two weeks between tests, a trace can be ignored) the candidate
is UNFIT as this may signify an underlying undiagnosed renal or urological condition that
may affect their ability to perform their military role safely and effectively. If a suitable renal
assessment excludes an underlying medical condition as the cause, the candidate should
be referred to sSMES. Of note proteinuria can be present because of urinary tract
infections and / or use of protein supplements.
7.
Glomerulonephritis (inflammation of the kidneys). Candidates with a history of
glomerulonephritis are UNFIT because glomerulonephritis is a disease process, resulting
in inflammation of the kidneys, which may follow a relapsing or progressive course
resulting in kidney failure which is likely to place an unacceptable demand on medical
resources.
8.
Chronic Kidney Disease (CKD). Candidates with CKD stage 1-2 who meet all the
following criteria are FIT E2. These candidates will require regular review inline with NICE
guidelines:
a.
No hypertension,
b.
No diuretic use,
c.
No proteinuria,
d.
No active renal comorbidity.
9.
Candidates with CKD stage 3-5 (eGFR 60 or less) are UNFIT because of the risk of
further deterioration in kidney function, the increased risk posed to the individual within the
military deployed environments and an increased risk of cardiovascular disease.
10.
Urinary Tract Infection (UTI). UTIs may be a sign of an underlying abnormality of
the urinary tract which may predispose the candidate to recurrent infections impacting on
their ability to perform their military role safely and effectively and risk sudden deterioration
/ incapacitation.
a.
Lower UTIs. Candidates may be diagnosed with a UTI and treated with
antibiotics on the history alone, urine dipstick or urine microscopy and culture. All
should be interpreted as a diagnosis of UTI.
(1)
Childhood UTIs. Candidates with a history of recurrent lower UTIs (two or
more infections in a 12-month period) in childhood are FIT if previous
investigations have confirmed normal anatomy and function. If the candidate
has not been investigated previously the results of an ultrasound of the kidneys,
ureter and bladder is required.
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(2)
Post-pubertal male. Candidates who had one infection post puberty are
FIT if previous investigations have confirmed normal anatomy and function. If
the candidate has not been investigated previously the results of an ultrasound
of the kidneys, ureter and bladder is required.
(3)
Post-pubertal female. Candidates with a history of a UTI more than two
years ago are FIT. Those with a history of a UTI within the last two years are
FIT unless the results of an ultrasound of the kidneys, ureter and bladder since
the last UTI shows abnormality.
b.
Upper UTIs. Candidates with a single episode of upper UTI more than two
years earlier6 are FIT in the absence of predisposing factors which as a minimum
requires confirmation of a normal ultrasound of the kidneys, ureter and bladder.
c.
Vesicoureteric reflux. This is a condition where urine flows backwards from
the bladder to one or both ureters and sometimes the kidneys. This can lead to UTIs
and kidney damage.
(1) A history of mild vesicoureteric reflux (Grades I-III) where an individual has
been discharged from follow-up, has been free of infection for at least two
years7, has no requirement for antibiotic prophylaxis, normal urinalysis and
normal blood pressure are FIT.
(2) Those with Grades IV-V reflux that required surgical correction and have
been discharged from follow-up, and are free of infection for at least two
years8, with evidence of GFR or eGFR of >60ml/min,
require referral to a
Service approved urologist
.
Urethral abnormality 11.
Urethral abnormalities.
a.
Abnormalities of the urethra such as a stricture (narrowing) may affect a
candidate’s ability to pass urine and lead to discomfort, distraction and UTI.
Candidates with unsuccessful or continuing treatment for urethral abnormalities
are UNFIT as it may impact on their ability to perform their military role safely and
effectively and risk sudden deterioration / incapacitation. Those who have been
successfully treated for a single urethral stricture and discharged from follow-
up, require
referral to Service approved urology
.
b.
Candidates with genital piercing (excluding the urethra) that has fully healed
(the piercing can remain in place) without complications are FIT. Due to the risk of
developing urethral stricture at a later date, candidates with history of genital piercing
involving the urethra will require
referral to Service approved urology.
12.
Urinary incontinence. Candidates with a history of persistent urinary
incontinence, or an episode of nocturnal enuresis (bed wetting) in the two years preceding
entry are UNFIT regardless of the presence of normal neurological and psychological
6 Service Urologist expert opinion.
7 Service Urologist expert opinion.
8 Service Urologist expert opinion.
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investigations. Urinary incontinence may cause distraction and embarrassment for a
candidate and affect their ability to perform their military role in all military environments.
13.
Genital infections. Candidates with a current or previous history of genital infection
or ulceration, including, but not limited to Herpes Genitalis or Condyloma Acuminatum
(genital warts), that can be managed routinely by primary healthcare or interfere with
function are FIT.
Congenital abnormalities
14.
Polycystic kidney disease. Candidates with a family history of polycystic kidney
disease and a normal screening ultrasound after the age of 16 years are FIT. Candidates
with confirmed polycystic kidney disease are UNFIT due to the risk of developing kidney
failure.
15.
Hypospadias. In this condition the opening of the urethra is not located at the tip of
the penis. Hypospadias, with no history of UTI, urethral stricture, or voiding dysfunction are
FIT subject to review by a service-approved Urologist.
16.
Duplex kidneys. In this condition the kidney has two ureters draining urine from the
kidney which can lead to complications such as recurrent UTIs, abdominal pain and
urinary incontinence.
Candidates with a normal ultrasound within the last two years, with
no hydronephrosis or unequal kidney size, are FIT subject to review by a service-approved
Urologist.
17.
Pelviureteric Junction (PUJ) Obstruction. Candidates with surgically corrected
PUJ obstruction are FIT subject to review by a service-approved Urologist provided all the
following criteria are met:
a.
Treatment and specialist follow-up are complete,
b.
There is evidence of correction and preservation of good renal function (as
assessed on isotope renography, no earlier than 12 months post-surgery),
c.
Candidates with unilateral PUJ obstruction with a non-functioning kidney or
those treated with nephrectomy should be regarded as having a single kidney
(see Para19 relating to Absence, loss or malfunction of a kidney).
18.
Megaureter (enlarged ureter). Candidates with a history of megaureter are prone to
UTIs and kidney damage. Candidates with resolved or surgically corrected megaureter
are FIT subject to review by a service-approved Urologist. If the eGFR exceeds 60ml/min
and they have been discharged from follow-up.
19.
Other congenital conditions. Candidates with all other congenital conditions
are UNFIT due to the risk of developing kidney failure or other urinary tract effects which
could affect function.
20.
Absence, loss or malfunction of a kidney.
a.
Candidates with a single functioning kidney are FIT subject to review by a
service-approved Nephrologist / Urologist, provided all the following criteria are met:
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(1) No evidence of disease in the remaining kidney,
(2) No persistent abnormality on urinalysis,
(3) GFR or eGFR of at least 60ml/min,
(4) Absence of raised blood pressure,
(5) No risk or recurrence of disease in the remaining kidney.
b.
Candidates with renal transplants are UNFIT as the ongoing requirement for
intensive specialist follow up, immunosuppressive medication and risk of transplant
failure is incompatible with unrestricted employment and the ability to perform their
military role safely and effectively.
21.
Ureteric spasm. Candidates with a history of a single episode of ureteric spasm (or
suspected renal colic), which has been investigated without demonstration of underlying
pathology, are FIT. More than one episode of ureteric spasm
requires referral for
Service approved urology opinion.
22.
Renal and Ureteric Stone Disease (RUSD). Candidates who have a confirmed
history of urinary tract stone formation in the collecting system are UNFIT because there is
an elevated risk of recurrence. This may be exacerbated in austere conditions. Renal colic
may present without warning and result in severe, distracting and potentially incapacitating
pain. Prolonged renal tract obstruction requires decompression to prevent permanent renal
damage. Those with small, stable areas of calcification in the renal parenchyma require
Service approved urology opinion.
23.
Bladder stones. The pathology of bladder stones / calcification differs from RUSD;
all candidates with a history of bladder stones / calcification require referral for
Service
approved urology opinion.
24.
Malignant disorders. Candidates with Wilms’ tumour treated in early childhood
which successfully treated and discharged from specialist follow-up are FIT. For all other
urological / nephrological malignant disorders, see Annex N Paras 12 and 13.
25.
Other painful urological conditions. Candidates with a past history of non-
specific or undiagnosed groin, scrotal, pelvic or loin pain who have been symptom and
treatment free whilst undertaking exercise comparable with military training for 12
months9 in the presence of normal or stable investigations are FIT. All other Candidates
are UNFIT because these symptoms may indicate the need for further specialist
investigation and may affect the candidate’s ability to undertake military duties.
9 DCA urology expert opinion.
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Annex G
NEUROLOGICAL PRE-ENTRY
1.
General principles for assessing Candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry are:
a.
Function. A Candidate must have the physical function, in all military
environments, to safely and effectively:
(1) Perform their military role. Where the branch or trade being applied for
has specific requirements, (e.g. aircrew) these must be met.
(2) Operate their personal weapon.
b.
Prognosis. Where a candidate is found to have a resolved or current
neurological condition, the following general criteria should be met in addition to the
relevant specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated by military service, particularly by:
(a) Fatigue.
(b) Stress.
(c) Alteration of time-zones.
(d) Dehydration.
(e) Prolonged standing.
(f)
Missed meals.
(g) Infection.
(h) Exposure to bright light or loud noise.
(i)
Exposure to certain dietary factors.
(2) Pose a significant risk of future temporary or permanent loss of function.
(3) Candidates with a neurological condition which either causes loss of
function or sudden incapacitation, poses a risk on operations to both the
candidate and others, as well as the mission, and are therefore UNFIT.
c.
Medical support requirements. Where a candidate has a pre-existing or
increased risk of a neurological condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication ≤ one week this should not lead to clinical
deterioration in the condition or functional degradation during that time. In the
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deployed environment the condition should not foreseeably impact military medical
resource.
d.
Exceptional considerations. Criteria within each condition has been outlined
to grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be
sought from the single Service Medical Entry Staff (sSMES)1 The resultant FIT or
UNFIT outcome will be determined by sSMES.
Conditions which may cause sudden incapacitation
Seizures
2.
Single seizure.
a.
Provoked seizures. Depending on the cause, these candidates have a lower
risk of recurrence than unprovoked seizures. Candidates are FIT, subject to sSMES
review, provided they meet all the following criteria:
(1) There is a clearly defined provoking stimulus such as:
(a) Cardiovascular syncope resulting in tonic-clonic seizure activity. This
differs from convulsive syncope in which myoclonic twitches occur on loss
of conscious. Candidates with a history of convulsive syncope are FIT
provided they meet the requirements of the paragraphs in the annex
relating to vasovagal syncope, reflex syncope and unexplained loss of
consciousness or altered awareness.
(b) A seizure occurring within one week of an acquired brain injury,
including head injury, stroke, TIA, subdural haemorrhage, or intracranial
surgery.
(c) A seizure occurring within 24 hours of a documented electrolyte or
biochemical abnormality (eg hyponatraemia or hypoglycaemia). See
Annex H Para 25 – Endocrinology.
(d) A seizure associated with drug use where the drug is known to
increases the risk of seizure (epileptogenicity).
(e) An alcohol withdrawal seizure.2
(2) The stimulus must be easily avoidable in service.
b.
Unprovoked seizures. These
are associated with a high risk of recurrence.
Candidates who have a single unprovoked seizure are FIT provided they meet all the
following criteria:
(1) More than five years has elapsed since the seizure,
(2) The individual has not required treatment in the past five years,
1 Delegated Authority arrangements may apply.
2 As opposed to an alcohol-induced seizure which is a strong marker of epilepsy.
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(3) Neurologist confirms the seizure risk is no greater than 2% per year.
3.
Epilepsy or multiple seizures. Candidates diagnosed as having epilepsy or who
have had more than one seizure are UNFIT due to the risk of sudden incapacitation which
may result in harm to self and / or others when conducting safety-critical tasks unless they
meet the following criteria:
a.
Febrile convulsions. Candidates with febrile convulsions no later than their
sixth birthday, and who have had no further seizures thereafter, are FIT.
b.
Benign childhood epilepsy (e.g. Rolandic epilepsy). Candidates with a
confirmed diagnosis of a benign childhood epilepsy, who have been seizure-free for
five years without treatment, are FIT.
c.
Epilepsy in remission. This is defined as being seizure free, without
medication, for 10 years. This includes absence seizures (petit mal). Candidates are
FIT subject to service-approved neurology review.
Blackouts, faints, loss of consciousness and altered awareness
4.
Clarification regarding any warning symptoms, triggers, length of unconsciousness,
physical appearance before, during, and after the event (paying close attention to skin
colour, body posture, and whether or not the eyes were open), degree of amnesia, and
any confusion on recovery must be obtained3. The underlying cause should be identified
where possible. The results of any cardiological and neurological investigations (including
imaging) must be acceptable or any underlying abnormalities fully treated. Candidates who
have not been adequately investigated are UNFIT due to the unknown risk of sudden
incapacitation.
5.
Vasovagal and reflex syncope (simple faints). These have definite provoking
factors, are unlikely to occur whilst lying or sitting and are benign in nature. Candidates are
FIT provided they meet all the following criteria:
a.
A clear provoking factor(s) is identified,
b.
The provoking factor(s) can easily be avoided in service,
c.
At least one warning symptom is present,
d.
The faint may be avoided by corrective action.
6.
All other candidates are UNFIT due to the risk of sudden incapacitation which may
result in harm to self and / or others when conducting safety-critical tasks.
7.
Loss of consciousness.
a.
Unexplained loss of consciousness or altered awareness. Candidates who
have had a single episode with no definite provoking factors, who have normal
cardiac and neurological examination and a normal ECG, are FIT provided 12
months have elapsed since the episode. Candidates with more than one episode
3 The account of those who witnessed the event may be of use.
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where no underlying cause can be found are UNFIT, due to the risk of sudden
incapacitation which may result in harm to self and / or others when conducting
safety-critical tasks.
b.
Loss of consciousness / altered awareness with seizure markers.
Candidates with a history of altered or loss of consciousness and seizure markers
(e.g. loss of awareness or amnesia lasting more than five minutes, lateral tongue
biting, urinary incontinence, or confusion on waking) are FIT provided they have been
symptom-free for five years and all cardiac and neurological investigations are
normal. All other candidates are UNFIT due to the risk of sudden incapacitation
which may result in harm to self and / or others when conducting safety-critical tasks.
Stroke / Transient Ischaemic Attack (TIA)
8.
Candidates who have had a stroke or TIA and have made a full functional recovery
require service-approved neurological review, when the provoking factor is one of the
following:
a.
Patent Foramen Ovale (PFO) which has subsequently been closed (see Annex
C Para 21 Cardiology for further requirements).
b.
Cervical artery dissection.
9.
All other candidates are UNFIT due to the risk of sudden incapacitation which may
result in harm to self and / or others when conducting safety-critical tasks.
Conditions which may impair function
Non-migrainous headache
10. Candidates with headaches within the last two years are FIT provided all the
following criteria are met:
a.
Not disrupted normal activities, including loss of time from school or work, or
required medical attention,
b.
Been successfully managed using Over-The-Counter (OTC) medication,
c.
Not required the use of medication to prevent (rather than treat) their onset
(prophylaxis),
d.
Not occurred more than once every six months where aggravated by factors
experienced in service (see list above).
Migraine
11. Migraine is an episodic disorder that affects a wide range of neurological functions
and can occur both with and without a headache. The risk of recurrence is unpredictable,
and attacks can be disabling or performance limiting. Typical migraine triggers are
commonly encountered in service and include irregular sleep patterns, missed meals,
exposure to bright light and loud noise, and relaxation after periods of stress. Migraine is
likely when a headache attack lasts 2-72 hours, is unilateral, occipital or retro-orbital, and /
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or has a pulsing quality. It is often aggravated by routine physical activity and it can be
associated with nausea and / or vomiting, light, sound and / or motion sensitivity, fatigue
and cognitive blunting (‘brain fog’). Candidates with a history of migraine are FIT provided
that in the last two years they have:
a.
Not had a migraine which is severe enough to disrupt normal activities,
including loss of time from school or work or been associated with difficulty with lights
(photophobia), sounds, or motion difficulties or any other accompanying neurological
features,
b.
Not had more than two episodes of migraine,
c.
Not required any prescribed medication or preventative (prophylactic)
treatment.
12. Candidates who do not meet the above criteria are UNFIT as risk of recurrence whilst
in service, especially where unavoidable tiggers are present can significantly impact on the
individual’s ability to function and perform their duties.
Traumatic Brain Injury (TBI)
13. For the purposes of assessing occupational risk, TBIs must be classified according to
the following criteria4:
a.
Mild. Any of the following features:
(1) Loss of consciousness lasting for less than 30 minutes.
(2) Post-traumatic Amnesia (memory loss associated with the injury) lasting
for less than 30 minutes.
b.
Moderate. Any of the following:
(1) Loss of consciousness lasting for 30 minutes to 24 hours.
(2) Post-traumatic Amnesia (memory loss associated with the injury) lasting
for 30 minutes to 24 hours.
(3) An undisplaced skull fracture.
c.
Severe. Any of the following:
(1) Loss of consciousness for more than 24 hours.
(2) Post-traumatic amnesia (memory loss associated with the injury) lasting
more than 24 hours.
(3) Bleeding inside the skull (intracranial haematoma).
(4) Depressed skull fracture.
4 The use of other categorisation systems is not permitted.
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(5) Brain contusion (bruising).
d.
Very Severe. Any of the following:
(1) Penetrating brain injury.
(2) Enduring neurological deficit.
(3) Seizures occurring after seven days.
14. The risk of seizures following head injury is directly related to the severity of the head
injury, therefore the following restrictions to entry apply:
a.
Candidates with a history of mild head injury are FIT.
b.
Candidates with a history of moderate head injury are FIT.
c.
Candidates with a history of severe head injury are FIT after one year providing
all the following criteria are met:
(1) No requirement for medication in the past year,
(2) No seizures in the past year,
(3) No ongoing neuro-behavioural symptoms.
d.
Candidates with a history of very severe head injury are UNFIT due to the risk
of sudden incapacitation which may result in harm to self and / or others when
conducting safety-critical tasks.
15.
Seizures related to head injuries. Seizures occurring at the exact time of a head
injury do not increase the risk of subsequent seizures and do not affect the restrictions
listed above. Seizures occurring within seven days of a head injury are provoked seizures
and should be managed accordingly (see guidance above Para 2a). One or more seizures
occurring more than seven days after head injury are considered a remote seizure(s) and
should be managed as epilepsy (see guidance above Para 3).
16. Candidates with a past history of TBI who show any evidence of persisting
intellectual, psychiatric or neurological deficit are UNFIT. The persistence of such features
indicates a very severe injury with a high risk of seizures and the potential for symptom
exacerbation attributable to Service.
Other Conditions
17.
Demyelinating disorders. In cases where demyelination is likely to be a single
event (e.g. Acute Disseminated Encephalomyelitis), provided there is no evidence of
enduring neurological or intellectual deficit the candidate is FIT subject to service-
approved neurology opinion. Candidates with conditions causing progressive
demyelination (multiple sclerosis, anti-MOG disease, and neuro-myelitis optica) are UNFIT
as these conditions are typically recurrent and can cause sudden incapacitation and need
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urgent specialist medical support. They often require treatment with potent
immunosuppression that may also lead to opportunistic infection and limited deployability.
18.
Functional neurological disorders (FND). Candidates with a past history of FND
which was functionally limiting and which have been fully investigated are FIT provided
they have been symptom-free for two years and undertaken activities comparable with
military service.
19.
Hydrocephalus. Candidates with a history of non-progressive hydrocephalus
developed in childhood, without neurological deficit, are FIT E2 (unfit contact sports,
including milling) subject to service-approved neurology opinion. Candidates with
symptomatic hydrocephalus, neurological deficit, or the presence of an intra-cranial shunt
are UNFIT due to the potential need for urgent access to highly specialised medical care.
20.
Arachnoid cyst. Candidates with an arachnoid cyst not causing mass effect and
who has no neurological deficit, are FIT E2 (unfit contact sports, including milling).
Candidates with an arachnoid cyst treated more than one year ago who has no evidence
of neurological deficit are FIT E2 (unfit contact sports, including milling).
21.
Tumours (brain cancers and growths). Candidates with a benign tumour5 or
treated low-grade cancer6 are FIT subject to service-approved neurology opinion.
Candidates with a history of other intracranial tumours are UNFIT due to the possibility of
recurrence or progression, and because of an increased risk of seizures and / or
neurological deficits. Refer to Annex N Paras 12 and 13, for further guidance.
22.
Degenerative genetic conditions affecting the nervous system (including but
not limited to Huntington’s Disease and Hereditary Neuropathy with Pressure
Palsies). See Annex N Other Conditions paragraphs on Congenital, chromosomal and
genetic conditions.
23.
Neurosurgery (brain surgery). Candidates with a history of neurosurgery with
ongoing symptoms, functional deficit or treatment are UNFIT. Candidates who have fully
recovered and have no functional deficit, and who have been discharged from specialist
care, may be UNFIT because of the risk of post-surgery seizure. Such candidates should
be referred to service-approved neurology including on risk of seizure. In all cases, the
underlying reason for surgery must be considered under the appropriate paragraph of this
annex.
24.
Dementia. Candidates with a diagnosis of dementia are UNFIT as these conditions
are progressive and affect the ability to conduct safety-critical tasks.
25.
Degenerative movement disorders. Candidates with degenerative movement
disorders, including Parkinson’s Disease, dystonia, multiple system atrophy, progressive
supranuclear palsy, tardive dyskinesia, cortico-basal degeneration are UNFIT as these
conditions are progressive and affect the ability to conduct safety-critical tasks.
26.
Other movements disorders:
5 e.g. meningioma
6 including low-grade gliomas with full excision
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a.
Tics. Candidates with mild tics are FIT provided they meet all the following
criteria:
(1) It does not significantly impact on function or ability to perform safety-
critical tasks (without medication),
(2)
It is not part of a progressive condition.
b.
Tremors. Candidates with tremors are FIT provided they do not significantly
impact on function or ability to perform safety critical tasks (even when undertaking
activities comparable to military duties). Where the tremor is part of an underlying
progressive disorder (including benign essential tremor), the candidate should be
referred to service-approved neurology.
c.
Candidates with significant involuntary movement disorders affecting daily
function are UNFIT as it may affect their ability to conduct safety-critical activities.
Sleep disorders
27.
Fatigue. Is associated with poor workplace performance and increased risk of safety
critical errors. Candidates with any sleep disorder affecting performance including
alertness, concentration and reaction times are UNFIT.
28.
Insomnia (inability to sleep).
Insomnia is defined as difficulty falling and / or staying
asleep (including early morning waking), for at least three months, resulting in significant
impairment of function in the absence of an underlying physical, psychiatric or external
factor which interrupts sleep (e.g. noise, poor accommodation). Candidates with a current
or past history of insomnia should be assessed for possible underlying causes of the
insomnia with a full physical and mental health assessment to exclude cardiovascular,
respiratory, neurological, pain, medication, depressive or anxiety related causes. Any
underlying cause identified should be considered elsewhere in Section 4.
29. Candidates with past history of insomnia are FIT provided they meet all the following
criteria:
a.
There was only a single episode of insomnia in the last two years,
b.
There is no other history of insomnia,
c.
There were no associated mental health issues,
d.
There were no associated co-morbidities,
e.
Any identified trigger is unlikely to recur in Service,
f.
The candidate did not receive more than 14 days7 of prescribed sleep medicine
(hypnotics).
7 Pre-existing significant insomnia is a significant risk factor for development of PTSD or Depression post-Deployment. Insomnia varies
from “normal” experience of sleeplessness from time-to-time to that requiring significant hypnotic treatment. Up to 14 days hypnotic
treatment can be considered not significant treatment, thereafter it is. A one off or infrequent requirement for treatment (up to 14 days
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30. All other candidates with any history of insomnia are UNFIT, due to fatigue being
associated with poor workplace performance and increased risk of safety-critical errors.
31.
Hypersomnolence (excessive sleepiness). Candidates with a current or past
history of hypersomnolence should be assessed for possible underlying causes with a full
physical and mental health assessment to exclude cardiovascular, respiratory,
neurological, pain, medication, depressive or anxiety-related causes. Any underlying
cause identified should be considered elsewhere in Section 4. Candidates with a history of
hypersomnolence with no underlying cause are UNFIT due to fatigue being associated
with poor workplace performance and increased risk of safety-critical errors.
32.
Parasomnias (sleep disruption). Parasomnias are episodic disorders of arousal,
partial arousal or sleep-stage transition that may be initiated or worsened by sleep.
Common parasomnias include sleep-walking and night terrors. Candidates with a history
of either of these conditions prior to the age of 13 are FIT, provided they did not require
specialist medical assessment or intervention. Candidates with episodes of sleep-walking
or night terrors after the age of 13 are UNFIT as episodes will impact on their ability to
operate safely in the military environment.
33.
REM sleep behaviour disorder (RBD). RBD is characterised by the intermittent loss
of atonia (abnormal retention of active movements that are typical of REM sleep), causing
suffers to physically enact their dreams, which can result in injury to self and others. RBD
is also significantly associated with neurodegenerative conditions that are not compatible
with service. Candidates with a history of RBD are UNFIT as this is likely to impede their
ability to operate safely in the military environment.
34.
Nightmares. Nightmares are frightening dreams that usually awaken the sleeper
from REM sleep (night terrors are non-REM sleep events and do not involve awakening).
Candidates with a history of nightmares are FIT provided they meet all the following
criteria:
a.
Have not had any episodes causing significant dysfunction to daily activities in
the past two years,
b.
Have no underlying psychiatric cause (such as PTSD) affecting fitness
elsewhere - see Annex L Psychiatry.
35.
Circadian rhythm sleep-wake disorders. Candidates with a sleep specialist
confirmed history of circadian rhythm sleep-wake disorder are UNFIT due to fatigue being
associated with poor workplace performance and increased risk of safety-critical errors.
36.
Narcolepsy (tendency to fall asleep). Candidates with a sleep specialist confirmed
history of Narcolepsy, current or past, are UNFIT as episodes of this life-long condition will
impact on their ability to operate safely in the military environment.
37.
Breathing related sleep disorders. Refer to Annex B Para 22.
hypnotic treatment in any 3 month period) can also be regarded as not achieving the significance threshold for barring entry. However,
in all cases, irrespective of the type or degree of treatment, careful consideration must be given to the effect on function in the military
setting of sedating side-effects of hypnotic medication. Reference for increased risk of mental disorder in those with insomnia: Gehrman
P; Seelig AD; Jacobson IG; Boyko EJ; Hooper TI; Gackstetter GD; Ulmer CS; Smith TC; for the Millennium Cohort Study Team.
Predeployment sleep duration and insomnia symptoms as risk factors for new-onset mental health disorders following military
deployment. SLEEP 2013;36(7):1009-1018.
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38.
Restless leg syndrome. This condition is common (general population prevalence is
15%), and in majority of cases is mild and causes little dysfunction. Candidates are FIT
provided they meet all the following criteria:
a.
Their restless leg syndrome does not cause any loss of function,
b.
Underlying causes, including hypoferritinaemia (low ferritin level), chronic neck
or spine pathology have been excluded.
39. Candidates whose restless leg syndrome causes any loss of function should be
referred to sSMES.
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Annex H
ENDOCRINE PRE-ENTRY
1.
General principles for assessing candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry, with respect to their
Endocrine conditions, are:
a.
Function. A candidate must have an adequate level of physical and cognitive
function in all environments to:
(1) Safely perform their military role.
b.
Prognosis. Where a candidate is found to have a resolved or current medical
condition, the following general criteria should be met in addition to the relevant
specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated by the demands of military service including
but not limited to extremes of heat / cold, atmospheric pressure, or
environmental conditions such as dust and allergens.
(2) Pose a significant risk of future temporary or permanent loss of function.
(3) Pose an unacceptable risk of sudden deterioration / incapacitation without
reasonable warning.
c.
Medical support requirements. Where a candidate has a pre-existing or
increased risk of an endocrine condition, there must be no reasonably foreseeable
requirement for medical care within the deployed location beyond deployed Primary
Healthcare (or equivalent). The medical condition must be stable with treatment.
Should loss of medication occur for ≤ 1 week this should not lead to clinical
deterioration in the condition or functional degradation during that time. In the
deployed environment the condition should not foreseeably impact military medical
resource.
2.
Exceptional considerations. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the Single Service Medical Entry Staff (sSMES)1.
Conditions affecting the pituitary gland
3.
Pituitary hormone production excess or insufficiency (hyper- and hypo
secretory conditions of the pituitary gland). Candidates with an established diagnosis
of pituitary hormone excess or deficiency are UNFIT with the exception of thyroid
stimulating hormone (TSH) deficiency (managed as per Paras 6 and 7). These conditions
are likely to result in long-term treatment and follow up, with potentially life-threatening
consequences if medication is interrupted.
4.
Pituitary adrenocorticotropic hormone (ACTH) insufficiency. Candidates with
ACTH deficiency are UNFIT due to potentially life-threatening complications which can be
induced by physiological stress with requirement for secondary care treatment during
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serious illness. Candidates must be able to work in challenging environments, in a
physically demanding job, including in austere locations with limited medical support.
5.
Non-functioning1 pituitary mass:
a.
Pituitary tumours <9mm (microadenoma) that are stable (no enlargement
demonstrated on two MRI scans performed a minimum of 12-months apart), are FIT
subject to sSMES review.
b.
Pituitary tumours > 9mm (macroadenoma) are UNFIT (extant clinical
guidelines2,3 state that tumours > 9mm require ongoing monitoring). Candidates must
be able to work in challenging environments, in a physically demanding job, including
in austere locations with limited medical support.
Conditions affecting the thyroid gland
6.
Hypothyroidism (underactive thyroid).
a.
Euthyroid (normal Thyroid Stimulating Hormone (TSH) blood test).
Candidates on a stable dose4 of thyroid replacement therapy (for a minimum of 12-
months), in the absence of an associated autoimmune condition (in the absence of
symptoms testing should not be initiated for employment purposes),5 are FIT E2.
Successfully treated hypothyroidism poses little health risk from short-term failure to
take medication,6 however, the condition requires continuous medication and regular
monitoring.
b.
Candidates who are not stable on thyroid replacement medications or who
require more regular blood tests and / or specialist medical follow up are UNFIT
pending further treatment under existing medical provider until the requirements in
Para 6a are met.
c.
Candidates with Autoimmune Polyendocrine Syndromes (APS) 1 or 2 are to be
referred to a service-approved endocrinologist.
d.
Candidates must be able to work in challenging environments, in a physically
demanding job, including in austere locations with limited medical support.
7.
Hyperthyroidism (overactive thyroid). Candidates with a history of an overactive
thyroid condition are FIT if all the following criteria are met:
a.
Successful definitive treatment with radioactive iodine or surgery.
b.
Have remained biochemically euthyroid without ongoing treatment for a
minimum of 12-months.7
1 Normal prolactin, stimulated cortisol and TSH.
2 https://www.endocrine.org/clinical-practice-guidelines/pituitary-incidentaloma, 3 Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 2, specific diseases
| Nature Reviews Endocrinology
4 Variations of dose of no more than 25mcg are acceptable in symptom-free candidates.
5 For example: Addison’s disease, coeliac disease, pernicious anaemia and some cases of primary ovarian failure.
6 Functional impairment (including muscular fatigue, cold intolerance and slowing of cognition) would develop over 1-2 months.
7 Following RAI, approx. 5% of patients per year will become hypothyroid (dose dependent) and require replacement therapy.
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c.
If replacement levothyroxine treatment is required, the candidate must have a
normal thyroid stimulating hormone blood test (Euthyroid) after being on treatment for
a minimum of 12-months. Individuals are then FIT E2.
8.
Grave’s. Candidates with previous Grave’s treated with thionamide medications (e.g.
carbimazole or propylthiouracil) are FIT provided they meet all the following criteria:
a.
Have remained euthyroid for five years or longer,
b.
Documented discussion with service-approved endocrinologist to determine the
risk of hyperthyroidism recurrence.8 Relapse after treatment is of occupational
importance since this is associated with short-term distractibility, excessive
psychological and physiological disturbance including a risk of cardiac arrhythmia9
(atrial fibrillation in 10%) in a physically demanding job, including in austere locations
with limited medical support.
9.
Thyroid cysts and nodules. Thyroid cysts and nodules deemed benign on
ultrasound (grade U2), histology or cytology (Thy2) and not requiring ongoing surveillance
are FIT. Thyroid cysts and nodules that do not meet the FIT criteria should be referred to
sSMES, where medical follow up requirement and supportability will be considered.
10.
Thyroid Cancer. Candidates with active thyroid cancer are UNFIT, due to the
requirement for long-term monitoring.
Candidates with a history of anaplastic or medullary
cancers are UNFIT. Other candidates with a history of thyroid cancer (such as with
incidentally diagnosed microcarcinomas), that meet the cancer criteria laid out in Annex N
(Paras 12 and 13) are FIT provided they also meet all the following criteria:
a.
Five years of follow up has been completed with no recurrence,
b.
Candidates must be able to work in challenging environments, in a physically
demanding job, including in austere locations with limited medical support.
Disorders of calcium metabolism
11.
Hyperparathyroidism (overactive parathyroid gland). Candidates with
hyperparathyroidism who have had definitive surgery, made a full recovery and have been
discharged from follow up are FIT.
12.
Other calcium disorders. Candidates with a history of calcium abnormalities (e.g.
vitamin D deficiency) are FIT provided serum calcium levels remain normal for a period of
six months without treatment. Candidates with familial hypocalciuric hypercalcaemia are
FIT subject to sSMES review. Conditions associated with hypercalcaemia (high calcium)
increase the risk of dehydration, osteoporosis and renal stone disease.
13.
Hypoparathyroidism (insufficient parathyroid gland activity). Candidates with
hypoparathyroidism are UNFIT, due to lifelong medication and monitoring requirements to
prevent hypocalcaemia (low calcium), that can cause muscle weakness and heart
8 For example: 36% relapse rate 2 years following cessation of an 18-month course of carbimazole: Antithyroid drugs and Graves’
disease – prospective randomized assessment of long-term treatment. Clin Endocrinol (Oxf). 1999 Jan;50(1):127-32. Relapse is more
common in individuals who were young, had raised thyroid receptor antibody, higher thyroid hormone levels or large goitre at diagnosis
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arrhythmias which are incompatible with service in austere locations with limited medical
support.
Conditions affecting the pancreas
14.
Diabetes mellitus. Candidates with diabetes mellitus are UNFIT. Both the disease
and its treatment can lead to disabilities and complications10 which affect employability and
deployability. Candidates must be able to work in challenging environments, in a physically
demanding job, including in austere locations with limited medical support.
15.
Pre-diabetes mellitus. Candidates
with a history of pre-diabetes11 that have
reversed the diagnosis for a period of 24 months12 and, at the two-year point, can
demonstrate two normal HbA1cs (<42mmol/mol) three months apart are FIT E2.
Candidates with pre-diabetes11 not meeting all these criteria are UNFIT. Candidates must
be able to work in challenging environments, in a physically demanding job, including in
austere locations with limited medical support.
16.
Gestational diabetes mellitus. Candidates with a history of gestational diabetes
mellitus are FIT E2 (requiring life-long HbA1c surveillance due to the raised life-long risk of
developing diabetes mellitus) provided they:
a.
Have not required anti-diabetic / anti-hyperglycaemic medication during the
preceding five years.13
b.
Demonstrate a normal HbA1c (<42mmol/mol) or Oral Glucose Tolerance Test,
without evidence of prediabetes11 during the past 24 months.
17.
Glycosuria. Candidates with
asymptomatic glycosuria, in the absence of underlying
disease (e.g., diabetes, pre-diabetes and or renal disease), are FIT following a normal
HbA1c (<42mmol/mol) taken three months after the positive urinalysis. A normal Oral
Glucose Tolerance Test (<7.8 mmol/L) taken at any time would meet this criteria.
Conditions affecting the adrenal gland
18.
Adrenal insufficiency. Candidates with a history of adrenal insufficiency are FIT
provided they meet the following criteria:
a.
Has not required treatment for one year,
b.
Has demonstrated an acceptable response to stimulated cortisol test and has
been discharged from follow-up.
19. Candidates with adrenal conditions requiring treatment are UNFIT. Interruption to
therapy can be life threatening. Candidates must be able to work in challenging
environments, in a physically demanding job, including in austere locations with limited
medical support.
10 For example: hypoglycaemia, infections, metabolic disturbance, ketoacidosis, retinopathy, peripheral vascular disease, coronary heart
disease, neuropathy and renal disease.
11 as defined by the World Health Organisation
12 his figure is based on the consensus view of the contributing Service Endocrinology Consultants
13 this figure is based on evidence that the risk of developing diabetes mellitus is higher in the first 5 years, and is attenuated over time:
Diabetes Care 2002;25(10):1862–1868; Diabetes Care. 1993;16(12):1598–1605, Clin Obstet Gynecol. 2021 Mar 1; 64(1): 234–243
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20.
Adrenal adenomas (benign non-cancerous tumour). Candidates with an adrenal
adenoma <4cm in size that demonstrate attenuation of ≤10 HU (Hounsfield Unit) on CT
scanning, which are non-functioning14,15 are FIT. Adrenal adenomas not meeting these
criteria that remain stable for 12-months and are non-functional may be considered FIT
following a referral to a service-approved Endocrinologist for specialist opinion. Candidates
must be able to work in challenging environments, in a physically demanding job, including
in austere locations with limited medical support.
Conditions affecting the ovary or testicle
21.
Male hypogonadism (insufficient gonad function) and testosterone. Candidates
requiring testosterone replacement are FIT E2, providing the following are met:
a.
The candidate is receiving intra-muscular testosterone undecanoate in oil
suspension (e.g., Nebido) only,
b.
The candidate is self-administering treatment (does not require a health care
professional or medical support to administer),
c.
Due to the challenges of self-administering, the candidate needs to demonstrate
that they are sufficiently trained, able and experienced to self-administer,
d.
Stable concentration levels within the local reference range for six months.
22. Candidates who use topical testosterone for menopausal and peri-menopausal
symptoms are FIT due to low dose involved and minimal impact on interruption. Other
candidates using topical testosterone preparations (e.g. gel) are UNFIT. With exogenous
testosterone administration (unlike the administration of exogenous oestradiol (HRT)),
stability of concentration is important because the on / off effect carries significant
implications for performance. Gels give poor stability of concentration, as do more frequent
depot injections (i.e. Enanthate, Sustanon).
23. Candidates using other testosterone preparations (including but not limited to
Sustanon and Enanthate) and Human Chorionic Gonadotrophin injections (e.g.
choriogonadotropin alfa) are UNFIT, for reasons of testosterone stability,16 cold chain
supply, storage, and ease of administration.
24.
Polycystic Ovary Syndrome (PCOS).17 Candidates whose symptoms have been
adequately controlled (use of contraceptives, eflornithine and metformin18 are acceptable)
and have regular periods (menses) (at least four menses per year) for at least 12-months
are FIT E2. Candidates prescribed spironolactone are UNFIT due to monitoring
requirements and risk of hyperkalaemia (elevated potassium levels) which can affect heart
function. Candidates that do not meet the FIT E2 criteria should be referred to sSMES,
where medical follow up requirement and supportability will be considered.
Other Endocrine Conditions
14 This figure is based on the consensus view of the contributing Service Endocrinology Consultants
15 Normal 1mg over-night dexamethasone suppression test, plasma or urine metanephrines, no hypokalaemia, no hypertension, or
evidence of clinical steroid hormone excess.
16 Topical testosterone absorption is affected by a host of individual and environmental factors.
17 Evidence provided by Birmingham Women’s Hospital.
18 Side effects must be absent. These are commonly gastrointestinal, usually in the form of nausea, and can be ameliorated by taking
the medication with food. Stopping treatment with metformin has noequelae and if BMI = 29 there is no increased incidence of NIDDM.
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25.
Hyponatremia (low sodium levels). Asymptomatic candidates whose
sodium levels
have remained in the normal range and stable for 12 months should be discussed with a
service-approved endocrinologist.
26.
Carcinoid tumours, thymic tumours and multiple endocrine neoplasia.
Candidates are UNFIT due to the requirement for continuous monitoring and regular
medication. See Annex N Paras 12 and 13.
27.
Diabetes insipidus (arginine vasopressin (AVP) deficiency or resistance). Due
to requirement for monitoring and potential difficulty adapting treatment to achieve normal
water balance in adverse environments, candidates with AVP deficiency or resistance are
UNFIT.
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Annex I
DERMATOLOGICAL PRE-ENTRY
1.
General principles for assessing candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry, with respect to their skin,
are:
a.
Function. A candidate must have the skin health, in all military environments, to
safely and effectively:
(1) Perform their military role wearing appropriate military clothing, including
Personal Protective Equipment (PPE) where required.
(2) Operate their personal weapon and use military equipment as required by
their role.
b.
Prognosis. Where a candidate is found to have a resolved, or current or is at
an increased risk of developing a skin condition, the following general criteria should
be met in addition to the relevant specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated by military service (in particular extremes of
heat, cold, or humidity, UV light, environmental conditions (e.g. dust), chemicals
(including oils), or use of military equipment).
(2) Pose a significant risk of future temporary or permanent loss of
occupational function.
(3) Pose a risk of sudden deterioration / incapacitation without reasonable
warning.
(4) Interfere with their ability to wear military clothing, PPE, or other military
equipment (including but not limited to body armour, respirators, CBRN
equipment, backpacks, camouflage cream).
c.
Medical support requirements. Where a candidate has a pre-existing or
increased risk of a dermatological condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication occur for ≤ one week this should not lead to
clinical deterioration in the condition or functional degradation during that time. In the
deployed environment the condition should not foreseeably impact military medical
resource.
2.
Exceptional considerations. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the single Service Medical Entry Staff (sSMES).
Assessment of skin conditions
3.
Skin conditions are often long term (chronic) and relapsing with times when the skin
appears ‘normal’ and times when the skin is clearly affected. A detailed history of skin
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symptoms, conditions, and predictable triggers should be taken, alongside adequate
examination, noting that the examination may be normal at the time of assessment.
4.
Skin conditions associated with underlying systemic conditions should prompt careful
examination and candidates may need to be advised to return to their GP for further
investigations.
Inflammatory skin conditions
5.
Acne. Candidates with acne that has resolved with or without treatment, are FIT.
Candidates with current acne are assessed as follows:
a.
Current treatment – topical and / or oral antibiotics. Candidates with current
acne using topical treatments and / or oral antibiotics are FIT providing that there are
no significant treatment side effects1 and they are able to wear military clothing and
PPE (including respirators) and shave for operational purposes.
b.
Current treatment –
isotretinoin. Candidates who are taking isotretinoin are
UNFIT but are FIT a minimum of four weeks after successful completion of treatment
as most adverse treatment side effects should have settled. If adverse side effects
are ongoing, candidates should be referred to sSMES. Candidates must be able to
wear military clothing and PPE (including respirators) and shave for operational
purposes.
c.
Current treatment – spironolactone. Candidates taking spironolactone are
UNFIT due to the risk of hyperkalaemia (high blood potassium) and the requirement
for ongoing blood monitoring.
d.
Untreated. Candidates who have active acne that affects the ability to wear
military clothing and PPE (including respirators) and shave for operational purposes
are UNFIT.
6.
Hidradenitis suppuritiva (Acne like condition affecting armpits and groins).
Candidates with a history of hidradenitis suppuritiva who have been symptom-free without
treatment for a minimum period of three years2 are FIT. Candidates with active hidradenitis
suppuritiva are UNFIT as military service is physically demanding and is likely to result in
worsening of symptoms.
Dermatitis
7.
Atopic dermatitis (Eczema). Living in field conditions is associated with multiple
triggers for exacerbations of eczema. Safe use of treatments such as topical steroids and
calcineurin inhibitors (e.g. Protopic®) may be limited by reduced access to normal
personal hygiene facilities. A history of eczema is also associated with a higher likelihood
of developing infection, irritant and allergic contact dermatitis.
8.
Severity should be classified following national guidance3 as summarised in the
following table:
1 For example, acid reflux, sun sensitivity
2 Military SME judgement
3 Adapted from
NICE CKS: Eczema – Atopic. Updated Mar 24
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Severity
Characteristics
Clear
Normal skin and no evidence of active eczema
Mild
Areas of dry skin, and infrequent itching (with or without small areas of
redness)
Moderate Areas of dry skin, frequent itching, and redness (with or without
excoriation and localized skin thickening)
Severe
Widespread areas of dry skin, incessant itching, and redness (with or
without excoriation, extensive skin thickening, bleeding, oozing,
cracking, and alteration of pigmentation).
9.
Candidates with a history and evidence from medical records compatible with mild
eczema and no active eczema are FIT provided they meet all the following criteria:
a.
There is no history or evidence from medical records indicating intense itching
in the last year4, such as documented or observed presence of excoriations or a
history of distractibility affecting ability to work / function due to itching,
b.
There is no history or evidence from medical records indicating recurrent sleep
disturbance caused by itching or skin discomfort, within the last year5,
c.
There has been no specialist or shared care management required to sustain
function (education or work attendance, or limiting exercise) and / or skin integrity
within the last three years.6
d.
Potent or strongly potent topical steroids7 have not been prescribed in the last
three years8, as use of these treatments are usually indicative of a more severe
condition.
e.
Use of occlusive dressings has not been recommended in the last three years9,
as this is usually indicative of a more severe condition.
f.
Systemic immunomodulatory therapy (including disease-modifying
antirheumatic drugs and biologics10) has never been prescribed, as this is usually
indicative of a more severe condition.
g.
Phototherapy has not been prescribed in the last three years.11
h.
There has been no involvement of the hands or feet in the last three years12 to
an extent that affects function (affecting education or work attendance, limiting
exercise. or resulting in sleep disturbance) or that would result in difficulty wearing
military gloves or military footwear.
4 Military SME judgement
5 Military SME judgement
6 Military SME judgement
7 BNF Topical corticosteroid preparation potencies
8 Military SME judgement
9 Military SME judgement
10 Including but not limited to methotrexate, sulphasalazine, hydroxychloroquine, daily prednisolone, cytokine modulators, TNF-alpha
inhibitors, monoclonal antibodies
11 Military SME judgement
12 Military SME judgement
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i.
There has been no involvement of the face or scalp in the last three years13 that
would affect wearing military personal protective equipment such as helmet and the
General Service Respirator.
10. Candidates with a past history of moderate eczema are FIT if they meet the criteria
for MILD eczema.
11. Candidates with active eczema or history from their medical records indicating severe
eczema after the age of 12 years are UNFIT due to the potential for further exacerbations
as a result of military service.
12.
Contact dermatitis. All Service Personnel may be called upon to operate in
environments where exposure to skin irritants and / or sensitisers cannot always be
adequately controlled.
a.
Irritant contact dermatitis. A candidate who has experienced isolated
episodes of irritant contact dermatitis are FIT subject to a normal skin assessment at
entry medical examination. Candidates with significant irritant contact dermatitis
related to a hazard likely to occur in service are UNFIT due to the risk of
exacerbation.
b.
Allergic contact dermatitis. Candidates with mild local reaction to nickel
products (e.g. jewellery, watches, belt buckles) are FIT. Candidates with a history of
allergic contact dermatitis confirmed by patch testing may be FIT if the allergen is
unlikely to be encountered during military service14, subject to assessment by
sSMES.
13.
Pompholyx (hand and / or foot eczema with tiny blisters). Candidates with a
history of recurrent and / or active pompholyx-type dermatitis should be assessed under
the criteria for atopic dermatitis (eczema Para 7).
Psoriasis 14. Candidates with psoriasis affecting <10% Body Surface Area (BSA)15,16 are FIT
provided they meet all the following criteria:
a.
The condition has not involved the hands17 or feet to an extent that affects
function (affecting education or work attendance, or limiting exercise, or resulting in
sleep disturbance) or that would result in difficulty wearing gloves, footwear, or head
coverings (e.g. helmet, beret, etc) or is in a location that would affect the ability to
wear military clothing or PPE (e.g. body armour, respirator etc).
b.
Treatment is self-managed and limited to emollients (moisturisers), soap
substitutes, bath additives, topical Vitamin D analogues, topical calcineurin inhibitors,
and / or up to topical potent steroids.18,19 Candidates using very potent steroids20 are
13 Military SME judgement
14 Potential exposures may be specific to role / specialism
15 Body Surface Area: Sect 1 and Figure 2 fro
m Hanifin JM et al. The Eczema area and Severity Index – A Practical Guide. Dermatitis.
2022;33(3):187-192. 16 NICE CKS requirement for specialist referral includes >10% BSA
(https://cks.nice.org.uk/topics/psoriasis/) 17 Mild nail involvement is acceptable (pitting, leukonychia, Beau lines)
18 BNF Topical corticosteroid preparation potencies
19 Treatment for eczema and psoriasis is differs because of disease biology, therefore acceptable level of topical steroids is different.
20 BNF Topical corticosteroid preparation potencies
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UNFIT because of the risk of rebound (symptoms getting worse) when they stop
using the steroid.
c.
The candidate has never required treatment with systemic agents (including but
not limited to methotrexate, ciclosporin, acitretin, apremilast, dimethyl fumarate,
prednisolone, cytokine modulators, TNF-alpha inhibitors, or monoclonal antibodies).
d.
Flexural areas are not currently affected (including under the breasts, in the
armpits, and / or in the groin) as these areas are more difficult to treat and are likely
to become problematic during Phase one training.
e.
Previous treatment with phototherapy (not including systemic
photochemotherapy21) is acceptable, provided criteria above are met.
15. Candidates with previous history of psoriasis affecting >10% BSA are FIT providing
they meet the criteria under Para 14 for the last five years.
16.
Guttate psoriasis. Candidates with a history of guttate psoriasis which has fully
resolved (irrespective of treatment) and are symptom free for a minimum period of two
years22 are FIT. Candidates with a history of guttate psoriasis that has developed into
plaque psoriasis should be assessed under Para 14 and 15 above.
17.
Nail changes due to psoriasis. Candidates with mild nail changes (e.g. pitting,
leukonychia, ridging, oil spots, onycholysis) are FIT provided that there is no impact on
ability to wear military clothing (e.g. gloves, footwear etc) and use military equipment
including PPE.
18.
Psoriatic arthritis. Candidates with psoriatic arthritis should be assessed under
Annex K Para 4.
Other skin diseases
19.
Cysts, scars and keloids. Candidates are FIT provided that the size or location of
cysts, scars or keloids (from whatever cause) does not affect the ability to wear military
clothing or the ability to operate military equipment.
20.
Birthmarks. Candidates are FIT unless the size or location of pigmented or vascular
lesions could affect the ability to wear military clothing or the ability to operate military
equipment.
21.
Bullous dermatoses (blistering skin conditions). Candidates with any immuno-
bullous disease such as dermatitis herpetiformis or any genetic bullous disease such as
epidermolysis bullosa are UNFIT as military environment may exacerbate blistering from
minor trauma.
22.
Fungal infections. Candidates with mild or limited fungal infections, that do not
impact function (e.g. ability to undertake physical training) are FIT. Candidates with
extensive or difficult to treat fungal infections to an extent that affects function (affecting
21 Oral PUVA
22 Persistent psoriasis is common post a single episode of guttate psoriasis (around 50%) but no increasing pattern in years 2 to 11 of
follow-up:
Galili E, Levy SR, Tzanani I, et al. New-Onset Guttate Psoriasis: A Long-Term Follow-Up Study. Dermatology.
2023;239(2):188-194.
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education or work attendance, or limiting exercise, or resulting in sleep disturbance) or that
would result in difficulty wearing military clothing or PPE are UNFIT due to the impact on
function, the risk of spread of infection, and the requirement for medical treatment.
23.
Viral warts and verrucae. Candidates with mild or limited verrucae or viral warts,
that do not impact function (e.g. ability to undertake physical training) are FIT. Candidates
with extensive or difficult to treat viral warts or verrucae to an extent that affects function
(affecting education or work attendance, or limiting exercise, or resulting in sleep
disturbance) or that would result in difficulty wearing military clothing or PPE are UNFIT
due to the impact on function.
24.
Bacterial Skin Infection. Candidates with active bacterial skin infection are UNFIT
due to the impact on function, the risk of spread of infection, and the requirement for
medical treatment.
25.
Infestations (Scabies or lice). Candidates with a history of an infestation are FIT
provided it has been treated. Candidates with active infestations are UNFIT due to the
impact on function, the risk of spread of infection, and the requirement for medical
treatment.
26.
Tropical skin diseases (including but not limited to cutaneous leishmaniasis,
cutaneous larva migrans, leprosy). Candidates with a history of a tropical skin disease
are FIT provided it has been treated. Candidates with active tropical skin disease are
UNFIT due to the impact on function, the risk of spread of infection, and the requirement
for medical treatment.
27.
Folliculitis including pseudofolliculitis barbae. Candidates with facial folliculitis
(inflamed hair follicles) who are able to shave for operational reasons for a minimum of two
weeks duration (i.e. a CBRN environment) and don’t require medically prescribed
treatment or supplies are FIT. Candidates with extensive or difficult to treat inflammation of
the hair follicles that would affect the ability to wear miliary clothing or PPE are UNFIT.
28.
Hyperhidrosis (excessive sweating). Candidates with hyperhidrosis who only
require topical treatment (e.g. antiperspirants) are FIT. Candidates with hyperhidrosis
affecting function (e.g. having to frequently change clothing, socks, footwear etc) or who
are receiving iontophoresis or botulinum toxin injections are UNFIT due to the requirement
for regular specialist medical appointments.
29.
Malignant skin disease (skin cancer). Candidates with a history of malignant skin
disease including malignant melanoma, squamous cell carcinoma, or basal cell carcinoma,
should be assessed in accordance with the guidance for malignant disease in Annex N
Paras 12 and 13. Candidates with malignant skin disease including malignant melanoma,
squamous cell carcinoma, or basal cell carcinoma, who are currently undergoing treatment
or who have not been discharged from follow-up are UNFIT.
30.
Pre-malignant skin conditions. Candidates with a history of pre-malignant skin
conditions are FIT if they are no longer under active dermatological review.
a.
Candidates with a history of keratinocyte derived disease such as actinic
keratosis, Bowen’s disease, vulval or penile intra-epithelial neoplasia who have
completed specialist treatment are FIT.
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b.
Candidates who have had complete excision of dysplastic naevus / naevi are
FIT.
31.
Photosensitivity. Candidates with a history of polymorphic light eruption and / or
juvenile spring eruption not requiring secondary care treatment in the last three years23 are
FIT. Candidates with a medical condition that causes sun-sensitivity (including but not
limited to cutaneous lupus, solar urticaria, porphyria) requiring treatment, including
specialist non-issue sunscreen or prescribed treatment, are UNFIT due to the requirement
for ongoing access to specialist medical care.
32.
Vitiligo. Candidates with vitiligo not associated with any other auto-immune disorder
are FIT. Candidates with vitiligo have a comparable risk profile for photosensitivity and skin
cancer as those with Type 1 skin.24
33.
Scleroderma. Refer to Annex K Musculoskeletal Para 10. Candidates with limited or
diffuse systemic sclerosis are UNFIT due to the ongoing requirement for secondary care
input.
34.
Morphoea. Candidates with morphoea that has been stable in size over the last
three years25 and does not affect their ability to wear military clothing, PPE, or operate
military equipment are FIT.
35.
Urticaria.
a.
Acute urticaria. Candidates with a history of acute idiopathic (no clear
provoking factor) urticaria or urticaria associated with viral illness are FIT if they have
been symptom free for six months.26 Candidates who have active acute urticaria are
UNFIT, even in the absence of systemic symptoms such as angioedema, because of
the distracting or incapacitating symptoms. Candidates with a history of acute
urticaria provoked by allergens should be assessed Annex N Other Conditions from
Para 33 - 36.
b.
Chronic spontaneous urticaria. Candidates with chronic spontaneous
urticaria (symptoms present for more than six weeks) which has fully resolved and
have been free from symptoms without medication for two years27 are FIT.
Candidates who have active chronic spontaneous urticaria are UNFIT, even if this is
controlled with regular medication, due to the distracting or incapacitating symptoms.
c.
Chronic physical urticaria. Candidates with a history of chronic physical
urticaria (i.e. in response to heat, cold, physical exercise, or sunlight) are UNFIT,
even if fully controlled with medication, due to the distracting or incapacitating
symptoms.
23 Military SME judgement
24 The Fitzpatrick skin type scale type 1 Ivory: pale skin, light or red hair, prone to freckles. Burns very easily and rarely tans.
25 Military SME judgement
26 Military SME judgement
27 Military SME judgement
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Annex J
GENDER HEALTH PRE-ENTRY
1.
The general principles against which an individual is assessed are:
a.
Function. Service personnel must have the physical and cognitive function, in
all military environments, to safely and effectively:
(1) Perform their military role.
(2) Operate their personal weapon.
b.
Prognosis. Where a candidate is found to have a resolved or current medical
condition, the following general criteria should be met in addition to the relevant
specific paragraph in policy, it should not:
(1) Be foreseeably exacerbated by military service (in particular, extremes of
cold/heat, atmospheric pressure, environmental conditions, or chemicals).
(2) Pose a significant risk of future temporary or permanent loss of function.
(3) Pose a risk of sudden deterioration/incapacitation without reasonable
warning.
c.
Medical support requirements. Where a candidate has a pre-existing or
increased risk of a gender health condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication occur for ≤ one week this should not lead to
clinical deterioration in the condition or functional degradation during that time. In the
deployed environment the condition should not foreseeably impact military medical
resource
2.
Exceptional considerations. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the Single Service Medical Entry Staff (sSMES).1The resultant FIT or UNFIT outcome
will be determined by sSMES.
Women’s Health
Breast conditions
3.
Breast Pain. Candidates with chronic breast pain are FIT provided their functional
ability to wear Personal Protective Equipment (e.g. body armour) or use military equipment
(e.g. Bergen, weapons) is not affected and they are able to fully participate in activities
comparable with military training. Candidates with chronic breast pain that causes
functional impairment are UNFIT.
1 Delegated Authority arrangements may apply.
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4.
Breast Surgery. Candidates with a history of breast surgery (including but not limited
to enhancement or reduction) are FIT provided their functional ability to wear Personal
Protective Equipment (e.g. body armour) or use military equipment (e.g. bergen, weapons
etc) is not affected and they are able to tolerate activities comparable with military training
for at least three months following surgery.
5.
Benign (non-cancerous) breast conditions. Candidates with a history of benign
(non-cancerous) breast conditions (including but not limited to fibroadenoma, breast cysts,
fat necrosis, breast abscess) are FIT following specialist breast clinic assessment that no
further medical or surgical management is required. Candidates who require ongoing
medical or surgical management are UNFIT until this has been completed and they are
able to tolerate activities comparable with military training over a minimum of three months
after surgery, due to the requirement to access specialist medical care.
6.
Breast cancer. Candidates with a history of breast cancer should be considered
under Annex N Paras 12 & 13. Candidates who are undergoing treatment for breast
cancer are UNFIT due to the requirement for uninterrupted access to specialist medical
care.
7.
Pre-malignant (pre-cancerous) or pre-invasive breast conditions.
a.
Lobular carcinoma in situ (LCIS). Candidates with a history of LCIS are FIT
provided surgical treatment (if indicated) is completed, specialist follow-up is no more
frequent than every six months and the candidate has tolerated activities comparable
with military over a minimum period of three months after surgery.
b.
Ductal carcinoma in situ (DCIS).2 Candidates with a history of DCIS are FIT
provided surgical treatment (if indicated) is completed, specialist follow-up is no more
frequent than every six months and the candidate has tolerated activities comparable
with military training over a minimum period of three months after surgery.
8.
Breast cancer (BRCA) gene carriers3 and equivalent risks. Candidates who have
a genetic predisposition to hereditary breast cancer are FIT E2 provided their health
surveillance requirements are compatible with service. Genetic testing should NOT be
initiated solely for the purposes of recruitment.
Conditions related to menstrual health (periods)
9.
Menorrhagia (heavy periods).4
Candidates with heavy periods (including those with
a diagnosis of adenomyosis5) are FIT provided there is no functional impairment (affecting
education or work attendance, or limiting exercise), or symptoms successfully treated with
readily available medication.6
Candidates who have
heavy periods affecting education or
work attendance, limiting exercise, or causing anaemia, are UNFIT.
10.
Amenorrhoea (absent periods). Candidates with absent periods due to hormonal /
contraceptive treatment are FIT. Candidates with absent periods not caused by hormonal /
2 This condition is a pre-invasive cancer, affecting the cells of the milk ducts in the breast. Local recurrence is reported as between 1-in-
3 and 1-in-6 patients at 5 years and patients are likely to require at least annual follow-up for a minimum of 5 years.
3 A beginner's guide to BRCA1 and BRCA2 | Royal Marsden Patient Information Library [accessed 21 May 24].
4 Defined by NICE as excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality
of life.
5 Adenomyosis is a condition where the lining of the womb (uterus) starts growing into the muscle in the wall of the womb.
6 Including but not limited to Oral Contraceptive Pill, simple analgesia, tranexamic acid, mefenamic acid.
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contraceptive treatment who have not been investigated to identify a cause are normally
UNFIT. Candidates with an established cause (not thought to be caused by a hormonal
treatment) should be discussed with the sSMES because absent periods are linked to an
increased risk of bone stress injury and musculoskeletal injury associated with physically
demanding activity.7
11.
Oligomenorrhoea (infrequent periods). Candidates who have at least four periods
per year are FIT. Candidates having three or fewer periods per year, who have not been
investigated to confirm the underlying reason are UNFIT because of the increased risk of
health complications (e.g. stress fractures).
12.
Unscheduled bleeding. Candidates with a benign or treated cause of unscheduled
bleeding are FIT provided there is no functional impairment (affecting education or work
attendance, or limiting exercise. Candidates with undiagnosed, unscheduled bleeding
(such as intermenstrual or post coital bleeding) are UNFIT until underlying conditions have
been excluded.
Pelvic conditions
13.
Chronic / Persistent pelvic pain. Chronic / persistent pelvic pain (defined as a
duration of over six months) is a symptom, not a diagnosis, and can be caused by a
number of conditions. These conditions are often complex to manage and can cause
significant functional limitations. The following list is not exhaustive:
a.
Dysmenorrhoea (painful periods). Candidates with a history of painful
periods (including those with a diagnosis of adenomyosis) are FIT provided there is
no significant functional impairment (affecting education or work attendance, or
limiting exercise), or they are successfully treated with readily available medication.8
b.
Endometriosis. Candidates with diagnosed endometriosis whose symptoms
remain well controlled with readily available medication9 (excluding GnRH analogues,
due to medical follow-up requirements) or 12 months post-surgery10 are FIT. Those
who continue to have symptoms after treatment that require time off education, work,
or limit exercise are UNFIT.
c.
Chronic / persistent or functional pelvic pain symptoms. Candidates with
chronic pelvic pain symptoms that do not cause functional impairment (affecting
education or work attendance, or limiting exercise), or which has been successfully
controlled with readily available medication11, are FIT. Candidates with undiagnosed
chronic pelvic pain symptoms or a diagnosis of functional pelvic pain or chronic pelvic
pain syndrome are UNFIT due to the requirement for ongoing access to specialist
care.
7 Ackerman KE et al. Fractures in relation to menstrual status and bone parameters in young athletes. Med Sci Sports Exerc. 2015;
47(8):1577–86. Lloyd T, Triantafyllou SJ, Baker ER, et al. Women athletes with menstrual irregularity have increased musculoskeletal
injuries. MedSci Sports Exerc. 1986;18(4):374–9. Hutson MJ, O’Donnell E, Petherick E, Brooke-Wavell K, Blagrove RC. Incidence of
bone stress injury is greater in competitive female distance runners with menstrual disturbances independent of participation
in plyometric training. J Sports Sci. 2021;39(22):2558–66. Heikura IA, Uusitalo ALT, Stellingwerff T, Bergland D, Mero AA,
Burke LM. Low energy availability is difficult to assess but outcomes have large impact on bone injury rates in elite distance athletes. Int
J Sport Nutr Exerc Metab. 2018;28(4):403–11.
8 Including but not limited to Oral Contraceptive Pill, simple analgesia, tranexamic acid, mefenamic acid
9 E.g. Mirena coil, oral contraceptive pill, simple analgesia, tranexamic acid, mefenamic acid
10 Due to post-surgical complications
11 Including but not limited to Oral Contraceptive Pill, simple analgesia, tranexamic acid, mefenamic acid
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14.
Pelvic Inflammatory Disease (PID). Candidates with a history of uncomplicated
pelvic inflammatory disease (PID) are FIT. Those with treated complications of PID without
ongoing functional impairment (affecting education or work attendance or limiting exercise)
are FIT. Only those with long-term sequelae of PID causing significant functional
impairment (affecting education or work attendance or limiting exercise) are UNFIT.
15.
Pelvic organ prolapse. This includes vaginal, urinary tract, and anorectal prolapse
symptoms. Candidates who are symptom-free with no functional impairment (affecting
education or work attendance, or limiting exercise) are FIT. Candidates who have received
successful treatment or surgical repair (without mesh) with no functional impairment
(affecting education or work attendance, or limiting exercise) are FIT. Candidates who
have undergone mesh repair should be referred to sSMES. Candidates with symptomatic
prolapse are UNFIT due to functional limitations associated with physical activity.
Uterine conditions
16.
Uterine tumours. Uterine tumours are classified as benign or malignant.
a.
Benign (non-cancerous). Candidates with uterine fibroids and adenomyomas
that do not cause significant functional impairment (affecting education or work
attendance, or limiting exercise), or those which have been successfully treated, are
FIT.
b.
Malignant (cancer). Candidates with a history of malignant uterine tumours
should be assessed in accordance with the guidance for malignant disease at Annex
N Paras 12 and 13.
17.
Hysterectomy. Candidates who have undergone laparoscopic, vaginal, or abdominal
hysterectomy more than three months previously and have no functional impairment are
FIT. Candidates with a history of malignancy (cancer) resulting in hysterectomy should be
assessed in accordance with the guidance for malignant disease at Annex N Paras 12 and
13.
Ovarian conditions
18.
Polycystic Ovary Syndrome (PCOS).12 Candidates should be assessed under
Annex H Endocrine Para 24.
19.
Absence or removal of ovary / ies. Candidates with one ovary are FIT. Candidates
with no ovaries should be assessed under the Premature Ovarian Insufficiency paragraph,
below.
20.
Ovarian cysts. Are classified as benign (non-cancerous), borderline, or malignant
(cancerous):
a.
Benign (non-cancerous). Candidates with small (<5 cm) simple (follicular)
ovarian cysts who have no symptoms are FIT. Candidates with successfully treated
large (>5 cm) ovarian cysts, and no functional impairment (affecting education or
work attendance, or limiting exercise) are FIT. Candidates with symptomatic cysts or
those >5 cm are UNFIT due to the risk of torsion and need for further investigation
12 Evidence provided by ESHRE https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Polycystic-Ovary-Syndrome
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and treatment. Candidates with dermoid cysts >5 cm are UNFIT due to risk of torsion.
Candidates with dermoid cysts <5 cm may require long term monitoring and all cases
should be referred to sSMES.
b.
Borderline. Candidates with a confirmed diagnosis of borderline ovarian cyst(s)
who have completed treatment but require long term monitoring should be referred to
sSMES.
c.
Malignant (cancerous). Candidates with a history of malignant ovarian
tumours should be graded in accordance with the guidance for malignant disease at
Annex N Paras 12 and 13.
21.
Premature Ovarian Insufficiency (POI). Candidates with a history of premature
ovarian insufficiency that has been investigated and treated by a specialist, who have been
returned to their GP for ongoing care, and who have no symptoms causing functional
impairment, and no concurrent co-morbidities13 needing treatment are FIT. Candidates
who are not adequately treated are UNFIT as they are at increased risk of long-term health
consequences.
Cervical Conditions
22.
Abnormal cervical screening test. Candidates with abnormal cervical screening
test should be assessed according to planned recall to the National Cervical Screening
Programme14, and need for investigation and treatment:
a.
The following candidates are FIT:
(1) Candidates whose most recent cervical screening is a high-risk Human
Papilloma Virus (hrHPV) NEGATIVE sample.
(2) Candidates whose most recent cervical screening is a hrHPV POSITIVE
sample on 12-month recall for cervical screening.
(3) Candidates whose most recent cervical screening is a hrHPV POSITIVE
sample who have had colposcopy and are on either 12-month or 36-month
recall for cervical screening.
(4) Candidates whose most recent cervical screening is a hrHPV POSITIVE
sample who have had colposcopy and a subsequent LLETZ15 and are on six-
month recall for cervical screening.
b.
The following candidates are UNFIT whilst they are under active clinical
management:
(1) Candidates whose most recent cervical screening result is INADEQUATE
SAMPLE as this must be repeated at three-months. Once the repeat result is
available, fitness should be considered under the appropriate result.
13 Hypertension, diabetes, hyperlipidaemia, cardiovascular disease, osteoporosis, osteopaenia
14 Cervical screening: programme overview - GOV.UK (www.gov.uk)
15 Large Loop Excision of Transformation Zone
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(2) Candidates whose most recent cervical screening is a hrHPV POSITIVE
sample, who have had colposcopy and require colposcopy follow-up.
(3) Candidates whose most recent cervical screening is a hrHPV POSITIVE
sample, who have had colposcopy and a subsequent LLETZ, and who have
been diagnosed with cervical cancer. These candidates should be assessed
under Annex N Paras 12 and 13.
c.
Participation in the National Cervical Screening Programme is not required for
the purposes of recruitment.
d.
Please see Figure 1 Flowchart
Figure 1 – Cervical Screening Flowchart
23.
Cervical cancer. Candidates with a history of cervical cancer should be in
accordance with the guidance for malignant disease at Annex N Paras 12 and 13.
Candidates with a history of treated cervical cancer Stage 1a1 may be FIT and should be
discussed with the sSMES.
Perimenopause / Menopause
24. Candidates with perimenopausal or menopausal symptoms that do not cause
cognitive and / or physical functional impairment, including those using hormone
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replacement therapy (HRT), are FIT. Candidates who have uncontrolled symptoms that
cause cognitive and / or physical functional impairment (impact on education or work
attendance, or limiting exercise) are UNFIT.
Fertility
25. Candidates actively undergoing fertility investigations or treatment, within secondary
care, are UNFIT until complete due to the requirement for timely access to treatment,
urgent review for treatment complications, and geographical stability.
Conditions related to pregnancy
26.
Pregnancy. Candidates who are pregnant are UNFIT due to the risk to the unborn
baby and maternal health. Candidates are FIT 26 weeks after birth provided there are no
significant post-natal complications.
27.
Pregnancy loss. Candidates who have had a recent pregnancy loss (within the last
26 weeks) are FIT provided there are no unresolved complications (e.g. excessive
bleeding, pain or ongoing medical care) as follows:
a.
Early (<14 weeks gestation). Candidates are FIT at six weeks after an early
pregnancy loss.
b.
Second trimester (14 – 24 weeks gestation). Candidates are FIT at 12 weeks
after a second trimester pregnancy loss.
c.
Late (>24 weeks). Candidates are FIT at 26 weeks after a late pregnancy loss.
28.
Termination of pregnancy. Candidates who have had a recent termination of
pregnancy (within the last 26 weeks) are FIT provided there are no unresolved
complications (e.g. excessive bleeding, pain or ongoing medical care) as follows:
a.
Early (<14 weeks gestation). Candidates are FIT at six weeks after an early
termination of pregnancy.
b.
Second trimester (14 – 24 weeks gestation). Candidates are FIT at 12 weeks
after a second trimester termination of pregnancy.
c.
Late (>24 weeks). Candidates are FIT at 26 weeks after termination of
pregnancy.
29.
Ectopic Pregnancy and Pregnancy of Unknown Location (PUL). Candidates who
have had a recent ectopic pregnancy or PUL (within the last 12 weeks) should be
assessed as follows:
a.
Conservative Management. Candidates who have been conservatively or
medically managed for an ectopic pregnancy or PUL are FIT after six weeks provided
they have been discharged from follow up and no ongoing treatment is needed.
b.
Surgical Management. Candidates with a history of surgically managed
ectopic pregnancy or PUL are FIT 12 weeks after surgery once discharged from
follow up and no ongoing treatment is needed.
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30.
Gestational trophoblast disease (Molar pregnancy). Molar pregnancies are
classified as invasive, non-invasive, or malignant (cancerous).
a.
Candidates with a history of non-invasive molar pregnancy are FIT once
discharged from follow up without ongoing treatment or functional impairment.
b.
Candidates with a history of invasive molar pregnancy may be FIT provided
they meet all the following criteria:
(1) Specialist follow-up is no more frequent than six-monthly.
(2) Surgical treatment (if indicated) has been completed.
(3) The candidate has tolerated activities comparable with military training for
at least three months following surgery.
(4) Each candidate should be considered on a case-by-case basis and
referred to sSMES for assessment.
c.
Candidates with a history of other malignant (cancerous) pregnancy should be
managed in accordance with Annex N Paras 12 and 13.
31.
Breastfeeding. Candidates who have given birth within the last 12 months should be
asked whether they are breastfeeding because this is associated with reduced bone
mineral density16 which may increase the risk of bone stress injuries. Candidates will be
expected to confirm they are able to conduct physical activities comparable with military
training / service.
Female Genital Mutilation (FGM)
32. Candidates who have undergone FGM, do not have ongoing physical symptoms and
have no functional impairment (impact on education or work attendance, or limiting
exercise) are FIT. Candidates who report that they have undergone FGM and have
complications or symptoms are to be referred to sSMES. Candidates are NOT to be
examined for signs of FGM. There is a mandatory reporting duty in UK legislation17; health
professionals MUST make a report to the police where they have been informed by a girl
under 18 that an act of FGM has been carried out on her.
Men’s Health
33. Prostate conditions, testicular conditions, and penile conditions are covered in Annex
F Renal and Urology.
34.
Male Pattern Baldness / Hair Loss. Candidates who are taking finasteride for
treatment of male pattern baldness / hair loss are FIT provided they have been taking the
medication for more than 28 days, and do not report any treatment side effects (including
but not limited to low mood and / or thoughts of self-harm or suicide). Candidates with
treatment side effects are UNFIT whilst they continue to take finasteride because military
16 which returns to normal once breastfeeding has finished.
17 Mandatory reporting of female genital mutilation: procedural information (accessible version) - GOV.UK (www.gov.uk) [accessed 21
May 24]
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training is physically and mentally demanding and could exacerbate mental health side
effects.
35.
Breast cancer (BRCA) gene carriers18 and equivalent risks. Candidates who have
a genetic predisposition to hereditary breast cancer are FIT E2 provided their health
surveillance requirements are compatible with service. Genetic testing should NOT be
initiated solely for the purposes of recruitment.
Fertility
36. Candidates actively undergoing fertility investigations or treatment, within secondary
care, are UNFIT until complete due to the requirement for timely access to treatment,
urgent review for treatment complications, and geographical stability.
Trans19 Medicine
Introduction 37. These paragraphs should be read in conjunction with JSP 889 Policy for the
Recruitment and Management of Transgender Personnel in the Armed Forces V1.1 dated
Aug 2019.20
38. Many Trans women and men change their gender expression to bring it into
alignment with their gender identity (which may include non-binary identities).21 This
process is known as ‘transition’ and may include physical, psychological, social and
emotional changes. It may also (but does not necessarily) involve various types of medical
treatment (e.g. hormones, surgery), to bring a person’s characteristics more into
conformity with their preferred gender identity and expression. Some Trans and non-binary
people have no desire to undergo surgery or take medicines to change their body. They
may transition in other ways.22
39. Whilst a ‘transgender applicant is ordinarily under no obligation to reveal to a
recruiter’, (or to anyone in the recruitment process) that they are transgender, or their
gender history’23, there is a requirement to understand the medical history and needs of
every candidate. Medical information about Trans medicine obtained, produced and
recorded by medical personnel involved in recruitment will be handled confidentially and is
not routinely disclosed to non-medical personnel.
40. Trans candidates are required to meet the same medical entry standards as any
other candidate. The requirements for assessment for specialist career employment
groups (e.g. aircrew, divers) are not included in this Section. Reference should be made to
the relevant single-Service guidelines.24
18 A beginner's guide to BRCA1 and BRCA2 | Royal Marsden Patient Information Library [accessed 21 May 24].
19 An ‘umbrella’ term incorporating all personnel who do not identify as cisgender, including but not limited to trans, non-binary, etc.
20 Available from: https://www.gov.uk/government/collections/joint-service-publication-jsp
21 This is an umbrella term used to describe people who do not feel male or female. They may feel they embody elements of both, that
they are somewhere in between or that they are something different. Non-binary people can find it very distressing to be told that they
must identify themselves as male or female. This may include gender-fluidity.
22 2023 BMA
Inclusive care of trans and non-binary patients (bma.org.uk)
23 JSP 889 Policy for the Recruitment and Management of Transgender Personnel in the Armed Forces V1.1 dated Aug 2019.
24 Current versions of BRd 1750A (RN), AGAI 78 (Army), AP1269A (RAF) and any associated DINs or single Service Policy Letters.
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41.
Gender-questioning. Candidates who may be processing, questioning, or exploring
how they want to express their gender identity (gender-questioning) are normally FIT,
noting the requirements of Paras 37 – 40, above.
42.
Gender Affirming Hormone Assessment. Candidates who are awaiting
assessment for Gender Affirming Hormone Treatment (GAHT) and / or gender
incongruence surgery are normally FIT, noting the requirements of Para 37 – 40, above.
43.
Interim medical assessment process. To ensure optimal assessment, all Trans
Candidates are to be referred to sSMES after relevant information gathering as detailed in
this leaflet.
Medication considerations 44. In the UK, medications and treatments used in Gender Affirming Hormone Treatment
(GAHT) are generally unlicensed for this purpose. The General Medical Council (GMC)
produces guidance on the prescribing of unlicensed medicines in general25 and Trans
healthcare in particular.26 Defence Medical Services also publish guidance on the ‘Use of
Unlicensed and Off-Label Medicines within the MOD’.27
45.
Transition history. Candidates who have commenced GAHT before the age of 17
years may need more detailed assessment.28 Where a candidate has a pre-existing or is at
increased risk of a medical condition, the condition must be manageable through
reasonably accessible routine and / or emergency specialist care.
46.
Prescribing. The following applies:
a.
Candidates prescribed GAHT by an NHS Gender Identity Clinic (GIC)29 or a
Care Quality Commission (CQC)30 accredited Trans Medicine service provider are
FIT. This is to ensure that Trans candidates are managed to the safest available
standards.
b.
Candidates prescribed GAHT by a non-accredited UK-based Trans Medicine
service provider or overseas Trans Medicine service provider are UNFIT. This is to
ensure that Trans candidates are managed by the safest available standards. Where
a candidate has a pre-existing or is at increased risk of a medical condition, the
condition must be manageable through reasonably accessible routine and / or
emergency specialist care.
c.
Candidates who source GAHT from independent sources31 are UNFIT. Such
candidates will be considered UNFIT until reviewed by an appropriate Gender Identity
Clinic (see Paras 12a and 12b, above) and prescribed authorised medicines. This is
to ensure that Trans candidates are managed by the safest available standards.32
25 Prescribing unlicensed medicines - GMC (gmc-uk.org)
26 Trans healthcare - GMC (gmc-uk.org) https://www.gmc-uk.org/professional-standards/ethical-hub/trans-healthcare
27 JSP 950 Lft 9-3-3 (V1.2 Jan 17). Available from:
https://modgovuk.sharepoint.com/sites/defnet/dinsjsps/DINSJSPS/20160421.1/20170116-
JSP_950_Leaflet_9_3_3_Unlicensed_Medicines_and%20_Off-Label_v1%202_final.pdf
28 ‘There is a significant lack of robust, comprehensive evidence around the outcomes, side effects and unintended consequences of
such treatments for people with gender dysphoria, particularly children and young people […]’. Source:
https://www.rcgp.org.uk/policy/rcgp-policy-areas/transgender-care
29 Or NHS Primary Healthcare provider, on behalf of the GIC.
30 Or equivalent National body.
31 Including online.
32 Including: correct clinical indication, correct dose, correct formulation from a from a regulated pharmaceutical suppliers.
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Where a candidate has a pre-existing or is at increased risk of a medical condition,
the condition must be manageable through reasonably accessible routine and / or
emergency specialist care.
47.
Access to Medication. A candidate’s medication needs to be routinely available.
This may be provided by Defence Primary Health Care (DPHC) or through sS provision
(through Joint Medical Capability) when deployed. Medications must be compatible with
deployment (considering administration, storage and resupply). If a candidate is unable to
safely change to medications available through DPHC/sS then they will normally be found
UNFIT because DPHC/sS cannot safely and effectively meet the clinical needs of the
candidate.
48.
Commencement and changes to medication. Candidates are UNFIT until twelve
months after commencing any form of GAHT. This is to allow sufficient time for:
a.
Optimal therapeutic outcome.
b.
Dose monitoring / stabilisation.
c.
Freedom of side effects and functional impairment to be confirmed.
49. A candidate must have the physical ability and mental stability required to perform
their role safely and efficiently in all military environments. Where a candidate has a pre-
existing or is at increased risk of a medical condition, the condition must be manageable
through reasonably accessible routine and / or emergency specialist care.
50.
Bone health considerations. The use of unopposed GnRH agonists (listed at
Appendix 1, Table 2) (i.e. in the absence of relevant sex hormone replacement) reduce
bone mineral density (BMD), foreseeably increasing the risk of fracture. Candidates who
have used GnRH agonist without the relevant sex hormone replacement for a period of six
months or more at any time require a DEXA scan to confirm acceptable BMD to inform
fitness for service in the context of the proposed branch and trade. Candidates are graded
FIT, provided the following criteria is met, depending on age:
a.
Candidate under 50 yrs. The Z-score must be greater than or equal to -2 SD.
b.
Candidate over 50 yrs. The T-score must be greater than or equal to -1.5 SD.
51.
Feminising hormone treatment. Candidates prescribed feminising hormone
preparations are normally FIT provided that:
a.
If prescribed oestrogen preparations, all of the following conditions are met:
(1) Using only acceptable medications (detailed at Appendix 1) and dose has
been stable for at least six months,
(2) Candidates have completed 12 months of treatment and are stable.
Stability on treatment and absence of side effects from oestrogen therapy will
reduce the risk of deterioration / incapacitation at the start of military service,
(3) Transgender recruits taking oral oestrogen therapy who have a past
history of VTE should be assessed in accordance with Annex N. This is
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because where oral oestrogen is used, there is a front-loaded risk of blood clots
(venous thromboembolic events [VTE] including deep vein thrombosis [DVT]
and pulmonary embolism [PE]),
(4) Blood test hormone levels, HbA1c and lipid profile (including triglycerides
and HDL) are within the target range set by their Trans medicine specialist,
(5) Prolactin level (as defined by the Trans medicine specialist) recorded as
normal in the six months prior to joining. Those with a history of prolactinoma
should be managed in accordance with Annex H Endocrinology.
b.
If prescribed gonadotrophin releasing hormone (GnRH) analogues, all of the
following conditions are met:
(1) Using only acceptable medications (detailed at Appendix 1) and dose has
been stable for at least six months,
(2) Candidates have completed 12 months of treatment,
(3) Blood test hormone levels (including oestrogen and testosterone) are
within the target range set by their Trans medicine specialist.
52.
Masculinising hormone treatment. Candidates prescribed masculinising hormone
preparations are normally FIT provided that:
a.
If prescribed Testosterone preparations, all of the following conditions are met:
(1) Using only acceptable medications (detailed at Appendix 1) and dose has
been stable for at least six months,
(2) Candidates have completed 12 months of treatment,
(3) Baseline blood test results, prior to commencement of therapy, (including
Testosterone, FBC, LFTs, FSH / LH, Oestradiol, Lipids, SHBG, U&Es, HbA1c
and Prolactin) were within the target range set by their Trans medicine
specialist,
(4) Routine blood test results (including Testosterone, FBC, LFTs, FSH / LH)
are within the target range set by their Trans medicine specialist,
(5) Haematocrit should be in the normal range (50% or below) within three
months of medical assessment. This is due to the risk of an excessive
concentration of circulating red blood cells (polycythaemia) which may lead to
life-threatening blood clots in the first year of testosterone therapy.
53.
Monitoring. To be graded FIT, all Transgender candidates on GAHT are required to
have normal measurements as defined by their Trans medicine specialist of the following
in the six months prior to entry:
a.
Sex hormone.
b.
Full blood count (FBC).
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c.
Lipid profile (including triglycerides).
d.
Liver function tests (LFTs).
54. Monitoring of bloods should not normally be required more often than six monthly.
Where a candidate has a pre-existing or is at increased risk of a medical condition, the
condition must be manageable through reasonably accessible routine and / or emergency
specialist care.
55. The GMC advocates: ‘Once the patient has been discharged by a GIC or gender
specialist, the prescribing and monitoring of hormone therapy can be carried out in primary
care without specialist input. However, it is reasonable for a GP to expect the GIC or
specialist to remain available to provide timely support and advice where necessary. From
the patient’s perspective, management in primary care is far easier, and there is no
specific expertise necessary to prescribe for and monitor patients on hormone therapy.33
Surgical considerations 56. Candidates who have undergone functional surgical procedures (listed at Appendix
2) are FIT provided they meet all the following criteria:
a.
There has been full recovery and stability,
b.
They have been discharged from routine follow-up,
c.
Unimpaired relevant function has been achieved (e.g. urination),
d.
The provisions of
Para 1, above, are met.
57. Candidates who have undergone aesthetic surgical procedures and treatments
(listed at Appendix 2) are normally FIT provided they meet all the following criteria:
a.
There has been full recovery and stability,
b.
They have been discharged from routine follow-up,
c.
The provisions of
Para 1, above, are met.
58. As with any surgical procedure, candidates who are on a waiting list or booked for
surgical procedures are UNFIT until those procedures are complete and they have met the
requirements o
f para 22, above. This is to ensure that initial training can be completed
uninterrupted and to ensure that treatment is not delayed and can be completed without
complication to the individual.34
Mental Health considerations
33 NHS Primary Care Responsibilities in Prescribing and Monitoring Hormone Therapy for Transgender and Non-Binary Adults.
Available from: https://medicines.necsu.nhs.uk/primary-care-responsibilities-in-prescribing-and-monitoring-hormone-therapy-for-
transgender-and-non-binary-adults/.
34 JSP 889. “A transgender Service person wanting to maintain stability in order for them to complete treatment will need to consult their
health professional and inform their CoC in order to set the conditions for stability as early as possible.”
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59. Transgender candidates are required to meet the same mental health entry
standards as any other candidate and careful assessment is required, see JSP 950 Lft 6-
7-7 Section 4 Annex L.
Clinical Monitoring
60.
Biological and physiological criteria. When considering biological and
physiological values, Trans candidates should be assessed against their biological sex at
birth criteria, including:
a.
Blood test results.
b.
Spirometry.
c.
Baseline audiometry.
61.
Body composition. Body mass index (BMI) and waist circumference (WC) will be
considered by sSMES. Where there are borderline values, potentially attributed to their
hormone treatment, such cases should be discussed with sSMES before making a final
determination on fitness.
General
62.
E2 Marker. All Trans candidates are FIT E2 for annual medical oversight to ensure:
a.
Appropriate medical monitoring is in line with individual treatment plans.
b.
Hearing Health Surveillance (routine periodic audiometry) is conducted with
reference to the candidate’s biological birth sex.
c.
Appropriate, personalised health screening is offered in accordance with
national guidelines.35
35 Information about national NHS screening Programmes for transgender and non-binary people can be found at:
www.gov.uk/government/publications/nhs-population-screening-information-for-transgender-people.
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Appendix 1 to
Annex J
ACCEPTABLE GENDER AFFIRMING HORMONE TREATMENT FOR
ADULTS
1.
Oestrogen therapy.
Preparation
Dose range
Tablets
Estradiol Valerate (generic)
1 mg bd – 4 mg bd
Progynova (Oestradiol Valerate)
1 mg bd – 4 mg bd
Elleste solo (oestradiol hemihydrate)
1 mg bd – 4 mg bd
Gel
Sandrena sachet (0.5 or 1mg sachet)
0.5 - 6 mg daily
Oestragel pump pack (1 measure 1.25g = 0.75 mg)
0.75 – 6 mg daily
Patches
Evorel (25, 50, 75 and 100 mcg/24 hr patches)
50 mcg - 400 mcg/24hr patches twice
Estradot (25, 37.5, 50, 75 and 100 mcg/24 hr patches)
weekly
50 mcg - 400 mcg/24hr patches twice
weekly
Target oestradiol level 400-600pmol/L.1
2.
GnRH therapy (GnRH agonists / testosterone blockers).
Frequency
Every 3 months
Drug and dose
Leuprorelin
Triptorelin
11.25mg
11.25mg
Brand name
Prostap 3
Decapeptyl SR
Form
Powder to reconstitute
Powder to reconstitute
Injection route
Subcutaneous (under the surface of
Subcutaneous (under the surface of
the skin)
the skin)
3.
Testosterone therapy.2
Preparation
Testosterone
and dose
Dose and
1000mg commonly every 12 weeks based on testosterone levels
frequency
Brand name
Nebido®
Form
Intramuscular (IM) Injection3
Typical target
8-14nmol/L
range
1 Adapted from: Feminising Hormone Treatment for Adults, Nottinghamshire Area Prescribing Committee, dated July 2022. Available
from: https://www.nottsapc.nhs.uk/media/qaafcl52/feminising-hormones-information-sheet.pdf
2 Adapted from: Masculinising Hormone Treatment for Adults, Nottinghamshire Area Prescribing Committee, dated July 2022. Available
from: https://www.nottsapc.nhs.uk/media/gxfnn13a/masculinising-hormones-information-sheet.pdf
3 Topical testosterone is not permitted as it is associated with less reliable concentration and absorption is impaired by environmental
conditions experienced in service (heat, cold, dust, damp). Testosterone administered more frequently than 3 monthly is associated with
‘on-off’ symptoms which can affect physical and cognitive function.
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Appendix 2 to
Annex J
ACCEPTABLE TRANSGENDER SURGICAL PROCEDURES AND
TREATMENTS
1.
Female to Male (FtM) functional procedures.
a.
Genital surgery. Procedures may include hysterectomy, ovariectomy
(salpingo-oophorectomy), vaginectomy, metoidioplasty, scrotoplasty, urethroplasty,
placement of testicular prostheses, and phalloplasty.
b.
Chest wall surgery. Procedures may include mastectomy and / or creation of
male chest.
2.
Male to Female (MtF) functional procedures.
a.
Genital surgery. Procedures may include: orchidectomy, penectomy,
vaginoplasty, clitoroplasty, and labiaplasty.
b.
Chest wall surgery. Breast augmentation (augmentation mammoplasty)
3.
Aesthetic surgery and treatments.
a.
Voice-modifying surgery.
b.
Facial feminisation surgery – treatments may include:
(1) Thyroid chondroplasty / tracheal shave (reducing size of larynx)
(2) Rhinoplasty (nasal surgery).
(3) Facial bone reduction.
(4) Blepharoplasty / facelift.
c.
Liposuction and / or body sculpture.
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Annex K
MUSCULOSKELETAL PRE-ENTRY
1.
General principles for assessing candidates against this Annex. All candidates
must be able to meet and maintain the physical fitness needed to complete military activity
in all deployed environments for the duration of their employment, recognising
musculoskeletal injuries significantly impact operational effectiveness. The general
principles against which a candidate is assessed as FIT for entry, with respect to their
musculoskeletal (MSK) system, are:
a.
Function. Candidates must have the physical function in all environments, to
safely and effectively complete training and perform their military role:
(1)
Movement. Candidates must be able to walk, run, jump, climb, lift, throw
and drag.
(2)
Weapon handling. Candidates must be able to safely handle their
personal weapon and adopt the required firing positions (standing, kneeling,
squatting, prone).
(3)
PPE. Candidates must be able to use issued military personal protective
equipment (PPE) and equipment e.g., clothing (especially gloves and boots),
body armour, helmet, eye protection and CBRN Individual Protective Equipment
(IPE).
(4)
Safety. Candidates must be able to carry out personal safety drills.
b.
Prognosis. Where a candidate is found to have a resolved or current MSK
condition, the following general criteria should be met in addition to the relevant
specific paragraph in this policy:
(1)
There is no unacceptable risk of sudden deterioration / incapacitation
without reasonable warning.
(2) Conditions will not foreseeably be exacerbated by military service (in
particular, extremes of cold / heat, atmospheric pressure, environment,
chemical and arduous training).
(3) The risk of future temporary / permanent loss of function and ability due to
military training / service is low.
(4) Conditions will be required to heal to a functional standard, others will
require a time bar to reflect underlying risk of recurrence.
c.
Medical support requirements. Where a candidate has a pre-existing or
increased risk of a musculoskeletal condition, there must be no reasonably
foreseeable requirement for medical care within the deployed location beyond
deployed Primary Healthcare (or equivalent). The medical condition must be stable
with treatment. Should loss of medication occur for ≤ week this should not lead to
clinical deterioration in the condition or functional degradation during that time. In the
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deployed environment the condition should not foreseeably impact military medical
resource.
2.
Exceptional considerations. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the single Service Medical Entry Staff (sSMES).1 The resultant outcome of FIT or
UNFIT will be determined by sSMES.
a.
Skeletal maturity. Ascertaining whether a candidate has reached skeletal
maturity might be relevant in some conditions. In general, this means being aged 16
years and over for women and 18 years for men.
3.
Fractures. Specific guidance is provided in the relevant paragraphs below. The
following general considerations apply:
a.
Non-union (fractures that have not healed). Candidates with fractures which
have not healed are UNFIT as they are unlikely to achieve the required level of
function required for military service and are at increased risk of foreseeable injury
associated with military training or service.
b.
Stress fractures. Stress fractures are described in various paragraphs of this
annex.2 Where specific guidance is not provided, this paragraph applies. Candidates
who have recovered from uncomplicated, single stress fractures (with the exemption
of lower limb stress fractures, which are listed separately) who are symptom free with
proven activity comparable with military training for a minimum of three months and
radiological confirmation of healing are FIT. Those with multiple or recurrent stress
fractures at any site are UNFIT, however exceptional cases (such as those where no
more than two fractures occurred during excessive / intensive training and the
candidate has since returned to activity comparable with military training) may be
referred to sSMES for a determination on FIT E2 / UNFIT. Previous pre-disposing
factors, including Vitamin D deficiency and reduced bone mineral density, should be
excluded prior to entry.
c.
Pathological fractures (fractures due to underlying disease). All Candidates
with pathological fractures are UNFIT as there is risk of further fractures caused by
military training or service.
Arthropathies / arthritidies (arthritis)
4.
Inflammatory arthritis / arthritidies. Candidates with a history of rheumatoid
arthritis, ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis or any other form of
auto-immune related inflammatory arthritis (including those in remission) are UNFIT. Such
conditions may require regular specialist medical review, with current / future potential for
immune-modulating medication and monitoring. Military service is physically demanding
and may include working in challenging and austere environments, with limited medical
support.
1 Delegated Authority arrangements may apply.
2 Para 90. Spondylolysis (pars fractures, stress fractures and defects).
Para 126. Stress fracture to the femur.
Para 172. Medical Tibial Stress Syndrome.
Para 173. Tibial stress response or fracture.
Para 222f. Metatarsal fracture, including stress fracture.
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5.
Reactive arthritis (following gastrointestinal or genitourinary infection).
Reactive arthritis is common in younger people following exposure to an infective
organism. The condition is typically self-limiting with most recovering within one year,
however 15-20% can have longer-term symptoms and some may develop other forms of
inflammatory arthritis. Asymptomatic candidates should be assessed according to the
criteria below:
a.
Single episode. Candidates with a history of a single episode of reactive
arthritis who meet all the following criteria are FIT:
(1) Not requiring treatment for the last 12 months,
(2) Symptom-free for at least 24 months,
(3) No radiographic evidence of degenerative joint disease on available
imaging,
(4) Undertaking regular and substantial levels of exercise comparable with
military training without experiencing adverse effects,
(5) No functionally significant deformity with normal joint mobility and range of
movement.
b.
Family history and / or HLA B-27 positive. Candidates who have a family
history of inflammatory arthritis and / or are HLA B-27 positive with no personal
history of reactive arthritis are considered FIT for military service.
c.
Multiple episodes. Candidates with more than one episode of reactive arthritis
are UNFIT because of the increased risk of recurrence and development of other
forms of inflammatory arthritis which would restrict their ability to perform usual
military duties. Recurrence risk is difficult to quantify, and the more common
presentation is ongoing low-level inflammatory symptoms which then begin to
represent chronic inflammatory arthritis.
6.
Septic arthritis (joint infection). Candidates with a history of uncomplicated
infection who meet all the following criteria are FIT:
a.
Single episode of infection affecting a single joint,
b.
More than 24 months since being discharged from follow up,
c.
Discharged from specialist care within six months of onset of symptoms,
d.
No functionally significant deformity with normal joint mobility and range of
movement, and no significant joint changes on available imaging,
e.
Undertaking regular and substantial levels of exercise comparable with military
training without experiencing adverse effects,
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f.
No associated co-morbidity3,
g.
Unrelated to intravenous (IV) drug use including anabolic steroids.4
7.
Candidates who do not meet these criteria are UNFIT.
8.
Juvenile Idiopathic Arthritis (JIA). JIA describes the onset of inflammatory arthritis
before the 16th birthday. Most people with JIA make full recovery with 75% achieving
sustained remission (symptom-free for 24 months). The remainder continue with
symptoms into adulthood and are UNFIT as they are unlikely to achieve the required level
of function required for military service and are at increased risk of foreseeable injury
during training or service. Candidates are FIT provided they meet all the following criteria:
a.
Discharged from follow up,
b.
Symptom-free for 24 months without medication,
c.
No evidence of active systemic disease or systemic deficit due to previous
systemic disease (e.g. cardiac / respiratory / neurological / ophthalmological
involvement as outlined in other Annexes),
d.
No functionally significant deformity with normal joint mobility and range of
movement, and no significant joint changes on available imaging.
9.
Gout. Acute gout can be severely disabling with repeat episodes causing permanent
joint damage. Recurrence is common with functionally limiting symptoms, requiring lifestyle
modification and long-term prophylactic oral medication. Candidates are FIT E2 provided
they meet all the following criteria:
a.
A single episode or multiple episodes more than 24 months apart,
b.
Symptom-free for at least 24 months,
c.
No medication requirement (including over-the-counter treatment such as
NSAIDs5),
d.
No functionally significant deformity with normal joint mobility and range of
movement, and no significant joint changes on available imaging.
Hypermobility Disorders
10.
Hypermobility (flexible joints). Joint hypermobility is very common affecting up to
20% of the population. Symptom-free joint hypermobility alone is unlikely to lead to
functional problems. Candidates should be assessed against the following criteria:
3 E.g. diabetes mellitus, rheumatoid arthritis, recent joint surgery, hip or knee prosthesis, skin infection, and immunosuppressive
medication use. Source: Earwood JS, Walker TR, Sue GJC. Septic Arthritis: Diagnosis and Treatment. Am Fam Physician. 2021 Dec
1;104(6):589-597. PMID: 34913662.
4 Septic arthritis amongst those who inject drugs tends to affect the sternoclavicular, sacroiliac, spinal facet joints. Septic arthritis
affecting these joints reflects a long-term susceptibility to osteoarthritis and back pain.
5 E.g. ibuprofen, diclofenac.
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a.
Hyperextension of less than 10° at the knee. Candidates are FIT provided
they meet all the following criteria:
(1) Symptom-free,
(2) Undertaking regular and substantial levels of exercise comparable with
military training without experiencing adverse effects,
(3) Good knee control assessed at pre-service medical assessment (PSMA).
b.
Hyperextension of more than 10° at the knee. Candidates with
hyperextension of greater than 10
° in either knee are UNFIT. Generalised
ligamentous laxity (hypermobility) may result in symptoms when walking, running and
/ or jumping. A candidate with >10
° of hypermobility is unlikely to be able to lock their
joints to achieve the required level of function required for military service. They are
unlikely to achieve the required level of function required for military service and are
at increased risk of foreseeable injury during training or service.
c.
Hypermobility diagnosed in adulthood.6 Candidates with a formal diagnosis
of hypermobility syndrome made in adulthood are UNFIT.
This is due to an increased
risk of injuries such as anterior cruciate ligament (ACL) rupture. Candidates are also
unlikely to be able to tolerate wearing PPE such as body armour and carry weight for
lengthy periods of time. They are unlikely to achieve the required level of function
required for military service and are at increased risk of foreseeable injury during
training or service.
d.
Hypermobility Spectrum Disorder (HSD) and hypermobile Ehlers-Danlos
Syndrome (hEDS). Symptomatic hypermobility is associated with systemic
disorders. The MSK manifestations include recurrent MSK pain, diffuse chronic pain,
atraumatic joint dislocations and joint instability. Candidates with HSD and / or hEDS
are UNFIT as they are unlikely to achieve the required level of function required for
military service and are at increased risk of foreseeable injury during training or
service.
11.
Connective Tissue Disease (CTD). CTD is a group of heritable and systemic
autoimmune conditions affecting multiple organs. Heritable CTD includes Marfan’s
Syndrome, Ehlers-Danlos syndrome, Osteogenesis Imperfecta, Stickler Syndrome, Alport
Syndrome, Beals Syndrome and Loeys-Dietz Syndrome. Autoimmune CTD includes
Systemic Lupus Erythematosus (SLE), Scleroderma, Sjogren’s7 Syndrome, mixed
connective tissue disease (MCTD) (including polymyositis and dermatomyositis) and
Undifferentiated CTD. Specialist diagnosis is essential as other conditions are sometimes
mislabelled. Candidates with these conditions are UNFIT because they are likely to require
long term specialist follow up and treatments, and will be unable to work in challenging
environments, in a physically demanding job, including in austere locations with limited
medical support.
Muscle disorders
6 As stated under skeletal maturity.
7 Also termed, Sjögren's.
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12.
Myopathy. Those with minimal post-traumatic wasting, causing no significant loss of
function, are
FIT
provided functional assessment is normal. All other causes of myopathy,
or those with functionally significant muscle wasting, are UNFIT as they are unlikely to
achieve the required level of function required for military service and are at increased risk
of foreseeable injury during training or service.
13.
Myositis. Candidates who have experienced a brief episode of myositis (e.g.
secondary to infection or statin use) are FIT provided they meet all the following criteria:
a.
Symptom-free for a period of three months,
b.
Undertaking regular and substantial levels of exercise comparable with military
training without experiencing adverse effects,
c.
Underlying cause which is likely to be provoke recurrence has been excluded,
d.
Normal dynamic functional assessment.8
14. Candidates with active myositis9 are UNFIT as they are unlikely to achieve the
required level of function required for military service and are at increased risk of
foreseeable injury during training or service.
15.
Inherited muscular dystrophies (genetic diseases of the muscles). See Annex N
Other Conditions, Congenital, chromosomal and genetic conditions.
Bone disorders
16.
Osteomyelitis (inflammation (including infection) of the bone). Candidates are
who meet all the following criteria are FIT:
a.
A single episode that recovered more than three years ago without any
complications or joint involvement and discharged from specialist follow-up,
b.
Symptom-free and with full function undertaking activities comparable with
military service for at least three months,
c.
Evidence of resolved infection on available imaging,
d.
No functionally significant deformity with normal joint mobility and range of
movement.
17. Candidates who do not meet the criteria above, or who have evidence of unresolved
infection such as a non-discharging sinus are UNFIT as there is a high risk of recurrence
of infection requiring long-term specialist follow up. They are unlikely to achieve the
required level of function required for military service and will be unable to work in
challenging environments, in a physically demanding job, including in austere locations
with limited medical support.
8 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
9 Including autoimmune myositis.
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18.
Osteopenia and osteoporosis (reduced bone density). Candidates with a history
of osteopenia and / or osteoporosis who meet all the following criteria are FIT:
a.
Fully resolved,
b.
Normal bone mass on DXA,
c.
Vitamin D level normal,
d.
Symptom-free and with full function undertaking activities comparable with
military service for at least three months.
19. Candidates with a current diagnosis of osteopenia10 or osteoporosis due to any
cause, are UNFIT. These candidates are at increased risk of fractures which is
incompatible with the demands of service life and are at increased risk of foreseeable
injury during training or service.
20.
Vitamin D. Vitamin D protects MSK and immune health. The following applies where
Vitamin D levels have been assessed:
a.
Candidates with adequate 25-hydroxyvitamin D levels (above 50 nmol / L) are
FIT.
b.
Candidates with insufficient or severely deficient 25-hydroxyvitamin D levels (50
nmol / L and below) are UNFIT due to the increased risk of fracture during military
training and service.
21.
Osteogenesis imperfecta (brittle bone disease). Candidates with osteogenesis
imperfecta are UNFIT due to the increased risk of fracture during military training and
service.
Conditions Affecting the Upper Limb
General considerations
22.
Overuse injuries. Candidates with a history of an overuse injury (for example
tendonitis, bursitis and / or epicondylitis) which has resolved are FIT. Candidates with
ongoing or recurrent pain related to overuse are UNFIT due to the risk of recurrence and
deterioration in symptoms during training or service requiring extended non-operative or
surgical treatment.
23.
Peripheral nerve entrapment syndromes. Candidates with history of a peripheral
nerve entrapment syndrome (for example carpal tunnel syndrome and / or cubital tunnel
syndrome) which has resolved are FIT. Candidates with ongoing (constant or intermittent)
pain, weakness or abnormal sensation related to peripheral nerve entrapment are UNFIT
due to the risk of recurrence and deterioration in symptoms during training or service
requiring extended non-operative or surgical treatment.
Fractures (Broken Bones) of the Upper Limb
10 Osteopenia is defined as a T Score of between -1 and -2.5 SD http://www.iofbonehealth.org / diagnosing-osteoporosis
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24.
Fractures (broken bones). Guidance about upper limb fractures is provided below.
Fractures of the clavicle, wrist, hand and fingers are described separately.
25.
Extra-articular fractures without surgical fixation (fracture of the upper limb
where the joint surface was not involved, and surgery was not required). Candidates
are FIT provided they meet all the following criteria:
a.
At least six months following injury,
b.
Fracture union is confirmed without a deformity affecting function,
c.
Discharged from treatment and rehabilitation,
d.
Symptom-free for three months while undertaking activity comparable with
military training (including the ability to perform press ups),
e.
Normal dynamic functional assessment.11
26. Candidates with any symptoms or deformity resulting in reduced function are UNFIT,
whether treated surgically or not, as they are unlikely to achieve the required level of
function required for military service and are at increased risk of foreseeable injury during
training or service.
27.
Extra-articular fractures with surgical fixation (fracture of the upper limb where
the joint surface was not involved, treated with surgery). Candidates are FIT provided
they meet all the following criteria:
a.
At least six months following injury,
b.
Fracture union is confirmed without a deformity affecting function,
c.
Discharged from treatment and rehabilitation,
d.
Symptom-free for three months, including from metalwork, while undertaking
activity comparable with military training (including the ability to perform press ups),
e.
Normal dynamic functional assessment.12
28. Candidates with any symptoms or deformity resulting in reduced function are UNFIT,
as they are unlikely to achieve the required level of function required for military service
and are at increased risk of foreseeable injury during training or service.
29.
Intra-articular fractures (broken bone of the upper limb where the joint surface
was involved). Following fractures involving a joint, early osteoarthritis is common.
Candidates are FIT provided they meet all the following criteria:
a.
At least twelve months following injury,
b.
Fracture union is confirmed without a deformity affecting function,
11 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
12 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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c.
Discharged from treatment and rehabilitation,
d.
No evidence of joint surface problems (e.g. a step in the cartilage on existing
imaging),
e.
Symptom-free for three months, including from metalwork, while undertaking
activity comparable with military training (including the ability to perform press ups),
f.
No suggestion of joint surface problems (such as stiffness, crepitus on
movement), normal dynamic functional assessment.13
30. If the candidate does not meet criteria above, they are UNFIT. These joint injuries
often degenerate with the activities expected of military personnel meaning they are
unlikely to achieve the required level of function required for military service and are at
increased risk of foreseeable injury during training or service.
Conditions of the Shoulder
31.
Shoulder. Candidates with functional limitation of shoulder movement or pain are
UNFIT due to the requirement to have full use of the upper limb / s to perform usual
military duties (e.g pushing, pulling, climbing, equipment and weapon handling).
32.
Clavicle fractures (broken collar bone). A history of clavicle fracture may affect the
ability to carry load on the shoulders. Mid-shaft fractures may leave a deformity or
symptomatic metalwork that makes load carriage difficult. Fractures of the medial or lateral
ends of the clavicle may lead to joint instability. Candidates are FIT provided they meet all
the following criteria:
a.
At least twelve months since injury.
b.
Discharged from treatment and rehabilitation.
c.
Full shoulder movement with normal scapula control.
d.
No evidence of sternoclavicular or acromioclavicular joint instability or pain.
e.
Symptom-free (including from metalwork) when carrying weight, with activity
comparable with military training, and where carrying weight on their shoulders for
minimum of three months, (including the ability to perform press ups).
f.
Normal dynamic functional assessment.14
33. Candidates who do not meet all the above criteria are UNFIT as they are unlikely to
achieve the required level of function required for military service and are at increased risk
of foreseeable injury during training or service.
34.
Sternoclavicular joints. The sternoclavicular joint is critical to upper limb function,
and posterior dislocation may compromise blood supply. Candidates with a history of
13 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
14 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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sternoclavicular joint injury, but who are symptom-free with normal function are FIT
provided they meet all the following criteria:
a.
At least six months from the time of injury to allow for recovery,
b.
Symptom-free during activity comparable with military training for a minimum of
three months, including when carrying weight on their shoulders (including the ability
to perform press ups).
c.
No evidence of reduced upper limb circulation.
d.
Normal dynamic functional assessment.15
35. Where there is significant functional compromise candidates are UNFIT as they are
unlikely to achieve the required level of function required for military service and are at
increased risk of foreseeable injury during training or service.
36.
Acromioclavicular sprains and dislocations. These are common injuries. Mild
sprains often return to full function even with persistent anatomical abnormality. The grade
relates to the degree of anatomical disruption and is therefore of functional
relevance. Grade I-II injuries represent sprained ligaments, whereas higher grade injuries
are normally associated with a ligament rupture.
a.
Grade I / II. Candidates who are symptom-free with normal function are FIT
provided they meet all the following criteria:
(1) At least six months from the time of injury to allow for recovery,
(2) Full shoulder movement with normal scapula control,
(3) Symptom-free during activity comparable with military training for a
minimum of three months, including when carrying weight on their shoulders
(including the ability to perform press ups),
(4) Normal dynamic functional assessment.16
b.
Grade III. Candidates managed either surgically or non-surgically are FIT after
a period of six months from the time of injury to allow recovery from injury or surgery
and rehabilitation provided they meet all the following criteria:
(1) Discharged from treatment and rehabilitation, with full shoulder movement
with normal scapula control,
(2) Symptom-free during activity comparable with military training for a
minimum of three months, including when carrying weight on their shoulders
(including the ability to perform press ups),
(3) Normal dynamic functional assessment.17
15 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
16 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
17 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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c.
Candidates who do not meet these criteria are UNFIT as they are unlikely to
achieve the required level of function required for military service and are at
increased risk of foreseeable injury during training or service.
d.
Grades IV-VI. Candidates are FIT six months following surgery provided they
meet all the following criteria:
(1) Successful stabilisation surgery,
(2) Discharged from treatment and rehabilitation, with full shoulder movement
with normal scapula control,
(3) Symptom-free during activity comparable with military training for a
minimum of three months, including when carrying weight on their shoulders
(including the ability to perform press ups),
(4) Normal dynamic functional assessment.18
e.
Candidates with grade IV-VI injuries with persistent instability or who have not
had surgery are UNFIT as they are unlikely to achieve the required level of function
required for military service and are at increased risk of foreseeable injury during
training or service.
37.
Single episode of shoulder dislocation or subluxation (partial dislocation). This
paragraph includes subluxation regardless of requirement for acute medical intervention
and includes both anterior and posterior19 dislocations. Candidates are FIT
provided they
meet all the following criteria:
a.
12 months since the dislocation / surgery to allow recovery and rehabilitation,
b.
Discharged from treatment and rehabilitation with full shoulder function and
negative apprehension test10 following full rehabilitation or surgery,
c.
No evidence of degenerative joint disease on available imaging,
d.
Symptom-free during activity comparable with military training for three months
(including the ability to perform press ups),
e.
Normal dynamic functional assessment.20
38.
Multiple anterior or posterior dislocations (in the same or both shoulders). Candidates are FIT provided they meet all the following criteria9:
a.
There is no history of multi-directional instability in the same shoulder,
b.
Successful surgical stabilisation, either by primary stabilisation or if an
unsuccessful primary soft tissue stabilisation is followed by a successful revision
bony stabilisation procedure, e.g. Latarjet or a bone graft procedure,
18 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
19 Candidates who have had a posterior dislocation without traumatic cause, and where seizure has not been ruled out, are UNFIT due
to the risk of undiagnosed neurological disorder (see Annex G Neurology).
20 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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c.
12 months must have elapsed since the dislocation / surgery to allow recovery
and rehabilitation,
d.
Discharged from treatment and rehabilitation with full shoulder function and
negative apprehension test21 following full rehabilitation or surgery,
e.
No subsequent dislocations in the same shoulder following surgery,
f.
No evidence of degenerative joint disease on available imaging,
g.
Symptom-free during activity comparable with military training for three months
(including the ability to perform press ups),
h.
Normal dynamic functional assessment.22
39. Candidates with a history of two or more dislocations in the same shoulder that have
not been surgically stabilised are UNFIT because there is an unacceptably high risk of
further dislocation during training or in service requiring extended non-operative or surgical
treatment.
40. Candidates who have had multiple soft tissue stabilisation procedures in the same
shoulder, regardless of current symptoms and findings on examination are UNFIT because
the risk of recurrence remains unacceptably high.
41.
Bankart lesions and Hill-Sachs defects. Candidates whose dislocation has
resulted in a Bankart lesion (glenoid labral tear) and / or a Hill Sachs defect (posterolateral
humeral head depression fracture) are FIT provided they meet all the following criteria:
a.
12 months must have elapsed since the dislocation / surgery to allow recovery
and rehabilitation,
b.
Discharged from treatment and rehabilitation with full shoulder function and
negative apprehension test10,
c.
No evidence of degenerative joint disease on available imaging,
d.
Symptom-free during activity comparable with military training for three months
(including the ability to perform press ups),
e.
Normal dynamic functional assessment.23
42. Candidates who do not meet these criteria are UNFIT due to the risk of recurrence
and deterioration in symptoms during training or service requiring extended non-operative
or surgical treatment.
21 Shoulder apprehension test: candidate’s elbow is flexed to 90
° and the shoulder is abducted to 90
°. The examiner holds the
candidate’s wrist and with the other hand applies forward pressure from behind the shoulder. The shoulder is then externally rotated by
manoeuvring the wrist. The test is positive if the manoeuvre produces pain.
22 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
23 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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43.
Chondral defect of the shoulder joint (cartilage damage to the humeral head or
glenoid). Candidates with partial thickness chondral defects are FIT
provided they meet all
the following criteria:
a.
12 months must have elapsed since the injury to allow recovery and
rehabilitation,
b.
Discharged from treatment and rehabilitation with full shoulder function,
c.
No evidence of degenerative joint disease on available imaging24,
d.
Symptom-free during activity comparable with military training for three months
(including the ability to perform press ups),
e.
Normal dynamic functional assessment.25
44. Candidates with
full thickness defects are UNFIT
due to the risk of deterioration in
symptoms during training or service requiring extended non-operative or surgical
treatment.
45.
Rotator cuff injuries. Candidates with rotator cuff tears (partial or full thickness)
managed non-operatively or with surgery are FIT provided they meet all the following
criteria:
a.
At least six months symptom-free,
b.
Discharged from treatment and rehabilitation with full shoulder function,
c.
Symptom-free during activity comparable with military training for three months
(including the ability to perform press ups),
d.
Normal dynamic functional assessment.26
46. Candidates who do not meet the above criteria are UNFIT due to the risk of
deterioration in symptoms during training or service requiring extended non-operative or
surgical treatment.
47.
Winged Scapula. Causes of winged scapula include trauma of the long thoracic
nerve (unilateral), weakness of scapular stabilisers and rare genetic reasons (e.g
facioscapulohumeral muscular dystrophy [FSHD]). Candidates with isolated winged
scapula are FIT provided they meet all the following criteria:
a.
No underlying medical cause,
b.
Symptom-free during activity comparable with military training for three months
(including the ability to perform press ups),
24 Including early arthritic change.
25 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
26 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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c.
Normal dynamic functional assessment.27
48. Candidates who do not meet the above criteria are UNFIT due to the risk of
deterioration in symptoms during training or service.
49.
Poland Syndrome. Poland syndrome refers to a congenital unilateral absence of
the pectoralis major and minor muscles and is non-progressive. Candidates are FIT
provided they meet all the following criteria:
a.
Symptom-free during activity comparable with military training for three months
(including the ability to perform press ups),
b.
Normal dynamic functional assessment.28
50. Candidates who do not fulfil these criteria are UNFIT as they are unlikely to have
sufficient function to carry out the full range of basic military tasks such as safely operating
their personal weapon.
51.
Pectoralis major tear. Pectoralis major tears are uncommon. Candidates with a
history of pectoralis major tear, managed non-operatively or with surgery, are FIT provided
they meet all the following criteria:
a.
Discharged from treatment and rehabilitation with full upper limb function,
b.
At least six months symptom-free including conducting activity comparable with
military training for three months (including the ability to perform press ups),
c.
Normal dynamic functional assessment.29
52. Candidates who do not meet the above criteria are UNFIT due to the risk of
deterioration in symptoms during training or service requiring extended non-operative or
surgical treatment.
53.
Glenohumeral joint (shoulder) arthritis. Care should be taken to distinguish
glenohumeral joint arthritis from acromio-clavicular joint arthritis. Glenohumeral joint
arthritis can be primary or post-traumatic in nature. To be diagnosed and investigated,
candidates will usually have reported symptoms such as pain, stiffness and loss of
function. It is rare for glenohumeral joint arthritis to be an incidental finding. Candidates
with proven arthritis of the glenohumeral joint are UNFIT because the condition will result
in pain, stiffness and loss of function which will impede the candidate’s ability to function in
the military environment. In addition, there is an unacceptably high risk of progression of
symptoms requiring extended non-operative or surgical treatment.
54.
Acromio-clavicular joint arthritis. This is a common condition which rarely presents
with significant functional impairment. Candidates are FIT provided provided they meet all
the following criteria, regardless of treatment modality (including excision):
a.
Full shoulder movement,
27 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
28 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
29 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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b.
Symptom-free during activity comparable with military training for a minimum of
three months, including when carrying weight on their shoulders (including the ability
to perform press ups),
c.
Normal dynamic functional assessment.30
55. Candidates are UNFIT if symptomatic with pain, stiffness and loss of function due to
the risk of deterioration in symptoms during training or service.
Conditions of the Elbow 56.
Elbow trauma. Following elbow injury, stiffness and instability are both common. To
function in a deployed role, the elbow must be stable to allow function and strength with an
outstretched arm and have adequate range of movement for the role. Candidates with a
history of elbow disorders are FIT provided they meet all the following criteria:
a.
No significant loss of elbow extension and / or flexion,31
b.
No significant loss of pronation or supination,32
c.
No significant varus or valgus angulation,
d.
Symptom-free during activity comparable with military training for a minimum of
three months, including when carrying weight on their shoulders (including the ability
to perform press ups),
e.
Normal dynamic functional assessment.33
57. Candidates who do not meet the above criteria are UNFIT due to the requirement to
have full use of the elbow to perform usual military duties (e.g pushing, pulling, climbing,
equipment and weapon handling).
58.
Elbow arthritis. For diagnosis and investigation to have occurred, candidates will
usually have reported symptoms such as pain, stiffness and loss of function. It is rare for
elbow arthritis to be an incidental finding. Candidates with proven arthritis of the elbow are
UNFIT due to the requirement to have full use of the elbow to perform usual military duties
(e.g pushing, pulling, climbing, equipment and weapon handling). In addition, there is an
unacceptably high risk of progression of symptoms requiring extended non-operative or
surgical treatment.
59.
Bicep tendon injuries. Candidates with a history of bicep tendon injury, whether
proximal or distal and regardless of treatment modality, are FIT provided they meet all the
following criteria:
a.
At least six months symptom-free,
b.
Discharged from treatment and rehabilitation with full upper limb function,
30 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
31 Less than 15
° loss of extension and, or flexion.
32 Less than 20
° loss of supination and, or pronation.
33 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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c.
Symptom-free during activity comparable with military training for a minimum of
three months, including when carrying weight on their shoulders (including the ability
to perform press ups),
d.
Normal dynamic functional assessment.34
60. Candidates who do not meet the above criteria are UNFIT due to the requirement to
have full use of the elbow to perform usual military duties (e.g pushing, pulling, climbing,
equipment and weapon handling).
61.
Lateral or medial epicondylitis (Tennis or Golfer’s Elbow). This is a common
cause of pain at the outer (lateral) or inner (medial) aspect of the elbow felt when lifting
and on palpation. Candidates are FIT after successful non-operative or operative
treatment, provided they meet all the following criteria:
a.
At least six months symptom-free,
b.
Discharged from treatment and rehabilitation with full upper limb function,
c.
Symptom-free during activity comparable with military training for a minimum of
three months (including the ability to perform press ups),
d.
Normal dynamic functional assessment.35
62. Candidates who do not fulfil the above criteria are UNFIT due to the requirement to
have full use of the elbow to perform usual military duties (e.g pushing, pulling, climbing,
equipment and weapon handling).
Conditions of the wrist
63.
Extra-articular wrist fractures (not inside the joint capsule). Candidates are FIT
provided they meet all the following criteria:
a.
12 months since injury,
b.
The fracture has healed normally and in good alignment,
c.
Discharged from treatment and rehabilitation with normal wrist function,
d.
At least three months symptom-free including conducting activity comparable
with military training for three months (including the ability to perform press ups),
e.
Normal dynamic functional assessment.36
64. Candidates who do not fulfil the above criteria are UNFIT due to the requirement to
have full use of the wrist to perform usual military duties (e.g pushing, pulling, climbing,
equipment and weapon handling). In addition, there is an unacceptably high risk of
progression of symptoms requiring extended non-operative or surgical treatment.
34 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
35 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
36 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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65.
Intra-articular wrist fractures. Candidates are FIT provided they meet all the
following criteria:
a.
12 months since injury,
b.
The fracture has healed normally and in good alignment,
c.
Discharged from treatment and rehabilitation with normal wrist function,
d.
No evidence of joint surface problems (e.g. a step in the joint surface on existing
imaging),
e.
At least three months symptom-free including conducting activity comparable
with military training for three months (including the ability to perform press ups),
f.
Normal dynamic functional assessment.37
66. Candidates who do not fulfil the above criteria are UNFIT due to the requirement to
have full use of the wrist to perform usual military duties (e.g pushing, pulling, climbing,
equipment and weapon handling). In addition, there is an unacceptably high risk of
progression of symptoms requiring extended non-operative or surgical treatment.
Fractures that involve the joint surface have a risk of degeneration during service.
67.
Carpal (wrist) bone fractures. Candidates are FIT provided they meet all the
following criteria:
a.
12 months since injury,
b.
No evidence of wrist ligament injury leading to instability,
c.
No evidence of avascular necrosis (see below),
d.
Discharged from treatment and rehabilitation with normal wrist function,
e.
No evidence of joint surface problems (e.g. a step of greater than 2mm in the
joint surface on existing imaging),
f.
At least three months symptom-free including conducting activity comparable
with military training for three months (including the ability to perform press ups),
g.
Normal dynamic functional assessment.38
68. Candidates who do not fulfil the above criteria are UNFIT due to the requirement to
have full use of the wrist to perform usual military duties (e.g pushing, pulling, climbing,
equipment and weapon handling). In addition, there is an unacceptably high risk of
progression of symptoms requiring extended non-operative or surgical treatment.
Fractures that involve the joint surface have a risk of degeneration during service. Carpal
instability will not allow the strength or dexterity required for military roles.
37 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
38 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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69.
Avascular necrosis of the carpal bones (disruption to the blood supply of the
wrist bones). All candidates with known avascular necrosis of any carpal bone are UNFIT
as there is an increased risk of post traumatic arthrosis and / or pain and stiffness limiting
their ability to perform usual military duties (e.g pushing, pulling, climbing, equipment and
weapon handling). In addition, there is an unacceptably high risk of progression of
symptoms requiring extended non-operative or surgical treatment.
70.
Wrist arthritis. Candidates with an incidental finding of mild degenerative changes
on imaging in a symptom-free wrist are FIT. Candidates with symptomatic arthritis of the
wrist are UNFIT due to the requirement to have full use of the wrist to perform usual
military duties (e.g pushing, pulling, climbing, equipment and weapon handling). In
addition, there is an unacceptably high risk of progression of symptoms requiring extended
non-operative or surgical treatment.
71.
Soft tissue injuries of the wrist. Candidates with normal range of movement
following injury are FIT provided they meet all the following criteria:
a.
Discharged from treatment and rehabilitation with normal wrist function,
b.
At least three months symptom-free including conducting activity comparable
with military training for three months (including the ability to perform press ups),
c.
Normal dynamic functional assessment.39
72. Candidates who do not meet all the above criteria are UNFIT due to the requirement
to have full use of the wrist to perform usual military duties (e.g pushing, pulling, climbing,
equipment and weapon handling). In addition, there is an unacceptably high risk of
progression of symptoms requiring extended non-operative or surgical treatment.
Conditions of the hands
73.
Loss of or absence of a finger (complete or partial) or loss or absence of a
thumb (distal to the interphalangeal joint). Candidates are FIT provided they meet all
the following criteria:
a.
Discharged from treatment and rehabilitation with normal hand function,
b.
Symptom-free including conducting activity comparable with military training for
three months,
c.
Normal dynamic functional assessment.40
74. Candidates who do not meet all the above criteria are UNFIT due to the requirement
to have full use of the hands to perform usual military duties (e.g holding, grabbing, pulling,
climbing, equipment and weapon handling).
75.
Thumb reconstruction. Candidates who have had reconstruction surgery for the
absence of a thumb should be assessed by the above criteria. Candidates who do not
meet these criteria are UNFIT due to the requirement to have full use of the hands to
perform usual military duties (e.g holding, grabbing, pulling, climbing, equipment and
39 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
40 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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weapon handling).
76.
Absence of the thumb. Candidates with the absence of a thumb at or proximal to
the interphalangeal joint are UNFIT. Candidates who do not meet these criteria are UNFIT
due to the requirement to have full use of the hands to perform usual military duties (e.g
holding, grabbing, pulling, climbing, equipment and weapon handling).
77.
Metacarpal and phalangeal (hand and finger) fractures. Candidates are FIT
provided they meet all the following criteria:
a.
Three months since injury for uncomplicated fractures (surgical fixation not
required) not involving a joint,
b.
Six months since injury where surgical fixation (including k-wire, screw, plate)
was required or where a joint was involved or where there was a volar plate injury,
c.
The fracture has healed normally and in good alignment,
d.
Discharged from treatment and rehabilitation with normal hand function,
e.
At least three months symptom-free including conducting activity comparable
with military training for three months,
f.
Normal dynamic functional assessment.41
78. Candidates who do not meet all the above criteria are UNFIT due to the requirement
to have full use of the hands to perform usual military duties (e.g holding, grabbing, pulling,
climbing, equipment and weapon handling).
79.
Hand and digit arthritis. Candidates with an incidental finding of mild degenerative
changes on imaging in a symptom-free hand are FIT. Candidates with symptomatic
arthritis of the hand (including pain, stiffness and loss of dexterity) are UNFIT due to the
requirement to have full use of the hands to perform usual military duties (e.g holding,
grabbing, pulling, climbing, equipment and weapon handling).
80.
Ulnar collateral ligament avulsion injury. These injuries have the potential to result
in an unstable thumb. Whether treated surgically or non surgically, candidates are FIT
provided they meet all the following criteria:
a.
Six months since injury,
b.
Discharged from treatment and rehabilitation with normal hand function,
c.
At least three months symptom-free including conducting activity comparable
with military training for three months,
d.
Normal dynamic functional assessment.42
81. Candidates who do not meet all the above criteria (including those with untreated
ligament avulsion injuries) are UNFIT due to the requirement to have full use of the hands
41 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
42 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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to perform usual military duties (e.g holding, grabbing, pulling, climbing, equipment and
weapon handling).
82.
Other finger anatomical abnormality. Candidates with any other anatomical
abnormalities of the finger are FIT provided they meet all the following criteria:
a.
Symptom-free with full function and have no foreseeable difficulty in weapon
handling and putting on personal protective equipment (PPE) (including gloves),
b.
Normal dynamic functional assessment.43
83. Candidates who do not meet all the above criteria are UNFIT due to the requirement
to have full use of the hands to perform usual military duties (e.g holding, grabbing, pulling,
climbing, equipment and weapon handling).
Spinal Conditions
84.
Vertebral fractures. Candidates with a vertebral body fracture are FIT, provided they
meet all the following criteria:
a.
At least three months post injury with no pain or other symptoms,
b.
The fracture has fully healed and there is no neurological deficit or significant
anatomical abnormality (confirmed on post-recovery imaging),
c.
Discharged from treatment and rehabilitation with normal spinal function,
d.
Full function (at least three months activity comparable with military training,
including load-carrying ability),
e.
Clinical examination is normal,
f.
Normal dynamic functional assessment.44
85. Candidates who do not meet all the above criteria are UNFIT as they are unlikely to
achieve the required level of function required for military service and are at increased risk
of foreseeable injury during training or service (the injuries predispose to accelerated
degenerative change at the level of the deformity).
86.
Single transverse process fractures. These are non-structural fractures that do not
affect spinal stability. Candidates with a history of an isolated transverse process fracture
are FIT, provided they meet all the following criteria:
a.
At least three months post injury with no pain or other symptoms,
b.
Discharged from treatment and rehabilitation with normal spinal function,
c.
Full function (at least three months activity comparable with military training.
including load-carrying ability),
43 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
44 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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d.
Clinical examination is normal,
e.
Normal dynamic functional assessment.45
87.
Multiple transverse process fractures are often associated with muscle and nerve
damage and candidates with this history are UNFIT due to the risk of deterioration during
training and service requiring extended non-operative or surgical treatment.
88.
Single spinous process fractures. Candidates with a history of an isolated spinous
process fracture are FIT provided they meet all the following criteria:
a.
At least three months post injury with no pain or other symptoms,
b.
The fracture has healed with either bony union or symptom-free non-union and
there is no neurological deficit or significant anatomical abnormality (confirmed on
post-recovery imaging),
c.
Discharged from treatment and rehabilitation with normal spinal function,
d.
Full function (at least three months activity comparable with military training,
including load-carrying ability),
e.
Clinical examination is normal,
f.
Normal dynamic functional assessment.46
89.
Multiple spinous process fractures are often associated with ligamentous injury
with an increased risk of biomechanical instability and persistent spinal pain. Candidates
with this history are UNFIT as they are unlikely to achieve the required level of function
required for military service and are at increased risk of foreseeable injury during training
or service.
90.
Spondylolysis (pars fractures, stress fractures and defects).
a.
Single vertebral level uncomplicated pars fracture. Candidates with a single
vertebral level uncomplicated (no spondylolisthesis, no pain, no neurological
symptoms) pars fracture that has healed fully with conservative management are FIT
provided they meet all the following criteria:
(1) At least 12 months post injury with no symptoms including pain, instability
or other symptoms,
(2) Discharged from treatment and rehabilitation with normal spinal function,
(3) Full function (at least three months activity comparable with military
training, including load-carrying ability),
(4) Clinical examination is normal,
45 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
46 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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(5) Normal dynamic functional assessment.47
b.
Candidates who do not fulfil these criteria are UNFIT as they are unlikely to
achieve the required level of function required for military service and are at
increased risk of foreseeable injury during training or service.
c.
Fracture at multiple levels or a more complex history. Candidates with more
than one fracture or a more complex history (presence of spondylolisthesis, history of
significant pain or neurological deficit) are FIT provided they meet all the following
criteria:
(1) At least 12 months post injury with no symptoms including pain, instability
or other symptoms,
(2) Discharged from treatment and rehabilitation with normal spinal function,
(3) Full function (at least twelve months activity comparable with military
training, including load-carrying ability),
(4) Opinion provided by a military approved spinal surgeon in respect of
recovery, function and prognosis,
(5) Clinical examination is normal,
(6) Normal dynamic functional assessment.48
d.
Candidates who do not fulfil these criteria are UNFIT as they are unlikely to
achieve the required level of function required for military service and are at
increased risk of foreseeable injury during training or service. There is a risk of
deterioration or re-injury during training and service requiring extended non-operative
or surgical treatment. In addition, there is a moderate risk of developing disc
degenerative disease and spondylolisthesis at the affected level.
91.
Fractured coccyx. Those who have made a full functional recovery after 12 months
and are symptom-free during activities comparable with military training for a minimum of
three months are FIT.
92.
Isolated interspinous ligamentous injury. Candidates with a history of isolated
ligamentous injury are FIT provided they meet all the following criteria:
a.
At least 12 months post injury with no symptoms including pain, instability or
other symptoms,
b.
Full function (at least three months activity comparable with military training,
including load-carrying ability),
c.
The candidate has been discharged from specialist follow-up,
d.
Clinical examination is normal,
47 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
48 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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e.
There is no neurological deficit,
93. Candidates who do not fulfil these criteria are UNFIT as they are unlikely to achieve
the required level of function required for military service and are at increased risk of
foreseeable injury during training or service.
94.
Cauda equina (spinal cord injury), spinal neurotrauma (spinal nerve root
injury)
. This includes, but is not limited to, spinal cord injuries, cauda equina syndrome
and isolated nerve root injuries. Candidates who have had any spinal trauma with residual
neurological deficit are UNFIT as they are unlikely to achieve the required level of function
required for military service and are at increased risk of foreseeable injury during training
or service.
95.
Spinal tumours. Candidates should be assessed according to the criteria below:
a.
Benign tumours (non-cancerous growths). These include aneurysmal bone
cysts and chondroma. The following applies:
(1) Candidates with small tumours, confined to the vertebral body that are
non-progressive are FIT.
(2) Candidates with other types of small non-progressive tumours without
involvement of bone cortex may be FIT and should be referred to a military
approved spinal surgery consultant for an opinion on prognosis.
(3) Candidates with large tumours which involve the cortex or tumours that
involve the joints of the spine are UNFIT because they can predispose to
vertebral body fractures. Fractures cause spinal pain, deformity and can cause
spinal cord injury. Benign tumours involving a joint may affect the motion at a
given segment of the spine and can alter spinal biomechanics increasing the
risk of injury and could be exacerbated by the rigours of military training.
b.
Malignant tumours (cancerous growths). Candidates are be FIT provided
they meet all the following criteria:
(1) Discharged from treatment and rehabilitation with normal spinal function,
(2) There is no reasonably predictable risk of recurrence,
(3) There is no significant residual anatomical abnormality or impairment in
function, movement, strength or pain,
(4) There was no joint or nerve involvement,
(5) The candidate has had no symptoms since with full symptom-free function
(at least three months activity comparable with military training, including load-
carrying ability),
(6) Those stated in Annex N Other Conditions under Oncology (cancers),
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(7) Opinion provided by a military approved spinal surgeon and oncologist in
respect of recovery, function and prognosis,
(8) Clinical examination is normal,
(9) Normal dynamic functional assessment.49
c.
Candidates who do not fulfil these criteria are UNFIT as they are unlikely to
achieve the required level of function required for military service and are at
increased risk of foreseeable injury during training or service and would need access
to routine specialist medical services.
Congenital Spinal Conditions
96.
Anatomical abnormalities of bone. Guidance on specific conditions is provided
below. Where there is another bony anatomical abnormality which does not affect spinal
biomechanics and there is normal pain-free full range of movement, candidates are FIT.
97.
Hyperkyphosis of the spine, Scheuermann’s disease (increased forward flexion
of the spine). Candidates are be FIT provided they meet all the following criteria:
a.
Other causes including Chiari malformation, tethered cord and neural tube
defect must have been excluded with appropriate radiological investigation,
b.
No significant anatomical abnormality (up to 60
° kyphosis is acceptable) and
have achieved three months activity comparable with military training (especially
load-carrying ability) without symptoms are FIT,
c.
The candidate has had no symptoms since with full symptom-free function (at
least three months activity comparable with military training, including load-carrying
ability),
d.
Clinical examination is normal,
e.
Normal dynamic functional assessment.50
98. Candidates who are currently symptomatic with spinal pain or neuropathic pain are
UNFIT due to the predisposition to biomechanical issues that would be incompatible with
an austere military environment and the rigours of military life. Candidates who have had
surgery to correct a hyperkyphosis are UNFIT due to very high chance of developing
adjacent level disease or implant failure as a result of military duty.
99.
Scoliosis (lateral curvature of the spine) Candidates should be assessed
according to the criteria below:
a.
Adolescent idiopathic scoliosis.
(1) Skeletally immature candidates with adolescent idiopathic scoliosis and a
Cobb angle of less than 10
° are FIT provided they are symptom-free and fully
functional. Candidates with a Cobb angle greater than 10
° are UNFIT until
49 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
50 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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skeletal maturity (described above) is achieved due to the possibility of
progression and compromised function.
(2) Skeletally mature candidates with Adolescent Idiopathic Scoliosis should
be assessed according to the criteria below:
(a)
Cobb angle of less than or equal to 20°. Candidates are FIT if
symptom-free and fully functional.
(b)
Cobb angle of 20-40°. Candidates with a Cobb angle of 20-40
° are
FIT if symptom-free and fully functional and have conducted activity
comparable to military training for three months (including load carrying
ability). Appropriate radiological investigation must have been performed
previously to rule out non-idiopathic causes.
(c)
Cobb angle greater than 40°. Candidates with a Cobb angle greater
than 40
° are UNFIT due to the risk of deterioration of the scoliosis with
arduous physical training.
b.
A new finding of scoliosis made during assessment. Candidates with
minimal abnormal scoliosis (determined by normal Adams' forward bend test, no
scapula asymmetry, no paraspinal or rib prominence, a scoliometer
measurement, where available, of less than 5
° which equates to a Cobb angle
less than 10
°) with no associated back pain with full and free movement of all
spinal segments are FIT. Candidates who do not fulfil these criteria require
referral to a military approved spinal surgeon for imaging and an opinion on
function and prognosis.
c.
Other causes of scoliosis. Candidates with other causes of scoliosis are
UNFIT due to a likely difficulty to perform physical tasks in an arduous
environment and the increased risk of worsening symptoms.
d.
Scoliosis surgery. Candidates who have had surgery to correct scoliosis
are UNFIT due to very high chance of developing adjacent level disease or
implant failure as a result of military duty.
100.
Vertebral anomalies including butterfly vertebra and hemivertebra. Candidates
with no associated anatomical abnormality or other symptoms are FIT provided they meet
all the following criteria:
a.
Discharged from treatment and rehabilitation with normal spinal function,
b.
Full function (at least three months activity comparable with military training,
including load-carrying ability),
c.
Clinical examination is normal,
d.
Normal dynamic functional assessment.51
51 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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101. Candidates who do not fulfil these criteria are UNFIT due to a likely difficulty to
perform physical tasks in an arduous environment and the increased risk of worsening
symptoms.
102.
Abnormal fusion of the spine (Klippel-Feil Syndrome). Candidates
with no
associated anatomical abnormality or other symptoms are FIT provided they meet all the
following criteria:
a.
Discharged from treatment and rehabilitation with normal spinal function,
b.
Full function (at least three months activity comparable with military training,
including load-carrying ability),
c.
Clinical examination is normal,
d.
Normal dynamic functional assessment.52
103. Candidates who do not fulfil these criteria are UNFIT due to a likely difficulty to
perform physical tasks in an arduous environment and the increased risk of worsening
symptoms.
104.
Spina bifida occulta. Candidates with an incidental finding, without history of
symptoms and in the absence of other abnormality are FIT. Candidates with either present
or previous symptoms are UNFIT due to a likely difficulty to perform physical tasks in an
arduous environment and the increased risk of worsening symptoms.
105.
Other neural tube defects. These include: spina bifida, lipomyelomeningocoele and
myelomeningocoele. Candidates are UNFIT as they are unlikely to achieve the required
level of function required for military service and are at increased risk of foreseeable injury
during training or service and would need access to routine specialist medical services.
These conditions can be associated with bladder, bowel, and lower limb dysfunction, as
well as incomplete formation of the lumbar spinal column.
Movement abnormalities
106.
Torticollis (fixed flexion and rotation of the neck). Candidates with a history of
torticollis should be assessed according to the criteria below:
a.
Congenital torticollis.
(1)
Non-surgical management. Candidates who have been conservatively
managed and have no residual symptoms are FIT.
(2)
Sternocleidomastoid surgery. Candidates who have had
sternocleidomastoid muscle lengthening surgery may be FIT provided they are
symptom-free and there is no limitation to function. A should be referral to a
military approved spinal surgeon for an opinion on recovery, function and
prognosis.
52 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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(3)
Other surgical treatment. Candidates with a history of other surgical
treatment for their torticollis or who remain symptomatic are UNFIT as they are
unlikely to achieve the required level of function required for military service and
are at increased risk of foreseeable injury during training or service and would
need access to routine specialist medical services. There is an increased risk of
deterioration during training and service requiring extended non-operative or
surgical treatment.
b.
Acquired Torticollis. Candidates with a history of acquired torticollis with
completely resolved symptoms without surgery are FIT. Candidates who have
required surgical treatment to the vertebral column are UNFIT as they are unlikely to
achieve the required level of function required for military service and are at
increased risk of foreseeable injury during training or service and would need access
to routine specialist medical services. The surgery increases the risk of accelerated
spinal degenerative disease and cervical trauma.
107.
Dystonias (movement disorders), myoclonus (tremors, shock-like jerking
movements and dyskinesias (abnormal movements). Candidates with these conditions
are UNFIT because of a likely difficulty to perform physical tasks in an arduous
environment and the increased risk of worsening symptoms.
Neck and low back pain
108.
Short episodes of neck pain or low back pain (lasting less than two months).
Candidates with two or fewer episodes associated with injury or excessive training, that
have fully resolved within two months with minimal clinical input (only GP and / or
Physiotherapy) are FIT once fully functional.
109.
Longer episodes of pre-existing neck pain or low back pain (lasting less than
three months). Candidates with longer episodes of previous neck or low back pain, that
required non-surgical clinical intervention are FIT provided they have been symptom-free
for at least six months (where history includes exercise comparable with military training
for three months).
110.
Persistent or recurrent neck or back pain (lasting three months or more). Candidates with historic episodes (more than five years ago) which did not require invasive
treatment, had fully resolved within a year, and where the candidate is both fully functional
and has undertaken activity comparable to military training including load-carrying ability
without pain or requirement for pain relief for three months should be referred to sSMES
for a determination of FIT / UNFIT. Candidates with persistent or recurrent neck or back
pain that has not responded to exercise, weight loss and physiotherapy are UNFIT as they
are unlikely to achieve the required level of function required for military service and are at
increased risk of foreseeable injury during training or service and would need access to
routine specialist medical services. This may be associated with underlying structural
disease (such as disc degenerative disease or facet hypertrophy) and the risk of
exacerbation during training and service is unacceptably high.
111.
Sciatic pain with or without back pain. Candidates with a history of sciatic pain53
should be assessed according to the criteria below:
53 Pain which arises in the back or buttock and can be felt down the front or back of the leg.
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a.
Non surgical management. Candidates who did not require surgical
intervention, whose condition resolved fully and where the candidate is now fully
functional and at least twelve months following successful treatment and have
undertaken activity comparable to military training including load carriage for three
months without pain or requirement for pain relief are FIT.
b.
Associated with disc prolapse. Candidates with sciatic pain secondary to a
disc prolapse, treated by a single level microdiscectomy are FIT provided they meet
all the following criteria:
(1) 12 months post-surgery,
(2) No evidence of treatment or injury related secondary effects,
(3) Discharged from treatment and rehabilitation with normal spinal function
and no evidence of degenerative disc disease at other spinal levels,
(4) Fully functional (at least three months activity comparable with military
training, including load-carrying ability),
(5) Clinical examination is normal,
(6) Normal dynamic functional assessment.54
c.
All other candidates, including those who have surgery at more than a single
level are UNFIT as they are unlikely to achieve the required level of function required
for military service and are at increased risk of foreseeable injury during training or
service.
112.
Cervical radiculopathy due to foraminal stenosis or disc prolapse (nerve
compression in the neck). Candidates with a history of cervical radiculopathy should be
assessed according to the criteria below:
a.
Non surgical management. Candidates who did not require surgical
intervention, whose condition resolved fully and where the candidate is now fully
functional and at least twelve months following successful treatment, and have
undertaken activity comparable to military training including load carriage for three
months without pain or requirement for pain relief are FIT.
b.
Surgical management. Candidates with cervical radiculopathy secondary to
foraminal stenosis or disc prolapse, treated by neural foraminal widening
(foraminotomy) or single level microdiscectomy are FIT provided they meet all the
following criteria:
(1) 12 months post-surgery,
(2) No evidence of treatment or injury related secondary effects,
(3) Discharged from treatment and rehabilitation with normal spinal function
and no evidence of degenerative disc disease at other spinal levels,
54 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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(4) Fully functional (at least three months activity comparable with military
training, including load-carrying ability),
(5) Clinical examination is normal,
(6) Normal dynamic functional assessment.55
113. Candidates who do not meet all the above criteria are UNFIT due to the risk of
deterioration during training and service requiring extended non-operative or surgical
treatment.
114.
Thoracic back pain. Candidates with two or fewer episodes associated with injury or
excessive training are FIT provided they meet all the following criteria:
a.
Resolved within three months with minimal clinical input (only GP and / or
Physiotherapy),
b.
Fully functional (at least three months activity comparable with military training,
including load-carrying ability),
c.
Clinical examination is normal,
d.
Normal dynamic functional assessment.56
115. Candidates who do not meet all the above criteria are UNFIT due to the risk of
deterioration during training and service requiring extended non-operative or surgical
treatment. There may be significant underlying pathology.
116.
Spinal stenosis (narrowing of the spinal canal). Candidates are UNFIT as they
are unlikely to achieve the required level of function required for military service and are at
increased risk of foreseeable injury during training or service and would need access to
routine specialist medical services. There is a likelihood of neurological deterioration,
including the onset of neuropathic pain.
117.
Spondylolisthesis (slipped vertebra). Spondylolisthesis describes the slippage of a
single vertebra relative to the one below. Fitness will be dependent on the cause and the
extent of slippage.
a.
Candidates with idiopathic Grade 1 (0-25% slippage) with no evidence of
degenerative, post-traumatic (including pars fractures) and / or pathological causes
who are symptom-free and able to carry out activities comparable with military
training (including load carriage) for a minimum of three months are FIT.
b.
Candidates with Grade 2 or higher (>25%) slippage and / or those with current
symptoms are UNFIT as they are unlikely to achieve the required level of function
required for military service and are at increased risk of foreseeable injury during
training or service and would need access to routine specialist medical services. due
to the risk of exacerbating their spondylolisthesis causing worsening back and
neuropathic pain.
55 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
56 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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118.
Spinal Infection. Candidates should be assessed according to the criteria below:
a.
Osteomyelitis and discitis (infection of the bones, intervertebral discs or
soft tissues around the spine). Candidates with a brief episode (up to three
months) of uncomplicated infection who meet all the following criteria are FIT:
(1) Single episode which recovered more than 36 months ago (due to the risk
of recurrence of infection and the time taken for full functional recovery),
(2) The candidate recovered with no complications,
(3) There was no joint or nerve involvement,
(4) Discharged from treatment and rehabilitation with normal spinal function,
(5) The candidate has had no symptoms since with full symptom-free function
(at least three months activity comparable with military training, including load-
carrying ability),
(6) There is no documentation of abnormal imaging post-recovery,
(7) Clinical examination is normal,
(8) Normal dynamic functional assessment.57
b.
All other candidates are UNFIT due to the risk of deterioration during training
and service requiring extended non-operative or surgical treatment.
Pelvis and Acetabulum Injuries
119.
Acetabular fractures. Intra-articular fractures of the acetabulum represent a
complex spectrum of injuries. Candidates with a history of acetabular fracture should be
assessed according to the criteria below:
a.
Non surgical management. Candidates are FIT provided they meet all the
following criteria:
(1) Managed without surgical fixation,
(2) More than 24 months post injury,
(3) Discharged from treatment and rehabilitation with no neurological injury,
(4) Fully functional (at least three months activity comparable with military
training, including load-carrying ability) without hip pain or stiffness,
(5) No significant joint changes on available imaging,
57 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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(6) Normal range of hip movement (at least 90° flexion, 25° abduction, 20°
external rotation in 90° flexion, and 5° internal rotation in 90° flexion),
(7) Normal dynamic functional assessment.58
b.
Candidates who do not meet these criteria are UNFIT as there is a significant
risk of deterioration in their symptoms during training and service requiring extended
non-operative or surgical treatment.
c.
Surgical management. There is a high rate of post traumatic or early onset
arthritis in people whose injury required surgical treatment. Candidates who have had
surgical fixation of an acetabular fracture and who meet all the criteria stated above
should be referred for a military orthopaedic consultant for an opinion on recovery,
function and prognosis.
120.
Fractures of the pelvic ring. Fractures of the pelvic ring represent a spectrum of
injuries, which can range from plastic deformation in the skeletally immature to life
threatening injury. Candidates should be assessed according to the criteria below:
a.
Non surgical management. Candidates are FIT if they required neither surgery
nor a period of reduced weightbearing for more than one month.
b.
Surgical management and / or prolonged protected weight-bearing.
Candidates who have had a period of protected weight bearing greater than one
month and / or surgical fixation of pelvic fracture and who meet all the criteria stated
below should be referred to a military orthopaedic consultant for an opinion on
recovery, function and prognosis:
(1) More than 24 months post injury,
(2) Discharged from treatment and rehabilitation with no neurological injury,
(3) Fully functional (at least three months activity comparable with military
training, including load-carrying ability) without hip pain or stiffness,
(4) No prior radiographic evidence of degenerative joint disease affecting the
sacroiliac joint,
(5) Normal range of hip movement (at least 90° flexion, 25° abduction, 20°
external rotation in 90° flexion, and 5° internal rotation in 90° flexion),
(6) Normal dynamic functional assessment.59
c.
Candidates who do not meet these criteria are UNFIT as they will have a high
risk of developing degenerative changes during training and service requiring
extended non-operative or surgical treatment.
Conditions of the hip joint
58 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
59 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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121.
Fracture-dislocations of the hip. These are high energy injuries involving severe
damage to both the bony (acetabulum and / or femoral head) and soft tissue components
of the hip joint. There is a high rate of post traumatic or early onset arthritis and therefore it
is unlikely that candidates would be suitable for military service. Candidates who meet all
the criteria below should be referred to a military orthopaedic consultant for an opinion on
function and prognosis:
a.
More than 24 months post injury,
b.
Discharged from treatment and rehabilitation,
c.
Fully functional (at least three months activity comparable with military training,
including load-carrying ability) without hip pain or stiffness,
d.
No prior radiographic evidence of degenerative joint disease,
e.
Normal range of hip movement (at least 90° flexion, 25° abduction, 20° external
rotation in 90° flexion, and 5° internal rotation in 90° flexion),
f.
Normal dynamic functional assessment.60
122. Candidates who do not meet all these criteria are UNFIT as there is a significant risk
of deterioration in their symptoms during training and service requiring extended non-
operative or surgical treatment.
123.
Traumatic dislocation of the hip without fracture. Candidates are FIT provided
they meet all the following criteria:
a.
More than 24 months post injury,
b.
No evidence of sciatic nerve injury, avascular necrosis or post-traumatic
arthritis,
c.
Discharged from treatment and rehabilitation,
d.
Fully functional (at least three months activity comparable with military training,
including load-carrying ability) without hip pain or stiffness,
e.
Normal range of hip movement (at least 90° flexion, 25° abduction, 20° external
rotation in 90° flexion, and 5° internal rotation in 90° flexion),
f.
Normal dynamic functional assessment.61
124. Candidates who do not fulfil these criteria are UNFIT as they will have a high risk of
deterioration during training and service requiring extended non-operative or surgical
treatment.
125.
Proximal femur fractures. These are injuries with a high rate of delayed
complications and recurrence due to the biomechanics and blood supply of the region.
60 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
61 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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Candidates with traumatic proximal femur fractures are FIT provided they meet all the
following criteria:
a.
A period of at least 24 months must have elapsed as remodelling following
fracture often takes up to 12 months and exclusion of avascular necrosis can take 24
months,
b.
Fracture union is confirmed,
c.
Discharged from treatment and rehabilitation,
d.
Fully functional (at least three months activity comparable with military training,
including load-carrying ability) without hip pain or stiffness,
e.
Normal anatomy (length, rotation and alignment) has been restored through
surgery,
f.
There is no tenderness over the area of metalwork / fracture site. It is not
necessary for metalwork to have been removed if the candidate is asymptomatic,
g.
There is full function of the joints above and below the injury including a normal
range of hip movement (at least 90° flexion, 25° abduction, 20° external rotation in
90° flexion, and 5° internal rotation in 90° flexion),
h.
Normal dynamic functional assessment.62
126.
Stress fracture to the femur. Candidates with a radiographically proven stress
fracture of the femur (pending or complete) are UNFIT due to the likelihood or recurrence
and the need for future prolonged treatment as a result of the rigours of military service.
127.
Developmental dysplasia of the hip (DDH) / Congenital Dislocation of the Hip,
(CDH). Candidates may have been treated non-surgically (splints, traction) to encourage
the socket to grow deeper, or by surgery to realign the hip joint. Candidates who meet all
the criteria below are FIT.
a.
At least 24 months since any treatment,
b.
Discharged from treatment and rehabilitation,
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least twelve months,
d.
Normal range of pain free hip movement (at least 90° flexion, 25° abduction, 20°
external rotation in 90° flexion, and 5° internal rotation in 90° flexion),
e.
Normal dynamic functional assessment.63
128. Candidates with painful hips, or restricted movement are UNFIT because these
limitations will prevent them from participating in military training and may deteriorate
requiring extended non-operative or surgical treatment.
62 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
63 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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129.
Perthes disease (abnormal hip due to loss of blood supply in childhood). In this
condition there is abnormal growth of the top of the thigh bone. Candidates may have been
treated non-surgically (reduced loading, splints, traction) or by surgery to encourage the
ball to maintain a round shape. Candidates who meet all the criteria below are FIT:
a.
At least 24 months since any treatment,
b.
Discharged from treatment and rehabilitation,
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least twelve months,
d.
Normal range of hip movement (at least 90° flexion, 25° abduction, 20° external
rotation in 90° flexion, and 5° internal rotation in 90° flexion),
e.
Normal dynamic functional assessment.64
130. Candidates with painful hips, or restricted movement are UNFIT because these
limitations will prevent them from participating in military training and may deteriorate
requiring extended non-operative or surgical treatment.
131.
Slipped Capital Femoral Epiphysis (SCFE) also called Slipped Upper Femoral
Epiphysis (SUFE) (Abnormal hip due to damage to the growth plate). In this condition
the ball of the hip slides on the top of the thigh bone during growth. Candidates may have
been treated non-surgically, or by surgery to stabilise the joint or to restore normal
anatomy. Candidates who meet the criteria below are FIT:
a.
At least 24 months since any treatment,
b.
Discharged from treatment and rehabilitation,
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least 12 months,
d.
Normal range of hip movement (at least 90° flexion, 25° abduction, 20° external
rotation in 90° flexion, and 5° internal rotation in 90° flexion),
e.
Normal dynamic functional assessment.65
132. Candidates with painful hips, or restricted movement are UNFIT because these
limitations will prevent them from participating in military training and may deteriorate
requiring extended non-operative or surgical treatment.
133.
Hip dysplasia (shallow hip socket). Some people with shallow hip sockets and
rotational abnormalities of the hip present as adults with painful hips. Those who have had
non-surgical treatment (usually physiotherapy), or surgery (pelvic or femoral osteotomy)
are FIT provided they meet all the following criteria:
64 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
65 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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a.
At least 24 months since any treatment,
b.
Discharged from treatment and rehabilitation,
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least twelve months,
d.
Normal range of hip movement (at least 90° flexion, 25° abduction, 20° external
rotation in 90° flexion, and 5° internal rotation in 90° flexion),
e.
Normal dynamic functional assessment.66
134. Candidates hip dysplasia and ongoing pain or treatment are UNFIT because these
limitations will prevent them from participating in military training and may deteriorate
requiring extended non-operative or surgical treatment.
135.
Femoroacetabular impingement (FAI) syndrome (restriction of the hip joint) and
labral tears (tears of the hip socket rim). In this condition the ball and socket of the hip
do not precisely fit and may rub together damaging the hip cartilage or labrum. Many
young people may have a reference to this condition in their records, (e.g. FAI,
impingement, cam, pincer, labral tear) and these should not be used to determine fitness
for entry because they are not determinants of function and may represent the normal
range of anatomy. Candidates who had non-surgical (usually physiotherapy) or surgical
(usually keyhole or arthroscopic surgery) treatment for an established diagnosis of hip
impingement; they are FIT provided they meet all the following criteria:
a.
At least 24 months since any treatment,
b.
Discharged from treatment and rehabilitation,
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least twelve months,
d.
Normal range of hip movement (at least 90° flexion, 25° abduction, 20° external
rotation in 90° flexion, and 5° internal rotation in 90° flexion),
e.
Normal dynamic functional assessment.67
136. Candidates with a diagnosis of hip impingement or labral tear who still have pain, or
are undergoing treatment, are UNFIT because these limitations will prevent them from
participating in military training and may deteriorate requiring extended non-operative or
surgical treatment.
137.
Avascular necrosis (AVN) (Interrupted blood supply to the hip). In this condition
there is interrupted blood supply to the ball of the hip, which can lead to flattening of the
top of the ball of the hip and osteoarthritis. Candidates are FIT provided they meet all the
following criteria:
a.
At least 24 months since any treatment,
66 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
67 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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b.
Discharged from treatment and rehabilitation,
c.
No evidence of secondary arthritis on available imaging,
d.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least twelve months,
e.
Normal range of hip movement (at least 90° flexion, 25° abduction, 20° external
rotation in 90° flexion, and 5° internal rotation in 90° flexion),
f.
Normal dynamic functional assessment.68
138.
Candidates not meeting these criteria are UNFIT because these limitations will
prevent them from participating in military training and may deteriorate requiring extended
non-operative or surgical treatment.
139.
Osteoarthritis (degenerative joint disease of the hip). All candidates with a history
of hip osteoarthritis are UNFIT as there is a significant risk of further deterioration in
symptoms requiring extended non-operative and / or surgical treatment.
140.
Total hip replacement / resurfacing. Candidates who have had a total hip
replacement are UNFIT because of the risk of hip dislocation requiring urgent treatment.
The need for complex revision surgery in the event of a fracture or infection is also
significant and applies to both hip replacements and resurfacings.
141.
Muscle injuries around the hip. These include adductor, hamstring, and quadriceps
strains or tears, and lower abdominal wall tears (sometimes called ‘sports hernia’ or
‘footballer’s groin’). All of these may be treated by rehabilitation or surgery and candidates
are FIT after successful treatment, provided they meet all the following criteria:
a.
At least six months since any treatment,
b.
Discharged from treatment and rehabilitation,
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
d.
Normal dynamic functional assessment.69
142. Candidates who still have pain or are undergoing treatment, are UNFIT because
there is a significant risk of deterioration in their symptoms during training and service
requiring extended non-operative or surgical treatment.
Conditions affecting the Knee
143.
Meniscal tears (tears to the fibrocartilage of the knee). Candidates should be
assessed according to the criteria below.
a.
Non-surgically managed meniscal tears. Candidates who meet all the
following criteria are FIT:
68 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
69 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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(1) At least 12 months post injury for a radiologically confirmed meniscal tear,
(2) Fully functional after conservative management,
(3) Discharged from treatment and rehabilitation,
(4) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months,
(5) Normal dynamic functional assessment.70
(6) Candidates who do not meet these criteria are UNFIT as there is a
significant risk that symptoms will deteriorate during training and service such
that extended non-operative or surgical treatment is required.
b.
Arthroscopic partial meniscectomy. If specified, this should be less than 50%
of meniscal depth. Extensive meniscectomy is associated with greater risk of
premature arthritis. Where not specified, partial meniscectomy should be interpreted
to mean less than 50% of the meniscal depth has been resected. Candidates are FIT
provided they meet all the following criteria:
(1) At least 12 months post-arthroscopic partial meniscectomy,
(2) Discharged from treatment and rehabilitation,
(3) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months,
(4) Normal dynamic functional assessment71,
(5) Have undertaken activity comparable with military training for three
months.
c.
Candidates who do not meet these criteria, including those who had extensive,
subtotal, complete meniscectomy, are UNFIT as there is a substantial risk that
symptoms may worsen or recur during training and subsequent service.
144.
Meniscal repair. Candidates are FIT provided they meet all the following criteria:
(1) Successful meniscal repair,
(2) At least 18 months from surgery because failed meniscal repairs may
present late,
(3) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months,
(4) Normal dynamic functional assessment.72
70 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
71 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
72 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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b.
Candidates who do not meet these criteria are UNFIT regardless of current
symptoms / function as failure of meniscal repair may present late, be precipitated by
military training and may require further surgical treatment.
c.
Complex meniscal injuries or if associated with other intra-articular injury.
Candidates who have had more complex meniscal injuries (co-existent medial and
lateral meniscal tears, meniscal root repair or saucerisation of discoid meniscus) or if
associated with other intra-articular injury may be referred to sSMES, unless the
associated injuries independently make the candidate UNFIT, no sooner than 18
months after completion of treatment.
d.
Meniscal transplantation. Candidates are UNFIT as there is a substantial risk
that, despite meniscal transplant, symptoms may worsen or recur during training and
service and that the transplanted meniscus does not offer equivalent protective
function, substantially increasing the risk of developing knee arthritis.
Knee Ligament Injuries 145.
Anterior Cruciate Ligament (ACL). Candidates should be assessed according to
the criteria below:
a.
Physiological laxity. Candidates with slight laxity of the ACL without a history
of injury and without any loss of function are FIT. Candidates with significant laxity of
the ACL are UNFIT as there is a high likelihood of a missed ACL injury or connective
tissue disorder. These factors substantially increase the risk of further knee injury or
deterioration during training and service.
b.
Isolated partial or complete ACL rupture who have undergone ACL
autograft reconstruction. Candidates with history of isolated ACL rupture who have
undergone ACL autograft reconstruction are FIT provided they meet all the following
criteria:
(1) Isolated ACL injury73,
(2) ACL autograft reconstruction (not ACL repair or alternative technique),
(3) Single surgical procedure to the affected knee only (no previous or
revision surgery permitted),
(4) Minimum of twenty-four months since surgery to allow for ligament
maturation,
(5) Pre-surgery MRI report and operation note available, confirming no
significant meniscal or cartilage injury/lesion and no associated ligament injury
other than MCL sprain,
(6) Relevant outpatient clinic letter/s available, including confirmation of
recovery and knee stability,
73 No significant damage to the articular cartilage or menisci identified.
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(7) Fully recovered with no chronic/recurrent knee symptoms,
(8) Completed a rehabilitation programme,
(9) Undertaken at least six months physical exercise, including weight
carriage and sporting/military comparable activities,
(10) Objectively stable knee and no abnormal clinical signs.
c.
Candidates who do not fulfil these criteria (including those who had ACL repair)
are UNFIT due to the risk of re-rupture of the ligament, particularly if subjected to
arduous training, and due to the risks of later progression to degenerative joint
disease (arthritis) during training and service.
d.
Isolated partial tear of the ACL managed non-surgically. Candidates with a
history of isolated partial tear of the ACL, who have been managed conservatively
are FIT provided they meet all the following criteria:
(1) At least 12 months from injury,
(2) No significant damage to the articular cartilage or menisci identified,
(3) Fully recovered with no chronic/recurrent knee symptoms,
(4) Completed a rehabilitation programme,
(5) Undertaken at least six months physical exercise, including weight
carriage and sporting/military comparable activities,
(6) Objectively stable knee and no abnormal clinical signs.
e.
Complete ACL rupture managed non-surgically. There may be candidates
with a history of complete ACL rupture who have been managed conservatively and
are FIT. This may be because an incorrect diagnosis has been made or adequate
ligament healing has taken place. Candidates are FIT provided they meet all the
following criteria:
(1) At least 24 months from injury,
(2) No significant damage to the articular cartilage or menisci identified,
(3) Fully recovered with no chronic/recurrent knee symptoms,
(4) Completed a rehabilitation programme,
(5) Undertaken at least six months physical exercise, including weight
carriage and sporting/military comparable activities,
(6) Objectively stable knee and no abnormal clinical signs.
f.
Candidates who have had complete ACL rupture managed non-surgically, but
who do not meet the criteria above, are UNFIT as there is a significant risk that knee
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symptoms may worsen or recur during training and service requiring extended non-
operative or surgical treatment.
146.
Posterior Cruciate Ligament (PCL). Candidates should be assessed according to
the criteria below.
a.
Isolated partial tear of the PCL managed non-surgically. Candidates with a
history of isolated partial tear of the PCL, and who have been managed
conservatively are FIT provided they meet all the following criteria:
(1) At least 12 months from injury,
(2) No significant damage to the articular cartilage or menisci identified,
(3) Completed a rehabilitation programme,
(4) Fully recovered with no chronic/recurrent knee symptoms,
(5) Undertaken at least six months physical exercise, including weight
carriage and sporting/military comparable activities,
(6) Objectively stable knee and no abnormal clinical signs.
b.
Candidates who do not meet these criteria are UNFIT as there is a significant
risk that knee symptoms may worsen or recur during training and service requiring
extended non-operative or surgical treatment.
c.
Reconstruction surgery for partial PCL tears. Candidates who have
undergone reconstruction surgery (including surgical repair) for a partial tear are
UNFIT as there is a substantial risk of re-rupture, particularly if subjected to arduous
training before ligament maturation. In other situations, there is a significant risk that
residual ligament laxity will result in knee symptoms worsening or recurring during
training and service requiring extended non-operative or surgical treatment.
d.
Complete PCL rupture. Candidates with any history of PCL rupture, whether
managed conservatively or surgically are UNFIT as there is a substantial risk of re-
rupture, particularly if subjected to arduous training. In other situations, there is a
significant risk that residual ligament laxity will result in knee symptoms worsening or
recurring during training and service requiring extended non-operative or surgical
treatment.
147.
Medial Collateral Ligament (MCL). Candidates should be assessed according to
the criteria below:
a.
Physiological laxity. Candidates with slight laxity of the MCL without a history
of injury and without any loss of function are FIT. Candidates with more than mild
laxity are UNFIT as there is a high likelihood of a missed MCL injury or connective
tissue disorder. These factors substantially increase the risk of further knee injury and
joint deterioration during training and service.
b.
Isolated partial rupture of the MCL managed non-surgically. Candidates
with a history of isolated partial rupture of the MCL, and who have been managed
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conservatively are FIT provided they meet all the following criteria:
(1) At least 12 months from injury,
(2) No significant damage to the articular cartilage or menisci identified,
(3) Completed a rehabilitation programme,
(4) Fully recovered with no chronic/recurrent knee symptoms,
(5) Undertaken at least six months physical exercise, including weight
carriage and sporting/military comparable activities,
(6) Objectively stable knee and no abnormal clinical signs.
c.
Candidates who do not meet these criteria are UNFIT as these factors
substantially increase the risk of further knee injury and joint deterioration during
training and service.
d.
Isolated complete rupture of the MCL. Candidates who have had an isolated
complete rupture of the MCL, whether managed non-surgically or surgically are FIT
provided they meet all the following criteria:
(1) At least 12 months since date of injury or subsequent surgery,
(2) No significant damage to the articular cartilage or menisci identified,
(3) Fully recovered with no chronic/recurrent knee symptoms,
(4) Completed a rehabilitation programme,
(5) Undertaken at least six months physical exercise, including weight
carriage and sporting/military comparable activities,
(6) Objectively stable knee and no abnormal clinical signs.
e.
Candidates who do not meet these criteria are UNFIT as there is a substantial
increase in the risk of further knee injury and joint deterioration during training and
service.
148.
Lateral Collateral Ligament (LCL). Candidates should be assessed according to the
criteria below:
a.
Physiological laxity. Candidates with slight laxity of the LCL without a history
of injury and without any loss of function are FIT. Candidates with more than a slight
laxity are UNFIT as there is a high likelihood of a missed LCL injury or connective
tissue disorder. These factors substantially increase the risk of further knee injury and
joint deterioration during training and service.
b.
Isolated partial rupture of LCL managed non-surgically. Candidates with a
history of isolated partial rupture of the LCL, managed conservatively, are FIT
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provided they meet all the following criteria:
(1) At least 12 months since injury,
(2) No significant damage to the articular cartilage or menisci identified,
(3) Completed a rehabilitation programme,
(4) Fully recovered with no chronic/recurrent knee symptoms,
(5) Undertaken at least six months physical exercise, including weight
carriage and sporting/military comparable activities,
(6) Objectively stable knee and no abnormal clinical signs.
c.
Candidates who do not meet these criteria are UNFIT as these factors
substantially increase the risk of further knee injury and joint deterioration during
training and service.
d.
Isolated complete rupture of the LCL or other posterolateral corner
injuries. Candidates who have had an isolated complete rupture of the LCL, whether
managed conservatively or surgically, are FIT provided they meet all the following
criteria:
(1) At least 12 months since surgery,
(2) No significant damage to the articular cartilage or menisci identified,
(3) Completed a rehabilitation programme,
(4) Fully recovered with no chronic/recurrent knee symptoms,
(5) Undertaken at least six months physical exercise, including weight
carriage and sporting/military comparable activities,
(6) Objectively stable knee and no abnormal clinical signs.
e.
Candidates who do not meet these criteria are UNFIT as there is a substantial
increase in the risk of further knee injury and joint deterioration during training and
service.
Multi-ligament knee injuries (MLKI) 149. Candidates who have had MLKI, other than partial or complete ACL rupture with MCL
sprain (see Para 150b), are UNFIT as there is a significant increase in the risk of further
knee injury requiring extended non-operative or surgical treatment and a high risk of
development of degenerative joint disease (arthritis) during training and service.
Conditions affecting the articular cartilage of the knee
150.
Osteochondritis dissecans (separation of a bone and cartilage fragment). Candidates who have evidence of full resolution, both radiologically and clinically, whether
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managed conservatively, with medication or surgically, with no other lesion and no
symptoms are FIT. Candidates with a residual defect, loose bodies or abnormal imaging
(including any residual oedema or cystic change) are UNFIT as there is a significant
increase in the risk of further knee injury requiring extended non-operative or surgical
treatment and a high risk of development of degenerative joint disease (arthritis) during
training and service.
151.
Osteochondral defects (Focal defects in Cartilage and Bone). Candidates with
small (no greater than than 1cm2) focal defects in non-weight bearing regions of the knee
are FIT provided they meet all the following criteria:
a.
Are at least 12 months from injury,
b.
Completed an adequate rehabilitation programme and been discharged from
follow up,
c.
Stable knee on examination,
d.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least six months,
e.
Normal dynamic functional assessment.74
152. Candidates who do not meet these criteria are UNFIT as there is a significant
increase in the risk of further knee injury requiring extended non-operative or surgical
treatment and a high risk of development of degenerative joint disease (arthritis) during
training and service.
153.
Larger defects (larger than 1cm2) and / or in weight bearing regions of the knee. Candidates are UNFIT as there is a significant increase in the risk of further knee injury
requiring extended non-operative or surgical treatment and a high risk of development of
degenerative joint disease (arthritis) during training and service.
154.
Osteoarthritis (degenerative joint disease). Candidates who have developed
radiologically apparent osteoarthritis of the knee, regardless of underlying cause, are
UNFIT as there is a significant increase in the risk of further deterioration in symptoms
requiring extended non-operative and / or surgical treatment.
155.
Knee joint replacement. Candidates who have had partial or total knee joint
prostheses (including articular resurfacing) are UNFIT. The physical demands of service
life are such that they carry an increased risk of premature revision of their artificial joint.
Revision surgery is associated with increased rates of complications and a lower level of
function than the primary joint replacement.
Lesions of bone around the knee
156.
Bone cysts, chondroma, non-ossifying fibroma, intraosseous ganglion cysts
(Fluid and soft tissue filled holes in bone). Candidates should be assessed according to
the criteria below:
74 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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a.
Spontaneous resolution without symptoms. Candidates who have lesions
which have spontaneously resolved with skeletal maturity are FIT.
b.
Unresolved conditions without symptoms. Skeletally mature candidates who
have lesions which have not resolved may be FIT if they meet all the criteria below.
They should be referred to a military orthopaedic consultant for opinion on prognosis
and future fracture risk.
(1) Symptom-free,
(2) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least six months,
(3) Normal dynamic functional assessment.75
c.
Symptomatic candidates or those who have not reached skeletal maturity.
and those with lesions at risk of progression or fracture. These are UNFIT as
there is a substantial increase in the risk of deterioration in symptoms during training
and service and a moderate risk of fracture requiring extended non-operative or
surgical treatment.
d.
Exostosis / osteochondroma (Isolated bony spurs). Candidates with isolated
single exostosis are FIT provided they meet all the following criteria:
(1) Symptom-free,
(2) Fully functional,
(3) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months,
(4) Normal dynamic functional assessment.76
e.
Symptomatic candidates are UNFIT as there is a substantial increase in the risk
of deterioration in symptoms during training and service and a moderate risk of this
requiring surgical treatment.
f.
Hereditary multiple osteochondromas / hereditary multiple exostoses /
diaphyseal aclasia (multiple bony spurs). Candidates with these conditions are
UNFIT as there is a substantial increase in the risk of deterioration in symptoms
during training and service and a moderate risk of this requiring surgical treatment.
There is also a low risk of progression to malignant disease requiring extensive
treatment.
Conditions affecting the joint lining 157.
Pigmented villonodular synovitis (PVNS).
a.
Focal PVNS. Candidates who have had a single isolated focus of PVNS which
has been removed and are symptom-free and fully functional are FIT provided they
75 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
76 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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meet all the following criteria:
(1) At least three months from surgery,
(2) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months,
(3) Normal dynamic functional assessment.77
b.
Generalised PVNS. Candidates with a history of generalised PVNS are UNFIT
due to risk of recurrence, debilitating symptoms and progressive joint damage.
158.
Synovial chondromatosis and synovial osteochondromatosis. Candidates are
UNFIT due to high risk of recurrence, debilitating symptoms and progressive joint damage
candidates with a history of synovial chondromatosis or synovial osteochondromatosis are
UNFIT.
Other conditions affecting the knee
159.
Anterior knee pain (pain in the front of the knee). Knee pain, often due to
unidentified causes, accounts for a large proportion of the medical discharges that occur
during recruit training.
160.
Isolated episodes of anterior knee pain, including patellar tendinitis. Candidates
with isolated episodes of knee pain who meet all the criteria below are FIT:
a.
Knee pain is associated with injury or overtraining,
b.
Pain resolved fully and quickly with minimal clinical input (only GP and / or
Physiotherapy),
c.
Fully functional for at least six months,
d.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
e.
Normal dynamic functional assessment.78
161. All other candidates are UNFIT as there is a significant increase in the risk of further
deterioration in symptoms requiring extended non-operative and / or surgical treatment.
Candidates require a high level of function to work in challenging environments, in a
physically demanding job, including in austere locations with limited medical support.
162.
Persistent or recurrent knee pain or patellar tendinopathy. Candidates with a
history of persistent (lasting three months or more) or recurrent knee pain with everyday
activity are UNFIT as there is a significant risk of deterioration and recurrence during
training and service which may require extended non-operative or surgical treatment.
163.
Osgood-Schlatter’s Disease and Sinding Larsen Johansen Syndrome
(Inflammation of the patella tendon at its origin or insertion). These are chronic
77 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
78 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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fatigue injuries due to repeated microtrauma of the patellar tendon at its origin at the
patella or its insertion at the tibial tuberosity, usually affecting boys between ages 10-15
years. Candidates who have been symptom-free for at least 12 months, can kneel without
difficulty / pain and have been able to undertake activity comparable with military training
for three months are FIT. Candidates not meeting these criteria are UNFIT as there is a
significant risk of deterioration and recurrence during training and service, which may
require extended non-operative and occasionally surgical treatment.
164.
Chondromalacia Patellae (softening and fragmentation of articular cartilage of
patella). Candidates should be assessed according to the criteria below.
a.
Non-confirmed diagnosis. Candidates who have a possible diagnosis which
has not required imaging, should be assessed as per the para “Isolated episodes of
anterior knee pain associated with injury or training, including patellar tendinitis”
above.
b.
Confirmed diagnosis. Candidates with current evidence of chondromalacia
patella on cross sectional imaging are UNFIT due to the high risk of recurrence,
debilitating symptoms and progression of joint damage during training and service
which may require extended non-operative or surgical treatment.
165.
Patella dislocation (dislocated kneecap). Patella dislocations are potentially
complex injuries, and all candidates will require careful assessment before their fitness can
be confirmed. All candidates should have had imaging (at the time of injury or after). If not,
this may be required for an opinion to be formed. Candidates should be assessed
according to the criteria below.
a.
Isolated acute traumatic patella dislocation in an anatomically normal
knee. Candidates who have suffered an
isolated acute traumatic patella dislocation
in an anatomically normal knee are FIT provided they meet all the following criteria:
(1) At least 12 months post injury,
(2) Successfully completed all rehabilitation and discharged from follow up,
(3) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months,
(4) No evidence of osteochondral damage on available imaging,
(5) Normal dynamic functional assessment.79
b.
All other candidates are UNFIT as there is a significant increase in the risk of
further deterioration in symptoms requiring extended non-operative and / or surgical
treatment.
c.
Recurrent dislocations. Candidates who had recurrent dislocations during
childhood are FIT, provided they meet all the below criteria:
79 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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(1) They are skeletally mature and have had no recurrence for the past 36
months.
(2) No evidence of degenerative joint disease or osteochondral damage.
(3) Successfully completed all rehabilitation and discharged from follow up.
(4) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months.
(5) No evidence of osteochondral damage on available imaging.
(6) Normal dynamic functional assessment.80
d.
All other candidates are UNFIT due to the significant risk of recurrence and
further knee injury requiring extended non-operative or surgical treatment.
e.
Single or recurrent dislocation secondary to anatomical anomaly.
Candidates who have suffered from single or recurrent dislocation secondary to
anatomical anomaly (e.g. femoral trochlear dysplasia, patella alta, abnormal
rotational profile) and have had corrective surgery are FIT, provided they fulfil all the
criteria listed below:
(1) No evidence of degenerative joint disease or osteochondral damage,
(2) At least 12 months following successful corrective surgery,
(3) Successfully completed all rehabilitation and discharged from follow up,
(4) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least six months,
(5) Normal dynamic functional assessment.81
f.
Candidates who do not meet these criteria are UNFIT regardless of whether
corrective surgery such as trochleopasty, tibial tuberosity transfer or rotational
osteotomy of the femur has been undertaken as there is a significant risk of recurrent
instability, persistent symptoms and progression to degenerative joint disease in
these patients.
166.
Medial patello-femoral ligament (MPFL) reconstruction. Candidates are FIT
provided they meet all the following criteria:
a.
At least 12 months post MPFL reconstruction,
b.
No evidence of previous anatomical abnormality,
c.
Successfully completed all rehabilitation and discharged from follow up,
80 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
81 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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d.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
e.
No evidence of osteochondral damage on available imaging,
f.
Normal dynamic functional assessment.82
167. All other candidates are UNFIT as there is a significant increase in the risk of further
deterioration in symptoms requiring extended non-operative and / or surgical treatment.
Conditions causing exercise related leg pain
168.
Medial Tibial Stress Syndrome (shin splints). Candidates are FIT
, provided they
meet all the following criteria:
a.
Successfully treated without surgery (physiotherapy, orthotics),
b.
Symptom-free for 12 months,
c.
Have undertaken activity comparable with military training for three months
including wearing military type footwear over extended distances, uneven ground and
variable inclines,
d.
Normal dynamic functional assessment.83
169. Other candidates who have had medial tibial stress syndrome and do not fulfil these
criteria are UNFIT due to the high risk of recurrence during training and service requiring
extended non-operative treatment.
170.
Tibial stress response or fracture. Candidates who have had a radiological proven
stress response or stress fracture of the tibia are UNFIT due to the high risk of recurrence
during training and service requiring extended non-operative or surgical treatment.
171.
Chronic Exertional Compartment Syndrome (CECS). Candidates are FIT,
provided they meet all the following criteria:
a.
Condition correctly diagnosed and successfully treated by surgical fasciotomy or
fasciectomy,
b.
Symptom-free for 12 months,
c.
Have undertaken activity comparable with military training for three months
including wearing military type footwear over extended distances, uneven ground and
variable inclines,
d.
Normal dynamic functional assessment.84
172. All other candidates are UNFIT due to the high risk of recurrence during training and
service requiring extended non-operative treatment.
82 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
83 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
84 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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173.
Popliteal artery entrapment syndrome (PAES). Candidates who meet all the
criteria below should be referred to sSMES, who may request a military orthopaedic
consultant’s opinion on recovery, function and prognosis:
a.
Successfully treated by surgical release,
b.
Symptom-free for 12 months,
c.
Fully functional,
d.
No underlying vessel injury,
e.
Have undertaken activity comparable with military training for three months
including wearing military type footwear over extended distances, uneven ground and
variable inclines,
f.
Normal dynamic functional assessment.85
174. Other candidates who do not fulfil all the above criteria or have functional PAES,
are
UNFIT due to significant risk of recurrence during training and service requiring extended
non-operative and / or surgical treatment.
175.
Quadriceps or patellar tendon ruptures. Candidates are FIT, provided they meet
all the following criteria:
a.
Rupture surgically repaired within three weeks of injury (delayed repair is
associated with a poorer outcome),
b.
At least one year from surgery,
c.
Symptom-free and fully functional,
d.
Stable knee on examination, with full range of movement and no weakness / lag
on straight leg raise,
e.
Completed an adequate rehabilitation programme and discharged from follow
up,
f.
Have undertaken activity comparable with military training for three months,
g.
Normal dynamic functional assessment.86
176. All other candidates are UNFIT, including those who underwent delayed repair or
reconstruction as there is a higher risk of failure of delayed repair / reconstruction. This is a
particular risk during training and service and may require extended non-operative or
surgical treatment.
Fractures around the knee
85 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
86 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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177.
Femoral shaft fracture or extra-articular distal femoral fracture (broken thigh
bone). Candidates are FIT, provided they meet all the following criteria:
a.
A period of at least twelve months must have elapsed as remodelling following
fracture often takes up to 12 months,
b.
Normal anatomy (length, rotation and alignment) has been restored through
treatment,
c.
Full function of the joints above and below the injury,
d.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
e.
Union is confirmed with no deformity,
f.
No tenderness over the area of metalwork / fracture site. It is not necessary for
metalwork to have been removed if the candidate is symptom-free,
g.
Normal dynamic functional assessment.87
178. All other candidates are UNFIT as there is a significant increase in the risk of further
deterioration in symptoms requiring extended non-operative and / or surgical treatment.
179.
Intra-articular distal femoral fracture (fracture involving the joint). Candidates
are FIT, provided they meet all the following criteria:
a.
A period of at least twelve months must have elapsed as remodelling following
fracture often takes up to twelve months,
b.
Simple fracture pattern,
c.
Fully united,
d.
No reported steps / gaps on the articular surface,
e.
No evidence of post-traumatic arthritis,
f.
Has completed a rehabilitation programme and is discharged from follow up,
g.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least six months,
h.
Normal knee examination (normal range of movement and no instability),
i.
Normal dynamic functional assessment.88
180. Candidates not meeting the criteria above are UNFIT due to risk of progression to
post-traumatic arthritis.
87 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
88 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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181.
Avulsion fractures around the knee (broken fragment of bone around the knee).
a.
Avulsion fractures of the medial and lateral collateral ligaments (b
roken
fragment of bone around the knee involving the medial and lateral collateral
ligaments). Candidates with a history of avulsion fractures of the medial and lateral
collateral ligaments are FIT, provided they meet all the following criteria:
(1) They are at least twelve months from surgery,
(2) Discharged from treatment and rehabilitation,
(3) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months,
(4) Stable knee on examination,
(5) Normal dynamic functional assessment.89
b.
Candidates not meeting the criteria above are UNFIT due to risk of re-injury and
ongoing instability during training, or progression to post-traumatic arthritis in service,
any of which may require extended non-operative or surgical treatment.
c.
ACL (tibial spine) or PCL avulsion fractures (broken fragment of bone
around the knee involving the ACL or PCL ligaments). Candidates with a history
of ACL (tibial spine) or PCL avulsion fractures who meet all the below criteria may be
FIT and should be referred to sSMES, who may request a military orthopaedic
consultant’s opinion on recovery, function and prognosis:
(1) They are at least twelve months from surgery,
(2) Discharged from treatment and rehabilitation,
(3) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months,
(4) Stable knee on examination,
(5) Normal dynamic functional assessment.90
d.
Candidates not meeting the criteria above are UNFIT due to risk of re-injury and
ongoing instability during training, or progression to post-traumatic arthritis in service,
any of which may require extended non-operative or surgical treatment.
182.
Salter-Harris / physeal fractures (Fracture involving the growth plates around
the knee during childhood). Candidates are FIT, provided they meet all the following
criteria:
a.
A period of at least 12 months must have elapsed as remodelling following
fracture often takes up to 12 months,
89 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
90 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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b.
Normal anatomy (length, rotation and alignment) has been restored through
surgery,
c.
Union is confirmed,
d.
There is no deformity or growth disturbance,
e.
No symptomatic or significant (greater than 2cm) limb length inequality,
f.
Discharged from treatment and rehabilitation,
g.
There is no tenderness over the area of metalwork / fracture site. It is not
necessary for metalwork to have been removed if the candidate is symptom-free,
h.
There is full function of the joints above and below the injury,
i.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
j.
Normal dynamic functional assessment.91
183. Candidates not meeting the criteria above are UNFIT due to risk of re-injury and
ongoing instability during training, or progression to post-traumatic arthritis in service, any
of which may require extended non-operative or surgical treatment.
184.
Patella fracture (fracture of the kneecap). Candidates are FIT, provided they meet
all the following criteria:
a.
They are at least twelve months from injury,
b.
Stable knee on examination,
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
d.
Normal dynamic functional assessment.92
185. Candidates with evidence of failure of union, malunion, degenerative joint disease or
metalwork irritation are UNFIT due to increased risk of worsening symptoms during
training, or progression to post-traumatic arthritis in service, either of which may require
extended non-operative or surgical treatment.
Tibia and / or fibula fractures (broken lower leg bone)
186.
Extra-articular tibial shaft fracture or proximal tibial fracture (not involving the
joint). Candidates are FIT, provided they meet all the following criteria:
a.
A period of at least 12 months must have elapsed as remodelling following
fracture often takes up to 12 months,
91 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
92 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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b.
Discharged from treatment and rehabilitation,
c.
Normal anatomy (length, rotation and alignment) has been restored through
treatment,
d.
Union is confirmed and there is no deformity,
e.
There is no tenderness over the area of metalwork / fracture site. It is not
necessary for metalwork to have been removed if the candidate is symptom-free,
f.
There is full function of the joints above and below the injury,
g.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
h.
Normal dynamic functional assessment.93
187. Candidates not meeting the criteria above are UNFIT due to risk of re-injury and
ongoing instability during training or in service, either of which may require extended non-
operative or surgical treatment.
188.
Proximal intra-articular tibial fracture (involving the joint). A candidate is FIT,
provided they meet all the following criteria:
a.
A period of at least 12 months must have elapsed as remodelling following
fracture often takes up to 12 months,
b.
Simple fracture pattern,
c.
Fully united,
d.
No reported steps / gaps on the articular surface,
e.
Discharged from treatment and rehabilitation,
f.
No evidence of post-traumatic arthritis,
g.
Normal knee examination (normal range of movement and no instability)
h.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least six months,
i.
Normal dynamic functional assessment.94
189. Candidates not meeting the criteria above are UNFIT due to risk of re-injury and
ongoing instability during training, or progression to post-traumatic arthritis in service, any
of which may require extended non-operative or surgical treatment.
190.
Proximal fibula fracture. Candidates are FIT, provided they meet all the following
criteria:
93 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
94 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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a.
A period of at least 12 months must have elapsed as remodelling following
fracture often takes up to 12 months,
b.
Discharged from treatment and rehabilitation,
c.
There is no tenderness over the area of metalwork / fracture site,
d.
There is full function of the joints above and below the injury.
e.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least six months,
f.
Normal dynamic functional assessment.95
191. Candidates not meeting the criteria above are UNFIT due to risk of re-injury and
ongoing instability during training, or progression to post-traumatic arthritis in service, any
of which may require extended non-operative or surgical treatment.
Conditions of the ankle joint
192.
Ankle ligament injuries (ankle sprain). Candidates with previous ankle sprain are
FIT if they have made a full recovery, have no limitation of movement, and are symptom-
free during activity comparable with military training for three months. Candidates with
persistent symptoms are UNFIT as these symptoms are likely to be exacerbated by the
arduous nature of military service (e.g. movement over broken or undulating ground).
193.
Ankle stiffness or recurrent instability. Candidates with a stiff or unstable ankle
(recurrent ankle injuries experienced during day-to-day activities, especially when walking
over uneven ground) are UNFIT. Military service places high demands on the foot and
ankle including weight carriage across rough ground and adopting fire positions.
Symptomatic candidates are unlikely to be able to reach or sustain the required activity
levels. There is a significant risk of further injury.
194.
Ankle stabilisation surgery. Candidates who have had a ligamentous repair (e.g.
Brostrom Gould Repair) or ligamentous replacement / reconstruction (e.g. Evans
Tenodesis) are FIT, provided they meet all the following criteria:
a.
At least 12 months post-surgery,
b.
Discharged from treatment and rehabilitation,
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least six months,
d.
Normal dynamic functional assessment.96
195. Candidates not meeting these criteria are UNFIT as the reconstruction / repair is
unproven and may fail during training or later in military service.
95 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
96 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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196.
Ankle cartilage damage. Candidates with diagnosed ankle cartilage injury including
those who have undergone microfracture or cartilage grafting are UNFIT. These
operations do not restore a normal joint surface. Candidates therefore have a high risk of
recurrence of symptoms or early joint degeneration as military service places high
demands on the foot and ankle including weight carriage across rough ground.
197.
Fusion or replacement of ankle. Candidates with previous ankle fusion or ankle
replacement are UNFIT. Military service places high demands on the ankle including
weight carriage across rough ground and adopting fire positions. Candidates are unlikely
to be able to reach or sustain the required activity levels. There is also a high risk of further
injury, further joint degeneration or need for revision surgery.
198.
Intra articular distal tibial fractures (Fractures involving the joint). Intra-articular
fractures involving the weight bearing part of the distal tibia i.e. the plafond are sometimes
referred to as Pilon fractures. These injures have a high rate of early degenerative
changes and poor function which would likely be worsened with by the rigours of military
service. Candidates who have previously sustained a fracture of this type are UNFIT.
199.
Ankle fractures not requiring surgical management. These are intra-articular
fractures of the ankle joint NOT involving the weightbearing surface of the distal tibia. The
candidate is FIT, provided they meet all the following criteria:
a.
At least six months post injury,
b.
Completed rehabilitation and discharged from follow up,
c.
Pain free with a normal range of movement and no evidence of syndesmotic
instability,
d.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least six months,
e.
Normal dynamic functional assessment.97
200. Candidates not meeting the above criteria are UNFIT as persisting symptoms are
highly likely to be worsened by the arduous nature of military service and may require
extended non-operative or surgical treatment.
201.
Ankle fractures requiring surgical management. These are intra-articular fractures
of the ankle joint NOT involving the weightbearing surface of the distal tibia. The candidate
is FIT, provided they meet all the following criteria:
a.
At least 12 months post injury,
b.
Completed rehabilitation and discharged from follow up (it is acceptable to have
remaining metalwork, provided it does not cause symptoms),
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least twelve months,
97 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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d.
Normal dynamic functional assessment.98
202. Candidates not meeting the above criteria are UNFIT as persisting symptoms are
highly likely to be worsened by the arduous nature of military service and may require
extended non-operative or surgical treatment.
203.
Ankle arthritis (degenerative change or articular damage of the ankle).
Candidates with any signs of degenerative change or articular damage after any ankle
fracture or other injury are UNFIT as this is likely to be exacerbated by the arduous nature
of military service particularly movement over rough ground bearing weight.
Ankle tendon pathology
204.
Tendinitis / tendinosis. Candidates with a single episode of tendinitis / tendinosis
who meet all the following criteria are FIT:
a.
Single episode per side more than 12 months ago,
b.
Discharged from follow up,
c.
Fully recovered with no residual weakness,
d.
No deformity,
e.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
f.
Normal dynamic functional assessment.99
205. All other candidates are UNFIT as military training is likely to worsen symptoms and /
or lead to long term functional deficit.
206.
Tendon rupture.
a.
Achilles tendon. Candidates are FIT, provided they meet all the following
criteria:
(1) At least 12 months post injury,
(2) Successfully completed rehabilitation and discharged from follow up,
(3) No clinically demonstrable weakness,
(4) No pain at rest or with activity, including activity consistent with military
training (including load carriage) for at least three months,
(5) Normal dynamic functional assessment.100
98 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
99 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
100 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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b.
Candidates are UNFIT if any of the criteria above are not met as candidates
would be at high risk of deterioration during training or service with increased risk of
subsequent injuries, including re-rupture.
c.
Toe flexor / extensor tendons. Candidates are FIT if there are no persisting
symptoms six months after the injury. Candidates who are symptomatic are UNFIT as
symptoms will likely worsen during training and service.
d.
Other foot / ankle tendons rupture (including tibialis anterior, tibialis
posterior, peroneal tendons). Candidates are UNFIT as persisting tendon
weakness or impaired strength following either repair or rupture places the candidate
at a greatly elevated risk of reinjury, exacerbation of existing symptoms or a fall
occasioning further injury.
Conditions of the foot
207.
Foot deformities (including hallux valgus).
a.
Minor deformities where normal footwear without orthotics is worn.
Candidates with minor conditions, that allow the use of normal footwear are FIT
provided there is no pain at rest or with activity, including activity consistent with
military training (including load carriage) for at least three months.
b.
Minor deformities where normal footwear with over-the-counter or
custom-made orthotics is worn. Candidates with minor conditions, that allow the
use of normal footwear with over the counter or custom-made orthotics are FIT
provided they provided there is no pain at rest or with activity, including activity
consistent with military training (including load carriage) for at least three months.
c.
Deformities requiring custom-made footwear. Candidates who use custom-
made footwear (excluding custom-made orthotics and issued off-the-shelf footwear
normally available through the military supply chain) are UNFIT. The supply chain
when deployed cannot reliably provide or replace such footwear. The requirement for
such footwear is a marker of the severity of the condition.
208.
Flat feet. Candidates with mobile flat feet causing no symptoms, or symptoms
controlled with orthotics alone are FIT. Candidates with mobile flat feet causing symptoms,
or with rigid flat feet, are UNFIT. Military service places high demands on the foot and
ankle including weight carriage across rough ground. When a candidate already has
symptoms, these are highly likely to worsen in military training.
209.
Talipes equinovarus (club foot). The following candidates are FIT:
a.
Confirmed positional talipes or metatarsus adductus which has resolved with
physiotherapy.
b.
Club foot, corrected or otherwise, who can use military footwear without any
problems.
210. All other candidates with clubfoot, corrected or otherwise are UNFIT.
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211.
Abnormal hindfoot morphology (shape of the back of the foot). Candidates with
abnormal hindfoot morphology requiring surgical correction are UNFIT. An abnormal
hindfoot markedly increases the risk of injury as it cannot accommodate as well to uneven
surfaces. Military service places high demands on the foot and ankle including weight
carriage across rough ground.
212.
Pes cavus / cavo varus foot (rigid high arched foot). Candidates are FIT, provided
they meet all the following criteria:
a.
Symptom-free,
b.
Foot is mobile without pressure areas or fixed clawing,
c.
Candidate is foreseeably able to use issued military footwear with / without over
the counter or custom-made orthotics.
d.
No associated neurological disorder (such as peroneal muscular dystrophy,
etc),
e.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
f.
Normal dynamic functional assessment.101
213. Candidates who do not meet the above criteria are UNFIT. Military service places
high demands on the foot and ankle including weight carriage across rough ground.
Typically, a rigid high arched foot / cavo varus foot places the candidate at increased risk
of injury because their feet cannot accommodate as well to uneven surfaces. They may
also represent an underlying neurological abnormality. Typically, their feet then worsen
with time.
214.
Plantar Fasciitis (inflammation of the plantar fascia of the foot). Candidates with
a prior history of plantar fasciitis who meet all the following criteria are FIT:
a.
Symptom-free for six months,
b.
Single episode lasting no more than one year,
c.
Have required no more than one corticosteroid injection, not required surgery or
cast immobilisation,
d.
No pain at rest or with activity, including activity consistent with military training
(including load carriage) for at least three months,
e.
Normal dynamic functional assessment.102
215. Candidates who do not meet the above criteria are UNFIT due to the risk of further
episodes exacerbated by load carriage, covering distances on foot or issued footwear.
101 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
102 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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216.
Sever’s disease (inflammation of the achilles tendon at its insertion).
Candidates who have been symptom-free for at least 12 months and have been able to
undertake activity comparable with military training (including weight carriage) for three
months are FIT. Candidates not meeting these criteria are UNFIT as there is a significant
risk of deterioration and recurrence during training and service, which may require
extended non-operative and occasionally surgical treatment.
217.
Foot joint fusions. Candidates who have undergone fusion surgery of any large joint
of the hindfoot or midfoot are UNFIT. Military service places high demands on the foot
including weight carriage across rough ground and adopting fire positions. The ability of
the foot to accommodate to rough and the increased strain on adjacent joints places the
candidate both at higher risk of injury during training and of further joint problems in the
future.
Foot fractures (broken bones of the foot)
218.
Fractures of the talus, calcaneum, navicular, cuboid or cuneiform bones.
a.
Flake avulsion fractures of navicular, calcaneum and / or navicular. These
fractures may be treated as severe ankle sprains. Candidates are FIT if they have
made a full recovery, have no limitation of movement, and are symptom-free during
activity comparable with military training for three months. Candidates with persistent
symptoms are UNFIT as the symptoms are likely to be exacerbated by military
employment.
b.
Fracture of the bones of the hind or midfoot, including osteochondral
lesions of the talus. Candidates known to have an additional or accessory bone in
the hind or midfoot and who are symptom-free are FIT. Candidates who have had a
cuboid fracture or isolated extra-articular calcaneal fracture and meet all the below
criteria are FIT:
(1) Twenty-four months post injury,
(2) Discharged from follow up,
(3) Symptom-free with a full range of subtalar joint motion and a normal heel
pad,
(4) No pain at rest or with activity, including activity consistent with military
training (including load carriage over uneven ground) for at least three months,
(5) Normal dynamic functional assessment.103
c.
Candidates who have any other fracture of the bones of the hind or midfoot,
including osteochondral lesions of the talus, are UNFIT due to the likelihood of
degenerative change causing persisting or worsening symptoms, and stiffness or
instability causing further injuries.
d.
Lisfranc fracture-dislocations (Lisfranc injuries). The most common type of
dislocation involving the foot, these involve dislocation of the articulation of the tarsus
103 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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with the metatarsal bases. Candidates are FIT, provided they meet all the following
criteria:
(1) Discharged from treatment follow up,
(2) Symptom-free with a full range of subtalar joint motion and a normal heel
pad,
(3) No pain at rest or with activity, including activity consistent with military
training (including load carriage over uneven ground) for at least three months,
(4) Normal dynamic functional assessment.104
e.
Candidates not meeting these criteria are UNFIT due to a significant increased
risk of developing symptomatic joint damage with military activity, which will need
extended non-operative or even surgical treatment.
f.
Metatarsal fracture, including stress fracture. Candidates who meet all the
following criteria are FIT:
(1) At least six months since injury,
(2) Discharged from follow up,
(3) Fully rehabilitated,
(4) No pain at rest or with activity, including activity consistent with military
training (including load carriage over uneven ground) for at least three months,
(5) Normal dynamic functional assessment105,
(6) For stress fractures, no more than one episode overall.
g.
Candidates who do not meet these criteria are UNFIT due to a significant
increased risk of deterioration during training which will need extended non-operative
or even surgical treatment.
Conditions of the toes
219.
Hallux rigidus (arthritis of the big toe). Candidates with hallux rigidus due to joint
degeneration or fusion are UNFIT. The rigid position of the toe affects safe adoption of a
range of firing positions, running and weight carriage and surgical treatment will not
improve this. There is also an increased risk of degeneration of adjacent joints.
220.
Hallux valgus (bunion). Candidates should be assessed according to the criteria
below.
a.
Symptom-free without treatment. Candidates who are symptom-free with no
over-riding or callosity of the second toe and no foreseeable issues with military
footwear are FIT.
104 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
105 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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b.
Symptom-free after treatment by corrective osteotomy. Candidates who
meet all the following criteria are FIT:
(1) At least 12 months post corrective osteotomy,
(2) Fully rehabilitated and discharged from follow up,
(3) Pain free with normal range of movement,
(4) No foreseeable issues with military footwear,
(5) No pain at rest or with activity, including activity consistent with military
training (including load carriage over uneven ground) for at least three months,
(6) Normal dynamic functional assessment.106
c.
Candidates who do not meet the criteria above are UNFIT due to the likelihood
that symptoms will be exacerbated by military service and the requirement for
specialist footwear.
221.
Symptomatic or loss of motion in the 1st MTP joint. Candidates with symptomatic
hallux valgus or loss of motion in the 1st MTP joint due to surgery are UNFIT as any
symptoms are likely to be exacerbated by military training and service.
222.
Hammer, mallet and clawed toes. Candidates with mild abnormalities without a
history of symptoms are FIT. Candidates with lesser toe anatomical abnormalities who
have undergone corrective surgery and meet all the following criteria are FIT:
a.
At least 12 months post-surgery,
b.
Fully rehabilitated and discharged from follow up,
c.
Pain free with normal range of movement,
d.
Have undertaken at least three months activities comparable to military training,
e.
No foreseeable issues with military footwear,
f.
No pain at rest or with activity, including activity consistent with military training
(including load carriage over uneven ground) for at least three months,
g.
Normal dynamic functional assessment.107
223. Candidates with symptomatic clawed, hammer or mallet toes, or toes that cannot be
accommodated in standard military footwear, are UNFIT. Military service places high
demands on the foot including weight carriage across rough ground and adopting fire
positions. Custom footwear cannot be reliably provided when deployed.
106 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
107 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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224.
Toe fractures (broken toes). Candidates who are symptom-free and meet all the
following criteria are FIT:
a.
Pain free with normal range of movement,
b.
No pain at rest or with activity, including activity consistent with military training
(including load carriage over uneven ground) for at least three months,
c.
Normal dynamic functional assessment.108
225. Candidates with symptoms are UNFIT as these conditions are likely to be worsened
by prolonged standing, marching and / or load carrying whilst wearing military footwear.
226.
Loss of toes. Candidates should be assessed according to both the functional
impact of amputation of the toe and the cause of the loss. Candidates with the loss of more
than one toe at, or distal to the metatarsophalangeal joint (MTPJ) or loss of the great toe
distal to the interphalangeal joint (IPJ) are FIT. Candidates with loss of more than one toe,
or loss of the great toe at or proximal to the IPJ who meet all the following criteria are FIT:
a.
At least 12 months post-surgery, if undertaken,
b.
Fully rehabilitated and discharged from follow up,
c.
No pain at rest or with activity, including activity consistent with military training
(including load carriage over uneven ground) for at least three months,
d.
Normal dynamic functional assessment.109
227. Candidates who do not meet the above criteria are UNFIT due to the likelihood that
symptoms will be exacerbated during service or training and require operative or non-
operative treatment.
Other conditions affecting the lower limb
228.
Leg length discrepancy. The following applies:
a.
Discrepancy of 2.0cm or less. Candidates with a discrepancy of 2.0cm or less
are FIT provided the functional assessment is normal, they are symptom-free and
can achieve activity comparable with military training for a minimum of three months.
Candidates may use an in-shoe orthotic but should not require bespoke footwear.
b.
Discrepancy of greater than 2.0cm. Candidates with a discrepancy of greater
than 2.0cm, are UNFIT. This degree of discrepancy is likely to cause a reduction in
function and require the use of bespoke footwear.
108 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
109 See Annex B, Guidelines for the conduct of a pre-service medical assessment.
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Annex L
PSYCHIATRY PRE-ENTRY
1.
General principles for assessing candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry are:
a.
Function. A candidate must have the cognitive function, in all military
environments, to safely and effectively perform their military role,1 which involves
safety critical tasks including weapon handling, operating vehicle and machinery,
decision making and managing sensitive information. This may be affected by any of
the following aspects of mental capacity and emotional stability:
(1) Emotional regulation (managing negative feelings).
(2) Motivation.
(3) Thought Disorder (disorganised thinking).
(4) Abnormal perceptions (seeing / hearing things that are not there).
(5) Cognition (understanding & learning).
(6) Concentration (focusing attention).
(7) Insight (self-awareness).
(8) Judgement.
(9) Impulsivity (acting without thinking).
(10) Fatigue (tiredness).
(11) Resilience (the ability to cope / adapt).
(12) Executive function (planning and organisation).
b.
Prognosis. For many mental health disorders, a previous episode increases
the likelihood of further episodes and persisting or severe stress acts as an
independent risk factor. In general, consideration should be given to the likelihood of
recurrence in the context of military service, the implications of recurrence for the
candidate and others, and operational effectiveness.
c.
Medical support requirements. Where a candidate is at increased risk of a
mental health condition, the condition should be manageable within resources readily
available in the deployed environment.
2.
Exceptional considerations. Criteria within each condition have been outlined to
determine candidates FIT or UNFIT. Where there is any doubt, advice should be sought
1 This includes but is not limited to: acceptance of hierarchy and discipline; maintaining physical fitness; living and working in close
proximity to others; short notice taskings with potential separation from family and / orsupport structures; safety critical tasks including
the use of weapons and handling sensitive information; exposure to austere environments and demands of operational deployment.
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from the single Service Medical Entry Staff (sSMES) 2. Additionally, for each condition
which requires service-approved specialist opinion, the resultant FIT or UNFIT outcome
will be determined by sSMES.
3.
Mental health in adolescence. Mental health symptoms in adolescence should be
carefully assessed to distinguish between proportionate reactions to life stressors and
diagnosable mental health disorders. If a candidate has recovered to demonstrate a
significant period (12 months or more) of good mental health and stability in socio-
occupational function, in the absence of co-morbidities (such as anxiety, sleep disorders,
addiction, violence, self-harm and physical health conditions), candidates may be referred
for single Service Medical Entry Staff (sSMES) opinion.
4.
Mental health in pregnancy, childbirth, or the puerperium. Candidates who
experience a mental health disorder during pregnancy, childbirth or the puerperium should
be assessed against the standards for the diagnosed disorder.
Additional considerations for psychiatric conditions
5.
Current psychological illness. Candidates with current mental disorder or
dysfunctional behaviour (with or without formal diagnosis) are UNFIT. Such candidates are
unlikely to be able to perform in training and the condition is likely to be exacerbated by
military service.
6.
Multiple diagnoses (comorbidity). Where a history of multiple common mental
health disorder (CMHD) diagnoses exist, this needs consideration of the possibility of an
underlying diagnosis that makes the candidate UNFIT. Candidates with a history of
multiple conditions can be raised to sSMES for further consideration. The resultant FIT or
UNFIT outcome will be determined by sSMES. A specialist assessment by a consultant
psychiatrist may be required.
7.
Diagnostic criteria. The diagnostic criteria used in this document are based on the
International Classification of Diseases and Disorders Index 11 (ICD-11) under ‘06 Mental,
behavioural or neurodevelopmental disorders’3. Prognostic information is based on the
relevan
t National Institute for Clinical Excellence (NICE) guidelines, where available.
Diagnoses must be made by clinicians with the appropriate level of skills, qualifications,
and experience to make the diagnoses in question. Consideration should be given as to
whether previous diagnoses meet the current diagnostic thresholds, against which the
current fitness standards are set.
The impact of specific psychiatric conditions
Neurodevelopmental disorders
8.
Candidates with a history of neurodiverse traits who have not received a clinical
diagnosis and have evidence of acceptable social functioning are FIT, provided there is no
increased risk that expression of the traits could impair military performance. Where there
is doubt the candidate should be referred to sSMES for determination of fitness.
9.
Autism spectrum disorder (ASD) 6A02. ASD symptoms can cause significant
functional impairment in a wide range of military settings. This includes impaired ability in
social interaction, communication and difficulty adapting to unpredictable situations.
2 Delegated Authority arrangements may apply.
3 https://icd.who.int/browse11/l-m/en
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Difficulties may become more marked with the increased social demands and
responsibility that come with promotion and may impact career progression. Individuals
with certain autistic traits are more vulnerable to common mental health disorder (CMHD).
Candidates diagnosed with ASD whose symptoms have no significant impact on
academic, occupational or social function and who need no ongoing specialist support
should be referred to sSMES to determine if they are FIT. Candidates needing support
from a specialist autism service or who have symptoms impacting on their academic,
occupational or social function are UNFIT4 because military employment and / or
deployment is likely to exacerbate symptoms and result in the candidate being unable to
carry out their duties. If an ASD diagnosis is revised in later life by a specialist autism
service, the candidate should be referred to sSMES for determination of fitness.
10.
Attention deficit hyperactivity disorder (ADHD) 6A05. ADHD symptoms include
inattention, hyperactivity and impulsivity which can negatively impact function in the
military environment, including ability to perform safety critical tasks. Candidates with
ADHD who meet all the following criteria are FIT:
a.
No evidence of past psychiatric co-morbidities, including substance abuse.
b.
Not used medication for the preceding 12 months without adverse impact on
function.
c.
Demonstrate evidence of function compatible with military employment for at
least 12 months.
11. Other candidates are UNFIT due to the risk of poor decision making, risky behaviour
and inability to safely conduct their military role, as well as medical support requirements.
12.
Disruptive behaviour or dissocial disorders; personality disorders and related
traits; paraphilic disorders; factitious disorders. These conditions indicate enduring
patterns of interpersonal behaviour. Candidates with a diagnosis in this group are UNFIT
due to the importance of effective interpersonal functioning and their negative impact on
others, particularly regarding operational effectiveness and close-quarter living.
Psychotic disorders
13.
Schizophrenia or other primary psychotic disorders5. Psychotic disorders
involve symptoms (such as delusions, hallucinations and thought disorder) that cause
severe behavioural disturbance with little or no warning and involve either high risk of
recurrence or persistence, even with treatment, rendering the candidate unsuitable for
service. All candidates with a current or past history of psychotic disorder are UNFIT.
14.
Other psychotic disorders. Candidates who develop a psychiatric disorder
associated with pregnancy, childbirth, or the puerperium, with psychotic symptoms, are
UNFIT due to the risk of recurrence. Candidates experiencing psychotic symptoms
secondary to general medical and brain conditions are assessed against the underlying
medical condition (as per Delirium and substance use paragraphs).
Mood disorders
4 Tri Service consultant psychiatrist consensus
5 ICD-11 differentiates ‘primary psychotic’ disorders excluding identified organic causes. General medical and brain conditions producing
psychotic symptoms are coded ‘6E61 Secondary psychotic syndrome’, and those related to psychoactive effects of substances including
medication are coded under ‘Substance-induced psychotic disorders.
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15.
Single episode depressive disorder, mild / moderate(ICD 11 Mild)
(ICD 11
Moderate) without psychotic symptoms 6A70.0-6A70.1. Candidates whose episode has
lasted for less than two years and remained asymptomatic without relapse following the
completion of all treatment for at least one year, are FIT.6
16.
Single episode depressive disorder, severe (ICD 11 Severe)
without psychotic
symptoms 6A70.3. Candidates whose episode has lasted for less than two years and
who have remained asymptomatic without relapse following the completion of all treatment
for at least two years, are FIT.7
17. All other diagnosed mood disorders, including
Recurrent Depressive Disorder
6A71, and bipolar and related disorders are UNFIT because of the high risk of relapse and
significant impact on military employability.
Anxiety or fear-related disorders
18.
Generalised anxiety disorder 6B00, Panic disorder 6B01, Agoraphobia 6B02,
Specific phobia 6B03 and Social anxiety disorder 6B04. These disorders are
characterised by excessive fear, anxiety and related behavioural disturbances, with
symptoms that are severe enough to result in significant distress or significant impairment
in personal, family, social, educational, occupational, or other important areas of
functioning. Individuals who develop these disorders early in life have a worse prognosis,
which if left untreated may persist for many years. Candidates who experience symptoms
for two years or less and are fully recovered without relapse following the completion of all
treatment (including medication) for at least one year are FIT.8 Candidates presenting with
a history of two or more episodes are UNFIT, because anxiety disorders have a high risk
of relapse and significantly impair military employability.
Obsessive-compulsive (F42) or related disorders
19. Candidates with a diagnosis of obsessive-compulsive or related disorders (including
hypochondriasis) are UNFIT as these disorders have a high risk of relapse and are likely to
impact on military employability. For transient tic disorders see Annex G Neurology.
Stress-related disorders
20.
Post-traumatic stress disorder (PTSD) 6B40. Candidates with a single episode of
non-complex PTSD lasting less than two years with a cause unlikely to be triggered by
military employment, with complete resolution of symptoms and without relapse for a
period of at least two years are FIT.9 Candidates with recurrent episodes of PTSD are
UNFIT due to the risk of developing a further stress-related disorder affecting fitness for
service.
21.
Complex post traumatic stress disorder (complex PTSD) 6B41. Candidates with
a history of complex PTSD are UNFIT due to the risk of severe problems with emotional
regulation such as violent outbursts, reckless or self-destructive behaviour, dissociative
symptoms when under stress, and emotional numbing.
6 Tri Service consultant psychiatrist consensus.
7 Tri Service consultant psychiatrist consensus.
8 Tri Service consultant psychiatrist consensus.
9 Tri Service consultant psychiatrist consensus.
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22.
Adjustment disorder 6B43. (ICD 11 Adjustment disorder) If symptoms of
adjustment disorder persist for longer than six months after the identified stressor has
ended, other diagnoses should be considered. Candidates with a single episode, with an
identified precipitating stressor who remain fully recovered for at least one year10 are FIT.
Candidates with more than one episode are UNFIT as they are more likely to develop a
stress related disorder in military employment.
Dissociative disorders
23. Dissociative states are characterised by ‘functional’ neurological symptoms (not
consistent with a recognised disease), multiple identities, amnesia, and trance states.
Candidates with dissociative disorders are UNFIT because the individual will be unable to
function reliably and perform their military role safely and effectively.
Eating disorders
24.
Anorexia nervosa 6B80. Candidates with a current or previous diagnosis are UNFIT
because it has a poor prognosis11 and military life is likely to exacerbate the symptoms and
the physical risks associated with malnourishment, including the risk of musculoskeletal
injury.
25.
Bulimia nervosa and 6B82 Binge eating disorder 6B81. Candidates with a single
episode, who have made a full recovery for one year, are FIT. Candidates with two or
more discrete episodes are UNFIT due to the risk of relapse and impact on military
employability.
Disorders of bodily distress or bodily experience
26. Candidates with a history of bodily distress disorders (previously categorised under
somatisation) are UNFIT because the individual will be unable to reliably function and
perform their military role safely and effectively.
Disorders due to substance use (including alcohol)12 27.
Harmful substance use. Candidates with a history of harmful use13 of substances
(including alcohol14), not amounting to dependence, with evidence of continued abstinence
for at least two years (including normalisation of abnormal blood parameters) and without
evidence of comorbid mental disorder are FIT.
10 Tri Service consultant psychiatrist consensus.
11 Although 20% make a full recovery and do not relapse in the future, it is not currently possible to reliably distinguish this group from
those relapse and remit or who remain severely ill.
12 Examiners are not obliged to inform recruiting staff of a history of illicit substance use.
13 Harmful use refers to one or more of the following: (1) behaviour related to intoxication; (2) direct or secondary toxic effects on body
organs and systems; (3) a harmful route of administration; (4) harm to the health of others.
14 The prognosis of those who have been diagnosed with harmful use of alcohol not amounting to dependence is variable and the risk of
dependence remains.
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28.
Substance dependence. Candidates with a previous diagnosis of substance
dependence (including alcohol), with evidence from an addiction service of absolutely no
substance15 use for at least three years16 prior to application are FIT.17
29.
Substance-induced psychotic disorder. Candidates with a history of a single
episode of psychotic symptoms related to substance use are FIT provided they meet all
the following criteria:
a.
The episode was a brief episode of psychosis and fully resolved once the effect
of the substance had worn off,
b.
There is no evidence of substance use since and for at least three years to
ensure there is no substance dependence,
c.
The episode was at least three years ago to ensure there is no underlying or
subsequent mental disorder.
Disorders due to addictive behaviours (unrelated to substance use)
30.
Addictive behaviours. Candidates with a history of hazardous addictive behaviours,
(such as gambling or gaming behaviours), without impairment in socio-occupational
functioning, or criminality and evidence of remission for three years or more18 are FIT. If
these conditions are not met then the candidate is UNFIT because of the potential risks for
associated behavioural disturbance.
31.
Addictive behaviour disorders. Candidates previously diagnosed with an addictive
behaviour disorder by a specialist service are UNFIT because of the high relapse rate.
Impulse control disorders (ICD 11 code)
32.
Candidates previously diagnosed with an impulse control disorder are UNFIT
because of the uncontrollable nature of these behaviours and their negative impact on
others.
Neurocognitive disorders
33.
Delirium 6D70. Candidates with a history of delirium due to an underlying medical
condition that has fully resolved are FIT.
34.
Amnestic disorder (acquired memory loss) 6D72. Candidates with this diagnosis
are UNFIT because the individual would be unable to reliably function and perform their
role safely and effectively.
Intentional self-harm
35. Candidates with a single episode of intentional self-harm (by any specified means;
most commonly cutting, scraping, burning, biting, hitting or exposure to harmful effects of
15 This includes Candidates who are prescribed methadone, naltrexone or buprenorphine as part of maintenance or detoxification
therapy.
16 Tri Service consultant psychiatrist consensus
17 Those who have been alcohol dependent have a 70% chance of relapse, with only 30% remaining abstinent or being able to drink in a
controlled way.
18 Tri Service consultant psychiatrist consensus
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substances e.g. medicines or poisons) in the absence of underlying psychiatric disorder
are FIT provided they meet all the following criteria:
a.
Symptoms lasted no more than three months,
b.
The episode was more than two years ago,
c.
Only minor physical harm was caused.
36. All other cases of intentional self-harm in adulthood, including interrupted, aborted or
unsuccessful suicide attempts, are UNFIT due to the increased risk of repetition and death
by suicide.
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Annex M
DENTAL AND ORO-MAXILLOFACIAL PRE-ENTRY
1.
General Principles for assessing candidates against this annex. The general
principles against which a candidate is assessed as FIT for entry, with respect to oral
health are:
a.
Function. A candidate must have the oral function and stability (speech and
chewing function) to:
(1) Perform their role safely and efficiently in all military environments.
b.
Prognosis. Where a candidate is found to have a has pre-existing oral health
condition(s) or is at increased risk of oral health morbidity, the following general
criteria should be met in addition to the relevant specific paragraph in policy, it should
not:
(1) Place a significant foreseeable demand on military primary dental care
resources.
(2) Be foreseeably exacerbated by military service.
(3) Pose a significant risk of future temporary or permanent loss of function.
(4) Pose a risk of sudden deterioration / incapacitation without reasonable
warning.
c.
Medical support requirements. Where a candidate has a pre-existing or
increased risk of a dental condition, there must be no reasonably
foreseeable requirement for medical / dental care within the deployed location
beyond deployed Primary Healthcare (or equivalent). The medical / dental condition
must be stable with treatment. Should loss of medication occur for ≤ one week this
should not lead to clinical deterioration in the condition or functional degradation
during that time. In the deployed environment the condition should not foreseeably
impact military medical resource.1
2.
Exceptional circumstances. Criteria within each condition has been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from the Single Service Medical Entry Staff (sSMES).2
Uncontrolled / untreated oral disease
3.
Candidates with mild / moderate dental disease(s) or other oral conditions that are
treatable by a general dental practitioner, are FIT. These candidates should have:
a.
An acceptable and functional occlusion of either natural teeth or well-fitting
standard removable or fixed prostheses.
1 Assessing clinicians should be aware of pericoronitis (impacted Wisdom Teeth).
2 Delegated Authority arrangements may apply.
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b.
Healthy gums (pink and stippled gingivae with an absence of swellings,
discharge, acute bleeding or tooth mobility), and oral mucosa, with no obvious soft
tissue disease or deformity.
4.
Candidates with gross oral neglect are UNFIT.3 This is because these candidates
would place a significant foreseeable demand on military primary dental care resources.
5.
In cases of doubt, the candidate should be referred to sSMES, who may refer to a sS
or HQ DPHC Dental Officer for further assessment of oral disease.4
Dental phobia
6.
Candidates
who cannot tolerate routine primary care dentistry under local
anaesthetic and require conscious sedation or general anaesthesia are UNFIT. This is
because anaesthesia requirements cannot be supported within an operational environment
or routinely within primary care. In cases of doubt, the candidate may be referred to
sSMES, who may refer to a sS or HQ DPHC Dental Officer.
Dental genetic disorders
7.
Amelogenesis imperfecta (condition affecting enamel) and dentinogenesis
imperfecta (condition affecting dentine). Candidates with a history of hypocalcified
amelogenesis imperfecta (AI) or dentinogenesis imperfecta (DI) must be referred to
sSMES, who should refer to a sS or HQ DPHC Dental Officer for further assessment to
determine if the candidate is FIT. This is because candidates with these specific genetic
conditions often have wide-ranging, multi-disciplinary treatment needs. Whilst the dentition
may be treated or remediable,5 the possibility of osteogenesis imperfecta6 must be
considered in candidates presenting with DI.
Dental and facial abnormalities
8.
Candidates with corrected cleft-lip and / or hard / soft palate. See Annex B –
ENT Para 23.
Facial fracture and orthognathic surgery
9.
Candidates with retained metalwork are FIT provided they are symptom-free, with
confirmation of fracture healing, and no residual deformity. Candidates with a history of
facial fractures, including those who have undergone orthognathic surgery and who
continue to have symptoms, are UNFIT until these have resolved. This is because
candidates undergoing bone healing are at a high risk of fracture for up to six months
following surgery. Where there is doubt, cases may be referred to sSMES, who may refer
to a sS or HQ DPHC Dental Officer.
Orthodontic treatment
3 This is defined as a patient with multiple open carious teeth (it should be noted by non-dental assessor that anterior incisor and canine
teeth are usually the last teeth to be affected and is an indicator of high levels of disease), uncontrolled severe periodontal disease
(2017 Periodontal disease classification), severe non-carious tooth surface loss (6 or more teeth with loss of enamel and extensive
dentine exposure), periradicular disease (affecting more than 2 teeth), atypical facial pain or unstable temporomandibular joint disorder.
4 Service Dental Officers asked for opinion, should determine TN (Treatment Need) by visual examination only, radiographs are not to
be taken. Utilising the DPHC(Dental) Project Molar agreement of 2 hours of dentistry per recruit, if the opinion is that disease cannot be
stabilised within 2 hours i.e. >TN4, the candidate is to be determined UNFIT.
5 Further advice / assessment by a Service Restorative Dentistry specialist may be required.
6 Including musculoskeletal and ophthalmological abnormalities.
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10. Active orthodontic treatment involves the use of both fixed and removable
appliances. On completion of active treatment, the use of fixed or removable retention
devices is frequently required for enduring stability.
11.
Active orthodontic treatment. Candidates who are undergoing active orthodontic
treatment are UNFIT until treatment is complete, as confirmed by a report from the treating
practitioner.7,8 This is because of the difficulties of continuing with orthodontic treatment
during military service.
12.
Active appliances. The removal of active appliances simply to facilitate Service
entry is not advised. Where a treatment course has not been completed cases may
be referred to sSMES, who may refer to a sS or HQ DPHC Dental Officer.
a.
Removable orthodontic aligners. Candidates who are undergoing removable
orthodontic aligner treatment are FIT. However, the duty of care for this treatment
must be preserved by the original dental provider (NHS / private).
b.
Fixed and removable retention devices. Fixed and removable retention
devices required for enduring stability on completion of active treatment, must
continue to be worn and are FIT.
Orthodontic Treatment for HM Forces sponsored students and members of
University Military Units9
13. Entry to these establishments is generally constrained by age. Recruits to these
establishments are FIT if treatment can be managed within the constraints of the training
timetable.10 Individuals applying must make arrangements to continue orthodontic
treatment with their civilian orthodontist / dental practitioner for the duration of their training
and treatment should be scheduled to be completed by the end of Phase one training.
Elective aesthetic treatment
14. Candidates who have had elective aesthetic treatment to five or fewer teeth are FIT.
Candidates who have had elective aesthetic treatments to six or more teeth are to be
referred to the sSMES, who may refer to a sS or HQ DPHC Dental Officer for further
assessment to determine if the candidate is FIT.11 This is because elective aesthetic dental
treatment conducted to a poor standard is complex and resource intensive to manage,
therefore cannot be addressed within military primary dental care resources.
Dental implants
7 Further advice / assessment by a DPHC Orthodontist may be required.
8 An acceptable end point to treatment may be considered as the position of teeth being beneath the NHS criteria for treatment (Index of
Orthodontic Treatment Need (IOTN) 3 and below, aesthetic component under 6.
9 Including but not limited to Army Foundation College (Harrogate), URNU, UOTC, UAS, Sixth Form and University Scholars and
Bursars.
10 Further advice / assessment by a DPHC Orthodontist may be required.
11 Service Dental Officers asked for opinion, should determine TN (Treatment Need), endodontic status and the overall maintenance of
restored teeth where complex elective treatment has been undertaken. Utilising the DPHC(Dental) Project Molar agreement of 2 hours
of dentistry per recruit, if the opinion is that disease cannot be
stabilised within 2 hours i.e. >TN4, the candidate is to be determined
UNFIT.
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15. Candidates wishing to enlist who have had implant treatment are FIT.12 Any
implanted prosthetic structure should have healthy associated mucosa.
12 It should be noted that Defence Primary Healthcare only supports Dentsply-Astra, Straumann, Nobel and 3i BioMet implants systems.
Therefore, those individuals who have had implant treatment using alternative systems would have to have to seek private treatment in
the event of replacement / repair.
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Annex N
OTHER CONDITIONS PRE-ENTRY
1.
General principles for assessing candidates against this Annex. The general
principles against which a candidate is assessed as FIT for entry are:
a.
Function. A candidate must have the physical and cognitive function, in all
military environments, to safely and effectively:
(1) Perform their military role.
(2) Operate their personal weapon.
b.
Prognosis. Where a candidate has a pre-existing or is at increased risk of a
medical or surgical condition, it should not:
(1) Be foreseeably exacerbated by military service (physically demanding
activities, blunt / penetrating trauma, extremes of heat / cold, atmospheric
pressure, UV light or environmental conditions).
(2) Pose a significant risk of future temporary or permanent loss of function.
(3) Pose a risk of sudden deterioration / incapacitation without reasonable
warning
(4) Pose an unacceptable employment risk to self and / or others.
c.
Medical support requirements. Where a candidate has a pre-existing or
increased risk of a condition, there must be no reasonably foreseeable requirement
for medical care within the deployed location beyond deployed Primary Healthcare
(or equivalent). The medical condition must be stable with treatment. Should loss of
medication ≤ one week this should not lead to clinical deterioration in the condition or
functional degradation during that time. In the deployed environment the condition
should not foreseeably impact military medical resource.
2.
Exceptional considerations. Criteria within each condition have been outlined to
grade a candidate as FIT or UNFIT. Where there is any doubt, advice should be sought
from single Service Medical Entry Staff (sSMES)1. The resultant FIT or UNFIT outcome will
be determined by sSMES.
Haematology (blood diseases and conditions)
3.
Chronic (long-standing) blood diseases. These conditions may be exacerbated by
military service (in particular, physically demanding activities, blunt / penetrating trauma,
extremes of heat / cold, atmospheric pressure) and pose an increased demand on military
medical care. Candidates with the following conditions are UNFIT:
a.
G6PD deficiency.
1 Delegated Authority arrangements may apply.
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b.
Hereditary spherocytosis.
c.
Homozygous (sickle cell anaemia) or compound heterozygous sickle cell
disease.
d.
Alpha (α) or Beta (β) thalassaemia (for trait, see below).
e.
Inherited or irreversible acquired platelet or clotting disorder resulting in
defective coagulation.
4.
Sickle cell trait (Hb A / S). Candidates with sickle cell trait (SCT) have a higher risk
of exertional rhabdomyolysis (muscle damage) and other conditions such as
hyposthenuria (reduced ability to concentrate urine), and blood clots (including deep vein
thrombosis and pulmonary embolism). A rare complication of SCT is exertional collapse
associated with sickle cell trait (ECAST). This can result in serious illness and death. The
following applies to all candidates:
a.
All candidates must be screened for SCT using an appropriate questionnaire
and, where required, diagnostic test.
b.
Candidates who have SCT are FIT with a permanent E2 marker (to reflect the
risks described above and the requirement for appropriate mitigation and
communication to the single Service employer), provided they meet all the following
criteria:
(1) There must be no history of ECAST. Candidates with a history of ECAST
are UNFIT as the condition is foreseeably exacerbated by military service
(physically demanding activities and extremes of heat) and there is a risk of
recurrent ECAST which may be life-threatening,
(2) There must be no history of exertional rhabdomyolysis or other significant
complication related to SCT. Candidates with a history of exertional
rhabdomyolysis (including history of passing black urine (likened to ‘flat cola’)
after exercise) or other significant complication related to SCT are UNFIT as the
condition is foreseeably exacerbated by military service (physically demanding
activities and extremes of heat) and there is a risk of recurrence which may be
life-threatening,
(3) There must be no history of heat illness with concurrent SCT. Candidates
with a history of heat illness with concurrent SCT are UNFIT due to the elevated
risk of recurrent heat illness which may be life-threatening.
5.
Alpha (α) or Beta (β) thalassaemia trait. The following applies:
a.
Candidates with heterozygous α or β thalassaemia traits are asymptomatic with
an altered blood picture (hypochromic – low MCH, microcytic – low MCV) and little or
no anaemia. Candidates with asymptomatic, isolated α or β trait conditions are FIT.
b.
Candidates with any thalassaemia trait in combination with sickle cell trait (for
example, Hb S / C or Hb S / D) have disease varying in clinical severity and require a
service-approved Haematology opinion and referral to sSMES for a determination of
FIT / UNFIT.
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6.
Thromboembolic disease (formation of blood clots in blood vessels). A previous
history of blood clots (including deep vein thrombosis (DVT) or pulmonary embolus (PE)) is
the strongest predictor for a future clot event2.
a.
Candidates with a clear history of provoked DVT or PE, who no longer require
treatment or clinical review are FIT, subject to sSMES reviewing the likelihood of the
provoking event recurring during military service.
b.
Candidates with a previous history of other thromboembolic events (including
unprovoked DVT or PE), whether on treatment or not, are UNFIT as risk of
recurrence is increased by military service (in particular dehydration and prolonged
travel times on deployment). For stroke and cardiac conditions refer to Annex C
Cardiology.
7.
Thrombophilia (tendency to form blood clots in the blood vessels). Testing
should not be initiated for the purposes of employment screening. The following applies:
a.
Candidates with antiphospholipid antibodies who do not require anticoagulation
are FIT.
b.
Candidates with antiphospholipid syndrome (APS / APLS) are UNFIT due to the
high risk of future thrombotic events which would require significant medical support.
c.
Candidates with Factor V Leiden and / or Prothrombin 20210A expressed in
heterozygote form, who have not had a thrombotic event (e.g. DVT or PE) and who
do not require anticoagulation are FIT.
d.
Candidates with Factor V Leiden and / or Prothrombin 20210A expressed in
heterozygote form, who have had a thrombotic event (e.g. DVT or PE) or who require
anticoagulation are UNFIT as they are at higher risk of future thrombotic events which
would require significant medical support.
e.
Candidates with Factor V Leiden and Prothrombin 20210A expressed in
homozygote form and present individually or in combination are UNFIT as they are at
higher risk of future thrombotic events which would require significant medical
support.
8.
Anti-coagulation therapy (blood-thinning medication).
a.
Candidates who previously required anti-coagulation are FIT provided the
underlying reason for the anti-coagulation is not disqualifying.
b.
Candidates who require any anti-coagulation therapy3 (including warfarin and
direct oral anti-coagulants4), are UNFIT. This is due to the risk of suffering a clot
should they be prevented from taking their medication due to loss of re-supply when
deployed on operations, and the additional / higher levels of medical care required in
the event of injury.
2 Arachchillage DJ, Mackillop L, Chandratheva A, Motawani J, MacCallum P, Laffan M. Thrombophilia testing: A British Society for
Haematology guideline. Br J Haematol. 2022 Aug;198(3):443-458. doi: 10.1111 / bjh.18239.
3 Including where advised for long distance travelling prophylaxis
4 This excludes anti-platelet medication (such as aspirin or clopidogrel)
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9.
Idiopathic thrombocytopenic purpura (ITP) (low platelet disorder of unknown
origin). Candidates with resolved ITP are FIT E2 (to reflect the need for extra vigilance in
the event of possible recurrence) provided they meet all the following criteria:
a.
In remission for more than two years,
b.
Symptom-free (no excessive or easy bruising),
c.
Platelet count is between 100 and 150x109 / l. Evidence of three platelet
measurements spanning a period of at least six months is required,
d.
Intact spleen.
10. Where the above criteria are not met, candidates are UNFIT. Severe
thrombocytopenia may result in sudden blood loss and even moderate thrombocytopenia
may be associated with excessive bleeding if injured. They may require additional / higher
levels of medical care.
11.
Leukaemia. The following applies:
a.
Acute lymphoblastic leukaemia (ALL) and acute myeloid leukaemia (AML).
Candidates with a history of ALL / AML who have remained free of recurrence for a
period of five years from the completion of treatment and fulfil the requirements of the
paragraphs relating to Oncology should be referred to sSMES for a determination on
FIT E25 / UNFIT.
b.
Chronic myeloid leukaemia (CML). Candidates with a history of CML who
have been off treatment for two years6 and fulfil the requirement of the paragraphs 12
and 13 which relate to Oncology should be referred to sSMES for a determination on
FIT E26 / UNFIT.
c.
Other leukaemias. This includes chronic lymphocytic leukaemia (CLL), chronic
myelomonocytic leukaemia (CMML) and myeloproliferative neoplasms (MPNs)7.
Candidates with these forms of leukaemia are UNFIT. This is due to the risk of
relapse, and increased need for ongoing specialist medical care and surveillance.
12.
Irradiated blood components. Candidates who require irradiated blood
components8 are UNFIT. Irradiated blood components cannot be provided routinely whilst
deployed. There is a risk of potentially fatal complications should they receive non-
irradiated blood components. This risk is further increased with transfusion of non-
leucodepleted blood components, such as whole blood collected in emergencies from an
emergency donor panel.
a.
The following candidates are likely to require irradiated blood:
(1) Those who have been treated with the following drugs:
5 The purpose of the E2 marker is to highlight a need for ongoing surveillance. MedLim 1100 may apply.
6 For some individuals, discontinuation of treatment after 3-5 years in deep remission can be successful and renders the disease cured.
7 Including: chronic eosinophilic leukaemia, chronic myelogenous leukaemia, chronic neutrophilic leukaemia, essential.
thrombocythaemia, polycythaemia vera, primary myelofibrosis or chronic idiopathic myelofibrosis.
8 British Society for Haematology. Guidelines on the use of irradiated blood components. Available from: https: / / b-s-h.org.uk /
guidelines / guidelines / guidelines-on-the-use-of-irradiated-blood-components
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(a) Fludarabine.
(b) Cladribine.
(c) Pentostatin.
(d) Alemtuzumab.
(e) Other novel purine analogues and related agents until evidence of
safety emerges.
(f)
Anti-thymocyte globulin.
(2) Those with Hodgkin's lymphoma (lifelong following diagnosis).
(3) Those with Immunoglobulin A (IgA) deficiency.
(4) Where the treating specialist has recommended the requirement for
irradiated blood components.
Oncology (cancers)
13. Candidates with a history of cancer who meet all the criteria stated below should be
referred to sSMES with a clinical report outlining diagnosis, treatment provided, risks of
recurrence, risks of present or future complications from treatment given:
a.
Treatment completed and discharged from secondary care follow up, (excluding
surveillance conducted annually or less frequently).9
b.
No ongoing side-effects or functional deficit from the underlying disease or
treatment.10
c.
No requirement for irradiated blood products.
d.
Requirements outlined in relevant Annexes are met.
sSMES will consider the risk of recurrence, the impact of medical surveillance
requirements and determine FIT E211 / UNFIT.
14. Candidates who are undergoing active treatment for cancer are UNFIT because:
a.
They may not have the functional level required for worldwide service due to
side effects of the treatments such as tiredness (fatigue).
b.
The effects of some treatments may also make them more susceptible to
infections (immunocompromised).
9 Candidates who are being followed-up for the purposes of clinical trials, long-term studies into treatment or disease effects or for long-
term holistic or psycho-social issues (where no active treatment or investigations are undertaken) may be considered to meet this
criterion.
10 Certain types of chemo- and radio-therapy may cause long-term impairment to the heart and or lungs. Anthracylines, Bleomycin and
trans-thoracic radiotherapy are therapies of interest.
11 The purpose of the E2 marker is to highlight a need for ongoing surveillance. MedLim 1100 may apply.
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c.
Continuity of clinical care may be compromised by military service, resulting in
adverse health outcomes for the candidate.
Human Immunodeficiency Virus (HIV) and hepatitis viruses
15. Routine pre-employment screening for these conditions is not required.
16.
Human Immunodeficiency Virus (HIV). For those who declare a relevant history,
the following applies:
a.
Candidates living with HIV who are prescribed and taking antiretroviral therapy
(ART) are FIT E2, provided they meet all the following criteria and subject to sSMES
review:
(1) Have been diagnosed for at least 12 months,
(2) Are on an effective and robust treatment regimen,
(3) And for at least 6 months have consistently maintained:
(a) a CD4 count of at least 350 cells / mm3.
(b) a viral load below 50 copies per ml12.
(4) Approval has been given by military recommended specialist in HIV.
(5) Specific guidance applies to certain employment groups such as
healthcare workers13, who may be UNFIT due to the need to comply with
national patient safety guidance.14
b.
All other candidates living with HIV are UNFIT due to increased risk of
significant illness including infection and / or cancer, decompensation on military
operations, and risk of transmission to others when deployed.
17.
HIV Pre-Exposure Prophylaxis (PrEP). Candidates who are prescribed and using
HIV PrEP are FIT E2 for the duration of PrEP use, to reflect the need for regular blood
testing. Specific guidance applies to certain employment groups such as aircrew.15
18.
Human T-cell lymphotrophic virus (HTLV) 1 & 2. Candidates with a diagnosis of
HTLV are UNFIT due to the risk of immunocompromise, leading to parasitic infection, and
potential neurological deterioration.
19.
Viral hepatitis.
a.
Hepatitis A or E. Candidates with resolved hepatitis A or E are FIT.
Candidates with a current acute or chronic viral hepatitis (abnormal liver function
12 Where the test has been conducted outside the UK, with a limit of detection of less than 200 copies / ml, a UK based assay may be
requested to confirm viral load is less than 50 copies / ml.
13 JSP 950 Part 1 Leaflet 6-8-1 Defence Medical Services Uniformed and Civilian Healthcare Workers: Tuberculosis and Blood-Borne
Viruses Screening and Management
14 Integrated guidance on health clearance and the management of HCWs living with BBVs (hepatitis B, hepatitis C and HIV): April 2024
15 PrEP policy for aircrew and controller recruits is detailed
in AP1269A Lft 5-10.
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test (LFT)), or persistence of symptoms after 6 months, or objective evidence of
impairment of liver function are UNFIT due to the risk of transmission to others,
and risk of long-term liver disease.
b.
Hepatitis B. Candidates with previous hepatitis B who are hepatitis B surface
antigen negative, and with no chronic liver disease are FIT. Candidates who are
hepatitis B surface antigen positive more than 6 months after infection are UNFIT
due to the risk of transmission to others and risk of long-term liver disease.
c.
Hepatitis C. Candidates with previous hepatitis C who are polymerase chain
reaction (PCR) negative for hepatitis C at least 6 months after completing antiviral
therapy or following spontaneous clearance of infection and who have no chronic
liver disease are FIT. Candidates with a current acute or chronic viral hepatitis C
are UNFIT due to the risk of transmission to others, and risk of long-term liver
disease.
Chronic fatigue syndrome and associated conditions
20.
Infectious mononucleosis (glandular fever / Epstein-Barr Virus). Candidates are
FIT provided they meet all the following criteria:
a.
The condition lasted no longer than twelve months,
b.
There are no ongoing symptoms (including breathlessness, muscle aches,
enduring tiredness, chest pain),
c.
There have been no serious complications,
d.
They are undertaking activities compatible with military training and service for
more than three months.
21. Where Candidates do not meet the above criteria, a referral should be made to
sSMES.
22.
Other chronic fatigue syndrome and associated conditions. This includes the
following conditions: chronic fatigue syndrome, fibromyalgia (FM), myalgic
encephalomyelitis (ME), long-COVID, or post-viral fatigue syndrome (PVFS). Candidates
are FIT provided they meet all the following criteria:
a.
The condition lasted no longer than twelve months and symptoms have
resolved for at least two years,
b.
There are no ongoing symptoms (including breathlessness, muscle aches,
enduring tiredness, chest pain),
c.
They are undertaking activities compatible with military training and service for
more than three months.
23. All other candidates with active chronic fatigue syndrome or the group of associated
disorders stated above are UNFIT. High levels of physical and / or psychological demand
are associated with relapse or recurrence of symptoms. A candidate must have the
physical function, in all military environments, to safely and effectively perform their military
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role.
Conditions affected by climate
24.
Heat illness. Candidates who have experienced a diagnosed episode of heat illness
(with or without physical exertion) are FIT provided they have been shown to
thermoregulate normally during an exercise-in-heat stress test.16 All others with a history of
diagnosed heat illness are UNFIT, because this condition is foreseeably exacerbated by
military service (in particular physical exercise) and the condition poses a risk of sudden
deterioration / incapacitation. This presents a risk to life.
25.
Hypohidrosis or anhidrosis (disorders of sweating). This is an inherited condition
affecting sweating characterised by a decrease in or complete loss of sweat production in
response to an appropriate thermal or pharmacological stimulus. Candidates should be
referred to sSMES who will consider the extent of the condition and whether an exercise-
in-heat stress test is required. An inability to sweat increases a candidate’s risk of heat
injury and death.
26.
Cold injury. The following applies:
a.
Candidates with a history of Freezing Cold Injury (FCI) (including frostbite),
Non-Freezing Cold Injury (NFCI) or Cold Sensitivity whose symptoms are fully
resolved should be referred to sSMES for a determination on FIT E2 / UNFIT. E2
reflects the requirement for clinical vigilance.
b.
Candidates with symptomatic FCI, NFCI, or Cold Sensitivity are UNFIT. These
conditions pose a significant risk of future, temporary or permanent loss of function.
27.
Raynaud’s disease or phenomenon (primary or secondary), acrocyanosis,
vasospasticity, or similar conditions. These conditions result in a tendency for
extremities to change colour and / or lose sensation and / or become painful in moderately
cold conditions or when experiencing stress. Candidates with a confirmed diagnosis of
these conditions are UNFIT because of cold sensitivity and an increased risk of temporary
or permanent loss of function.
Congenital, chromosomal and genetic conditions
28. The spectrum of congenital, chromosomal and genetic conditions is broad and the
impact on military service is variable. In all cases, the general requirements stated at the
start of this Annex should be considered. Genetic testing should not be initiated solely for
the purposes of recruitment.
29.
Specified congenital, chromosomal and genetic conditions. The following
applies:
a.
Phenylketonuria. Candidates with this condition are UNFIT. Although there is
no clear evidence which provides overwhelming support for the need for lifelong
dietary treatment, regular annual clinical review remains essential. This condition
poses a significant risk of future temporary or permanent loss of function. Candidates
require specialist lifelong medical support and follow up. Dietary restrictions are
16 Such as those available at the Institute of Naval Medicine.
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generally necessary with protein supplements normally required and the military
cannot guarantee that specialist diet (lower protein) will be available17.
b.
Malignant hyperpyrexia. (1) Candidates known to have the gene / s associated with this condition18 are
UNFIT due to the elevated risk of heat injury and adverse reaction to
anaesthetic medicines. This condition is foreseeably exacerbated by military
service (in particular, physical exercise). This condition poses a risk of sudden
deterioration / incapacitation without reasonable warning. Safe delivery of
anaesthetic on operations cannot be guaranteed for these conditions and poses
a foreseeable risk to life.
(2) Candidates with a family history, but who have not been tested are UNFIT
for the reasons stated above.
(3) Candidates with a positive family history but a negative test should be
referred to sSMES for a determination on fitness.
c.
Suxamethonium sensitivity. The following applies:
(1) Candidates who are homozygous for the atypical cholinesterase gene and
have been identified as requiring special anaesthetic precautions are UNFIT as
the safe delivery of anaesthetic on operations cannot be guaranteed for this
condition and may pose a risk to life.
(2) Candidates who are heterozygous of the atypical cholinesterase gene
should be referred to sSMES for a determination on fitness.
d.
Neurofibromatosis Types 1 and 2. Candidates known to be carriers of either
of the genes associated with these conditions are UNFIT as there are associated
consequences of unpredictable onset, including intra-cerebral tumours (most
commonly optic nerve gliomas), renal artery stenosis and thyroid carcinoma. The risk
of seizures is approximately 20 times higher than that of the general population19.
The condition poses a risk of sudden deterioration / incapacitation without reasonable
warning. It may prevent the wearing of operational Personal Protective Equipment
(such as helmet or combat body armour).
e.
Hereditary cardiac conditions See Annex C Cardiology Paras 13 and 22.
f.
Hereditary gastro-intestinal cancer syndromes. See Annex E
Gastroenterology Para 22.
g.
Breast cancer (BRCA) gene carriers and equivalent risks. See Annex J
Gender Para 8.
h.
Hereditary musculoskeletal conditions. See Annex K Musculoskeletal Para
127(e).
17 From National Society for PKU ‘Management of PKU’ Feb 2004.
18 Including RYR1 and mutations of CACNA1S.
19 Adams & Victor: Principles of Neurology.
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30.
Family history of congenital, chromosomal and genetic conditions – Candidate
confirmed to not carry gene. Where there is a known family history, but the Candidate
does not exhibit the condition and has a documented negative test, they are FIT.
31.
Family history of other congenital, chromosomal and genetic conditions –
Candidate not undergone genetic testing. Where there is a known family history, but
the Candidate does not exhibit the condition and has not been tested, they are to be
referred to sSMES to determine FIT E2 / UNFIT. Genetic testing should not be initiated
solely for the purposes of recruitment. sSMES will apply the following general
considerations:
a.
The probability of the Candidate having the relevant gene / being susceptible to
the condition.
b.
The probability of developing the disease if the gene is present.
c.
The likely onset time / age of the condition.
d.
The likely rate of progression of the condition.
e.
Whether screening or surveillance is available for the condition, the frequency of
such screening and Candidate participation.
f.
Whether appropriate mitigations are available (e.g. medical, surgical
intervention). This includes whether the condition is compatible with / supportable on
deployments.
g.
Whether the condition poses a risk to life or of sudden incapacitation.
h.
The short, medium and long-term prognosis of the condition once present.
i.
Whether the condition onset or severity is likely to be accelerated by service.
j.
What impact the condition may have on the Candidate’s physical and mental
function and ability to undertake military duties.
32.
Candidates with a documented positive test result for a congenital,
chromosomal or genetic condition. The following applies:
a.
Where a Candidate has a documented positive test, they are to be referred to
sSMES for an opinion on fitness. The general considerations stated in Para 29 apply.
b.
Where a Candidate has already developed an associated condition, they should
be considered under the relevant part of Section 4 or, where there is doubt, be
referred to sSMES.
Systemic Conditions
33.
Sarcoidosis. See Annex D Respiratory Paras 16 and 17.
34.
Tuberculosis. See Annex D Respiratory Para 19.
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Immune system disorders
35.
Anaphylaxis (severe allergy). Anaphylaxis is a severe life-threatening allergic
reaction, typically to foods, insect stings / bites or medications. Dermal and systemic signs
and symptoms manifest which may include urticaria, angioedema, hypotension and
bronchospasm. It may require urgent treatment with adrenaline or hospitalisation. The
following applies:
a.
Adrenaline auto-injector. Any candidate who has to have access to an
adrenaline auto-injector is UNFIT as this is a marker for anaphylaxis risk. Rapid
access to life-saving treatment cannot be guaranteed.
b.
Medication anaphylaxis. Candidates with a history of anaphylaxis to drugs
should have a careful history taken, including whether anaphylaxis has been formally
diagnosed.
(1)
Operationally essential medications and latex. The operationally
essential medications include:
(a) Neuromuscular blocking agents (NMBAs).
(b) Intravenous (i.v.) anaesthetics.
(c) Antibiotics.
(d) Opioid analgesics (such as morphine, codeine).
(e) Non-steroidal anti-inflammatory drugs (NSAIDs) (such as ibuprofen,
diclofenac).
(f)
Local anaesthetics (such as lidocaine).
(g) Colloids (a type of intravenous fluid).
(h) Other agents likely to be used on operations.
(i)
Latex.
(2) Candidates with anaphylaxis to any of the above are UNFIT due to the
inability to guarantee avoidance of the allergen when deployed and the potential
risk to life.
(3)
Chemical, Biological, Radiation & Nuclear (CBRN) medications.
Candidates with an anaphylaxis to drugs used in prophylaxis or treatment in a
CBRN20 environment are UNFIT due to the inability to guarantee avoidance of
the allergen when deployed and the potential risk to life.
(4) Candidates with anaphylaxis to other medications, which are readily
avoidable are FIT E2 with a requirement for a NATO Medical Warning Tag
20 Including: atropine, pralidoxime, benzodiazepines including midazolam, pyridostigmine, naloxone.
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subject to sSMES opinion on suitability.
c.
Food anaphylaxis. Candidates with anaphylaxis to foodstuffs are UNFIT. This
is due to the inability to guarantee avoidance of allergen cross-contamination in
operational rations and / or catering when deployed. Where an adrenaline auto-
injector has been prescribed to manage food allergy, the Candidate is UNFIT.
d.
Insect bite / sting anaphylaxis. Candidates with a history of anaphylaxis to
insect bites / stings are UNFIT due to the inability to guarantee avoidance of the
allergen when deployed and the potential risk to life.
(1)
Venom Immunotherapy (VIT). Candidates who have completed a
programme of VIT at a British Society for Allergy and Clinical Immunology
(BSACI) clinic and are no longer required to carry an adrenaline autoinjector are
UNFIT due to the risk of the effectiveness of the therapy deteriorating over time
and the risk of an anaphylactic event occurring.
36.
Seasonal allergic rhinitis (hayfever). Candidates with hayfever are FIT provided
they meet all the following criteria:
a.
symptoms are controlled with over-the-counter non-sedating oral21,22, nasal and
/ or ocular medicine,
b.
the deliberate avoidance of allergen is not required,
c.
symptoms are not functionally disabling (in particular, vision),
d.
symptoms do not cause wheeze or require an inhaler.
37.
Birch Pollen Food Syndrome (Oral Allergy Syndrome). This is a hypersensitivity
reaction to fruits, vegetables and nuts (often referred to as plant-based foods). The
following applies:
a.
Where the trigger is a raw plant food (not including nuts). Candidates with
mild symptoms (including: itching and swelling of the lips, tongue, inside of the
mouth, ears and throat, usually within five to ten minutes of eating the allergic food
and these settle within an hour, often without any medical intervention) are FIT. In
these cases, there must be no evidence of any airway compromise or wheeze. Risk
of incapacitation is assessed as being very low.
b.
Where the trigger is cooked fruit / vegetables, any nuts (including pine
nuts and seeds), wheats, cereals, composite meal / snacks. Candidates should
have been investigated in accordance with British Society for Allergy and Clinical
Immunology (BSACI) guidance23 for confirmation of diagnosis. Candidates should be
referred to sSMES for a determination on FIT / UNFIT.
c.
Where symptoms have included throat closure, itching or swelling of
extremities, hives and / or angioedema, wheeze or difficulty in breathing,
21 Including: acrivastine, cetirizine, fexofenadine and loratadine.
22 Where montelukast is prescribed, referral should made to sSMES to evaluate impact of disease and to assess whether there are
asthma-like symptoms. In the UK, oral montelukast is only licensed for the symptomatic relief of seasonal allergic rhinitis in people with
asthma (Source: BNF, BNFC, 2023). A possible uncommon adverse effect is a neuro-psychiatric reaction.
23 The British Society for Allergy and Clinical Immunology (BSACI) .
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tachycardia or hypotension, fainting or dizziness. Candidates should have been
investigated in accordance with British Society for Allergy and Clinical Immunology
(BSACI) guidance23 for confirmation of diagnosis. Candidate should be referred to
sSMES for a determination on FIT / UNFIT.
38.
Other mild and moderate allergy. Candidates with mild allergic symptoms are FIT
provided they meet all the following criteria:
a.
symptoms are controlled with over-the-counter non-sedating oral21 22 , nasal and
/ or ocular medicine,
b.
the deliberate avoidance of allergen is not required,
c.
symptoms are not functionally disabling,
d.
symptoms do not cause wheeze, require an inhaler or adrenaline autoinjector,
e.
not foreseeably exacerbated by military service.
All other Candidates, including those with severe symptoms are UNFIT due to the
foreseeable impact on military employment.
39.
Immuno-suppressive conditions. Candidates with immuno-suppressive conditions
which make them more vulnerable to developing infections are UNFIT due to the risks of
worldwide deployed service.
40.
Sleep disorders. See Annex B ENT Para 22 and Annex G Neurology Paras 26 –35.
Miscellaneous and unspecified conditions 41.
Malaria. Candidates who have lived overseas in endemic areas may have an
incomplete medical record. These candidates are encouraged to provide as much
information as they can to verify treatment received. Candidates should not have
experienced symptoms or any restriction to exercise tolerance within the previous three
months.
a.
Candidates with past history of malaria who have received an appropriate
course of treatment and have been discharged from appropriate specialist follow-up,
including Plasmodium ovale or P. vivax that has had a radical cure24 are FIT.
b.
Candidates who are known to have been infected with the Plasmodium ovale or
P. vivax strains of malaria, and have not received a radical cure24, are FIT E2. The
E2 marker is required for the first two years of service, to reflect the potential for
malaria reactivation which would require early treatment.
c.
All others, including those with active disease are UNFIT due to the impact on
function and requirement for medical treatment.
42.
Other tropical diseases. Candidates with a history of tropical disease who have
made a full recovery, who are considered cured and have no functional impairment are
24 A course of treatment targeting the hypnozoite phase, typically primaquine.
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FIT. Where there is uncertainty surrounding diagnosis and treatment, referral should be
made to sSMES. Conditions of concern include, but are not limited to:
a.
Schistosomiaisis.
b.
Lymphatic filariasis.
c.
Onchocerciasis.
d.
Chagas disease.
e.
African trypanosomiasis.
f.
Leishmaniasis.
g.
Leprosy.
h.
Strongyloidiasis.
i.
Dengue fever.
43.
Splenectomy and reduced splenic function. Candidates who have reduced splenic
function (for example, partial splenectomy or splenunculus) who do not require regular
prophylactic antibiotics or specific immunisations are FIT. Candidates who have had a
splenectomy or have reduced splenic function for any reason who require regular
prophylactic antibiotics or specific immunisations are UNFIT. This is due to the increased
susceptibility to several potentially life-threatening infections which may be encountered
during service life, such as Haemophilus influenzae, Neisseria meningitidis, malaria,
Capnocytophaga canimorsus and babesiosis.
44.
Transplantation of organs. Candidates in receipt of a transplanted organ25 are
UNFIT. This is due to the long-term risk of life-threatening infection, organ failure and / or
transplant rejection. The condition poses a risk of sudden deterioration / incapacitation.
45.
Organ donors. The following applies:
a.
Kidney. Candidates who have donated a single kidney and have no other
complications are FIT six months post-surgery, provided they meet the requirements
o
f Annex F Renal and Urological Para 19.
b.
Bone marrow and peripheral blood stem cells. Candidates who have
donated bone marrow and / or peripheral blood stem cells
and have no other
complications are FIT one month post-surgery.
c.
Candidates who have donated all or part of any other organ are to be referred to
sSMES.
46.
Congenital lymphoedema. All candidates with congenital lymphoedema are UNFIT
due to functional limitation and risk of infection.
25 Excluding blood transfusions
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47.
Medically unexplained conditions and symptoms. Candidates with medically
unexplained conditions and symptoms that were functionally limiting, and which have been
fully investigated are FIT provided they have been symptom free for two years and
undertaken activities comparable with military service.
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SECTION FIVE: THE INFLUENCE OF PARTICULAR CONDITIONS ON
MEDICAL FITNESS DURING SERVICE
General 1.
Personnel in the Armed Forces are subject to both intensive training and physically
arduous, mentally taxing, operational tours. Stringent entry standards are required;
however for serving personnel the physical requirements placed on them may change
as they progress through their career. Personnel must undergo appropriate1 medical
reviews to ensure that their functional capacity is sufficient to meet the demands of their
employment and that this employment will not have a deleterious effect on the health of
the individual.
2.
This Section gives guidance on appropriate medical grading during service.
Adherence to this guidance will both ensure standardisation and a dynamic and
responsive assessment of personnel with regard to their best employment within the
Services, thus facilitating the most efficient use of manpower by management. Variance
from these standards can only be sanctioned by a Service Consultant Occupational
Physician either working independently or as part of a Service Medical Board or single-
Service Medical Authority.
3.
When there is a change to an individual’s P grade and/or joint medical employment
standard (JMES) their line manager must be notified and the employing authority informed
including whether the change is permanent or temporary. Initial grading would normally be
carried out by the Unit Medical Officer with advice from or referral to secondary care and/or
occupational medicine if appropriate. Those with protracted or serious conditions that are
likely to lead to a permanent change in P grade and JMES or requiring invaliding from the
Service should be reviewed by a Service2 occupational medicine consultant. Review by
an appropriate secondary care specialist may be sought for advice on diagnosis, prognosis
and treatment3.
4.
Account should be taken of the following points and any areas of concern discussed
with a
Service Occupational Physician:
a.
Individuals with conditions requiring periodic medical care, review or medication
and those in whom deterioration might occur, may not be fully deployable, but may
be suited for limited deployment or other employment.
b.
In assessing overall employability it is not sufficient simply to consider an
individual’s fitness for their current defined post. It is important to consider the:
(1) General Service duties that may be required of all Service
personnel.
(2) Specific branch/trade duties.
(3) Potential branch/trade duties required on deployed operations.
1 As stated in JSP 950 Leaflet 6-7-7 and single Service policy.
2 ‘Service’ is defined as being employed by the single Services or DPHC.
3 3 See Paragraph 13.
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5.
Certain categories of employment (e.g. Special Forces, Submariners, Parachutists,
Divers and, Aircrew) require more stringent standards, which are promulgated separately.
Medical board procedures
Temporary downgrading
6.
The majority of disorders will be managed in the first instance within primary
healthcare. For those conditions likely to last more than 28 days (Army 56 days),
alterations to the P grade and JMES are to be initiated by the unit medical officer.
Referral to secondary care should be made on clinical need. Advice on employability
can be sought from a Service Occupational Physician.
7.
Individuals who are
temporarily incapable of any employment and are under
medical supervision or treatment either in hospital or the community are to be
designated P0 as required by single-Service policy.
Permanent downgrading and medical discharge 8
Any personnel developing a permanent condition that degrades their functional
capacity for the foreseeable future4 may need to be permanently re-graded or invalided.
Permanent grading will be undertaken in accordance with single-Service medical boarding
procedures. The aim of the Medical Board is to determine the functional capacity of
individuals and their fitness for work. Advice and recommendations are to be given to the
employer, stating what limitations to employment are necessary as a result of an
individual’s medical fitness status.
9.
Conditions compatible with limited employment within the Services will normally
attract a change in P grade and JMES. To enable a judgement to be reached on the
individual’s medical grade there is a requirement to access all available information on
an individual’s employment, career, welfare, and medical detail. The ‘wants and desires’
of individuals, their medical officer and employing unit should not form the basis for a
recommendation of a medical grade.
10. The decision on employment in a grade will be made by the employing authority,
taking into account the ability of the Service to accommodate the employment
restrictions.To achieve co- ordination of this process appropriate to single-Service
requirements, employment boards (which may include representatives drawn from the
manning authority, personnel management, employing unit and medical service) will take
decisions on future employment based on medical board recommendations.
11. Medical discharge boards should be conducted in accordance with Section 6. A
recommendation for discharge should only be made for those individuals who are
assessed by a Medical Board as being MND.
Role of clinical consultants in the determination of employability
4 Foreseeable future – The maximum period of validity of a Temporary P grade is normally 12 months for the RN and Army and 18
months for the RAF.
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12. Occupational physicians and unit medical staff are responsible for the medical
grading of personnel under their care.To support this, other consultants will provide
opinions relating to restrictions to activities or functional capabilities
13. Defence clinical consultants, when asked, are to:
a.
Provide a diagnosis and an occupationally orientated prognosis, together
with as much generic advice as possible on medical restrictions affecting
functional capability in the Service environment.
b.
Provide supplementary information at the request of unit medical staff and
Service Occupational Physicians or provide written reports to service Medical
Boards.
c.
In exceptional circumstances, make themselves available in person to assist
Medical Boards/Boards of Survey at the request of the Board President.
Principles of occupational medicine practice 14. In order to assess fitness for work effectively, medical staff need to be aware of the
employment requirements and working conditions of their patients. This awareness is best
achieved through regular involvement in visiting and assessing workplaces, liaison with
management, and through enhancement of knowledge of activities outside the immediate
unit environment (e.g. Branch and Trade requirements or the requirements of specific
courses that must be completed). Medical staff should gain experience of the wider
Service and Joint environments through activities such as visits to other units, unit
exercises and operational deployments. Essential to this undertaking is an
understanding of the basic tenets of occupational medicine practice. Readers are directed
to guidance from Faculty of Occupational Medicine
(FOM) publications5.
15. In the Services, the PULHHEEMS system describes individual functional capacity
for work (See Section 1). In turn, this allows a ‘fitness for work’ grading to be conveyed to
the employer using the JMES system (see Section 2), whilst at the same time maintaining
the individual’s medical confidentiality, protecting their health and facilitating their most
appropriate employment within the organisation.
16. All Medical Officers are to familiarise themselves with MOD Health and Safety (H&S)
practices for reporting of Prescribed Diseases or Diseases reportable under RIDDOR6, as
detailed in JSP 3757. This publication gives direction on the implementation of UK H&S
regulations within the MOD for line managers to discharge their H&S responsibilities, and
is important to medical officers who provide advice to patients and their line-management.
In addition, medical officers should be aware of JSP 4428 , and single-Service accident
reporting systems, which should be initiated by line managers to report any condition
(disease or injury) or dangerous occurrence developing in association with work.
17. Whilst not having any direct responsibility for implementing H&S legislation (unless
they also have direct line management responsibility), all healthcare workers who are
5 https://www.fom.ac.uk/ 6 Reporting of Diseases Injuries and Dangerous Occurrences Regulations.
7 JSP375 MOD Health and Safety Handbook Volume 2 Leaflet 14.
8 JSP 442 Accident Reporting System.
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employed with a remit to provide care in an occupational setting should be aware of the
following basic tenets of good H&S practice:
a.
All placements within the workplace should take account of any risk(s) to the
individual following a risk assessment, and risks the individual brings to that
workplace and co-workers and any special requirements of the work being
undertaken (e.g. safety critical tasks).
b.
Prevention is the key to minimising the risk of development of any
occupational disorders.
c.
Control measures should include the hierarchy of elimination, substitution,
engineering controls, good working practice and the use of personal protective
equipment (PPE).
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Annex A
EYES IN-SERVICE
1.
Diseases of the eye and orbit are assessed and recorded under P. The entries
under EE are records of visual acuity only. The uncorrected refractive limits are generally
acceptable (with the exception of those undergoing refractive error surgical correction).
Outside this range, eyes are rarely structurally normal, and unless all other visual
parameters are normal, should lead to medical downgrading as indicated above.
Consideration must be given to whether a lesion is progressive and likely to lead to future
incapacity. Where doubt exists referral should be made to a consultant ophthalmologist.
The following should be noted:
a.
The discovery or first development of any significant functional loss in visual
acuity, or field defects, ocular mobility, or conditions or diseases affecting either intra-
ocular (uveal tract, lens defects etc) or extra-ocular structures (i.e. lids, lachrymal
system) in either or both eyes, will normally necessitate specialist opinion from an
ophthalmologist, together with appropriate grading based on their advice.
b.
The combined impact on overall visual function of visual acuity, visual field,
contrast sensitivity, colour perception, ocular mobility, and structural integrity of one
or both eyes, will be reflected in the medical category. Primarily this will be
determined by the limitation of functional capacity in one or both eyes, and its likely
effects on the individual’s employability. For example:
(1) Individuals with right sided monocular1 loss of vision and whose main
military employment is largely dependent on binocular or uni-ocular vision (e.g.
infantryman, pilots, air traffic control, vocational drivers etc). In these cases the
visual function alone will not be the only determinant of their suitability for
continued Service (See Section 5 paragraphs 7-10).
(2) Those suffering from night blindness, which if affecting employment and
ability to function in a military environment, would need to be regraded no
higher than P3.
c.
Special work problems and restrictions. Those with significant defective
vision are at increased risk of accidents, particularly in hazardous situations.
Restrictions should apply to any individual with defective vision, restricted visual
fields, or imbalance of the eyes with diplopia. Careful consideration needs to be
given for those employed to work in the following circumstances:
(1) Work at heights, e.g. on ladders, gantries, or scaffolding, where they
might overstep the boundaries and fall.
(2) Work in the vicinity of moving machinery.
(3) Driving of vehicles, both on public highways and heavy plant operation
at construction, industrial, and other sites.
1
Uniocular. When one eye is normal and the other eye is either absent or is blind.
Blind Eye. An eye possessing a best attainable corrected Snellen visual acuity (VA) of 6/60 or worse.
Monocular. When an individual has two seeing eyes, one eye with normal vision but the other eye possessing a best corrected VA
between 6/60 and 6/24.
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(4) Operation of cranes, hoists, and fork lift trucks2.
d.
Colour perception (CP). Normal CP has greater importance in those
single Services, and trade groups, which place a reliance on colour coding
for safety and technical reasons. CP requirements are detailed in the
respective single Service publications on employment standards.
Corneal Refractive Surgery 2.
Corneal Refractive Surgery (CRS) for aviation and diving must be specifically
approved by the single Service employing authorities before being considered. Guidance
for aircrew is in AP1269A.
3.
The following methods of surgical correction of myopia or hypermetropia
may be considered suitable for serving personnel on an individual, case by case
basis:
a.
Photorefractive keratectomy (PRK)/ Laser epithelial keratomileusis
(LASEK).
b.
Laser in-situ keratomileusis (LASIK)
c.
Intrastromal corneal rings (ICRs), otherwise known as intrastromal
corneal segments (ICSs).
4.
Radial keratotomy (RK), or astigmatic keratotomy (AK) and other form of intrusive
refractive surgery, not listed above, are not acceptable. Serving personnel identified as
having previously undergone these surgical operations should be brought before a Medical
Board with an opinion from a service ophthalmologist.
5.
In order to be considered for a grading of P2 all personnel who have undergone
refractive surgery must fulfil the following criteria and provide supporting documentary
evidence when required:
a.
The pre-operatively refractive error was not more than +6.00 or –6.00 dioptre
[Equivalent Spherical Error (ESE)] in either eye. To calculate the refractive error
see Sect 4 Annex A Appendix 1.
b.
The best spectacle corrected visual acuity meets the appropriate single-
Service standard.
c.
To protect against the development of issues such as UV light related
haze on
operations, at least 6 months to have elapsed since the date of the last
surgery. In exceptional circumstances, on the advice of single Service CAs
Ophth, this may be reduced to 3 months.
2 JSP 950 Leaflet 6-6-2 ‘Medical standards for mechanical handling equipment operators’. Safe use of lifting equipment. Lifting
Operations and Lifting Equipment Regulations 1998. Approved Code of Practice and Guidance L113 HSE Books 1998 ISBN 0 7176
1628 2.
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d.
There have been no significant visual side effects secondary to the surgery
affecting daily activities.
e.
Refraction is stable, as defined by two refractions performed at least 1 month
apart with no more than 0.50 dioptre difference in ESE in each eye.
6.
It should be emphasised to personnel contemplating these procedures that they
may not be rendered spectacle independent, and that there is a low risk of permanent
side effects. They must be told that failure to meet the required standards as given
above may result in them being regraded no higher than P3 and it is possible that
significant deterioration in vision may require a grade of P7 or P8. This advice should be
recorded in their medical record.
7.
Personnel having refractive surgery are obliged to disclose it to their medical officer.
The individual must be referred to a Service consultant ophthalmologist who will make
assessment of the visual function and Service suitability. Personnel who do not meet the
required criteria for P2 must be referred to the appropriate Medical Board.
8.
These procedures are not available from public funding, unless authorised by the
single
Services in the following
circumstances:
a.
As a requirement for individuals to meet operational imperatives (i.e. where
correction by spectacles or contact lenses is not practicable for occupational
reasons).
b.
Where correction by spectacles or contact lenses is not practicable for
clinical reasons, on the recommendation of a Service consultant
ophthalmologist.
9.
A single revision of CRS is acceptable, subject to the same criteria above
being met.
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Annex B
EAR, NOSE AND THROAT IN-SERVICE
1.
Diseases of the ear are assessed and recorded under P. The entries under HH are
records of hearing acuity only as determined by audiometry. The discovery of any
functional loss in hearing acuity (with or without tinnitus), balance problems (with or
without nystagmus), or any of the conditions as detailed in Annex B should be reflected in
the P quality. This will be determined primarily by the limitation of functional capacity in
one or both ears. The effects on employability are reflected in JMES. The following
should be noted:
a.
There is a requirement for compliance with single Service Hearing Conservation
Programmes (HCP), and current Health and Safety legislation.
b.
Generally, perfect hearing is not essential, however, there may be
circumstances when for safety and/or technical reasons, satisfactory hearing is
deemed an absolute requirement of specific employment groups, e.g. aircrew,
divers, sonar operators etc, and where there is a need to hear verbal signals and
instructions. Speech pattern recognition (identifying any low frequency decrement) is
a better indicator of hearing function than reliance on H grades, which do not
discriminate between high and low frequency hearing loss.
c.
Further guidance on interpretation of audiograms and deployability can be found
in JSP 950 Lft 6-4-2.
2.
Balance. Persistent or frequently recurring balance problems, no matter
what the aetiology, should be reflected in the P quality.
3.
Tinnitus. Tinnitus may occur alone or in combination with loss of hearing acuity. Any
effect on function should be reflected in the P quality.
4.
Sleep Apnoea. Service personnel who develop sleep apnoea should be graded
according to their degree of disability and their treatment needs. Evidence of compliance
with treatment should be sought to inform the grading decision.
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Annex C
CARDIOVASCULAR IN-SERVICE
1.
When advising on employability and deployability a full assessment of
cardiovascular risk should be undertaken. Particular consideration should be given to
the risk of sudden or subtle incapacitation.
2.
Special work problems and restrictions. In established cardiovascular
disease, the following should be considered:
a.
Driving. Fitness to return to driving after a cardiac event normally follows
Driver Vehicle Licensing Authority (DVLA) guidance1. Additionally an individual risk
assessment for Service specific driving tasks must be undertaken.
b.
Pacemakers and implantable cardiac defibrillators (ICDs)2. Depending on
the manufacturer and type of the pacemaker or ICD fitted, electromagnetic fields
(EMF) from a wide variety of electrical devices may have the potential to produce
induction currents, which can adversely affect the pacemaker causing dysrhythmias
or cause the ICD to deliver a shock. Those with pacemakers/ICDs should be warned
of this possibility, and employment may need to be restricted to avoid exposure to
strong EMF.
c.
Environmental. Ability to work in hot and cold climates, confined spaces
or at altitude requires an individual risk assessment.
d.
Diving. Vocational divers are covered by
BRd1750A which prohibits those with
an organic heart condition from diving.
BRd1750A applies to military vocational
divers and all sports diving under military auspices. If in doubt advice should be
sought from Senior Medical Officer (SMO) Diving Medicine at the Institute of Naval
Medicine.
e.
Flying. Fitness to fly as a passenger on transport aircraft after a cardiac
event normally follows British Cardiac Society (BCS) Guidance3. Guidance for
aircrew is contained within
AP1269A.
Hypertension 3.
Hypertension is defined and measured in accordance with current National
Institute for Health and Care Excellence (NICE) guidelines.4 Those with treated mild
hypertension and an acceptable cardiovascular risk profile, whose functional capacity
is otherwise unaffected may be graded MFD with an E2 medical marker. Those with
untreated, significantly elevated (> 160 mmHg systolic and/or >100 mmHg diastolic) or
labile hypertension should be regraded MND where treatment is
recommended/required. Any subsequent return to MLD or MFD should include
1 For further information on this you are referred to the Driver Vehicle Licensing Authority (DVLA) website and the publication For
medical practitioners - At a glance guide to the current medical standards of fitness to drive November 2014
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418165/aagv1.pdf.
2 Details of the device must be established from the patient’s cardiologist or surgeon and device manufacturer.
3 https://www.bcs.com/documents/BCS_FITNESS_TO_FLY_REPORT.pdf 4 NICE (2019
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evidence of stable, well-controlled blood pressure, with consideration given to fitness
for safety critical duties5 and/or physical exertion restrictions6.
Peripheral vascular disorders 4.
Account should be taken of the following:
a.
Peripheral vascular disease. Peripheral vascular disease is likely to
affect functional capacity and personnel should be assessed and graded
accordingly.
b.
Varicose veins. The functional limitations imposed on those with minor
varicosities will determine the grade. Following surgery with satisfactory outcome,
individuals may be graded P2 MFD. Less than satisfactory treatment may
necessitate the individual being
graded P3 MLD or P7, depending on the severity. In addition, the effect of varicose
veins on the locomotor system is assessed under L of PULHHEEMS.
Cardiomyopathies 5.
In dilated, hypertrophic and restrictive cardiomyopathy there is a risk of
progressive haemodynamic deterioration, emboli and sudden death, even in patients
who have previously been asymptomatic. All personnel are to be assessed by a
cardiologist and a service occupational physician to assess their risks and functional
limitations. The highest achievable grading will be P3 MLD.
Arrythmogenic Syndromes 6.
A variety of syndromes leading to an enhanced risk of arrhythmia exist. These
include Wolf-Parkinson White and other accessory pathways, Brugada Syndrome, and
arrythmogenic right ventricular cardiomyopathy as well as isolated atrial fibrillation.
Following assessment and treatment by a cardiologist and assessment by a service
occupational physician grading should be based on the risk of arrhythmia, likely
severity of the symptoms, need to restrict physical activities and the need for ongoing
medication and review. Treatment may include implantation of a pacemaker or ICD
(see 2.b above).Unless treatment fully resolves the symptoms and the risk of future
episodes the highest achievable grade will be P3 MLD. Grading changes of those with
asymptomatic incidental findings should be based on the advice on future risks of the
treating a cardiologist and include discussion with a single-Service occupational
physician as necessary.
5 Military aircrew in flying roles should only be managed by a MAME qualified doctor in accordance with
: AP1269A Lflt 5.02
Cardiovascular System and Lflt 5.19 Drugs for Aircrew and Controllers.
DVLA:
Assessing fitness to drive A guide for medical professionals, Group 2 drivers must not drive and must notify DVLA if resting BP is
consistently >180 mmHg systolic and/or >100 mmHg diastolic.
CAA
: https://www.caa.co.uk/uploadedFiles/CAA/Content/Standard_Content/Medical/Cardiology/Flow_Charts/Hypertension%20FC.pdf
Unfit or Certificate issue delayed if BP exceeds 160 systolic and/or 95 diastolic
MCA: Seafarers, Temporarily unfit if >170 systolic or >100 diastolic mmHg until investigated and treated.
HSE
: The medical examination and assessment of commercial divers (MA1) BP >160 mmHg systolic or >100 mg diastolic is a
contraindication to diving.
6 European Society of Cardiolog
y 2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease
ESC Clinic Practice Guidelines para 4.2.3 “When BP is uncontrolled, temporary restriction from competitive sports is recommended, with
the possible exception of skill sports”.
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Annex D
RESPIRATORY IN-SERVICE
1.
Service Personnel developing respiratory conditions such as wheezing diatheses
(inclusive of asthma), severe hay fever, spontaneous pneumothorax, chronic bronchitis,
emphysema and/or bronchiectasis are normally graded no higher than MLD if any of the
following apply:
a.
Degradation in functional capacity and/or performance.
b.
Failure to respond satisfactorily to treatment.
c.
Dependent on treatment.
Special Work Problems and Restrictions
2.
Certain work environments or safety critical areas require higher standards of
respiratory fitness e.g. aircrew, divers, submariners and career employment groups
utilising breathing apparatus or respiratory protective equipment, work in hyper/hypo-baric
atmospheres, or in confined spaces1.
Asthma
3.
A proportion of Service Personnel will develop asthma in Service. It is essential that a
high index of suspicion is maintained to differentiate occupational asthma from non-
occupational causes. The following points should be noted:
a.
Any work involving potential respiratory sensitisers is to be subject to a risk
assessment, together with appropriate health surveillance for the Service Person.
b.
The most frequently reported causative agents include isocyanates, flour and
grain dust, colophony and fluxes, latex, animals, aldehydes and wood dust.
c.
Certain employment groups are at increased risk of developing occupational
asthma. These include individuals directly or indirectly exposed to hazards arising
from the following activities/occupations: paint spraying, baking, chemical workers,
animal handling, welding, plastics and rubber workers, metal working, electrical and
electronic production workers, painting, dental professionals, printers, soldering,
safety equipment fitters, healthcare workers, and laboratory workers.
d.
A diagnosis of occupational asthma should only be made following appropriate
investigation by a Consultant Respiratory Physician in liaison with a Service
Consultant Occupational Physician. The aim of management is to identify the cause
and minimise or remove the individual from further exposure. Complete avoidance of
exposure may or may not improve symptoms and bronchial hyper-responsiveness.
1 Further details contained
in BRd 1750A Handbook of Naval Medical Standards, AP 1269A Royal Air Force Manual of Medical Fitness
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e.
Personnel with pre-existing non-occupational asthma may be permitted to work
with respiratory sensitisers, providing that they follow the standard requirements for
exposure control and health surveillance.
4.
Irrespective of causation, Service Personnel should be graded appropriate to their:
a.
Employment.
b.
Residual function.
c.
Requirement for supportive therapy.
d.
Control of symptoms.
5.
Service Personnel with a diagnosis of asthma who are taking treatment up to and
including the “initial add-on therapy” step of the British Thoracic Society 2016 Guideline2
will normally be graded no higher than MLD. If asthma is well controlled (no exacerbations,
less than 3 doses per week of reliever therapy and an ACT score3 greater than 23 on two
occasions at least 6 weeks apart) for 6 months, Service Personnel may potentially be
graded MFD following review by a Service Consultant Occupational Physician.
6.
Poor symptom control or continuous or frequent use of oral steroids. Service
Personnel unable to achieve complete control4 or continuous or frequent use of oral
steroids are normally graded MND.
7.
Exercise induced asthma. For most patients, exercise induced asthma is an
expression of poorly-controlled asthma and regular treatment including inhaled
corticosteroids should be reviewed. Service Personnel should be graded as above.
Tuberculosis
8.
Service Personnel infected with respiratory tuberculosis should be initially graded MND
pending Consultant Respiratory Physician and Service Consultant Occupational Physician
review.
Sleep apnoea
9.
Service Personnel who develop sleep apnoea should be graded according to their
degree of disability and treatment needs. Objective evidence of adequate control5 should
be sought to inform the grading decision. The opinion of a Consultant Respiratory
Physician is to be sought. Service Personnel with a confirmed specialist diagnosis of sleep
apnoea are normally graded no higher than MLD.
2 British Thoracic Society – British Guidelines on the Management of Asthma (2016) Page 7
0 https://www.brit-thoracic.org.uk/quality-
improvement/guidelines/asthma.
3https://www.asthma.com/content/dam/NA_Pharma/Country/US/Unbranded/Consumer/Common/Images/MPY/documents/80108R0_Ast
hmaControlTest_ICAD.pdf.
4 Complete control is defined in British Thoracic Society – British Guidelines on the Management of Asthma (2016) Page 62
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma.
5 Apnoea Hypoapnoea Index (AHI) within the normal range, greater than 90% usage data of CPAP machine and Epworth Sleepiness
Score <7.
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Annex E
GASTROINTESTINAL IN-SERVICE
General
1.
Alimentary system problems are common and can result in chronic ill health and/or
invaliding. The presence of continuing signs and symptoms should be managed in
accordance with current clinical guidelines. Individuals may require to be permanently
graded to P3 or P7, or recommended for medical discharge (P8). Each case should be
dealt with on merit.
Special work problems and restrictions
2.
Non-infective conditions generally require no specific work limitations although the
avoidance of stressful environments, shift work, and remote locations may be advisable in
those with ongoing symptoms. Those with infective disease must be excluded from work
involving food handling until medically certified as free from disease and fit to work.
Similarly, healthcare workers will require restriction of duties dependent on the relative risk
of the infective agent, and their speciality.
Dyspeptic Disease 3.
Following a diagnosis of presumptive peptic ulcer disease, individuals are graded P7
MND for three months. After completion of a course of ulcer healing therapy and/or
Helicobacter pylori eradication treatment, those who remain symptom-free at the end of the
3 month period may be graded P2 MFD. In cases complicated by perforation or significant
haemorrhage, individuals are to be made P7 MND for one year before considering a return
to P2 MFD, subject to satisfactory endoscopic review.
Irritable Bowel Syndrome (IBS) 4.
The response of IBS to treatment is very variable.Grading will be dependant upon
the influence of symptoms on the ability to conduct activities of daily living as well as work
roles. Of particular importance is the ability to avoid dietary triggers when deployed away
from home. Only those with mild symptoms not requiring medication and who have
triggers that are easily avoidable if deployed may be P2 MFD.
Coeliac disease and gluten sensitivity 5.
Care should be taken in grading patients with Coeliac disease as there is evidence
that poor dietary control is associated with a wide range of potential GI and non-GI
complications, including malignancy. The MOD is responsible for ensuring service
personnel have access to a gluten free diet as far as is reasonably practicable; however,
gluten-free ration packs are not available. The potential inability to provide a continuous
gluten-free diet means that service personnel with Coeliac disease must have a risk
assessment performed by a single-Service occupational medicine consultant prior to
deployment. The assessment must include defining whether a reliable supply of gluten-
free produce is available and whether appropriate catering facilities exist to produce
gluten-free food in the proposed deployed location
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6.
Where sSs are able reliably to provide a gluten free diet and appropriate
preparation facilities, or where appointments or postings are to units in countries418
where a gluten-free diet is achievable then a grading of no higher than P3 MLD (ALME
L3) may be awarded by a consultant occupational physician led Medical Board.
Appropriate Med Lim Codes or restrictions may need to be applied to ensure that the
service person is not moved away from that assessed catering facility and supply chain.
Where any of these requirements are not achievable a grading no higher than P7 MND
is to be applied.
Inflammatory bowel disease 7.
Medical grading of patients with inflammatory bowel disease relates to the level of
ongoing symptoms, number and frequency of recurrences, known triggers (and the ability
to avoid them) and the requirement for medication, surgery and follow-up. They are to be
graded no higher than P3 MLD.
Liver Disease 8.
Abnormal liver function (2 tests 1 month apart) should be graded dependant upon
the underlying cause. Chronic viral hepatitis, particularly in HCW, is graded in
accordance with current BBV policy.Other conditions, including hepatosplenomegaly,
are likely to achieve P3
MLD as the highest grade, dependant upon response to treatment and the requirement for
medication and regular follow up. Those with Gilbert’s Syndrome may remain P2 MFD
with an E2 risk marker unless episodes are sufficiently frequent to affect daily living or
ability to work.
9.
The discovery of evidence of oesophageal varices on endoscopy will lead to a
grading no higher than P7 MND.
Pancreatitis 10. Patients with a single episode of pancreatitis may be graded P2 MFD at least 6
months post full recovery as long as any underlying or triggering cause has been
treated. Those with recurrent episodes should be graded no higher than P3 MLD.
Food allergy and intolerance 11. Those developing food allergy or intolerance in service should be graded on a case
by case basis. Grading should be based on the effects of symptoms, the severity of the
response and the ability to avoid triggers in the deployed environment. The advice of a
specialist physician in allergy or immunology should be sought. Those formally
diagnosed with a significant allergic response sufficient to require them to carry a self-
administered adrenaline autoinjector (Epipen or similar) are to be graded no higher than
P3 MLD in accordance with single Service policies. See also Section 5 Annex N – Other
Conditions in Service.
Bariatric surgery
418 Including BFG, Cyprus and Gibraltar, appointments to embassies in developed countries, exchange posts in developed countries and
other appointments where pre-boarding assessment indicates that the service-person can achieve an unbroken gluten-free diet.
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12. The 2014 NICE Clinical guideline [CG189] advises that bariatric surgery is a
treatment option for people with obesity if all of the following criteria are fulfilled:
a.
They have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and
other significant disease (for example, type 2 diabetes mellitus [DM] or high blood
pressure) that could be improved if they lost weight.
b.
All appropriate non-surgical measures have been tried but the person has not
achieved or maintained adequate, clinically beneficial weight loss.
c.
The person has been receiving or will receive intensive management in a tier 3
service419.
d.
The person is generally fit for anaesthesia and surgery.
e.
The person commits to the need for long-term follow-up.
13. Bariatric surgery is the option of choice (instead of lifestyle interventions or drug
treatment) for adults with a BMI of more than 50 kg/m2 when other interventions have not
been effective.
14. Expedited assessment for bariatric surgery should be
offered to people with BMI ≥35
kg/m2 who have recent-onset type 2 DM as long as they are also receiving or will receive
assessment in a tier 3 service (or equivalent).
15. Expedited assessment for bariatric surgery should be
considered for people with
BMI 30 to 34.9 kg/m2 who have recent-onset type 2 DM as long as they are also receiving
or will receive assessment in a tier 3 service (or equivalent).
16. Expedited assessment for bariatric surgery should be
considered for people of
Asian family origin who have recent-onset type 2 diabetes at a lower BMI than other
populations as long as they are also receiving or will receive assessment in a tier 3 service
(or equivalent).
17. Because of the potential for post-operative complications, including mal-absorption,
dumping syndrome and problems with anastomoses and gastric bands, all personnel
contemplating gastric surgery should be carefully counselled about the occupational
implications. Due to the very high rate of complications, specifically slippage and erosions,
gastric bands should be avoided. Sleeve gastrectomy, and gastric bypass (with Roux-en-Y
reconstruction) are considered preferable, with sleeve gastrectomy the less technically
complex.
18. All personnel undergoing bariatric surgery require a two year follow up period, during
which the most likely appropriate medical category will be MND. If, after two years their
weight is stable, there are no surgical or metabolic complications, and no ongoing
requirement for dietary supplementation, then the Serviceperson may be regraded MFD. If
there is an ongoing requirement for dietary supplementation, then the highest medical
category will be MLD
419 Tier 3 obesity services are defined as: Specially commissioned specialist weight management clinics with an MDT approach that
consists of doctor with a special interest on obesity (physician or GP), specialist nurses, specialist dietitian, psychological support and
specialist exercise therapists/physiotherapist.
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Annex F
RENAL AND UROLOGICAL IN-SERVICE
Urinary disorders 1.
A persistent abnormality of urinalysis (defined as haematuria of any degree and
proteinuria above "trace" on dipstick testing on each of three occasions), with or without
raised blood pressure, may indicate a nephrological pathology. Any persistent abnormality
should be investigated, with referral to a nephrologist, as appropriate.
a.
Nephro-urological conditions. Permanent medical grading of P3 or P7 should
be considered for any personnel developing nephro-urological conditions (e.g.
nephritis (acute glomerulonephritis, pyelonephritis), urinary incontinence, recurrent
urolithiasis or malignant disease), which either degrades the functional capacity
and/or fails to respond satisfactorily to treatment (whether there is persisting
abnormality of urinalysis, blood pressure, and glomerular filtration rate/creatinine
clearance rate, or not).
b.
Special work problems and restrictions. Personnel with renal or urinary tract
disease should be subject to appropriate risk assessment prior to any deployment or
posting.
Impaired renal function 2.
Individuals requiring haemodialysis, peritoneal dialysis or renal transplantation need
regular specialist follow-up and are likely to have limited functional capacity. They will
normally be unfit for operational deployment and will have major employment limitations.
Nephrectomy 3.
PULHHEEMS assessment post-nephrectomy will depend on the underlying
pathology and the surgical outcome.
a.
If the nephrectomy was for disease or trauma and specialist opinion confirms
that the remaining kidney is fully functional, with no likelihood of recurrence or
progression of the condition, a grading of P2 can be considered.
b.
Those who have donated a kidney should be graded P7 for a minimum
period of 6 months after which, if fully fit, they may be re-graded P2.
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Annex G
NEUROLOGICAL IN-SERVICE
Peripheral neuropathy 1.
Peripheral neuropathies require consideration of impact on function and any
underlying condition. This is further considered under the respective sections dealing
with upper and lower limb function at Section 5 Annex K.
Seizures and epilepsy 2.
Those who suffer a single seizure after entry are to be referred for a neurological
opinion. are to be graded P7 MND for a period of 18 months with appropriate risk
assessment and restrictions on employment. Certain occupations may be incompatible
with a history of even a solitary seizure1 and specific employment guidance should be
sought.
a.
Single seizures. Individuals in whom no abnormalities are detected,
including a normal MRI brain and EEG, may be graded P2 following a period of
18 months without anticonvulsant treatment dependent upon consultant
neurologist advice on the risk of recurrence.
b.
Recurrent seizures. Whilst under investigation individuals are to be graded
no higher than P7 MND. Those who are well controlled on medication are to be
permanently graded P7, or exceptionally P3 after assessment by a Service
consultant occupational physician. All others are to be permanently graded no
higher than P7 or P8 as appropriate
.
Head injury2,3 3.
Head injuries may be classified according to the following criteria:
a.
Mild.
(1) Loss of consciousness lasting for less than 30
minutes.
(2) Amnesia lasting for less than 30 minutes.
b.
Moderate. Any of the following
(1) Loss of consciousness lasting for 30 minutes to 24
hours.
1 Aircrew, divers and holders of DVLA Group 2 licence.
2 Annegers, JF et al;
A population-based study of seizures after traumatic brain injuries. N Engl J Med. 1998 Jan 1;338(1):20-4.
3 Christensen, J et al; Long-term risk of epilepsy after traumatic brain injury in children and young adults: a population-based cohort
study. Lancet 2009; 373: 1105-10.
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(2) Amnesia lasting for 30 minutes to 24 hours.
(3) An undisplaced skull fracture.
c.
Severe. Any of the following:
(1) Loss of consciousness for more than 24 hours.
(2) Amnesia for more than 24 hours.
(3) Intracranial haematoma4.
(4) Depressed skull fracture.
(5) Brain contusion.
4.
Personnel with a history of head injury, particularly those with a history compatible
with a severe or moderate injury or with evidence of persisting intellectual, psychiatric or
neurological disability require neurological and psychometric assessment. Where there
is considered to be a significant risk of post-traumatic epilepsy, grading should be in
accordance with that outlined at paragraphs 2 above.
Loss of consciousness/altered awareness 5.
A full history should be taken including any pro-dromal symptoms, length of time
unconscious, degree of amnesia and any confusion on recovery. A witness account
should be recorded if available. Neurological and/or cardiac investigation should be
carried out as appropriate. Temporary re-grading (P7) and restriction of duties will be
necessary to protect the individual whilst the episode is investigated. Personnel should be
considered unfit to handle live weapons during this period. Grading thereafter will depend
on the immediate or likely longer term effect on functional capacity.
6.
Simple faint. Unless the diagnosis is uncertain non-recurrent cases may be
graded P2. For those with recurrent faints, an assessment of the effect on functional
capacity and risk of recurrence should be made and an appropriate medical grade
given.
7.
Unexplained loss of consciousness or altered awareness. Candidates who have
had a single episode with no definite provoking factors, who have normal cardiac and
neurological examination and a normal ECG, may be graded P2 providing 6 months have
elapsed since the episode and they are considered to be at low risk of recurrence. Those
whose job requires DVLA Gp 2 licensing will require a downgrading for a minimum of 12
months. Candidates with recurring episodes where no underlying cause can be found
should be graded according to effect on functional capacity in role, but they should remain
downgraded for at least 12 months after the last episode.
8.
Loss of consciousness/altered awareness where epilepsy is strongly
suspected. Factors that may indicate that epilepsy is a likely diagnosis include
amnesia for more than 5 minutes, injury, tongue biting, incontinence, having remained
conscious but with confused behaviour and post attack headache. Such individuals
should be managed in accordance with para 2 above.
4 All intracranial haematomata, including epidural, subdural and subarachnoid.
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Narcolepsy 9.
Personnel suffering from narcolepsy should normally be graded no higher than P7.
A higher grade may be considered provided satisfactory control of symptoms has been
achieved on medication. Individuals may be graded P2 once off medication and
asymptomatic for one year.
CVA (including TIAs) 10. Personnel who have had a CVA should be graded initially according to their
functional ability, risk of recurrence and neurological deficit. Personnel who have been
fully investigated and made a full recovery remain at increased risk of a further event.
They should normally be graded no higher than P3.
Headaches and migraine 11. Personnel suffering from recurrent headaches should be graded according the
frequency of the headaches, requirement for medication, degree of functional impairment
and the requirement
to avoid trigger factors.
Demyelinating disorders 12. Personnel diagnosed with demyelinating disorders would normally be graded no
higher than P7 as it is not always possible to predict a deterioration in their symptoms.
However, the natural history may encompass a very benign disease course and following
neurological advice and input from a consultant occupational physician a grade of P3
may be awarded. Disease modifying medications have further implications for grading
and in most situations individuals will normally be graded no higher than P7 and
specialist advice sought should any immunisations be required.
Neurological tumours 13. Personnel undergoing treatment for neurological tumours would normally be
graded no higher than P7. Grading will otherwise depend on effect on function,
requirement for treatment, specialist review and likelihood of sudden and/or subtle
incapacitation.
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Annex H
ENDOCRINE IN-SERVICE
Diabetes Mellitus 1.
Clear differentiation should be made between those personnel suffering from insulin
dependent or non-insulin dependent diabetes mellitus, and the respective risk levels with
military service. For this reason all cases should be graded P7 MND when first
diagnosed while their disorder is assessed. Following assessment, they are graded as
follows:
a.
Type 2 Diabetes Mellitus (Type 2 DM). Those suffering from Type 2 DM (i.e.
asymptomatic glycosuria), controlled by diet or medications without a significant risk
of hypoglycaemia1, with no other signs or risk factors present (e.g. a
personal/family history of heart disease, stroke, other endocrine dysfunction,
smoker, obesity, hyperlipidaemia, eye or renal disease etc), and whose functional
capacity is otherwise unaffected, may exceptionally be graded P2 MFD E22 by a
formal medical board or Regional Occupational Health Consultant.
Normally those
in this category with anything other than asymptomatic glycosuria should be
graded P3 MLD or P7 MLD/ MND. This includes individuals on sulphonylurea and
other medications which carry a risk of hypoglycaemia including those requiring
insulin therapy.
b.
Type 1 Diabetes Mellitus (Type 1 DM).Those with well controlled Type 1 DM,
with no other signs or risk factors present (see paragraph 1.a above), and
whose functional capacity is otherwise unaffected, may be graded P3 MLD3; all
others should be graded no higher than P7.
c.
Special work problems and restrictions. There remain a number of
restrictions that need to be considered for patients with DM:
(1) Fitness for aircrew, diving, seafaring duties, adventurous training etc.
(2) Vocational Group 2 drivers are subject to individual assessment by DVLA.
(3) Shift work and lone working can be problematic; however, if sensible
working practices are adopted, it is not absolutely contra-indicated.
(4) All require appropriate access to both nutritional and medical
supportive facilities.
(5) Personnel who undertake safety-critical tasks or who are lone workers
should have a risk assessment of their risk of hypoglycaemia and incapacitation
before returning to those duties.
1 Biguanides, Thiazolidinediones and Alpha Glucosidase inhibitors.
2 Specific occupational groups require further assessment in accordance with single-Service Regulations, BR1750A and AP1269A.
3 This is subject to individual circumstances and single Service requirements.
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Other Endocrine Conditions 2.
Those with a history of other endocrine disorders (i.e. thyroid, parathyroid, adrenal
or pituitary dysfunction), which either degrades the functional capacity and/or fails to
respond satisfactorily to treatment or replacement therapy, may need to be graded P3 or
P7, or P8, as appropriate. A risk assessment including the treatment requirements, the
need for follow-up, and the potential for sudden onset of symptoms must be undertaken
as part of the grading decision.
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Annex I
DERMATOLOGICAL IN-SERVICE
General
1.
Extensive skin disease is not compatible with operational military service (i.e. on
ships, in front line units, or aircrew); limited skin disease may be acceptable. Acute self-
limiting conditions do not affect permanent grading, unless they recur frequently. The
types of chronic skin conditions, which may cause concern, were previously detailed in
the Section on entry standards (e.g. acne, eczema/dermatitis, psoriasis, hyperhidrosis,
vitiligo, chronic urticaria and angio-oedema, photosensitivity or photo-aggravated
dermatoses, cold-related dermatoses, viral warts, malignant melanoma, and keloid or
scarring etc). It is important with serving personnel that differentiation is made between
dermatoses of non-occupational and occupational aetiology and recorded in the F Med
4; however, it is not always easy to make this distinction. Those with a history of any
significant skin disorder as detailed above, which either degrades the functional
capacity and, or fails to respond satisfactorily to treatment, may require to be graded P3
or P7, or medically discharged (P8), as appropriate (see Section 5 paras 6-11).
Special work problems and restrictions
2.
Some or all of these diseases may be subject to significant exacerbation with
exposure to extremes of climate (i.e. humidity, cold, heat, and sunlight), stress, or
specific employment groups (catering, vehicle mechanics/automotive repairs, healthcare
work, etc), which may degrade the individual’s performance.
a.
Public health risks. Certain skin disorders can be at significantly increased
risk of developing bacterial colonisation, which makes working in the catering trade,
and also certain areas of health care, both impractical and contraindicated for
potential public health reasons.
b.
Employment considerations. Whatever the aetiology, some dermatoses
may not be amenable to treatment, and/or it may not be reasonably practicable for
the individual to avoid the exacerbating hazard in that employment. Therefore
those individuals who develop skin conditions require an individual assessment. In
these cases it may be necessary to consider change to the employment. An
individual may therefore be unfit to continue in a specific branch, although
remaining fit for general service employment. If a branch transfer is unable to be
arranged, medical invaliding may then be necessary.
Occupational skin disorders 3.
Certain employment groups (e.g. caterers, healthcare and laboratory workers,
painters, printers and vehicle mechanics) are at increased risk of developing occupational
dermatitis. This is an industrial prescribed disease and as such may be eligible for
compensation. It is important therefore that the diagnosis should only be made following
extensive and appropriate investigation by a consultant dermatologist in liaison with a
Service consultant occupational physician. Prevention is the key to minimising the risk of
developing of occupational disorders; see Section 5 paragraphs 14-17.
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Annex J
REPRODUCTIVE IN-SERVICE
Females general 1.
With the development of breast, menstrual or pelvic disorders a menstrual,
obstetric and gynaecological history should be taken and recorded. The effect on
functional capacity at work should be evaluated. Examination of the breasts or
genitalia is not required at routine PULHHEEMS examination and should not be
performed unless there is a clinical need, and a
systematic enquiry indicates doing so. Any condition which either degrades the functional
capacity and, or, fails to respond satisfactorily to treatment, may lead to permanent
regrading P3 or P7, or medically discharged (P8), as appropriate (see Section 5 paras 6-
11).
Gynaecological conditions 2.
Further details on those conditions which commonly arise are given below:
a.
Amenorrhoea. Pregnancy should always be excluded. Amenorrhea is not
usually problematic and may be related to dietary factors and/or exercise. Specialist
opinion may be necessary to confirm the absence of serious pathology.
b.
Dysmenorrhoea. Those with mild or moderate dysmenorrhoea, manageable
with mild analgesia, may be graded P2.
c.
Endometriosis. This can be recurrent and progressive in up to 50% of
patients. Medical grading will be dependent on the severity and degradation in
functional capacity.
d.
Uterine and ovarian tumours. Those with significant fibroids, and other
uterine or ovarian tumours who have benefited from successful treatment of benign
lesions, may after six months, be re-graded P2. Small fibroids and ovarian cysts,
particularly recurrent follicular cysts, are common and, more often than not, benign.
If there is no effect on functional capacity, individuals may be graded P2.
e.
Uterine prolapse. Those undergoing surgical repair should be graded P7R
or P0 as appropriate, but with successful outcome they may be re-graded P2 after
6 months. Women with residual deficiencies (e.g. symptomatic prolapse), affecting
their functional capacity will be graded P3, P7, or P8, if their condition renders
them unfit for any form of military service.
f.
Cervical dysplasia. Those with abnormalities previously found at cervical
cytology are graded as follows:
(1)
CIN 1 or 2. May remain P2, but require continuing review at six
monthly intervals, or as determined by clinical best practice.
(2)
CIN 3. On diagnosis, re-grading to P7R should be undertaken. Following
satisfactory surgical treatment (with concomitant temporary downgrading), and
following two consecutive normal smears, at least six months apart, they may
be re- graded P2.
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(3)
Invasive carcinoma and other cervical abnormalities. A history of
invasive carcinoma and those with other cervical abnormalities, including
viral changes, should be treated on individual merit and graded accordingly.
g.
Polycystic Ovary. A history of polycystic ovary, which has never given rise to
acute symptoms, need not affect the grading; all others who develop symptoms
should be graded appropriate to any degradation in function.
Infertility 3.
Infertility affects 1 in 7 couples in the UK. It may not produce physical symptoms
but the emotional stresses can be considerable. The mental and physical stresses, on
both men and women, of the necessary investigations and treatments may affect
functional capacity and deployability and the individual should be graded appropriately.
Obstetric conditions 4.
Personnel who declare pregnancies are graded P4 until at least three months after
vaginal or caesarean delivery. Provided that evidence is available of satisfactory post-
natal examination, requiring no subsequent follow up, they may then be graded P2, if
their functional capacity meets the Standards. Extant policy on pregnant workers is
detailed in Appendix 1. The latter details the obligations on Serving personnel when first
aware of pregnancy, and on the employer with regard to a risk assessment of the
workplace where servicewomen are, or may be employed, under the Management of
Health and Safety at Work Regulations 1999.
5.
After pregnancy, consideration should be given for a rehabilitation or remedial
exercise programme to enable them to attain the necessary fitness and functional
capacity, and this may preclude regrading to P2 for a further 3 to 6 months; with any
caveat in accordance with current single-Service policies. The employment policy
concerning maternity arrangements for servicewomen is published elsewhere
.
a.
Spontaneous or induced termination of pregnancy. If not already graded
P4, personnel should be temporarily graded P3R or P7R as appropriate, for at least four
weeks after a spontaneous or induced termination of pregnancy.
b.
Ectopic pregnancy. Those suffering an ectopic pregnancy should be graded
P7R. If treatment has been successful and without complication, they are usually fit to
be considered for upgrade to P2 approximately 6 months following surgery; this decision
should be made on individual functional capacity.
Appendices:
1.
Instructions for the Guidance of Medical officers: Medical Aspects of Legislation on
Pregnant Workers.
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Appendix 1 to
Annex J
INSTRUCTIONS FOR THE GUIDANCE OF MEDICAL OFFICERS:
MEDICAL ASPECTS OF LEGISLATION ON PREGNANT WORKERS
References A.
Management of Health and Safety at Work Regulations
1999.
B.
JSP 375 Vol 2 Ch 36
C.
JSP 950 Part 6 Section 7. PULHHEEMS: A Joint Service System of Medical
Classification.
D.
New and Expectant Mothers at Work; a guide for employers (HS(G)122)HSE, 19941.
E.
Workplace (Health Safety and Welfare) Regulations 1992.
F.
D/AMD/521/3/1 dated 6 January 1995
Introduction 1.
UK legislation to implement the European Directive on Pregnant Workers was
introduced with effect from 1 December 1994. The legislation has been formulated
under regulations which apply to three groups of workers:
a.
Those who are pregnant.
b.
Those who have recently given
birth
c.
Those who are breast feeding.
2.
The regulations require employers to:
a.
Assess the risks to the health and safety of each of these groups of
workers.
b.
Ensure that these workers are not exposed to risks identified by the risk
assessment, which would present a danger to their health and safety.
c.
Change the worker’s hours and, or conditions of work to avoid any risk that
remains after taking whatever preventative action is reasonable; or offer alternative
work; or if neither is possible, give paid leave from work for as long as is necessary
to protect the health and safety of the worker, her unborn child or breast-fed infant.
3.
The Management of Health and Safety at Work Regulations (MHSWR) 1999 (at
Reference A) requires employers to assess risks to all workers and in respect to MOD is
further described in Reference B. Although the specific provisions of Reference A apply
only after the pregnant worker has informed her employer of her pregnancy, it is prudent
that assessments of workplaces, where Service women are, or may be, employed, should
include anticipatory consideration of the three groups described in paragraph 1, above.
Definitions
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4.
The phrase “new or expectant mother” means a service woman who is pregnant,
who has given birth within the previous six months or who is breast-feeding. “Given birth”
is defined in the regulations as “delivered a living child or, after 24 weeks of pregnancy, a
stillborn child”.
Broad employment policy 5.
It is for line managers to conduct the assessments and to define the physical
demands of particular jobs, seeking advice from specialists, including medical officers, as
required.The appropriate employment of Service women is a command responsibility but
medical officers might contribute advice to assist in this process. Medical officers will be
expected to provide opinion on the employability of individual pregnant Service women in
specified jobs according to their particular medical circumstances. A medical officer will,
in practice, assist managers in conducting risk assessments in relation to individual
pregnant Service women and their abilities to perform the tasks entailed without undue
risk to their health and safety, or that of the unborn babies.
Employment category 6.
On diagnosis of pregnancy. A pregnant Service woman is to be regarded P4
qualified by the appropriate single-service caveat, i.e.:
a.
RN “No Sea Service”
b.
Army “RE(PP)”.
c.
RAF “Base Areas Only”.
7.
She will remain in this category until regraded, when and as appropriate, after the
birth of the child or following miscarriage. This PES is intended to protect both mother
and child from the more environmentally extreme exposures of military service. It is
unnecessary for pregnant women serving abroad to be returned to UK provided that
adequate primary and obstetric care is available, or unless they elect to do so. However,
judgements about specific employability, within this restricted PES, are likely still to be
required.
8.
On return to work. Employment grading on return to duty post-confinement should
address both the requirements of Reference A and any residual physical limitations on the
ability of the Service woman to resume military duties. Medical re-grading will take account
of any specialist post-natal review but will in any case be determined on an individual basis.
The P4 category may require to be extended beyond return to duty. (Authority for regrading
- Any medical officer with responsibility for primary or relevant specialist care of a Service
woman may regrade her on diagnosis of pregnancy and on return to duty post-
confinement1).
Specific Service considerations 9.
Service women covered by Reference A should not be required to undertake
training or testing in relation to otherwise compulsory military fitness standards. They
might, however, be encouraged to participate in suitably graded low impact recreational
1 Subject to single-Service procedures on medical grading.
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aerobic exercise as advised by medical officers while avoiding contact sports and
games.
10. Reference D makes explicit mention of both night work and shift work, which
are common components of military employment. The principles described at
paragraph 5 will inform decisions on the appropriateness of such work for Service
women considered under the provisions of Reference A. These Service women may
be excused such work at the discretion of medical officers
11. Any authorised medical officer (see paragraph 10) may, of course, further
downgrade the PULHHEEMS or adjust the medical employment standard as the
individual conditions and circumstances of pregnant Service women require.
Specific hazards 12. Tables 1 and 2 below, adapted from Reference D, list the agents, processes and
working conditions included in the initiating European Directive and directs attention to
other relevant legislation; additionally, however, Reference E requires employers to
provide rest facilities for pregnant women and nursing mothers and should be private and
include or be close to sanitary facilities.This should be used as a checklist (not
exhaustive), and due account must be taken of the factors considered during risk
assessment. Reference A requires that women to whom the regulations apply should not
be exposed to these identified hazards at work if assessment reveals risk which exceeds
that which might be encountered outside the workplace.
13. In addition to Table 1, the annotated bibliography at Reference F should provide
additional and more Service-specific assistance to medical officers who will also have
access to specialised advice through usual Service channels.
Tables:
1.
Agents, Processes and Working Conditions Giving Rise to Risk in Pregnancy and
Breastfeeding.
2.
The Employability of Pregnant Service Women - Guidelines for Medical Officers
(Revised) January 1995.
A. Occupational Hazards To Pregnant Servicewomen- Physical Agents
B. Occupational Hazards To Pregnant Servicewomen- Biological Agents
C. Occupational Hazards To Pregnant Servicewomen - Chemical Agents
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Table Agents, processes and working conditions giving rise to risk in pregnancy and breastfeeding2
Physical
Risk
How to avoid risk
Other
Agents
legislation
Shocks,
Regular exposure may increase risk of
Avoid work likely to involve uncomfortable
None specific.
vibration or
miscarriage. May be increased risk of prematurity
whole body vibration or where abdomen is
movement
or low birth weight. Breastfeeding mothers at no
exposed to shocks or jolts.
greater risk than other workers.
Manual
Pregnant workers especially at risk; hormonal
Varies according to circumstances: alter
Manual
handling of
changes can affect ligaments; postural problems
task to reduce risks for all employees, or
Handling
loads where may increase as pregnancy progresses. Risks for
address specific needs of the individual, or Operations
there is a
those who have recently given birth, e.g. limitations
provide aids to reduce risk.
Regulations
risk of injury on lifting and handling capability after caesarean
1992.
section. Breastfeeding mothers at no greater risk
than other workers.
Noise
No specific risk, but prolonged exposure may lead
Requirements of Noise at Work
Noise at Work
to increased blood pressure and tiredness.
Regulations 1989 should be sufficient.
Regulations
1989
Ionizing
Significant exposure can harm the foetus. If a
Design worker procedures to keep
Ionising
Radiation
nursing mother works with radioactive liquids or
exposure of the pregnant woman as low as Radiations
dusts the child can be exposed, particularly
reasonably practicable and certainly below Regulations
through contamination of the mother’s skin.
the statutory dose limit for pregnant
1999 and
Possible risk to foetus from significant amounts of
women. Nursing mothers should not be
supporting
radioactive contamination breathed in or ingested
employed where the risk of radioactive
Approved
by the mother.
contamination is high.
Codes of
Practice.
Working conditions should be such as to
make it unlikely that a pregnant woman
might receive high accidental exposure.
Non-iodising Optical Radiation: pregnant or breastfeeding
Exposure to electric and magnetic fields
None specific.
electro-
mothers at no greater risk than other workers.
should not exceed restrictions on human
magnetic
Electromagnetic fields and waves: exposure within
exposure published by National
radiation
current recommendations is not known to cause
Radiological Protection Board.
harm, but extreme overexposure to radio- frequency
could cause harm by raising body temperature.
Extremes of When pregnant, women tolerate heat less well and
Take great care when exposed to
None specific.
cold or heat may more readily faint or be liable to heat stress.
prolonged heat. Rest facilities access to
Breastfeeding may be impaired by heat
refreshments would help.
dehydration. No specific problems from working in
extreme cold.
Movements Fatigue is associated with miscarriage, premature
Ensure that hours, volume and pacing of
None specific
and
birth and low birth weight. Excessive physical or
work are not excessive and that, where
postures,
mental pressure may cause stress, anxiety and
possible employees have some control
travelling,
raised blood pressure. Pregnant employees may
over how their work is organized. Ensure
mental and
experience problems in working at heights or in
that seating is available where appropriate.
physical
tightly fitting workplaces.
Give longer or more frequent rest breaks.
fatigue and
Adjust workstations or work procedures.
other
physical
burdens
2 This list is not exhaustive.
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Physical
Risk
How to avoid risk
Other
Agents
legislation
Work in
Compressed air risk of bends. Not clear whether
Pregnant employees should not work in
Work in
hyperbaric
pregnant women are more at risk but foetus could
compressed air. Pregnant employees
Compressed Air
atmosphere be seriously harmed. Small increase in risk for
should not dive at all during pregnancy.
Regulations
those who have recently given birth. No
1996.
physiological reason why breastfeeding mothers
should not work in compressed air, but practical
difficulties. Diving: possible effects on foetus. No
evidence that breastfeeding and diving are
incompatible.
Biological
Risk
How to avoid risk
Other
Agents
legislation
Any
Many of these agents can affect the unborn child if
Depends on the risk assessment. Control
Control of
biological
the mother is infected during pregnancy. Examples
measures may include physical
Substances
agent of
are hepatitis B, HIV, TB, syphilis, chickenpox and
containment, hygiene measures or use of
Hazardous
hazard
typhoid. For most workers the risk of infection is not vaccines. If there is a known high risk of
to Health
groups 2, 3
higher at work than from living in the community,
exposure to a highly infectious agent, a
Regulations
and 4
but exposure to infection is more likely in certain
pregnant employee should avoid exposure 1999.
occupations such as laboratory workers, health care altogether.
Approved Code
and looking after animals.
of Practice on
the control of
biological
agents;
approved list of
biological
agents.
Biological
Rubella (German measles), Toxoplasma and
See above.
See above.
agent
some other biological agents can harm the foetus.
known to
Risk of infection is generally no higher for workers
cause
than others, except in exposed occupations (see
abortion
above).
of the
foetus or
physical and
neurological
damage
(included in
hazard
groups 2, 3
and 4
Chemical
Risk
How to avoid risk
Other
Agents
legislation
Substances R40: possible risk of irreversible effects
With the exception of lead (see below) and Control of
Labelled
R45: may cause cancer
asbestos these substances all fall
Substances
R40, R45,
R46: may cause heritable genetic damage
within the scope of the Control of
Hazardous
R46 and
R47: may cause birth defects - due to be replaced
Substances Hazardous to Health
to Health
R47
by the risk phrases:
Regulations. Employers are required
Regulations
R61: may cause harm to the unborn child
to assess health risks and where
1999.
R63: possible risk of harm to the unborn child
appropriate prevent or control them,
Chemicals
R64: may cause harm to breastfed babies.
having regard for women who are
(Hazard
Actual risk can only be determined following a risk
pregnant or have recently given birth.
Information and
assessment of a particular substance at the place
Packaging)
of work.
Regulations
1994.
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Chemical
Risk
How to avoid risk
Other
Agents
legislation
Chemicals
Includes manufacture of auramine; exposure to
Covered by the Control of Substances
Control of
agents and
aromatic polycyclic hydrocarbons present in coal
Hazardous to Health Regulations (see
Substances
industrial
soots, tar, pitch, fumes or dust; exposure to dusts,
above).
Hazardous
processes
fumes and sprays produced during the roasting and
to Health
in Annex 1
electro-refining of cupro-nickel matters; and strong
Regulations
to EC
acid process in the manufacture of isopropyl
1999
Directive
alcohol.
90/394/EEC
on the
Control of
Carcino-
genic
Substances
Mercury
Exposure to organic mercury compounds during
Covered by requirements of the Control of
Control of
and mercury pregnancy can slow the growth of the unborn
Substances Hazardous to Health
Substances
derivatives
baby, disrupt the nervous system and cause the
Regulations. HSE Guidance Notes EH17: Hazardous
mother to be poisoned. No clear evidence of
Mercury - health and safety precautions
to Health
adverse effects on developing foetus of
and MS 12: Mercury - medical surveillance Regulations
exposure to mercury and inorganic mercury
give practical guidance on risks of working 1999
compounds. No indication that mothers are
with mercury and how to control them.
more likely to suffer greater adverse effects
from mercury and its compounds after birth of
the baby. Potential for health effects in children
from exposure of mother to mercury and its
compounds is uncertain.
Antimitotic
In the long term, damage to genetic information
No known threshold limit; exposure must
Control of
(cytotoxic)
in sperm and egg. Some can cause cancer.
be reduced to as low a level as is
Substances
drugs
reasonably practical. Assessment of risk
Hazardous
should look particularly at preparation of
to Health
the drug for use (pharmacists, nurses),
Regulations
administration of the drug, and disposal of
1999.
waste (chemical and human). Those who
are trying to conceive or are pregnant or
breastfeeding should be fully informed of
the reproductive hazard HSE Guidance
Note MS21 Precautions for the sofa
handling of cytotoxic drugs gives guidance
on hazards and avoidance/reduction of
risk.
Chemical
HSE Guidance Note EH40: Occupational
Take special precautions to prevent skin
Control of
agents of
exposure limits contains tables of inhalation
contact. Where possible use engineering
Substances
known and
exposure limits for certain hazardous substances.
methods to control exposure in preference Hazardous
dangerous
Risks will depend on the way the substance is
to personal protective equipment. The
to Health
skin
being used as well as on its hazardous properties.
Control of Pesticides Regulations 1986 set Regulations
absorption
out general restrictions on the way that
1999. Control of
(includes
pesticides can be used.
Pesticides
some
Regulations
pesticides)
1997
(Amended).
Carbon
Carbon monoxide crossing the placenta can
HSE Guidance Note EH43: Carbon
None specific,
monoxide
result in the foetus being starved of oxygen. Level
monoxide gives guidance on risks and how except for
and duration of maternal exposure are important
to control them.
general
factors in the effect on the foetus. No indication
requirements of
that breastfed babies suffer adverse effects from
Control of
the mother’s exposure, to carbon monoxide, nor
Substances
that the mother is significantly more sensitive to
Hazardous to
carbon monoxide after giving birth.
Health
Regulations
1999.
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Chemical
Risk
How to avoid risk
Other
Agents
legislation
Lead and
Occupational exposure to lead in the early
The Approved Code of Practice Control of
Control of Lead
lead
1900s, when exposure was poorly controlled,
lead at work sets out exposure limits for
at Work
derivatives,
was associated with spontaneous abortion,
lead and maximum permissible blood
Regulations
in so far as
stillbirth and infertility. More recent studies
lead levels for workers who are
1998.
they are
associate low-level lead exposure form
exposed to lead to such a degree that
capable of
environmental sources before the baby is born
they are subject to medical surveillance.
with mild decreases in intellectual performance
being
Once pregnancy is confirmed, women
in childhood. Effects on breastfed babies of their
who are subject to medical surveillance
absorbed by mothers’ lead exposure have not been studied, but under the lead regulations will normally
the human
lead can enter breast mild and it is thought that the
be suspended from work which
organism
nervous system of young children is particularly
exposes them significantly to lead.
sensitive to the toxic effects of lead.
Work with
Although there has been widespread anxiety
Pregnant women do not need to stop
Health and
display
about radiation emissions from display screen
working with VDUs, but to avoid problems
Safety (Display
screen
equipment and possible effects on pregnant
caused by stress and anxiety those who
Screen
equipment
women, there is substantial evidence that these
are worried about the effects should be
Equipment)
(VDUs)
concerns are unfounded.
given the opportunity to discuss their
Regulations
concerns with someone adequately
1992
informed of current authoritative scientific
information and advice.
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Table 2 The employability of pregnant Servicewomen - guidelines for Medical Officers
a.
Occupational Hazards To Pregnant Servicewomen- Physical Agents
Agents
Human Reproductive Hazard
Scientific Evidence
Recommendation for MO
Ionising
With high maternal exposures
Numerous studies
Pregnant radiologists and radiographers are
Radiation
only: congenital malformations,
at a theoretical risk. However, the nationally-
especially of central nervous
recommended exposure levels for pregnant
system (including microcephaly
women are generally one-tenth of the upper
and mental retardation). With
limits recommended for non-pregnant
lower maternal exposures:
workers. This should constitute sufficient
increased incidence of
protection for the foetus. There is not
childhood cancers, particularly
therefore any requirement for an MO to
leukaemias.
impose additional restrictions.
Non-
Congenital malformations,
There exists one import study3 of
MO should restrict pregnant
Ionising
perinatal
physiotherapists who had used
physiotherapists from all duties involving
Radiation -
deaths.
short-wave therapeutic equipment
short-wave therapeutic equipment.
Short-
whilst pregnant, with adverse
Pregnant servicewomen complaining of
Wave
effects on their pregnancies.
soft tissue or skeletal injuries should not be
Equipment
There are no known studies on
referred by MO for any treatment involving
the reproductive hazards of high-
short-wave therapeutic equipment. MO
frequency radio sets (which
should restrict pregnant servicewomen
operate on short wavelengths),
from all duties with Clansman HF or VHF
but a sensible precaution would
sets, or any other high-frequency radio
be to avoid them in pregnancy.
sets. The restriction should apply to both
transmitters and receivers.
Non-
??Spontaneous abortion.
In fact the electromagnetic radiation Where advice is sought from a pregnant
Ionising
??Congenital malformations.
emitted from VDUs is rarely if ever
VDU user, MO should offer reassurance that
Radiation -
above natural background levels,
there is no substantiated risk. If the
Visual
except at the extremely low
individual remains unconvinced or anxious,
Display
frequency end of the range1. The
the MO should agree to restrict work with
Units
epidemiological evidence to date
VDUs.
(VDUs)
does not support the suggestion
that there is a casual relationship
between adverse pregnancy
outcome and VDU use .
Tracked
?Spontaneous abortion.
Some studies have shown that
As a sensible precaution, MO should restrict
Vehicle
?Foetal growth retardation.
prolonged exposure to industrial
pregnant servicewomen from any travel in
Noise
??Impaired hearing in offspring. noise jeopardises the outcome of
tracked vehicles. The same exclusion should
pregnancy, particularly when
apply to any travel (unless of only a few
combined with shift work. However, minutes’ duration) in rotary wing aircraft, i.e.
the majority of studies have not
helicopters.
demonstrated such effects.
The preliminary data relating to the
Gunfire
??Impaired hearing in offspring. There are no known studies
As a sensible precaution, MO should restrict
effect of industrial noise exposure
Noise
demonstrating a casual relationship pregnant servicewomen from all exposure to
of the mother on hearing levels in
between impulse noise and
gunfire noise. Therefore:
the offspring are difficult to
damage to the foetal auditory
interp
appa r
r e
att.
us. It would be difficult,
Pregnant servicewomen
however, to defend a legal action
should not be armed.
against MOD alleging childhood
deafness as a consequence of
They should not take part in any range
exposure to gunfire noise
in utero.
duties, nor any military exercise where
they are likely to be exposed at close
range to small arms noise, heavy
weapons noise, or pyrotechnics noise.
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Agents
Human Reproductive Hazard
Scientific Evidence
Recommendation for MO
Vibration -
?Preterm labour.
Some studies12 have shown
As sensible precaution, MO should
Whole-
?Low birth weight.
whole-body vibration to be a
impose the following restrictions on the
Body
hazard in pregnancy. Moreover
employability of pregnant
the European Physical Agents
servicewomen:
(Vibration) Directive
(2002/44/EC) seeks to impose
No off-road travel in military vehicles.
extremely conservative upper
limits for the daily vibration
No usage of fork lift trucks only limited
exposure of employees (even
travel (no more than a few minutes
where not pregnant).
duration) in rotary wing aircraft, i.e.
helicopters.
Vibration -
??Preterm labour.
Although formal studies are few,
Based on a detailed work history, MO should
Hand-
??Low birth weight.
the effects on pregnancy of
restrict prolonged usage in pregnancy of:
Transmitted
prolonged hand- transmitted
vibration are likely to be similar to
Pneumatic or electric power tools (e.g.
those for whole-body vibration.
drilling machines, power saws,
grinders, chipping hammers).
Vibrating work pieces (e.g. mobile
generators, compressors, pumps).
Heavy
?Adverse outcome of
Some studies have shown heavy
MO should restrict all duties involving heavy
Lifting
pregnancy
lifting in pregnancy to constitute a
lifting (e.g. movement of stores, erection of
hazard to the foetus.
tentage, casualty handling). This is likely to
be a hazard in many trades.
Long/
??Preterm labour.
Some studies have suggested that
MO should consider restricting work where
Irregular
??Low birth weight.
long/irregular hours of work are a
there is a likelihood of a pregnant
Hours of
hazard in pregnancy. However,
servicewoman having to undertake
Work
there are also conflicting studies of
particularly long and irregular hours of work.
no effect with this parameter.
Night Work
??Adverse outcome of
Animal studies have shown that the As a sensible precaution, MO should restrict
pregnancy
foetus is adversely affected by
all night duties where the pregnant
inversion of the normal light/dark
servicewoman complains of excessive
cycle of the mother. There are no
fatigue resulting from night work.
known human studies
demonstrating a casual relationship
between night work and damage to
the foetus.
Physical
??Adverse outcome of
In fact, maternal exercise is well-
MO should not restrict normal PT or
Exercise
pregnancy,
tolerated by the foetus at least up
adventurous training in a pregnant
if excessive.
to 70% of maximal exercise.
servicewoman, unless there are clear
The exercise should be in regular
contraindications to physical exercise. These
short bursts rather than arduous
contraindications include:
one-off efforts. A maximum
maternal heart rate of 140
acute infectious disease,
beats/min is recommended.
multiple pregnancy,
Exercise should be avoided only if
incompetent cervix,
there are any adverse obstetric
intrauterine growth retardation,
history or risk factors, or a previous
hypertension,
history of inactivity.
uterine bleeding,
ruptured membranes.
Pregnant servicewomen should not
undertake BFT or CFT.
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Agents
Human Reproductive Hazard
Scientific Evidence
Recommendation for MO
Trauma
?Spontaneous abortion
In fact the foetus is well-protected
MO should restrict all sports in all pregnant
within the pelvis and later by the
servicewomen after the first trimester.
layers of the abdominal wall and
Military parachuting must not be undertaken
uterus with the amniotic fluid.
at any stage of pregnancy. MO should
advise pregnant service women who work in
However, largely for medico legal
equine divisions (e.g. RAVC and RMP
reasons, most sporting bodies bar
personnel) to avoid all contact with horses
pregnant women from participating
on account of possible trauma. If this is
beyond the second trimester.
impossible, the MO should consider
imposing a formal restriction.
Extremes
?Neural tube defects
Animal studies and retrospective
MO should advise pregnant servicewomen
Of Heat
data in women have shown
to exercise during the cool part of the day,
maternal hypothermia to be a risk
and to ensure adequate hydration at all
factor. The prolonged fever (>39C
times. Pregnant servicewomen must not
for 3 days) cited in these reports,
undertake CBRN training, other than in
however, does not equate with the
CBRN Dress Category Zero or CBRN Dress
mild temperature changes
Category 1.
experienced during most
occupational activities.
Extremes
?Adverse outcome of
Some studies have shown cold to
MO should advise pregnant servicewomen
Of Cold
pregnancy
be a hazard in pregnancy.
of the theoretical risk. They should not
However, there are also conflicting
undertake any adventurous training which
studies of no effect with this
might entail prolonged exposure to extreme
parameter .
cold. During exceptionally cold weather (e.g.
in Germany, Norway) pregnant
servicewomen should be excused guard
duty.
Electrical
?Adverse outcome of
There is anecdotal evidence in the
MO must assess the risk realistically. In
Contact
pregnancy
obstetrical literature of low voltage
most military employments, and with most
(110 -220 volts) electrical shock to
electrical equipments, there is likely to be no
a pregnant woman having the
danger at all to the pregnant servicewoman.
potential for harm to the foetus,
If a known danger of electrical hazard from
including death.
old or unreliable military equipment (as e.g.
from some armoured vehicle power packs)
exists, the MO should restrict pregnant
servicewomen from all contact with such
equipment.
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b.
Occupational Hazards To Pregnant Servicewomen- Biological Agents.
Agents
Human Reproductive Hazard
Scientific Evidence
Recommendation for MO
Cyto-
CMV infection in pregnancy is
Numerous studies
MO should advise hospital personnel who
Megalo-
associated with foetal
are
Virus
hepatosplenomegaly,
pregnant to avoid contact with known CMV
(CMV)
microcephaly,
shedders
microphthalmia, mental retardation.
Toxoplasma
Toxoplasma gondii is an intracellular
Numerous studies
MOs should be aware of the risk to:
gondii
coccidian protozoan of cats, and the
cause of toxoplasmosis. This is a
Pregnant RAVC personnel who work in
common infection which is frequently
veterinary hospitals which operate on
asymptomatic or else presents as an
cats.
infectious disease resembling infectious
mononucleosis. A primary infection
during early pregnancy, however, may
Pregnant RAVC or RMP personnel
lead to foetal infection with death of the
who work in equine divisions
foetus or choreoretinitis, brain damage
(where barn cats are an essential
with intracerebral calcification,
part of the establishment).
hydrocephaly, microcephaly, fever,
jaundice, rash, hepatosplenomegaly and
They should advise such personnel
convulsions evident at birth or shortly
accordingly, and if necessary impose a
thereafter.
formal restriction on any contact with cats.
Maternal infection later in pregnancy results
in mild or subclinical foetal disease with
delayed manifestations, especially recurrent
or chronic choreoretinitis.
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c.
Occupational Hazards To Pregnant Servicewomen- Chemical Agents.
Agents
Human Reproductive Hazard
Scientific Evidence
Recommendation for MO
Lead
Reduced fertility, spontaneous
Numerous studies.
MO should restrict pregnant
abortion, prematurity, stillbirth,
servicewomen from all duties within
neonatal death, congenital
indoor firing ranges.
malformations, abnormal central
nervous system development,
behavioural abnormalities.
Benzene
Vaginal bleeding, haemorrhagic
Numerous studies. It should be
MO should restrict pregnant
complications of pregnancy,
noted that petrol by law may
servicewomen from any direct contact
spontaneous abortion.
contain up to 5% benzene. Diesel with benzene or with benzene vapour,
fuel, on the other hand, may
even when wearing protective
contain a variable amount of
equipment. Pregnant women should
benzene. Currently, the levels are not be permitted to refuel military
not regulated by law.
vehicles at any time. This applies also
to military drivers, who must not refuel
their own vehicle if pregnant.
Carbon
Congenital malformations
Carbon monoxide readily
MO should restrict pregnant
Monoxide
crosses the placenta and is
servicewomen from all duties in vehicle
likely to cause reduced
parks, other than brief visits.
foetal haemoglobin
concentration. The potential
for this hazard has been
demonstrated in numerous
studies. It should be noted
that vehicle exhausts
contain carbon monoxide as
well as oxides of nitrogen
(which are also believed to
have an adverse effects on
pregnancy).
Anaesthetic Spontaneous abortion (one and a
Numerous retrospective studies.
MO should restrict DMS
Gases
half to three fold increases).
servicewomen who are
pregnant from any exposure
? Foetal grown retardation,
to anaesthetic gases. This
congenital malformation, low birth
applies to surgeons,
weight, stillbirth.
anaesthetists, operating
theatre nurses, operating
theatre technicians, etc.
Antimitotic
Pregnant doctors and nurses
Numerous studies.
MO should restrict pregnant DMS
(Cytotoxic)
administering antimitotic agents
servicewomen (including doctors,
Drugs
(even when doing so with extreme
nurses, pharmacists and pharmacy
care) have shown a significant
technicians) from handling antimitotic
increase in foetal loss and/or
drugs in any form.
congenital malformations
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Agents
Human Reproductive Hazard
Scientific Evidence
Recommendation for MO
Antimalarial ?Congenital malformations
Mefloquine is teratogenic when
MO should not prescribe mefloquine to
Chemoprop
administered to rats and mice
any servicewoman
hylaxis -
in early gestation. Its
travelling to a malarious area, unless
Mefloquine
prophylactic use during
there is no risk at all of pregnancy (e.g.
human pregnancy should
following a hysterectomy or
therefore be avoided as a
sterilisation).
matter of principle.
Pregnancy should also be
avoided for 3 months after
completing a course of
mefloquine, on account of its long
half- life.
Pesticides
? Spontaneous abortion.
Various studies
Although the majority of service-
approved pesticides are likely
?? Congenital malformations.
to pose no threat at all in pregnancy,
MO should nevertheless restrict
pregnant servicewomen from all duties
involving the use of pesticides.
CS Gas
?? Adverse outcome of
No known studies
As a sensible precaution, MO should
pregnancy
restrict pregnant servicewomen from
any exposure to CS gas, e.g. during
CBRN training.
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Annex K
MUSCULOSKELETAL IN-SERVICE
General
1.
Musculoskeletal (MSK) disease and injury are the most common conditions seen in
Primary Care. All individuals with MSK conditions whether acute or chronic are to be
graded according to their functionality as well as bearing in mind the prognosis and the
requirement for any ongoing medical treatment. Any surgical intervention should result in a
grading of P7 MND until such time as the long term degree of functional impairment can be
assessed. An Orthopaedic or Rheumatology and Rehabilitation Consultant clinical opinion
may be sought to inform the occupational assessment.
Overuse injuries
2.
These injuries are generally attributable to one of more of overuse or repetitive
actions, rapid changes to load and/or frequency of the action. Medical grading should
reflect the functional decrement and the need to afford protection.
3.
Appropriate modification to working practices should be implemented. The line
management/employer should be involved in performing a risk assessment1 to consider
necessary changes in working practices to minimise exposure to, or exclude entirely the
hazard/risk.
Arthropathies and collagen disorders
4.
A small minority of those with MSK conditions have inflammatory joint or collagen
disorders (including connective tissue and vascular diseases) and these usually require
referral to a Consultant Rheumatologist. The severity of these conditions range from mild
and self-limiting to the immediately life threatening, and many have functional limitations.
Evidence strongly suggests that early treatment to suppress inflammation or correct
deformity retards disease progression and can therefore improve functional capacity,
quality of life and life expectancy. Medical grade should be based upon treatment
requirements, impact of medical treatment2 and functional restrictions.
5.
Patients on Disease Modifying Anti-Rheumatic Drugs (DMARDs) will initially be
graded P7 MND and once established on treatment may be considered for upgrading to
MLD by a single Service (single-Service) Consultant Occupational Physician. Patients on
Methotrexate, Anti-TNF or other novel agents with a similar side effect and/or hazard
profile will usually remain P7 MND3.
Amputations
6.
Whilst grading is primarily based on function when wearing a prosthesis,
consideration must be given to the safety of the individual and others when the prosthesis
1JSP 375 ‘Management of Health and Safety in Defence’ Part 2 Volume 1 Chapter 8 Risk Assessment. Health and Safety Risk
Assessment.
2This includes supply and storage of medication, potential side effects, requirement for monitoring and potential to place a burden on the
deployed medical capability.
3Due to the complexities of drug supply, storage and administration, monitoring requirements and recurrence of the condition or
occurrence of treatment complications in a deployed environment with the consequent load on deployed medical services.
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is not being worn. Grading must also safeguard the wellbeing of the individual by avoiding
further functional loss and by minimising degradation of the prosthesis and its points of
attachment. Minor amputations with no functional sequellae may be graded P2 MFD;
amputations normally requiring prosthetics will be graded no higher than P7 MLD.
7.
Generally individuals with lower limb amputations should not be considered for
operational deployment but this should be judged on an individual basis in terms of the
deployed role, their functional ability and the operational environment.
Fractures
8.
Fractures are normally graded P7 MND whilst under treatment. Re-grading should be
based upon functional capacity and the requirement for any ongoing treatment and
rehabilitation. Dependant on individual functional recovery a graduated return to specific
activity may be appropriate. Following completion of medical treatment and a period of
rehabilitation, if function is still impaired the individual should be referred back to their
treating Consultant or if available locally a Service Consultant.
9.
Individuals with asymptomatic metalwork in place can be graded P2 MFD. Removal
of asymptomatic metalwork has a significant complication rate4 and should not normally be
considered for specific occupational reasons5.
10. Stress fractures are generally caused by a sustained increased level of physical
activity, including weight-bearing, which is greater than the pace of bone remodelling.
Individuals should initially be graded P7 MND. For subsequent re-grading, consideration
should be given to:
a.
Evidence of a sustained return to appropriate activity.
b.
Site of the fracture.
c.
Risk of recurrence.
Patients with recurrent stress fractures, particularly those affecting the femoral neck should
be reviewed by a Service Orthopaedic Consultant.
Joint replacements
11. For individuals with a joint prosthesis, functional capacity and the job demands (in
terms of excessive stress on the prosthesis) must be considered when grading.
a.
Upper limbs. Grading is on an individual basis.
b.
Lower limbs.
(1) Successful hip replacement graded P3 MLD.
(2)
Hip resurfacing graded P2 MFD.
4Sanderson PL, Ryan W, Turner PG. Complications of metalwork removal. Injury 1992;23(1):29-30.
5Certain specific single-Service roles my require consideration of whether the metalwork can remain e.g. clearance divers.
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(3) Uni-compartment knee replacement and total knee replacement should
not normally be graded higher than P3 MLD and must have a risk assessment
conducted by a single-Service Consultant Occupational Physician prior to
operational deployment.
Conditions affecting upper limb function
12. Deformities of the upper limbs including loss of part or all of a digit must be judged
against the residual functionality and the employment of the individual. The dominance of
the affected hand must be borne in mind, as must the ability to fire a weapon, drive and
use tools as appropriate to the individual job. Those with osteoarthritis must be graded, on
an individual basis, to minimise any adverse effects of their work on their condition.
Fingers and hands 13. Loss of part or all of any finger of either hand will be graded according to residual
function. The ability to wear protective gloves, including Chemical Biological Radiation and
Nuclear Personal Protection Equipment, and operate a weapon system is important as
well as dexterity in relation to their Career Employment Group (CEG). Individuals may be
graded P2 MFD providing they can maintain full function, good grip strength, and have
adequate sensation to maintain safety. Partial loss of the thumb should be graded
according to function although complete loss is normally graded P7 MND.
Wrist
14. Significant loss of wrist function should be graded no higher than P3 MLD. A
scaphoid fracture should remain graded P7 MND until healing is confirmed and sustained
functional recovery demonstrated.
Elbow 15. Any residual instability or loss of functional capacity is graded no higher than MLD
except:
a.
Where the loss is of the last 5° - 10° of full extension which may be graded P2
MFD.
b.
Individuals with a loss of greater than 20° of pronation or supination should be
graded no higher than MLD.
c.
Those with a varus or valgus deformity can be graded P2 MFD provided a
functional assessment against role related and military tasks is satisfactory.
Shoulder
16.
Recent dislocation or symptomatic instability. Individuals with a recent dislocation
or symptomatic instability of the shoulder should initially be graded P7 MND. Those
requiring surgical intervention should remain P7 MND pending stabilisation and
rehabilitation. If despite rehabilitation they have a further dislocation or functional
instability, they should be P7 MND until surgery and rehabilitation but could be upgraded at
6 months post-surgery to P2 MFD if fully recovered.
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17.
First dislocation. The individual may be graded P2 MFD at 6 months provided that:
a.
Completed adequate rehabilitation.
b.
No further symptoms.
c.
Negative apprehension test.
d.
Does not require surgery.
Clavicle
18.
Healed clavicular fractures. Individuals may be graded P2 MFD after 3-6 months
provided that:
a.
Full weight-bearing is possible.
b.
The pressure from load bearing and equipment such as webbing gives no pain.
19.
Chronic non-union or painful mal-union. Individuals should be graded no higher
than MLD.
20.
Excision of the lateral end of the clavicle. Individuals following excision of the
lateral end of the clavicle leaving the coracoid and trapezoid parts of the coraco-clavicular
ligament intact may be graded P2 MFD after review by a Consultant Orthopaedic Surgeon
to confirm full function.
Sterno-clavicular or acromio-clavicular dislocations
21. Sterno-clavicular or acromio-clavicular dislocation should initially be graded no higher
than P3 MLD. Subsequent re-grading to P2 MFD may be considered depending on
functional capacity and risk of recurrence.
Other Conditions
22. Other conditions, including those of the cervical and/or thoracic spine, causing
restriction of function or pain are graded according to treatment requirements, functional
capacity and the demands of employment.
Conditions affecting locomotion
Low Back Pain (LBP)
23. Individuals should normally be graded no higher than MLD with the following
conditions:
a.
Persistent or recurrent LBP.
b.
Sciatica.
c.
Connective tissue disorders.
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d.
Arthropathies of the lumbo-sacral spine.
24. LBP requiring surgical or invasive pain management intervention should be graded
P7 MND. Subsequent re-grading must consider the risk exacerbation or recurrence on
return to military activities and should be based upon:
a.
Functional capacity.
b.
The requirement for any ongoing treatment.
c.
The requirement for any ongoing rehabilitation.
d.
The impact of medication.
25. LBP may be associated with shock loading and whole body vibration and where this
is suspected, appropriate modification to working practices should be implemented. The
line manager/employer should be involved in performing risk assessment to consider
necessary changes to working pract
ices1.
Hallux valgus, hallux rigidus, hammer toes and clawed feet
26. The symptomatic development of these conditions will result in re-grading depending
upon:
a.
The severity of symptoms.
b.
Ability to wear Service or protective footwear.
c.
Ability to undertake CEG tasks.
Medical grading following treatment is dependent on the functional outcome.
Loss of toes
27. Loss of the terminal phalanx of the great toe with no residual pain and full
functionality can be graded P2 MFD. Those with total or complete loss of other toes may
be P2 MFD subject to the outcome of:
a.
Ability to wear Service or protective footwear.
b.
Ability to undertake CEG tasks.
Flat Feet
28. Flat feet do not require re-grading unless there is a history of discomfort whilst
walking, standing or running. Those with mobile flat feet, i.e. those who can form an arch
standing on tip-toes, only require re-grading if they are symptomatic.
Ankle joint
29. Those with limitation of movement are initially graded no higher than MLD in
accordance with their remaining function. Consideration should be given to the risk of
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exacerbation or recurrence on return to military activities and subsequent re-grading
should be based upon:
a.
Functional capacity.
b.
The requirement for any ongoing treatment/rehabilitation.
c.
The impact of medication.
Individuals who have had surgical treatment may be graded P2 MFD post rehabilitation if:
a.
There is a good level of function.
b.
No residual pain.
c.
No need for protection from future re-injury or complications.
Knee Joint
30. Knee conditions requiring surgical or invasive pain management intervention should
normally be graded P7 MND. Consideration should be given to the risk of exacerbation, re-
injury or recurrence on return to military activities and subsequent re-grading should be
based upon:
a.
Functional capacity.
b.
The requirement for any ongoing treatment/rehabilitation.
c.
The impact of medication.
31.
Cruciate and collateral ligaments. Personnel who have symptomatic instability of
their cruciate or collateral ligaments of the knee joint should normally be graded no higher
than P3 MLD.
a.
Anterior cruciate ligament reconstruction. If the anterior cruciate ligament
reconstruction has been successful and there is no evidence of additional intra-
articular damage, then personnel who have returned to full function may be
considered for re-grading to P2 MFD, following discussion with single-Service
Occupation
Physician.
b.
Anterior cruciate ligament repair. Those individuals who have had a
successful anterior cruciate ligament repair should normally be graded no higher than
P3 MLD.
c.
Deficient anterior cruciate ligament. Those individuals who have deficient
anterior cruciate ligament but who have a clinically stable knee joint confirmed by a
Service specialist in orthopaedics may be considered for a re-grading to P2 MFD.
Asymptomatic incidental findings
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32. Asymptomatic spina bifida occulta, failure of fusion, spondylosis and
spondylolisthesis which is detected incidentally only on imaging does not require re-
grading.
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Annex L
PSYCHIATRY IN-SERVICE
Special conditions affecting mental capacity
1.
Mental capacity is dependent not only on the innate mental ability of a Service
Person, but also on their capacity to use that ability. During most medical examinations, no
formal clinical assessment of mental capacity is practicable or required. Where this area is
being reviewed following completion of basic training, such as after physical illness or
injury, full psychometric testing by a clinical psychologist should be undertaken. Any
changes in JMES should only be conducted following the above and on advice from a
consultant neurologist, consultant psychiatrist, clinical psychologist or other recognised
subject matter expert in the field.
Special conditions affecting psychological stability
2.
Requirements to be considered for Medically Fully Deployable (MFD) status1.
Service life places great psychological demands on individuals. Individuals with underlying
psychiatric conditions may be at increased risk of exacerbating their condition during
military service. Therefore, it is important to consider the following factors when grading
individuals as MFD:
a.
Must be fit to deploy at short notice to any location world-wide, and serve as
directed by Command.
b.
There must be a high degree of certainty that they will be able to cope with
heightened levels of stress, and maintain sufficient psychological stability to remain
functional and effective.
c.
They must be able to deploy away from their support network for prolonged
periods, in a largely self-reliant capacity, without becoming an administrative burden
or operational risk due to psychological instability.
d.
They must be able to safely operate weapon systems on operations and in
training.
e.
They must be able to deploy without additional special support requirements
(i.e. JMES E1 or E2).
f.
Relapse of symptoms must not pose a risk of high risk behaviours that may
present significant problems in theatre, e.g. serious self-harm, violence or
unpredictable behaviour that may endanger others.
3.
General considerations for awarding a JMES. In deciding on the JMES for a
psychological condition the clinician should consider the following factors:
a.
The level of hardship individuals are likely to encounter (temperature, noise,
nutrition, hydration, arduous physical activities, sleep disturbance, loss of social
support etc).
1 Further details on definition and award in JSP 950 Leaflet 6-7-7 Section 2 Annex A and sS policy.
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b.
The level of medical support required (immediacy, availability, skill mix,
resources).
c.
The duties to be performed (likelihood of exposure to traumatic events, burden
of working hours, likelihood of new/novel tasking requiring adaptation, leadership role
etc) and the person’s previous experience of, or training for, these duties.
d.
The current welfare of individuals and their personal support networks (current
relationship difficulties, financial difficulties and legal problems etc) and the ability to
communicate with that network.
e.
The degree to which the current and anticipated symptoms affect function;
particularly how symptoms affect concentration, sleep, judgement, impulsivity,
attitude, morale and motivation.
f.
The risk and speed of relapse, potential for incapacitation by a relapse and the
responsiveness of the condition to treatment.
g.
The Service Person’s degree of insight about their condition and its effect on
the team around them and the operational tasks.
h.
Clear consideration should be given to the need for performing safety critical
tasks, e.g. in aviation-related roles, that may confer a lower tolerance of risk and
require higher assurances of stability.
4.
Care pathways. In mental health, care pathways can be very lengthy and in
deciding a permanent JMES the length of the care pathway is a secondary consideration,
and it may be appropriate to set a permanent JMES before completion of treatment.
Grading decisions will take into account whether the patient has received an appropriate
evidence-based level of care, requires further treatment, prognosis and the likelihood of
recovery to an employable status. Treatment provided should be at least equivalent to the
prevailing standard in the National Health Service. Single Service authorities dictate
assessment points in this regard and final grading is the remit of Single Service Medical
Boards.
5.
In specialist groups such as aircrew, divers, submariners and Special Forces, this
policy does not take precedence over the specific occupational policies that govern these
specialist areas.
Common mental disorders (including adjustment disorders, mood and anxiety
disorders, phobias, post-traumatic stress disorder (PTSD), and eating disorders)
6.
Common Mental Disorders (CMD) form the bulk of the clinical activity within the
Defence Mental Health Services.
7.
Stepped care. Patients requiring psychological therapy are stepped through levels of
care according to need.
a.
Initial interventions. Self-help material and resources with no formal
psychotherapeutic intervention by the clinician, other than to provide the material and
signpost the patient to the appropriate resources, including formal referral to mental
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health services. This is commonly the step conducted in non-specialist mental health
settings like Primary Care.
b.
Low intensity therapy. Guided self-help where a patient is assisted by a
clinician, usually on a weekly basis, to complete a psychotherapy programme. Low
intensity therapy is often standardised, of shorter duration, less intensive and aimed
at mild to moderate presentations.
c.
High intensity therapy. Individualised therapy, usually by a qualified therapist
in the modality, using an individual approach and more intensive treatment. High
intensity therapy is generally aimed at moderate to severe presentations or where no
standardised low intensity therapy exists for the condition (e.g. PTSD).
d.
Complex case management and specialist psychotherapy. Severe and
complex conditions that require long-term care from multiple professionals. Patients
requiring this level of care are likely to be significantly functionally limited and should
normally be considered unfit for military service.
8.
In setting this policy
“NICE guidance CG123: Common mental health problems:
identification and pathways to care” May 2011 (reviewed August 2018)” introduces the
stepped care model for CMD. This is mirrored in the guidelines for individual disorders,
and these are delivered within the tenets of providing lower level, least intrusive
interventions first, then escalating as required through the steps. The specific guidelines
also specify a number of sessions of intervention at each level of care, which differs
slightly between conditions but are broadly comparable:
a.
Initial interventions. Session limit does not apply.
b.
Low intensity therapy. 6-10 sessions.
c.
High intensity therapy. 12-30 sessions.
d.
Complex case management and specialist psychotherapy. On-going,
long-term care.
9.
Temporary grading for CMD. Patients undergoing stepped care for CMD should
normally be graded MND to allow them to access treatment with appropriate occupational
restrictions to manage access to treatment, address risks (to self and others),
accommodate psychotropic medication and enable the care pathway as required.
However, patients undergoing initial intervention in Primary Care may not need to be
graded MND and pragmatism and an individual occupational assessment should guide
clinicians, including consideration of any psychotropic medication the patient may be
taking. For patient undergoing low intensity interventions and above, there may also be
rare, individual cases where MND grading may not be appropriate, but in such cases a
grading discussion with an occupational health physician or Service2 consultant
psychiatrist represents best practice. On successful completion of treatment and a period
of stability of not less than one month, Service Persons may be upgraded (please see
stability requirements for other specific conditions below).
2 This term encompasses all consultant psychiatrists working for the MOD, uniformed or civilian.
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10.
Permanent grading for CMD. Permanent grading is the sole remit of Single Service
Medical Boards, taking account of recommendations by specialist clinicians as required.
As a general rule, patients should be awarded a permanent grading if:
a.
Required by sS policy.
b.
The stepped care pathway has been completed. See Para 3 for considerations
to be reviewed in defining a permanent grade.
c.
Patients requiring long-term treatment with psychotropic medications should be
graded no higher than MLD with appropriate restrictions.
d.
Service Personnel should be graded permanently MND if, after treatment, one
or more of the following criteria are met:
(1) They have had the maximum of 12-30 high intensity sessions (if
appropriate) of an acceptable quality and continuity (which may or may not have
been preceded by 6-10 sessions of low intensity therapy) and the condition
remains unresolved.
(2) They have had adequate trials of 2 psychotropic medications appropriate
to their condition (providing the patient opted for this treatment), and has not
demonstrated an adequate therapeutic response. This is a significant marker of
treatment-resistance.
(3) Their condition and social environment is so unstable that it prohibits
meaningful progress or engagement with psychotherapy after 6 months of
attempts at stabilisation, regardless of the stage they have reached in the
stepped care process.
(4) If, in the opinion of a service consultant psychiatrist, the risk of relapse on
exposure to the operational environment is unacceptably elevated.
Conditions normally incompatible with military service
11.
Psychosis. Service Persons with psychotic illness, whether recurrent or not, are
normally graded permanently MND. The only clear exception is a single, brief psychotic
episode of less than 7 days’ duration where there is a clear, definable organic aetiology
(e.g. delirium, drug side effect etc). In these exceptional cases the patient should remain
symptom free for 6 months off all psychotropic medications before being considered for a
deployable medical category.
12.
Bipolar affective disorder. Service Persons with bipolar affective disorder (Types I
and II) are normally are normally graded permanently MND.
13.
Personality disorders. Service Persons with these disorders are normally graded
permanently MND.
14.
Recurrent CMD. Patients who re-present with a CMD within 3 years of completing a
stepped care pathway would are normally graded permanently MND if they fail to respond
to maintenance medication and/or 6 booster sessions of high intensity therapy. Exceptions
in these circumstances are individuals that can be offered sufficient occupational
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protection to minimise recurrence risks, whilst still being able to fulfil an employable and/or
deployable function for their Service.
15.
Lithium therapy. Service Persons on lithium therapy should normally be graded
MND due to the risks associated with this medication and the conditions it is used for.
However, at the discretion of the Single Service Medical Board, retention may be
considered in a MLD category.
16.
Recurrent and/or persistent self-harm. A single episode of self-harm3 in response
to a stressful event does not in itself render an individual unfit for military service.
However, Service persons with a history of 2 or more episodes, even with clear stressors,
should normally be considered unfit for military service, as repetition indicates a
substantial risk of further repetition and, of more concern, a significant increase in risk of
later death by suicide. However, there are exceptional cases where Service persons with a
second episode of self-harm may be fit for further military Service, for example an
individual with a long period of stability in between episodes. In such cases, retention can
be considered but this should normally be supported by a comprehensive risk assessment
from a MOD Consultant Psychiatrist, including an assessment for any underlying pre-
disposing conditions. If multiple attempts occur over a short period of time (weeks rather
than months), and can clearly be ascribed to the same single stressful event or occur
whilst the patient is still undergoing treatment or waiting for therapeutic intervention to
commence, then for the purposes of this policy, these may be regarded as a single
episode.
17.
Repeated or prolonged inpatient care. Due to the likelihood of relapse and long-
term illness, Service Persons requiring repeated (3 or more) or a single prolonged (longer
than 56 days) inpatient admission to a mental health ward are normally graded
permanently MND.
18
Substance misuse disorders requiring detoxification. Service Persons requiring
more than 2 episodes of inpatient detoxification or more than 4 detoxifications overall
(inpatient and community) for dependent use of any substance are normally graded
permanently MND. The Executive management of substance misuse is covered under the
relevant single Service policies.
Substance misuse disorders4
19. Most Service Persons considered as part of this policy will misuse alcohol, but it can
be applied to all psycho-active substance misuse5. Service Persons who present with
substance misuse disorders should be graded MND and offered 6-10 sessions of low
intensity therapy and/or a maximum of 12-30 sessions of high intensity therapy (if
appropriate) of an evidenced-based therapeutic modality depending on severity and need.
Treatment is independent of any required disciplinary processes which may run
concurrently.
20. If treatment is completed and the Service Person continues to misuse the substance
but is not dependent on the substance, then it is a Chain of Command responsibility to
manage them through the normal administrative routes. Grading is dependent upon
functional ability to perform all duties6.
3 Self-harm refers to an intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act and is
an expression of emotional distress.
4 Substance misuse is an over-arching term that includes both harmful use of a substance(s) and dependence on it.
5 https://www.gov.uk/government/collections/defence-mental-health-statistics-index 6 Reference should be made to single Service substance misuse policies.
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21. If the Service Person has a recognised dependence syndrome, they should normally
be graded MND.
22. Clinicians may need to disclose illicit substance misuse to Command if the public
interest test or the requirement to protect others is met, and this is incumbent on clinicians
to do in cases of risk that needs to be mitigated by command. This same approach holds
true for these risks that are encountered in any condition in this policy. If the clinician
considers this necessary the clinician should seek consent to disclose, take account of
GMC guidance on confidentiality and seek senior guidance as required. Disclosure without
consent may be necessary.
Adult Attention Deficit Hyperactivity Disorder (ADHD)
23. ADHD has a high association with co-morbid CMD and substance misuse, and in
cases where a CMD or substance misuse is present, the occupational management
should follow that of the CMD or substance misuse disorder as detailed above.
24. Service Persons with ADHD, in the absence of a CMD or substance misuse disorder,
are fit for deployable service. Service Persons with ADHD tend not to be adversely
affected by a rapidly changing, high-tempo and challenging working pattern or
environment, such as operations. They usually remain on stimulant medication long-term
as normally it improves functioning (from a lower but functional threshold); long-acting
preparations are preferable in the deployed setting. However, a disruption in stimulant
medication is unlikely to have an operational impact in individuals with a functional pre-
medication threshold, and there is no withdrawal syndrome. If a decision is made to
continue the medication during a deployment, which is reasonable to do, it is best practice
to test functioning without stimulant medication on an appropriate UK-based exercise to
simulate the disruption of stimulant supply on operations to confirm functionality. Service
Persons who have been stable on stimulant medication for 6 months can be graded MLD.
Transgender personnel7
25. The grading of all transgender Service Persons requires consideration of their mental
health, surgical/medical treatment and follow-up requirements.
26.
Medical grading of Service Persons who do not wish to undergo hormonal or
surgical gender confirmation.
Service Persons may remain MFD unless, as a result of
physical or mental health issues that affect deployability, a Service psychiatrist,
psychologist or occupational physician advises otherwise.
27.
Medical grading of serving personnel wishing to undergo hormonal or surgical
gender confirmation. Initially, Service Persons are to be graded MND. MLD and MFD
may be considered once their condition is stable, taking into account their on-going
medical support needs and compatibility with military environments.
Psychiatric Reports for Medical Boards
28. There is no absolute requirement for a grading recommendation or report from a
Service consultant psychiatrist when awarding a permanent JMES. owever, it is best
7 Further information can be found i
n JSP 889 'Policy for the Recruitment and Management of Transgender Personnel in the Armed
Forces'.
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practice for such reports to be prepared in order for the determining clinician to have the
best possible information to inform the JMES. Psychiatric reports submitted for Medical
Boards must follow the format detailed at Appendix 1. A psychiatric report must be
provided to a Medical Board if requested.
Appendices
1.
Standard Psychiatric Report for Medical Boards.
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Appendix 1 to
Annex L
STANDARD PSYCHIATRIC REPORT FOR MEDICAL BOARDS
SERVICE CONSULTANT PSYCHIATRIST REPORT FOR THE MEDICAL
BOARD
Patient name:
Rank:
Service Number:
Principal psychiatric
condition(s) affecting
fitness for service
Brief summary of the salient
features of the case
Does the patient have a
Yes
No
Comment:
condition that is normally
incompatible with
employment in the military
as per JSP 950, Annex L to
Lft 6-7-7(5)?
If appropriate, did the
Yes
No
N/A
Comment:
patient have access to 6-10
sessions of low intensity
therapy if they did not go
directly to high intensity
therapy?
If appropriate, did the
Yes
No
N/A
Comment:
patient have access to 12-
30 high intensity therapy
sessions if appropriate?
If appropriate, did the
Yes
No
N/A
Comment:
patient have access to at
least 2 adequate trials of
psychotropic medications
appropriate to their
condition?
Were the patient’s condition Yes
No
N/A
Comment:
and/or social environment
so unstable that they were
unable to adequately
engage in treatment over 6
months or longer? If yes
please comment.
In your opinion, did the
Yes
No
Comment:
patient engage adequately
with treatment offered? If
no, please comment.
In your opinion, will the
Yes
No
Comment:
patient reach deployable
fitness in the next 6
months? Please comment
on prognosis either way.
In your opinion, will the
Yes
No
Comment:
patient reach deployable
fitness again in the
foreseeable future? Please
comment on prognosis and
timeframe.
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What are your
recommendation for the
permanent occupational
limitations that should apply
to this patient? It is the role
of the board to consider
how these translate into a
permanent JMES.
Name of service
psychiatrist completing
report:
Date of report
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Annex M
DENTAL AND ORO-MAXILLOFACIAL IN-SERVICE
General
1.
Dental Fitness is categorised using the NATO Dental Fitness Classification system1
(DF Cat). Further policy direction on the United Kingdom Armed Forces interpretation of
NATO DF Cats is available a
t JSP 950 2-23-1 ‘Primary Dental Care Policy’. NATO DF Cat
reports on the dental health of the force, quantifies dental risk and aids the allocation of
dental resources. There are circumstances when managing dental disease or other oral
pathology is not possible within the deployed primary care environment and would
adversely affect operational effectiveness.
2.
The JMES grading should be reviewed if the Service Person’s oral health status
adversely affects their employability or overall health if deployed, or their oral care needs
would be difficult to deliver in the deployed environment2. This will allow the Service
Person to access appropriate care in a timely manner, be returned to optimal health and
not be placed at risk of avoidable strategic medical evacuation. The Service Person is to
be graded according the frequency of the symptoms, requirement for medication and
medical support, and degree of functional impairment.
JMES Review
3.
Defence Primary Healthcare (DPHC) Medical Officers (MO) are able to change the
JMES of Service Personnel based on advice and referral from a Dental Officer (DO).
Communication of Occupational Dental and Oro-Maxillofacial JMES grading advice to the
MO by a DO or Oral and Maxillofacial Surgery (OMFS) Consultant should be undertaken
by a formal FMed 7 referral letter. The advice should include the nature of the condition
and how it can impact on deployability and employability as defined in Section 2 The Joint
Medical Employment Standard. Primary Care Medical Practitioners can seek advice from
DMS Dental Officers
via the
DPHC Directory or, if appropriate via military OMFS
Consultants3.
Dental treatment need
4.
In the majority of cases of dental disease or oral pathology military personnel will be
classified as NATO Cat 3 and will be so for short periods only, until they receive the
appropriate dental treatment. In these circumstances medical downgrading is not
necessary. For individuals likely to be held at NATO Cat 3 for extended periods4 or Service
Personnel held at a high state of readiness5, consideration must be given to changing
JMES to MLD or MND. Assessment of JMES must consider the advice of a suitably
qualified dental practitioner with regard to treatment need and duration.
5.
The treating dentist is to consider referral for review of JMES in the following
circumstances:
1 AMedP-4.4 STANAG 2466
2 Examples include 1: Access to care 2. Treatment tolerance 3. Complexity of treatment beyond GDP 4. Management of treatment
morbidity.
3 Service OMFS Consultants can be contacted by liaising with the DCA OMFS (contact details cited in the DCA list availab
le here). 4 Beyond single Service restricted duties timeframes.
5 R1 to R5.
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a.
Complex surgical intervention. Cases referred to secondary care are likely to
require JMES MND.
b.
Dental phobia6. Service Personnel who become reliant on conscious sedation
or have a phobic disorder that will not allow treatment within primary dental care
should be graded no higher than MLD. In consultation with JSP 950 Part 1 Lft 6-7-7
Section 5 Annex L Psychiatry Service Personnel with an anxiety disorder should be
referred to Department of Community Mental Health.
c.
Needle phobia. Service Personnel with an established history of needle phobia
should be managed in accordance with JSP 950 Part 1 Lft 6-7-7 Section 5 Annex L
Psychiatry.
d.
Recurring pericoronitis. Service Personnel with an established history of
recurring pericoronitis who are awaiting surgical removal of third molars are to be
graded according the frequency of the symptoms, requirement for medication and
degree of functional impairment. MOD policy on
JSP 950 Lft 2-23-1 Annex H
Managing Third Molars should be consulted.
e.
Suspected malignancy. Service Personnel with an oral lesion with any
suspicion of malignancy7 are to be graded MND until the nature of the lesion is
established.
f.
Orofacial pain. Service Personnel suffering from:
(1) Orofacial pain that does not improve or resolve within one month of
provision of treatment must be reviewed by a specialist clinician. Grading
should be checked to ensure that it allows attendance at this specialist review.
(2) Diagnosed recurrent orofacial pain8 should be graded according the
frequency of the symptoms, requirement for medication, degree of functional
impairment and the nature of trigger factors.
6.
Specialist Employment Groups. Service Personnel in specialist employment
groups (e.g. aviation, diving, parachutists, and submarines) and air passengers can be
exposed to the risks of barotrauma and barodontalgia9. Special consideration should be
given to these groups of Service Personnel when diagnosing and treating dental
pathology. In the majority of cases this will be via a short term restriction of duties.
7.
Oro-antral communication. The healing and repair of oro-antral communications is
significantly hampered by barotrauma. Service Personnel with suspected or confirmed oro-
antral communication are to be protected from activities which expose them to the risk of
barotrauma until the condition has resolved. In the majority of cases this will be via a short
term restriction of duties and will not need a JMES change. A formal communication (Oro-
Antral Fistula) will require grading no higher than MLD whilst awaiting repair.
6 Dental phobia is a complex anxiety disorder, with the dental setting acting as an identifiable stressor. For the majority of Service
Personnel desensitisation, behavioural strategies and pain control can facilitate effective treatment within primary dental care.
Conscious sedation should be considered when behavioural strategies are contra-indicated due to surgical complexity or have failed.
7 https://www.nice.org.uk/guidance/NG12/chapter/1-Recommendations-organised-by-site-of-cancer. 8 Examples: TMJDS, Atypical Facial Pain, Trigeminal Neuralgia.
9 Toothache caused by changes in atmospheric pressure. Contained apical pathology can cause significant barodontalgia during ascent
when the gas of putrefaction leads to distraction of the tooth.
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8.
Medication. Guidance on medication and award of JMES for Aircrew, Military Divers
and Operations Support personnel (Air Battlespace Managers and Air Traffic Controllers)
can be found at:
a.
Chapter 12 Standards for diving and hyperbaric exposure - medication and
drugs:
BRd 1750A Handbook of Naval Medical Standards b.
Leaflet 5-19 Drugs and aircrew:
AP1269A RAF Manual of Assessment of Medical Fitness
9.
Local Anaesthetic. Local anaesthetic has the potential to mask post-operative
dental pain, therefore Aircrew, Military Divers
and Operations Support personnel (Air
Battlespace Managers and Air Traffic Controllers) are not to control aircraft or dive, within
12 hours (see above) of receiving local anaesthetic10. If post-operative pain continues
Service Personnel are to extend the ‘no-fly/dive’ period and present to a Dental/Medical
Officer for further evaluation.
10.
Analgesia. Moderate or severe pain is usually associated with a limitation of physical
function, psychological distress or cognitive distraction. For these reasons, moderate or
severe pain is incompatible with flying / controlling, diving and other safety critical duties.
Medical and Dental Officers should apply guidance at Paragraph 7 on paracetamol,
NSAID and Opioid use.
Facial fractures
11. Service Personnel with facial fractures are normally graded MND whilst under
treatment.
a.
Internal fixation. Service Personnel with no symptoms or signs from their
in
situ internal fixation can be graded MFD. Removal of pathology free internal fixation
is unnecessary and should not normally be considered unless for specific
occupational reasons11.
b.
Facial fractures and sport. Service Personnel who have sustained a facial
fracture should be placed on limited physical duties for 6 weeks12. All contact sports,
e.g. boxing and rugby football, must be avoided for 3 months and appropriate JMES
and MedLim awarded.
Orthodontic Treatment
12. Service Personnel undergoing orthodontic treatment will not normally require a JMES
change. Orthodontic treatment within the Services may be suspended, by making the
appliance passive, to facilitate a change in the Service Person’s employment /deployment.
10 Except when directed by a Military Aviation/Diving Medicine Examiner.
11 Certain specific single-Service roles may require consideration of whether the metalwork can remain e.g. clearance divers.
12 Current practice of British Oral and Maxillofacial Surgeons: advice regarding length of time to refrain from contact sports after
treatment of zygomatic fractures S Mahmood, DJW Keith, GE Lello British Journal of Oral and Maxillofacial Surgery 2002 Dec; Vol. 40,
Issue 6: p488–490.
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Orthognathic surgery
13. Service Personnel who are undergoing orthognathic surgery need a prolonged period
of pre-surgical orthodontics13. Whilst orthodontic treatment does not normally require
changing of their JMES, the pre-surgical orthodontic component of orthognathic treatment
requires Consultant level support normally delivered in the UK. Extended overseas
employment can challenge treatment progression and therefore the Service Person should
be graded MLD to allow a MRA to be conducted. A minimum of L3 E3 MES codes and
Medical Limitation
“5501 to be made available for regular medical reviews”, should be
applied. This highlights to single-Service manning authorities that consideration should be
given prior to overseas assignments and deployments.
14. Once the surgical plan and timings are confirmed, the Service Person is to be graded
MND until no less than 3 months after confirmation of fracture healing.
Head and neck tumours
15. Service Personnel undergoing treatment for head and neck tumours are to be graded
MND. Service Personnel with a history of head and neck malignancy require regular
review for a period of up to 5 years and are to be graded MND until the recall period is
annual or less frequently.
13 This may last up to two years.
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Annex N
OTHER CONDITIONS IN-SERVICE
Blood disorders
1.
The identification of blood disorders should prompt re-grading to MND Temp.
Permanent grading is dependent on the outcome of investigations.
2.
Sickle Cell Trait Sickle Cell Trait. When grading personnel with SCT, the impact of
physiological challenges inherent in their employment and in the deployed environment
must be considered. SCT is not a bar to ongoing Service and personnel with SCT are to
be given an E2 marker. Individuals with SCT should be advised on the risk of External
Collapse Associated with Sickle Cell Trait [ECAST], exertional rhabdomyolysis and the
increased risk of problems at high altitude. Hypoxia and altitude1 may influence the risk of
incapacitation / ECAST. Medical assessors should refer to AP1269A and Aviation
Medicine trained specialists where appropriate. With respect to diving, SME (INM) input
should be sought on a case-by-case basis. Personnel with SCT who have had an episode
of ECAST, or rhabdomyolysis should be assessed on an individual basis by a Consultant
in Occupational Medicine.
3.
Anti-coagulation therapy. Personnel who require anti-coagulation therapy (including
warfarin and direct oral anti-coagulants) are to be MND while therapy is started and
stabilised. Once stable, where therapy is to continue for 12 months or longer (i.e. for the
foreseeable future), Consultant Occupational Medicine input is required in order to advise
on both long-term employability and deployability. Such personnel will normally be MND,
but MLD may be awarded by exception. In all cases there is need to consider:
a. Stability of the underlying condition and medication (in terms of the need for
monitoring/dose adjustment).
b. Potential for blunt/penetrating injury during the course of any future
employment/deployment (including sporting and adventurous training activities),
and subsequent increased risk of bleeding complications,
c. Access to NHS level of secondary care in the case of injury, noting the
requirement for CT head within 8 hrs of head injury2.
In all cases, personnel requiring anti-coagulation are UNFIT contact sports.
Blood Borne Viruses (BBVs)
4.
The following disorders require re-grading in line with clinical condition, viral loads
and treatment requirements. Service Personnel (SP) in specialist employment groups (e.g.
aviation, diving, and submarines) should refer to the extant regulations for those groups3.
Healthcare Workers must have standard and additional health checks and be graded in
accordance with
JSP 950 Part 1 Leaflet 6-8-1 Defence Medical Services Uniformed and
Civilian Healthcare Workers: Tuberculosis and Blood-Borne Viruses Screening and
Management. Prior to acceptance, current SP wishing to undertake an internal transfer to
1 Where participation in adventurous training (see
JSP 419 ‘Adventurous training in the UK Armed Forces’) presents a particular risk to
personnel with SCT (i.e. high altitude > 2500m or diving) they should have an individual assessment. Participants with SCT should be
advised to seek Consultant Occupational Medicine advice from their MO in the first instance.
2 NICE Quality Statement [QS74]: Quality statement 2: CT head scans for people taking anticoagulants
(here) 3 BRd 1750A Handbook of Naval Medical Standards AP 1269A Royal Air Force Manual of Medical Fitness. Return to Contents Page
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the Defence Medical Services (DMS) should be screened in accordance with
Section 4
Annex N Other Conditions Pre-Entry. 5.
Human Immunodeficiency Virus (HIV) infection
a.
Personnel found to be infected with HIV are MND during the initial 12 months
following diagnosis to allow for investigation and initiation of treatment, to assess
treatment response, and stability of CD4 count and viral load on treatment.
b.
Personnel known to be infected with HIV who are on Antiretroviral Therapy
(ART) may be graded MFD with an E2 marker, subject to approval by the Military
Advisor in Sexual Health and HIV Medicine (MASHH)*, if they:
(1) Have been diagnosed for at least 12 months
(2) Are on a stable treatment regimen
and for at least 6 months have consistently maintained:
(a) A CD4 count of at least 350 cells/mm3
(b) A viral load below 50 Copies per ml
c.
In line with sS employment policy, those with an E2 marker require annual
review of their grading, informed by MASHH, to confirm they remain fully deployable.
d. Personnel known to be infected with HIV who are on Antiretroviral Therapy
(ART) may be graded MLD, subject to approval by the Military Advisor in Sexual
Health and HIV Medicine (MASHH)4, if they:
(1) Have been on a stable treatment regimen
and for at least six months have consistently maintained:
(a) A CD4 count of at least 200 cells/mm3
(b) A viral load below 50 copies per ml
e.
Personnel infected with HIV who do not adhere to medication or follow-up
requirements, have abnormal CD4 counts, viral loads over 50 copies per ml
(repeated tests 4 weeks apart) or any signs of HIV related illnesses or recurrent
infections must be graded no higher than MND.
f.
Aircrew:
Entry / Serving - In accordance with AP1269A
6.
Hepatitis B, Hepatitis C and other Hepatitis Viral Infections
a.
Hepatitis B
(1) SP found to be infected with hepatitis B should be initially graded MND for
investigation and assessment for treatment. SP who are inactive carriers or who
are treated for medical reasons and successfully maintained on long-term HBV
antiviral therapy with a hepatitis B DNA <1000 copies/ml may be upgraded to no
higher than MLD. They should be subject to a uniformed OM Consultant led
4 MASHH On-call e
mail: xxx.xx@xxx.xxx On-call phone: 07929 788873 or Sec: 0121 424 2358
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medical review before commencing IPDT / Deployment and Exercises to assess
the risk of ballistic injury and ballistic transmission to others, and their medical
support requirements in relation to the medical support available.
(2) All other SP are to be graded by a uniformed OM Consultant led medical
board due to the requirement for on-going healthcare and the risk of infection to
other SP and local civilians in situations where ballistic injury may cause
exposure to blood and bone fragments from the infected person5. SP are to be
graded no higher than MND E3 Perm.
(3) Commencement of anti-viral medication for occupational reasons alone
is not justified.
b.
Hepatitis C
(1) SP who are diagnosed with hepatitis C should be graded MND for
treatment by a uniformed Hepatologist where possible. Those who achieve a
sustained virological response (undetectable hepatitis C RNA at 6 months
post-treatment) can be upgraded MFD noting any need for further follow-up.
(2) SP who do not achieve a sustained virological response are to be graded
by a uniformed OM Consultant led medical board due to the transmission risk
in an Operational theatre and potential on-going medical requirements. SP are
to be graded no higher than MND E3 Perm.
c.
Other Viral Hepatitis. SP diagnosed with non-A, B or C viral hepatitis should
be initially graded MND for investigations. Thereafter, grading should be based on
the advice of a uniformed Hepatologist and uniformed OM Consultant where
appropriate, taking into account potential infectivity to others, treatment and follow up
requirements.
Pre-Exposure Prophylaxis (PrEP)
7.
Individuals taking PrEP medications as a preventative measure may be graded MFD
with an E2 marker. Certain employment groups such as aircrew require more stringent
management, these standards can be found in the relevant single-Service publications6.
a.
In order to comply with national guidance for PrEP, the individual has personal
responsibility
prior to a deployment to agree the arrangements for ongoing
prescriptions and any required testing with their sexual health provider. It is
recommended that the individual informs deployed medical support if HIV self tests
are undertaken, in order to ensure that any required assistance is provided and any
results can be documented into an individual’s medical records. Any further queries
about individual cases can be discussed with MASHH on the duty mobile (+44 7929
788873) or via PANDO.
Irradiated blood products
8.
SP who require irradiated blood products7 should normally be graded no higher than
MND, as such blood products are not routinely available when deployed. RN and RAF SP
5 Prof Mutimer (Head UBHNHSFT Hepato-Biliary Team) agrees you cannot exclude infection whatever the viral load given ballistic
injury.
6 PrEP policy for In-Service aircrew and controllers is detailed
in AP1269A Lft 5-10.
7 Treleaven J. et al, Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in
Haematology blood transfusion task force 2010 Blackwell Publishing Ltd, British Journal of Haematology, 152
. Irradiation_BJH_2011. Return to Contents Page
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may be graded MLD (with E4 – subject to an individual risk assessment), but only
deployed/employed out of the UK where there is access to emergency medical care at a
level equivalent to that provided in the UK. In addition, RN SP are limited to major
overseas bases only (excludes Falklands and Diego Garcia). For all SP, limitations on
overseas exercises and assignments will also need to be considered as irradiated blood
products will not be available in all overseas locations. Irradiated blood products are
required to prevent potentially fatal transfusion-associated graft versus host disease for the
following:
a.
Patients treated with the following drugs:
(1) Fludarabine.
(2) Cladribine.
(3) Pentostatin.
(4) Alemtuzumab.
(5) Other novel purine analogues and related agents until evidence of safety
proven.
b.
Hodgkin's lymphoma (lifelong following diagnosis).
c.
Aplastic anaemia patients receiving immunosuppressive therapy with anti-
thymocyte globulin and/or Alemtuzumab.
Medically unexplained symptoms following operational deployment
9.
In the aftermath of every conflict for which records exist some returning SP have
complained of ill-health. This includes any individuals who have returned from
Operational deployment, or who were prepared for deployment but did not actually
deploy, who believe that their health has been adversely affected’. In many cases
symptoms are vague and non-specific, which can lead to inappropriate and unwelcome
reassurance, delays in investigation and, often, loss of confidence in the DMS. All
medical practitioners must be aware of ways in which health concerns can present
following Operational deployment, the investigations which should be carried out, and the
procedures for obtaining referral for specialist investigation. These are detailed in
JSP 950
Part 1 Lft 2-1-2 The Management of Medically Unexplained Symptoms Following
Operational Deployment.
Confirmed COVID-19 infection
10. COVID-19 infection ranges from asymptomatic to severe clinical illness requiring
hospitalisation and ventilation for prolonged periods. As such, the sequelae of this infection
will vary significantly between affected individuals. SP should be managed in accordance
with current DPHC guidance and the DMRC post-COVID-19 rehabilitation pathway8. SP
should be graded MND until such time as they have completed the appropriate
rehabilitation pathway. Future grading will depend on level of function, demands of
employment and the presence of any complications. These complications should be
considered in accordance with the appropriate section of this JSP. Consideration should
be given to the presence of any underlying chronic condition which could have resulted in
8 JSP 950 COVID Lft 002 ‘Clinical and occupational assessment prior to return to duty and training post-COVID-19’.
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increased susceptibility to COVID-19, and this may not always have been apparent prior to
COVID infection.
Fatigue syndrome(s)
11. The diagnosis of the group of conditions known as chronic fatigue syndrome,
fibromyalgia, myalgic encephalomyelitis, and post-viral fatigue syndrome, is often made by
exclusion of somatic pathology. All have similar poorly defined symptoms with variable
somatic (i.e. variable and flitting muscle and joint pains, trigger points etc), and
psychological (i.e. anxiety and, or depression etc) manifestations. Each should be dealt
with on an individual basis, and they should be graded in accordance with functional
capacity taking appropriate occupational medicine advice. Cognitive behavioural therapy
and graded exercise therapy have been shown to be of definite benefit, with pacing of
possible benefit and so early referral for such interventions should be considered; guidance
has been published by NHS Plus with the support of the Faculty of Occupational
Medicine9. Grading should reflect the functional level during this rehabilitation phase. Final
outcomes are variable and consideration may have to be given to medical discharge.
Climatic injuries
12. Individuals who have conditions known to be aggravated by service in hot or cold
climatic conditions should be grader no higher than MLD E2 or E3 to reduce the risk of
further exacerbation, recurrence or harm. Examples of such conditions are chronic otitis
externa, chronic suppurative otitis media, hyperhidrosis, severe ichthyosis, sprue, chronic
blepharitis, Raynaud’s phenomenon and previous heat or cold injury (including freezing
and non-freezing cold injury).
13.
JSP 539 Heat Illness and Cold Injury: Prevention and Management covers Force
Protection and the initial medical management of heat illnesses and cold injuries. These
cases should initially be graded MND until assessed and stabilised. Thereafter, grading
is based upon the functional capacity, on-going treatment and the requirement to protect
against further exposure as above. Appropriate MedLims should be used to indicate the
requirement for enhanced PPE or limitations of exposure to cold or heat where required.
A tri-Service Heat Illness Clinic (HIC) and Cold Injury Clinic (CIC) is offered by the
Institute of Naval Medicine (INM) which can provide clinical assessment of and advice on
SP, with grading and employability advice available from the ROHTs.
Immune system disorders
14.
Allergy and anaphylaxis. The development of severe allergic reactions and/or
anaphylaxis during service should be dealt with on a case-by-case basis and grading
should be responsive to risk assessment conducted with due regard to continuing
employment and the specific medical and logistic support requirements of the individual.
SP should be referred to the Lead Consultant at any of the British Society of Allergy and
Immunology allergy clinics detailed in Table 1. SP with a requirement to carry a self-
administered adrenaline auto-injector (confirmed by an appropriate medical specialist)
require uniformed OM Consultant review to determine their grading, which will be no higher
than MLD).
15. Desensitisation treatment is prolonged (usually >3 years) and is not guaranteed to
resolve the allergy (most sites do not undertake post-treatment exposure tests to confirm
the results). SP deciding to undertake desensitisation treatment should be advised of the
9 Occupational Aspects of the Management of Chronic fatigue Syndrome – a national guideline.
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potential employment consequences of long-term downgrading without a guarantee of
being MFD on completion.
16.
Drug allergy. Allergic reactions to drugs should be investigated and appropriately
recorded in both the medical records and on warning tags. Downgrading to MND may be
necessary to allow for investigations to be completed and is mandatory for anyone who is
under investigation for allergy to key drugs on Operations (e.g. morphine in auto-injectors,
CBRN prophylaxis or treatments or regularly used anaesthetic drugs). SP with a proven
allergy must as a minimum have a E2 Perm medical marker. SP who have proven allergy
to drugs that are required on Operations are permanently non-deployable.
Table 1 – Recommended allergy and immunology clinics for military patients.
Region
Hospital Clinic/Service
Bath
Adult Allergy Clinic, Combe Park, Bath BA1 3NG
Belfast
Regional Immunology Clinic, Immunology Day Centre, Belfast, BT12 6BN
Birmingham
Allergy University Hospitals Birmingham, Mindelsohn Way, Birmingham B15 2GW
Adult Allergy Clinic, City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18
Birmingham
7QH
Adult Allergy Clinic, Birmingham Heartlands Hospital, Bordesely Green East
Birmingham
Birmingham B9 5SS
Cambridge
Allergy Clinic, Addenbrookes Hospital, Hills Road, Cambridge CB2 0QQ
Cardiff
Allergy Clinic, University Hospital Wales, Heath Park, Cardiff CF14 4XW
Edinburgh
Allergy Clinic, Royal Infimrary Edinburgh, Lauriston Place Edinburgh EH3 9HA
Essex
Allery Clinic, Broomfield Hospital, Court Road Chelmsford CM1 7ET
West of Scotland Anaphylaxis Service, West Glasgow ACH, Dalnair St, Glasgow G3
Glasgow
8SJ General Adult Allergy Clinic, St James' University Hospital, Beckett Street, Leeds LS9
Leeds
7TF
Leicester
Allergy Clinic, Glenfield Hospital, Groby Road, Leicester LE3 9QP
London
Allergy Clinic, Kings College Hospital, Denmark Hill, London SE5 9RS
London
Department of Allergy, Guys Hospital, Great Maze Pond, London, SE1 9RT
London
Asthma and Allergy Clinic, Royal Brompton Hospital, Fulham Road, London, SW3 6NP
Frankland Allergy Clinic, St Marys Hospital, Imperial College NHS Trust, Praed Street,
London
London W2 1NY
Manchester
Allergy Centre, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT
Manchester
Allergy Clinic, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL
Adult and Paediatric Allergy Clinic, Churchill and John Radcliffe Hospitals, Headington,
Oxford
Oxford OX3 7LJ Peninsula Allergy and Immunology Service, Derriford Hospital, Derriford Road,
Plymouth
Plymouth, PL6 8DH
Clinical Immunology and Allergy Unit, Northern General Hospital, Herries Road,
Sheffield
Sheffield S5 7AU
Adult Allergy Clinic, Southampton University Hospital NHS Trust, Department of
Southampton
Asthma, Allergy & Clinical Immunlogy (AACI), Room CG89, Mailpoint 52, Level G,
West Wing, Tremona Road, Southampton SO16 6YD
Clinical Immunology Clinic, University Hospital of North Staffordshire, Hilton Road,
Staffordshire
Stoke-On-Trent ST4 6QG
Surrey
Adult Allergy Clinic, Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX
17. Immune deficiency disorders will require specialist opinion from a Consultant
Physician experienced with the management of these conditions and also require
uniformed OM Consultant review. Grading will depend on assessed susceptibility to
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infection, and the requirement for on-going treatment and follow-up, and will be no higher
than MLD.
Malignant disease
18. SP with proven malignant disease in the first instance should be graded MND. In
such cases, continuance of employment and medical grading should be governed by
current functional capacity and requirement for on-going treatment and follow-up. Where
malignancy has been successfully treated, consideration may be given to a grading of
MFD.
Malignant hyperpyrexia
19. The diagnosis of malignant hyperpyrexia will require permanent grading no higher
than MLD and not fit for Operational deployments or isolated environments. Medical
Warning Tags should record this information in accordance with single-Service
instructions.
Suxamethonium sensitivity
20. Individuals who are discovered to carry the atypical cholinesterase gene should be
graded MND until they are assessed to identify whether they require special anaesthetic
precautions. SP who require special anaesthetic precautions are to be graded no higher
than MLD, and are not fit Operational or isolated environments, due to the risk of SP with
this condition obstructing the critical pathways associated with casualty treatment and
evacuation. If Service anaesthetic opinion is that they do not require special anaesthetic
precautions they may be graded MFD with an E2 marker. Medical Warning Tags should
record this information in accordance with single-Service instructions.
Sexually Transmitted Infections (STIs) (excluding BBVs)
21. These are commonly treated outside of, and may not be declared to, the DMS.
Certain STIs for example syphilis, gonorrhoea, chancroid, chlamydia, non-specific
urethritis, should not affect the grading unless affecting functional capacity or requiring
regular hospital-based treatment.
Absent or dysfunctional spleen
22. SP who have had a splenectomy or who have significant splenic dysfunction
(hyposplenism) should be graded MND in the first instance. SP suffering recurrent
infections should remain graded no higher than MND. All individuals should be encouraged
to take long-term antibacterial chemoprophylaxis, together with appropriate vaccination in
accordance with
JSP 950 Part 1 Lft 7-1-1 Immunological Protection of Entitled Personnel
and guidance from a Consultant in Infectious Diseases. They must not be deployed
into tropical areas, or where there is a risk of contracting malaria. There is a lifelong risk of
Overwhelming Post Splenectomy Infection (OPSI), which may be caused by a wide range
of pathogens, which in turn may be transmitted by a number of vectors. This risk must be
considered when advising about fitness for duty and travel outside the UK. Occupational
exposure to certain pathogens is a risk factor and dog handling is contraindicated for those
SP. Other occupational exposure to pathogens should be considered on a case-by-case
basis.
23. If the individuals are otherwise fit in all respects with no evidence of recurrent
disease, and / or abdominal sequelae, or occupational exposure risk, they can be
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considered for grading no higher than MLD L3, E2 unfit malarial areas by a Medical Board
with input from a uniformed OM Consultant. The assessment should include consideration
of the following factors associated with an increased risk of OPSI:
a. Age ≥ 50 yrs.
b. ≤ 2 yrs since splenectomy/diagnosis of hyposplenism.
Sleep disorders
24.
Insomnia. Insomnia is a symptom not a diagnosis. SP with insomnia causing
disability need a physical and mental health assessment to determine possible underlying
cause. Any underlying cause then suspected will need to be referred to the relevant
specialist as appropriate. SP with persistent insomnia (< 4 weeks) or that requires more
than 2 weeks hypnotic medication should be graded MLD pending either further or
specialist assessment or a return to normal sleep.
25.
Hypersomnolence disorders. SP with hypersomnolence causing disability need a
physical and mental health assessment to determine possible underlying cause. Any
underlying cause then suspected will need to be referred to the relevant specialist as
appropriate. Whilst symptomatic, awaiting assessment and evaluation of treatment, SP
should be graded MND.
26.
Narcolepsy. Suspected cases of Narcolepsy should be referred to a sleep clinic. A
confirmed diagnosis of Narcolepsy would normally be graded MND.
27.
Breathing related sleep disorders. Suspected cases of Sleep Apnoea should be
referred to a sleep clinic. SP with sleep apnoea should be graded MND until treatment
response has been evaluated. Successful conservative or surgical treatment with no
residual disability can lead to MFD E2. If Continuous Positive Airway Pressure is required
the person will need to be restricted in their fitness to allow access to this treatment and
regular medical follow-up; normally graded MLD.
28.
Circadian rhythm sleep-wake disorders. Suspected cases of Circadian Rhythm
Sleep-Wake Disorders should be referred to a sleep clinic. Whilst occupational and social
dysfunction is interfering with safe or satisfactory military role, the person should be graded
MND, pending assessment and successful treatment.
29.
Non-REM sleep arousal disorders. This includes Sleep Walking (Somnambulism)
and Night Terrors. Sleep walking considered to interrupt safe or satisfactory military role
should be referred to a psychiatrist for exclusion of mental illness, and graded MND until
satisfactory resolution of the sleep walking.
30.
REM sleep behaviour disorders. This includes a variety of behavioural anomalies
that occur only during REM sleep (Sleep Paralysis, Nightmares, Dream enactment etc).
SP with these symptoms should be referred to a psychiatrist to exclude mental disorder,
and a sleep clinic for proper diagnostic assessment. Whilst symptomatic, awaiting
assessment and evaluation of treatment, SP should be graded MND.
31.
Restless Leg Syndrome (RLS). This condition is common (general population
prevalence is 15%), and in majority of cases is mild and causes little dysfunction. However,
it can worsen the prognosis of some mental disorders and be exacerbated by psychotropic
medication. SP with RLS (or Peripheral Limb Movement Disorder – a closely related
disorder – see below for details) with significant daytime dysfunction resulting, should be
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graded MND pending assessment and treatment. Underlying causes, including anaemia,
chronic neck or spine pathology should be excluded. If long term medication is required,
the person will need to be graded MLD to account for medication supply and infrequent
review by a medical officer.
32.
Periodic Limb Movement Disorder (PLMD). Diagnosis is made following
polysomnography. If PLMS (periodic limb movements occurring during sleep) are present
without clinical sleep disturbance or daytime impairment, the PLMS can be noted as a
polysomnographic finding, but the criteria are not met for a diagnosis of PLMD. To
establish the diagnosis of PLMD, it is essential to establish a reasonable cause and effect
relationship between the insomnia or hypersomnia and the PLMS. PLMS are common but
PLMD is thought to be rare in adults. It cannot be diagnosed in the context of RLS,
narcolepsy, untreated Obstructive Sleep Apnoea or REM sleep Behaviour Disorder. The
diagnosis of RLS takes precedence over that of PLMD when potentially sleep disrupting
PLMS occurs in the context of RLS. In such cases, the diagnosis of RLS is made and the
PLMS are noted. See RLS for grading advice.
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SECTION SIX: HARMONISATION OF MEDICAL BOARDS LEADING TO
DISCHARGE
Summary
1.
This leaflet introduces policy concerning tri-Service medical discharge boards for
servicemen and women. It also introduces the FMed 23, to be used for recording the
outcome of all medical boards leading to discharge. This policy aligns the single
Services (sSs) together in terms of procedure and consistency of process for medical
discharge boards and harmonises the output to other organisations.
Introduction
2.
The term ‘medical discharge board’, used throughout this policy leaflet indicates a
medical board that has the authority to recommend a medical category that may lead to
discharge from the Armed Services. Such boards are not the route by which Service
personnel are actually discharged, for medical reasons or otherwise, from the Armed
Services. The actual discharge will involve non-medical processes that take place once
the recommendation of the medical board has been made.
3.
Appearance by Service personnel at a medical discharge board is necessary when
a medical condition renders the service person unable to achieve the functional capacity
required of them for continued service, or when the condition increases the risk of harm to
themselves or colleagues to an unacceptable level, should they continue to serve. Such
boards are convened by and run according to single-Service regulations but have a
common function. A common medical discharge policy aims to harmonise the outputs of
these medical boards and ensure consistency of process and fairness across the three
Services.
Background
4.
The momentum for developing a harmonised policy for medical discharge boards
has come from a number of initiatives already in progress. The Defence Medical
Discharge Policy Committee includes a common medical discharge process as one of the
3 important strands of work required to ensure the seamless transition of medical
discharges from service to civilian life. The Managed Military Health System has a
requirement for common policies, processes and standards. The Defence Medical
Information Capability Programme ( DMICP) provides a common medical information
solution for the Defence Medical Services and harmonised processes, particularly outputs,
are inherent to this programme. The output from medical discharge boards helps a
number of organisations (for example, the Service Personnel and Veterans Agency
(SPVA)1 and the Department of Work and Pensions) to facilitate the move for the
Service leaver to civilian life. Common outputs will lead to better understanding of
Service leavers’ requirements and quicker assessments of benefit.
Aim
5.
The aim of this leaflet is to promulgate the policy governing medical discharge
boards.
1 The Veterans Agency (VA) merged with the Armed Forces Personnel Administration Agency to form the Service Personnel and
Veterans' Agency (SPVA) on 1 Apr 07.
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Policy
6.
Constitution:
a.
The process for medical discharge boards is to involve 3 Medical Officers.
This is consistent with other tribunals. The 3 doctors need not all sit together at
the medical board that recommends the discharge, but the decision to discharge
should involve them all. The constitution of specific medical boards will remain an
issue for single Services and detailed instructions are included in the relevant
regulations.
b.
The chairman or president of a medical discharge board is to be a consultant in
occupational medicine.
7.
Medical Category and Employability:
a.
Medical Category. A medical board’s primary role is to award a permanent
medical category. Medical discharge boards are to award the highest possible
medical category for the service person presenting to it. This will ensure consistency
of application of PULHHEEMS profiles and ‘P’ factors across the 3 Services. In
particular P8 has the universal meaning ‘Medically Unfit for Further Service’ and is
only to be awarded by a properly constituted medical discharge board. The
consistency of application of PULHHEEMS profiles is necessary to allow common
codes, relating to ‘P’ values, to be used within the DMICP while a variation in MES
remains necessary.
b.
Employment Standards. Individual sSs have their own systems for awarding
medical employment standards and it is not intended for this policy to influence with
these.
c.
Employability. The decision of the medical discharge board will inevitably
provide some degree of opinion concerning the future functional capacity of an
individual. However, it is the role of an employability board2 to determine whether
an individual should continue to be employed in the medical category awarded to
them by the medical board. At any time an employability board may request that a
medical board reviews its decision on medical category, but the award of a medical
category, in particular P8, should only be made by a medical board. The final
decision on employability rests with the employability board, or similar body that
undertakes this function; it is not a medical board decision.
d.
Specialist Advice. Secondary care consultants should be invited to provide
occupationally-orientated prognoses on their patients who are due to attend a
medical board at which their discharge is likely to be recommended. This is in line
with current policy3 . However, whilst consultants might make recommendations
based on their own experience and competence, it is for the medical board to make
the final decision concerning medical category.
2 An employability board considers all aspects of employability, including current and future Service requirement, bearing within branch
or trade and promotion prospects, in reaching a decision on whether a particular individual should be retained in Service in the medical
category recommended by the medical board.
3 SGPL 05/04 – Role of Secondary Care Consultants in Medical Board Procedures.
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e.
Attributability. Decisions on attributability are not to be made by medical
discharge boards. MOD operates several pensions and compensation schemes
with different criteria, aims and standards of proof, and such decisions should be
made by the scheme administrators at the SPVA. This position has been clarified by
SPPol4.
f.
The organisation of continuing clinical or occupational healthcare is not the
responsibility of medical boards and therefore there are no fields on the F Med 23
concerned with treatment, investigations or sick leave. Board presidents may
however consider it necessary to contact medical officers in some circumstances to
make recommendations.
8.
Timing. The timing of a discharge medical board must strike an appropriate balance
between the needs of the individual Service and those of the service person. Current
procedures allow for single Service differences (‘tolerable variation’) between the time of
referral and attendance at a medical discharge board. Whilst this might appear
anomalous, it is felt that the timing of medical discharge boards is likely to be appropriate
to attendees’ needs and wishes in the majority of cases. The date of the medical
discharge board should always allow the timely provision of occupational health advice
following the initial referral. Time elapsed waiting for further treatment may hinder this
process and all cases should be carefully considered on their individual merits, with the
interests of the potential Service leaver paramount.
9.
Resettlement. There are acceptable differences in single Service rules concerning
access to resettlement processes and briefings. Despite these differences it is vital that
resettlement advice should be available as soon as possible once the decision has been
made to refer a patient to a medical board where discharge is a possibility. Medical
of icers are to advise units to arrange access to resettlement advice at the time of
initial referral to the medical board. The unit must arrange an initial resettlement
interview before attendance at the medical board.
10.
Common Reporting.
a.
The most important benefit of harmonising medical discharge board processes
is to provide a common reporting process. Reports from medical discharge boards
are used by a variety of organisations, outside of the MOD, for the benefit of both the
Service leaver and the wider Armed Forces. DMICP has an inbuilt quality
assurance system and this will ensure a consistent standard is applied to the
medical discharge process.
b.
The adjudicative medical input to the SPVA processes, leading to consistent
equitable decisions in pension and compensation once the Service leaver has been
discharged, will be facilitated by the presentation of clear evidence in the form of a
standard board output.
c.
The form to be used to record the decisions of medical discharge boards is
the FMed 23. This has been completely revised and is attached at Annex A, with
completion instructions at Annex B. The new form has been incorporated into a
DMICP template. The form has already been incorporated into single-Service
medical administrative instructions.
4 DD SPPol (Pensions) letter reference ‘AFCS 75/Attributable’ dated 23 Mar 05.
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d.
The form has wide scope and will provide a unified method by which new
Armed Forces Compensation Scheme claims and earlier War Pensions claims can
be processed by the SPVA. Benefits and compensation awards are determined
primarily by the nature of the principal condition and it is important that the wording of
the form is not altered locally.
11.
Consent. The consent of the Service leaver is required for the completed F Med 23
to be forwarded to any of the various organisations that may require it to process the
leaver’s transition to civilian life. Single Services are to develop a form appropriate to their
individual needs. The form used by the RN is considered to be an appropriate template for
this purpose and is attached for information at Annex C.
Annexes:
A.
FMed 23 Revised 04/07
B.
Completion of FMed 23
C.
Consent to Disclosure of Medical and Administrative Records and Information
following Naval Service Board of Survey (NSMBOS) – In accordance with Data Protection
and Access to Medical Reports Legilsation
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Annex A
F Med 23 (04/07)
OFFICIAL SENSITIVE PERSONAL
Medical in Confidence (when completed)
Service number
Rank/Rating
Branch/Trade
Date of Entry
Surname
Command
Forename(s)
Ship/Unit/Station
Date of Birth
Enlistment/Commission
type
Place of Board
Expected Departure Date
Authority for Board
Ceased duty on
Date of Board
Principal condition(s) affecting the Medical
Other condition(s) affecting the Medical Deployment
Deployment Standard leading to the Medical Board
Standard at the time of the Medical Board
Date(s) of origin
Places(s) of origin
Date(s) of origin
Places(s) of origin
FINDINGS OF THE BOARD
P
U
L
H
H
E
E
M
S
Medical Employment Standard
A
L
M
E
Medical Limitations on employability and future plans
Period of validity of Medical Deployment
Standard
OFFICIAL SENSITIVE PERSONAL
Medical in Confidence (when completed)
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NARRATIVE
(Continued on FMed 15 as necessary)
Name
Rank
Signature
President
Member
Member
APPROVAL (NOT RN)
Discharge approved under QR
Name
paragraph
Signature of Medical Officer
Rank
Appointment
Date
OFFICIAL SENSITIVE PERSONAL
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Annex B
COMPLETION OF FMED 23
1.
The FMed 23 is the form for recording the outcome of a medical board leading to
medical discharge. It is a stand-alone document and as such should not make reference to
other documents without summarising their contents. If loose leafed sheets are
incorporated, personal details (minimum service number, rank and name) are to be
included on each sheet.
2.
This guidance on the completion of the F Med 23 is provided in order to ensure all
relevant information is included, consistency is achieved and that the information is
presented in the most suitable form.
Procedure
3.
The FMed 23 has been recently revised. For convenience, the front sheet of the
FMed 23 has been annotated with numbers referred to in the notes below. The relevant
boxes on the FMed
23 should be completed in line with the guidance notes below.
Guidance notes relating to annotated FMed 23 front sheet
4.
Full Service Number. Self-explanatory.
5.
Rank/rating. Use the approved abbreviations.
6.
Branch/Trade. Use the approved abbreviations. Branch and trade names are subject
to change, and the correct terminology should be checked with the patient at the time of the
Board during the initial interview.
7.
Total full time Service. This information should be taken from the documentation
provided by the parent medical centre for prelims. It should be checked with the patient
during the initial interview. It is not necessary to corroborate this with the personnel record
as a matter of routine.
8.
Surname and forename(s). Current full names, as appear on the medical record,
should be used. Do not include previous surnames (e.g. maiden names) and nick names,
which should be explained in the narrative if required.
9.
Dates. To avoid any possible confusion with dates, the correct Service date format
should be used throughout. This is in the form of numbers for the day, a 3 letter
abbreviation for the month, and 2 numbers for the year, such as 29 Jul 93.
10.
Command. Insert the appropriate abbreviation.
11.
Ship/Unit/Station. The current parent unit is to be listed. Note that some referrals
will have come from a different unit, which has medical parenting responsibilities, and
that patients may have been posted between referral and the time of the board. This
information should be checked with the patient at the time of the Board.
12.
Type of Enlistment/Commission. Use the approved abbreviations.
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13.
Authority of Board. Insert the appropriate authority for the board.
14.
Principal condition(s) affecting the medical employment standard leading to
Medical Board. This section should be completed with care, as it may have a direct
impact of the later award of a War Pension, an Armed Forces Pension or compensation
under the AFCS. This should normal y only list one condition. In exceptional cases where
more than one condition has an equal effect on the award of P grades / PES, more than
one condition may be listed. The justification for this should be included in the text.
15.
Place of Board. This will normally be listed as the Medical Centre or Standing
Medical Board.
16.
Date of board and signatures. All dates for the Board and date of signing are to
be the same, and are to be the date on which the patient was seen and the PES
awarded. Delays due to typing are to be ignored.
17.
Other condition(s) affecting the medical employment standard at the time of
the Medical Board. Details of other medical conditions affecting the patient and
contributing to the PES awarded should be listed here.
18.
Date (of principal and other conditions). The date listed should be as accurate as
possible, to the day. If the exact date of onset is uncertain, such as when a patient
presents late with a problem, then the date of presentation should be stated with the fact
noted (e.g. 1 Feb 98 (presented)), and the matter noted in the narrative. (e.g. “on 1 Feb
98, LCpl Bloggs presented with a history of wheeze of several months duration”). A
separate date should be noted for each condition listed, using the same numbering
system.
19.
Place of origin. The Place of Origin should be confined to a broad geographical
area,
(e.g. UK, Germany, SBA Cyprus, or USA). If the event occurred on operations,
then the inclusion of the operation is recommended (e.g. Op Telic, Iraq). A separate place
should be noted for each condition listed in the Principal Disabilities box, using the same
numbering system.
20.
Ceased duty on. For those patients not currently at work, being non-effective or
on sick leave (SL), the day after the individual was last fit for duty in any capacity should
be recorded. This information should be sought from the patient during the Board.
21.
PULHHEEMS. The PULHHEEMS block should be completed in accordance with
Section 1.
a.
Place, type and date of next Medical Board. If the medical board
wishes to review a PES at a set interval, the appropriate information should be
entered here.
b.
Probable period of unfitness. Those awarded a PES other than ‘NONE’
are deemed to be fit. For those graded P0 the probable period of time before
return to duty / next medical board should be noted
. If a period of SL is granted,
then the appropriate period should be noted here.
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c.
For those graded P7 and above, any employment restrictions should be
recorded here.
22.
Normal date of termination. The current exit date should be entered here, as
related to the type of enlistment/commission (see note 9). If a patient is due to leave on
or some other mode of exit other than at the end of their normal engagement, this should
be annotated here (e.g. 1 May 08 (PVR)), and full details noted in the narrative.
23.
Narrative. The following information must be recorded:
a.
Relevant medical history including medical treatment and medication (both past
and planned)
b.
Relevant medical examination details and findings.
c.
The board is satisfied that advice about prognosis has been obtained
from a relevant clinician.
d.
That the board is satisfied that on- going treatment is appropriate.
e.
Current Employment (including any adaptations made for medical
condition).
f.
Rehabilitation.
g.
Social and Employment History.
h.
Other considerations (e.g. relevant information from Appendix 18 if used,
patient’s wishes, Unit view etc).
i.
Recommendation.
j.
Confirmation that the patient was given an opportunity to ask questions and
will be
given a copy of the FMed 23.
24.
President’s signature. This space is for the President’s signature.
25.
Board Members’ details. These boxes should contain the rank, initials and
surnames of the Board President and Members.
26.
Members’ signatures. These spaces are for the Members’ signatures.
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Annex C
CONSENT TO DISCLOSURE OF MEDICAL AND ADMINISTRATIVE
RECORDS AND INFORMATION FOLLOWING NAVAL SERVICE
MEDICAL BOARD OF SURVEY (NSMBOS) – IN ACCORDANCE WITH
DATA PROTECTION AND ACCESS TO MEDICAL REPORTS
LEGISLATION
Information to Patient
1.
Following your attendance at NSMBOS there will be various other external and
internal departments / authorities who will be required to assess your individual
circumstances and case for the purpose of making various decisions relating to your
employment or eligibility for financial benefits on discharge. These other departments will
usually require the release of certain records or information to them in order to enable a full
and proper assessment / decision to be determined.
2.
This information that may be requested is
confidential and cannot be disclosed
without your specific consent.
3.
The table in this paragraph gives details of the departments / authorities that are
normally involved in your case after NSMBOS and also gives details of the usual
information or records that are required by them. Records or information that is not usually
required but
may be requested by them dependent upon the circumstances of the case
are marked with an asterisk (*).
Agency / Authority
Records that may be required
Usual purpose of disclosure
to be disclosed
Naval Service Employability
NSMBOS Forms 1,2,3 and 5
To enable a full and proper
Board (NSMEB)
FMed 24.
assessment of your employability
to be determined.
Naval Resettlement Information
DP1 E,H or U as appropriate.
For forwarding to the Disability
Officer (Medical) (NRIO(M))
* FMed 24
Employment Advisor / Careers
Advisor and providing adequate
resettlement advice
Armed Forces Pension Authority FMed 23, FMed 24
To enable a full and proper
(AFPAA(G))
* All Personal Medical Records
assessment of your eligibility for
(FMed 4) and
any NSMBOS
AFPS invaliding and Service
Records Held.
Attributable benefits to be
determined.
Armed Forces Pay Authority
FMed 23
To enable assessment of any
(AFPAA (C))
* Any medical Information
LSAP waiver to be determined.
related to your boarding
condition only.
Veterans Agency (VA)
All Personal Medical Records
To enable a full and proper
(FMed 4) and
any NSMBOS
assessment of your eligibility for
Records Held.
War Pension / Armed Forces
Compensation Scheme benefits to
be determined.
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Discretionary Awards Panel
All Personal Medical Records
To enable a full and proper
(DAP)
(FMed 4) and
any NSMBOS
assessment of your eligibility for
Records Held.
AFPS invaliding and Service
Attributable benefits to be
determined if further scrutiny is
required in the case of an appeal
against AFPAA(G) decision.
MDG(N) Med Legal
All Personal Medical Records
To deal effectively with any legal
(FMed 4) and
an y NSMBOS
claim that you may have.
Records Held.
Defence Analytical Statistics
FMed 23
For statistical recording and
Agency (DASA)
analysis.
4.
In some instances this information may be requested again at a later date following
initial disclosure at the time of the NSMBOS (for example your condition changes and
your pension / benefits needs to be re-assessed, your case reviewed etc). If you are not
invalided this information may be required by some departments / authorities after you
leave the service if you make a subsequent or further claim. In these circumstances the
departments / authorities involved will need to obtain further consent from you before we
will release the information / records to them, since the consent that you are giving on
this form is not continuous, it will only last and be used for the purpose of concluding
your attendance at this particular NSMBOS.
5.
There is no requirement for you to view any documents or reports prior to us
forwarding them (under the Access to Medical Reports Act 1988) since there is no
information or reports being forwarded that have not already been sighted by you prior to
the NSMBOS taking place, for which your separate consent was obtained.
6.
You
do not have to consent to the release of this information or records if you
do not wish to and NSMBOS will not disclose it / them if you have not done so. You
must obviously bear in mind the implications that this
may have on any decision that
those departments / authorities are required to make.
Consent
Name
Rank/Rate
Service No
Date of
NSMBOS
a.
I have read and understand the ‘Information to Patient’ notes 1 – 6 overleaf.
b.
I consent / do not consent * to the disclosure of the medical and
administrative records / information that is, or may be required following NSMBOS,
only to those departments / authorities and only for those purposes, as detailed
overleaf at paragraph 3 of this form, until expiry of this consent.
c.
I understand that if any other records / information is / are required by any
other department / authority, or for any other purposes, other than those detailed at
paragraph 3 of this form my separate consent will be required to be obtained.
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d.
I understand that this consent is not continuous and will automatically
expire after 12 calendar months from the date of the NSMBOS attended.
* Delete as required.
Signed
Date
e.
I have explained the contents of and requirements for this consent form and
have witnessed his / her signature.
Signed
Date
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