JSP 950 MEDICAL POLICY
LEAFLET 6-7-7
JOINT
SERVICE MANUAL OF MEDICAL FITNESS
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Effective from 1000Z 18 Oct 22
Intentionally blank
Return to Contents Page
i
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Contents
Page Number
Amendments table iii-vii
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 Reproductive 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
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
Return to Contents Page
ii
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Annex B FMed 23 Completion Instructions
6-B-1
Annex C Consent to Disclosure of Medical and Administrative Records and Information
6-C-2
following Naval Service Board of Survey (NSMBOS) – In accordance with Data Protection
and Access to Medical Reports Legislation
Return to Contents Page
iii
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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’.
6 Apr 20 1.7
Deletion of footnote 3 from para 2 a (3).
Return to Contents Page
iv
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Amendments table
Date and
Summary of amendments/remarks
Version
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
20 Jun 22 2.2 Addition to Paragraph 4 (a) HIV
Return to Contents Page
v
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Amendments table
Date and
Summary of amendments/remarks
Version
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).
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’.
Return to Contents Page
vi
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Amendments table
Date and
Summary of amendments/remarks
Version
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.
Return to Contents Page
vii
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
The qualities in more detail
5.
The following list clarifies the factors to be considered when assessing each of the qualities:
Return to Contents Page
1-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 wil 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 wil result in a reduced ‘L’ grading
which wil 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 wil 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 wil
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 wil 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.
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
Return to Contents Page
1-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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
Return to Contents Page
1-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
Return to Contents Page
1-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 il ness and has been awarded a grading of 7 under the ‘S’
quality. Note that the il ness wil also affect the individual’s physical capacity and deployability, so
the ‘P’ grading has also been reduced to 7.
Return to Contents Page
1-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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).
c.
AP 1269A Royal Air Force Manual of Medical Fitness.
Return to Contents Page
2-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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):
12 months for the Army
12 months before referral to RNMBOS / regional OH Board for the RN
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 ‘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.
Return to Contents Page
2-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
2-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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).
Return to Contents Page
2-A-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Return to Contents Page
2-A-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
4-
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 20d AP 1269A Royal Air Force Manual of Medical Fitness
3 VGS Gliding Instructors AP1269A Lft 4-02 para 16 AP 1269A Royal Air Force Manual of Medical Fitness
Return to Contents Page
2-B-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 PJHQ4 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
Return to Contents Page
2-B-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
2-B-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
2-B-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
2-B-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
2-B-7
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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).
Return to Contents Page
2-B-8
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
2-B-9
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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’ wil automatical y 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.
Return to Contents Page
2-C-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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).
Return to Contents Page
2-C-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Ships / submarines
4006
Permanently unfit submarine service
Return to Contents Page
2-C-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 iaw 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)
Return to Contents Page
2-C-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Lifting/Carrying
6201
No load carrying
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”.
Return to Contents Page
2-C-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Return to Contents Page
2-C-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
2-C-7
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 grade16 is to be recorded on the medical record and (with the
individual’s consent) the result passed to the appropriate administrative office17. 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 requirement18 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).
(2) Service Medical Boards19 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.
16 Including suffixes to the grading in accordance with single Service guidelines.
17 In accordance with single Service policy.
18 E.g. change of commission or re-engagement.
19 Refer to single Service guidelines for further instructions.
Return to Contents Page
3-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 work20. For guidelines on the evaluation of the
M and
S qualities,
see Annex F.
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 wil 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
20 Elucidation of all biopsychosocial factors is recommended.
Return to Contents Page
3-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 role21 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 PULHHEEMS
profile. This assessment may be required as evidence of illness or injury attributed to service22and
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
work23. 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.
21 Both geographic and activity aspects are to be determined.
22 The examining medical officer is not required to determine attributability.
23 Elucidation of all biopsychosocial factors is recommended.
Return to Contents Page
3-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
3-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
3-A-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
3-A-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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
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 with 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.
Return to Contents Page
3-B-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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
7 https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/intimate-examinations-and-chaperones
Return to Contents Page
3-B-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
8 Physically immature candidates may not be acceptable.
9 In accordance with single Service procedures.
10 With the examination room darkened.
Return to Contents Page
3-B-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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
11 A DVD titled: The Functional Orthopaedic Examination of the Potential Recruit is available from BDFL (Catalogue Number
C52127/07).
Return to Contents Page
3-B-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
12 Ideal: touch the floor. Minimum acceptable: reach the level of the ankle.
Return to Contents Page
3-B-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
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.
1 INM Report No. 2007.026 dated Jun 07.
2 https://www.nice.org.uk/guidance/cg43
3 Based on anthropometric and other considerations.
4 As assessed by pre-employment physical selection tests and subject to single Service requirements.
Return to Contents Page
3-C-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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 from: 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.
Return to Contents Page
3-C-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 surveil ance 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.
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
1 SGPL 12/06: Noise at work health surveillance.
Return to Contents Page
3-D-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
3-D-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
(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
Return to Contents Page
3-E-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
(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
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 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).
Return to Contents Page
3-E-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
1
1
Period of validity of MES
Return to Contents Page
3-E-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
3-F-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 surveil ance2.
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.
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.
1 The CAD test has replaced the Holmes-Wright Lantern (HWL) test due to obsolescence of replacement parts. Research by 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.
Return to Contents Page
3-G-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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).
Table 1: CV Categories
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.
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).
6 CV-1 equates to a HWL pass on the dim B setting.
Return to Contents Page
3-G-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
7 CV-3 equates to a HWL pass on the bright A setting.
Return to Contents Page
3-G-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX H
DEMOBILISATION HEALTH DECLARATION EXAMPLE
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.
Return to Contents Page
3-H-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Return to Contents Page
3-H-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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
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.
Return to Contents Page
3-I-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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
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.
6 Only required if there are clinical concerns over an audiometric result, or more general concerns about the quality of audiometry at a
unit.
Return to Contents Page
3-I-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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.
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.
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.
Return to Contents Page
3-I-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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:
-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
Return to Contents Page
3-I-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
24. Policy on interpretation of audiograms can be found in JSP 950 Lft 6-4-2 ‘Assessing
Audiograms - Guidance for Medical Staff’.
Return to Contents Page
3-I-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Return to Contents Page
3-I-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Return to Contents Page
3-I-7
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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).
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.
4.
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.
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.
5.
Definitions. The following definitions apply throughout this section.
FIT - Meets the Medical Entry Standard. Fit to undertake entry training and Service without
restriction.
1 Current versions of BRd 1750A (RN), AGAI 78 (Army), AP1269A (RAF) and any associated DINs or single Service Policy Letters.
2 BRd 1750A (RN), AGAI 78 (Army), AP 3391 Vol 3 Part B Lflt 220 (RAF).
Return to Contents Page
4-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
UNFIT - Not fit to undertake entry training and Service without additional medical risk.
Normally UNFIT - The expectation is that the candidate is UNFIT, but in exceptional
circumstances an experienced clinician may determine that the candidate is FIT3.
6.
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.
7.
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.
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.
8.
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.
3 See paragraph 6b.
4 SSMES must have appropriate oversight from a Consultant in Occupational Medicine.
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.
Return to Contents Page
4-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
9.
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).
10. 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.
11. 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.
12.
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.
13.
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.
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.
Return to Contents Page
4-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX A
EYES PRE-ENTRY
1.
Diseases of the eye and orbit are assessed and recorded under P. The entries under EE are
records of visual acuity only (see Section 3); however, the refractive limit below at sub-paragraph
2a(3), is included as, outside this range, eyes are rarely structurally normal. Consideration must be
given to whether a lesion is progressive and likely to lead to future incapacity. Where doubt exists
advice should be sought from the single-Service Occupational Physician responsible for the
selection of recruits who will seek an ophthalmology opinion where required. 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.
2.
The following conditions, in either or both eyes, will normally exclude entry:
a.
General.
(1)
Orbital fractures and reconstruction if causing, or having the potential to cause,
disability. The presence of metalwork, provided ocular function and mobility are normal,
would not be a bar to entry.
(2)
Monocular (or uniocular) vision1; or reduction of corrected vision in one eye to
below either entry EE standard.
(3)
Refractive errors:
(a)
Spherical Equivalent (ESE) greater than +5.00 or -6.002 dioptres.
(b)
Cylindrical error greater than +3.00 or -3.00 diotres in any meridian.
To calculate the refractive error and for further guidance on the application of standards
see Appendix 1.
(4)
History of penetrating injury to either eye with abnormal function is considered
UNFIT. Those with such a history who achieve the VA and other visual functional
requirements should be referred for a Service ophthalmological opinion.
(5)
Scotoma or limitation of binocular visual field, from all causes.
(6)
Night blindness whether congenital or acquired.
(7)
Neoplasm.
(8)
Ophthalmic migraine (see Annex G Neurological).
(9)
Glaucoma or history of ocular hypertension.
b.
Ocular motility.
(1)
Nystagmus that impairs visual function.
1 Uniocula
r: 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 Correspondence DCA Ophthalmology 16 Jun 21 to align with RCOpth definition of high myopia.
Return to Contents Page
4-A-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
(2)
History of incomitant squint.
(3) Squint surgery within preceding 6 months.
(4)
Diplopia.
c.
Lids.
(1)
Blepharitis, chronic; acute, until controlled.
(2)
Blepharospasm that impairs visual function.
(3)
Damage to the eyelids or eyelid movement sufficient to impair protection of the
eye or affecting the visual fields.
(4)
Entropion or ectropion
(5)
Ptosis, affecting the visual fields.
d.
Lacrimal apparatus.
(1)
Persistent chronic epiphora.
(2)
Dacryocystitis, chronic; acute, until cured.
(3)
Keratoconjunctivitis sicca (dry eye syndrome).
e.
Conjunctiva.
(1)
Conjunctivitis, chronic; acute, until cured.
(2)
Pterygium3; if threatening the visual axis.
f.
Cornea.
(1)
Keratitis, more than one episode; acute until cured.
(2)
Keratoconus.
(3)
Any type of corneal dystrophy.
(4)
Corneal graft.
(5)
Refractive surgery: Radial Keratotomy (RK) and Astigmatic Keratotomy (AK)
remain an absolute bar to entry. However, Photorefractive (Excimer) Keratectomy
(PRK) or Laser Epithelial Keratomileusis (LASEK) or Intrastromal corneal rings (ICRs),
otherwise known as Intrastromal Corneal Segments (ICSs), if meeting the specific
requirements given below at Corneal refractive surgery section below, may be
acceptable.
(6)
Ulcer, recurrent.
(7)
Vascularisation or opacity reducing visual acuity (VA) below single-Service entry
standards.
3 Recurrence is 10-30% after surgery, depending on type of surgery.
Return to Contents Page
4-A-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
g.
Lens.
(1)
Aphakia.
(2)
Pseudophakia (intraocular lens implant).
(3)
Opacity (including cataracts or past cataract surgery). Specialist opinion is
normally required.
(4)
Dislocation, partial or complete.
h.
Uveal tract.
(1)
Coloboma (excluding iris)4.
(2)
Uveitis5 that is chronic or recurrent; anterior, intermediate or posterior (syn-iritis,
pars-planitis, vitritis, choroiditis, panuveitis).
i.
Retina.
(1)
Vascular lesions.
(2)
Retinitis, active or recurrent.
(3)
Retinal detachment 6
All cases with a history of retinal detachment are to be
referred to an ophthalmologist.
(4)
Retinitis pigmentosa. Non progressive sectoral RP may be acceptable following
ophthalmological review.
(5)
Macular dystrophies or degenerations.
j.
Sclera. A history of scleritis.
k.
Optic Nerve.
(1)
Neuritis.
(2)
Neuropathy.
(3)
Atrophy (primary or secondary).
(4)
Papilloedema.
Corneal Refractive Surgery
3.
It is recommended that the following methods of surgical correction of myopia or
hypermetropia are now considered suitable for entry on an individual, case by case basis for non-
specialist employment groups and subject to single-Service requirements:
a.
Photorefractive keratectomy (PRK)
4 Iris colobomata are generally benign, unless associated with other systemic syndromes and are normally acceptable.
5 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.
6 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.
Return to Contents Page
4-A-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
b.
Laser epithelial keratomileusis (LASEK)
c.
Laser in-situ keratomileusis LASIK.
d.
Intrastromal corneal rings (ICRs), otherwise known as intrastromal corneal segments
(ICSs)
Entry will not be considered for radial keratotomy (RK), or astigmatic keratotomy (AK), or any other
form of incisional refractive surgery, other than those procedures listed above. All invasive
intraocular surgical procedures will remain a bar to entry.
4.
In order to be considered the prospective entry candidate must provide appropriate
documentary evidence that they fulfil the following criteria:
a.
The total preoperative refractive error was not outside the limits for selection, and in no
case than +6.00 or –6.00 dioptre [Equivalent Spherical Error (ESE)] in either eye.
b.
The preoperative best spectacle corrected visual acuity was within selection limits and;
c.
At least 6 months have elapsed since the date of the last surgery or enhancement
procedure;
d.
The candidate is at least 22 years old and;
e.
There have been no significant visual side effects secondary to the surgery affecting
daily activities or night vision, such as glare, halos or discomfort, no requirement for topical
eye medication and;
f
Stability of refraction post procedure; no more than 0.50 dioptre difference in the
spherical equivalent of either eye should be demonstrated by two consecutive post-treatment
refractions separated by a minimum of 3 months and;
g.
Paper case review by a Service ophthalmologist or Service-approved ophthalmologist
for confirmation that the candidate is acceptable.
5.
A single revision of CRS is acceptable, subject to the candidate meeting all the criteria as
above, including the preoperative limits before the first CR
Return to Contents Page
4-A-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Appendix 1
Calculation of Spherical Equivalent (Equivalent Spherical Error (ESE))
1.
The spherical equivalent is the sum of the spherical component of refraction added to (or
subtracted from) HALF of the cylindrical component of refraction. For example:
a.
Spherical +4.00D with cylindrical +2.00D = (+4) + (2/2) = ESE 5.00
b.
Spherical -7.00D with cylindrical +3.00D = (-7) + (3/2) = ESE -5.50
2.
The standard refers ONLY to the calculated spherical equivalent, and the individual
components, namely spherical and cylindrical are NOT to be used in isolation. For example:
a.
Spherical +7.00D with cylindrical -4.00D = (+7) + (-4/2) = ESE + 5.00. In this example,
even though the spherical component is greater than +6.00, the calculated Spherical
Equivalent is only +5.00. The candidate is therefore FIT.
b.
Spherical -5.50D with cylindrical -3.00D = (-5.5) + (-3/2) = ESE -7.00. In this example,
even though the spherical component is less than -6.00 and the cylindrical component is less
than -6.00, the Spherical Equivalent is greater than -6.00. The candidate is therefore UNFIT.
Return to Contents Page
4-A-A1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX B
EAR, NOSE AND THROAT PRE-ENTRY
Introduction
1.
Disorders of the ear nose and throat are assessed and recorded under the P factor. Entries
under HH are records of auditory acuity only. Consideration must be given as to whether a
condition gives rise to a degree of incapacity that is sufficient to impair an individual’s ability to
perform the normal tasks expected of the individual, either currently or in the future; whether the
condition may be exacerbated by exposure to the service environment, or whether the condition is
likely to give rise to a continuing need for medical supervision or treatment. In cases of doubt, an
opinion should be sought from the single-Service Occupational Physician responsible for the
selection of recruits who may request advice from a Service consultant otorhinolaryngologist (ORL).
Ears, nose and throat – general
2.
Candidates with the following conditions will normally be UNFIT:
a.
Existing or past history of malignant disease.
b.
Wegener’s granulomatosis1.
c.
Narrowing of the airway sufficient to cause limited exercise tolerance.
d.
Persistent facial nerve palsy.
Ears
3.
Deformity of the external ear. Candidates with deformity of the external ear sufficient to
interfere with the wearing of normal hearing protection or use of communication headsets are
normally UNFIT.
4.
Otitis Externa. Candidates with recurrent or persistent otitis externa are UNFIT.
5.
Acute Otitis Media (AOM). Candidates with recurrent AOM are normally UNFIT.
However, candidates may be determined FIT provided the last episode was not less than one
year2 ago, the tympanic membrane (TM) has healed, the hearing acuity is within entry limits and
tympanometry is normal. Following an isolated episode of AOM, a candidate may be determined
FIT as soon as the TM and hearing have returned to normal.
6.
Perforation. Candidates with a perforated TM are UNFIT. However, candidates may be
determined FIT not less than three months3 after spontaneous healing or successful surgery to
repair a perforation, provided that the TM has returned to normal, hearing acuity is within entry
limits and tympanometry is normal.
7.
Ventilation tubes. Candidates with ventilation tubes (grommets, T tubes) are UNFIT. As
’glue ear’ may recur, candidates may be considered FIT not less than six months after the tube
has been expelled or removed, provided that the TM has healed, hearing acuity is within entry
limits and tympanometry is normal4.
1 This is one of a number of conditions whose main feature is vasculitis.
2 Service ORL consultant opinion.
3 Service ORL consultant opinion.
4 Tympanometry is not mandatory if the ventilation tube was expelled more than 12 months ago, the TMs appear mobile and hearing is
within normal limits.
Return to Contents Page
4-B-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
8.
Myringitis. Candidates with myringitis are UNFIT.
9.
Chronic Otitis Media (COM). Candidates with active COM (including cholesteatoma) are
UNFIT. However, candidates with inactive or healed COM who are no longer under ORL follow-
up may be determined FIT provided that the TM has healed, hearing acuity is within entry limits
and tympanometry is normal.
10.
Mastoidectomy. Candidates may be considered FIT not less than two years after
successful mastoid surgery provided that the tympanic membrane has healed, hearing acuity is
within entry limits and tympanometry is normal. All cases should be reviewed by a Service ORL
consultant prior to acceptance to determine whether the cavity is stable and whether the condition
is likely to give rise to a continuing need for medical supervision or treatment.
11.
Otosclerosis. Otosclerosis is a progressive condition resulting in hearing loss. Candidates
with this condition are therefore UNFIT even if hearing acuity is within the entry limits.
12.
Hearing loss. Candidates with hearing loss sufficient to require external or intra-aural
hearing aids or cochlear implants are UNFIT. Entry limits for hearing acuity are based on
unaided hearing thresholds.
13.
Meniere’s disease. Candidates with Meniere’s disease are UNFIT.
Nose and sinuses
14.
Nasal deformity. Candidates with deformity of the nose sufficient to interfere with the use
of face masks, breathing apparatus and other similar devices are UNFIT. Candidates may,
however, be determined FIT following successful reconstructive surgery on the advice of the
single-Service Occupational Physician responsible for the selection of recruits.
15.
Epistaxis. Candidates with recurrent epistaxis (more than one episode per week (average)
over three months or more), unless treated and free of recurrence for at least six months, are
UNFIT. Candidates with hereditary haemorrhagic telangiectasia are UNFIT.
16.
Rhinosinusitis. Candidates with chronic rhinosinusitis requiring medication are normally
UNFIT but may be referred to single-Service Occupational Physician responsible for the
selection of recruits.
17.
Nasal polyposis. Candidates with active nasal polyposis are normally UNFIT. Those
with a history of treated polyposis may be acceptable following referral to the single-Service
Occupational Physician responsible for the selection of recruits.
Pharynx, larynx and trachea
18.
Adenoid hypertrophy. Candidates may be determined FIT following successful
adenoidectomy.
19.
Obstructive sleep apnoea/hypopnoea syndrome. Candidates with obstructive
sleep apnoea/hypopnoea syndrome are UNFIT.
20.
Cleft lip/palate. Candidates who have had successful surgery to correct a cleft lip/palate
may be determined FIT. Candidates with persistent/uncorrected cleft lip/palate should be
referred to the single-Service Occupational Physician responsible for the selection of recruits.
Those who have on-going treatment requirements should be deferred until treatment is
complete.
Return to Contents Page
4-B-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
21.
Laryngeal conditions. Candidates with respiratory papillomatosis or a history of respiratory
papillomatosis, whether treated or not, are UNFIT. Other laryngeal conditions will be assessed on
their likelihood of recurrence and functional impact.
22.
Tracheostomy. Candidates with an open tracheostomy are d UNFIT. Candidates presenting
with a healed tracheostomy may be determined FIT5.
5 The reason for tracheostomy should be explored to ensure there are no associated disabilities.
Return to Contents Page
4-B-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX C
CARDIOVASCULAR PRE-ENTRY
Heart disease
1.
Candidates with established heart disease are UNFIT, except in the following specific
circumstances.
2.
Congenital heart conditions.Candidates who have undergone successful correction of the
following conditions may be determined FIT, subject to the availability of relevant specialist
correspondence:
a.
Patent Ductus Arteriosus (PDA)
b.
Atrial Septal Defect (ASD)
c.
Ventricular Septal Defect (VSD)
All cases must be referred to the single-Service occupational physician responsible for the
selection of recruits.
3.
Cardiac murmurs. Although cardiac murmurs may be of no pathological significance, all
murmurs are to be assessed by a consultant cardiologist or consultant general physician. The
following guidance applies after confirmation of the cause of the murmur:
a.
Benign physiological murmurs. Grade FIT.
b.
Mitral Valve Leaflet Prolapse. If uncomplicated, functionally acceptable and
requiring no treatment, grade FIT.
c.
Bicuspid aortic valve and other valvular conditions. Normally UNFIT.
4.
Disturbances of rhythm.
a.
Candidates with any symptomatic dysrhythmia or those who require medication to
suppress disturbance of rhythm should be considered UNFIT.
b.
Candidates with asymptomatic dysrhythmia or who have had dysrhythmic foci or
accessory pathways ablated should be assessed on an individual basis with the benefit of a
full report from that individual’s specialist physician. Advice should be sought from the
single-Service occupational physician responsible for the selection of recruits. Many of
these candidates may be determined FIT if a procedure is deemed to have been curative.
c.
Where candidates are required to have an ECG as part of their entry medical this
should be formally read by a service approved physician1 to allow the exclusion of subtle,
asymptomatic cardiac diagnoses such as Brugada Syndrome or undiagnosed accessory
pathways.
5.
Cardiomyopathy. A family history, which must be specifically sought, of sudden death
before the age of 40 raises the question of inherited cardiomyopathy. Where there is a familial
1 For Royal Navy divers ECGs may be read by the HSE AMED conducting the diving medical.
Return to Contents Page
4-C-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
history, assessment by a consultant cardiologist is required, with as much information about the
family as possible. If a diagnosis of cardiomyopathy is made all such candidates should be
considered UNFIT.
Hyperlipidaemia
6.
Candidates with uncontrolled hyperlipidaemia are UNFIT due to the increased morbidity
associated with their condition.
7.
Candidates with previously elevated lipids (including familial hypercholesterolaemia), on
appropriate primary prevention medications2, should be referred to the SSMES responsible for the
selection of recruits for case review, seeking specialist advice from a single-Service cardiologist or
endocrinologist with expertise and experience in managing dyslipidaemia, if required.
8.
Due to the possibility of side-effects of statins on muscle, candidates taking a statin should
have a stable medication history for 6 months and normal exercise tolerance whilst completing
exercise compatible with military training requirements over at least the last 3 months without
unusual muscle pain or fatigue. If acceptable for entry they are FIT with an E2 marker for annual
medical review.
Hypertension
9.
Blood pressure should be measured in accordance with the British Hypertension Society
(BHS) guidelines (BHS IV). Cases of suspected “white coat” hypertension must be carefully
evaluated. Where there is doubt, a 24-hour ambulatory record, should be obtained and
interpreted3,4,5 . Candidates with uncontrolled hypertension6 are UNFIT. Candidates with
treated hypertension will normally be UNFIT.
Peripheral vascular diseases
10.
Raynaud’s phenomenon or vasospastic disease. Candidates with primary or secondary
Raynaud’s or similar phenomena are UNFIT7 .
11.
Congenital arterio-venous malformations. Candidates with congenital arterio-venous
malformations affecting function are UNFIT. Other congenital A-V malformations should be
discussed with the single-Service consultant occupational physician responsible for the selection
of recruits.
12.
Congenital lymphoedema. All candidates with congenital lymphoedema are UNFIT.
13.
Deep venous thrombosis (DVT). The opinion of the single-Service occupational physician
responsible for the selection of recruits should be sought on candidates with a previous history of
DVT. The referral should detail the clinical circumstances and investigations of the DVT episode.
14.
Thrombophilia. All candidates with thrombophilia should be referred to the single-Service
occupational physician responsible for the selection of recruits for an opinion as to medical
suitability for Service.
2 To be managed in accordance with NICE guidelines.
3 https://bihsoc.org/guidelines/
4 https://bihsoc.org/bp-monitors/
5 Ambulatory BP monitoring values are usually lower than clinic measurements and thresholds and targets should, therefore, be
adjusted downwards (e.g. by 10/5mmHg).
6 BHS IV defines hypertension as a sustained systolic BP ≥ 140 mm Hg and/or sustained diastolic BP ≥ 90 mm Hg.
7 Candidates deemed manageable by lifestyle changes alone are unfit for entry as the ability to keep the periphery warm at all times
cannot be guaranteed and the functional capacity of affected individuals is likely to be impaired.
Return to Contents Page
4-C-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
15.
Varicose veins. Candidates with symptomatic varicose veins affecting lower limb function
should normally be UNFIT. Those with asymptomatic minor varicosities, or who have undergone
successful treatment, may be determined FIT.
16.
Pericarditis. Pericarditis is a challenging disease with a significant recurrence rate and
presenting significant challenge in an occupational context. Candidates with a history of pericarditis
in the 2 years prior to application are UNFIT. Candidates with a single episode of pericarditis who
meet the following criteria are normally FIT:
a.
Episode resolved more than 2 years prior to application.
b.
Episode lasted no more than 6 weeks.
c.
Normal ECG.
d.
Normal echocardiogram.
17. Candidates with a history of complicated pericarditis (persistence beyond 6 weeks,
recurrence, constrictive) are normally UNFIT; cases of doubt should be referred to SSMES for
spec med opinion. Any known underlying causative condition should also be considered under the
relevant Annex.
Return to Contents Page
4-C-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX D
RESPIRATORY PRE-ENTRY
Introduction 1.
It is important that conditions adversely affecting respiratory fitness are identified at the pre-
employment stage. Active disease, or a significant decrease in pulmonary function (standardised
for age, gender and race) from whatever cause, is a bar to entry.
Wheezing 2.
Wheezing (including asthma) is common and recruiting medical officers must take a careful
respiratory history including:
a.
Symptoms of wheezy bronchitis, night-time or recurrent cough.
b.
Exercise and cold induced wheeze.
c.
Previous use of bronchodilators, inhalers and/or oral medication1.
d.
Admission to hospital (including Emergency Department) for wheeze.
It may be necessary to obtain a report from the applicant's general practitioner to clarify the
history.
3.
In cases where the examining medical officer has concerns or the diagnosis is in doubt,
guidance should be sought from the single-Service occupational physician responsible for
recruiting. This includes where the PEFR result at selection examination is less than 80% of
predicted, adjusted for age, gender, height and ethnicity.
4.
Candidates with symptoms confined to age less than 5yrs of age2, or a single episode of
wheeze associated with an acute respiratory tract infection (during which bronchodilator / inhaled
steroid treatment may have been prescribed) may be determined FIT.
5.
Candidates with a recorded history of asthma, with the following features, would be
normally be UNFIT.
a.
Those who have experienced symptoms or taken, or been prescribed any form of
treatment within the last 4 yrs.
b.
Those who have required more than one
course of oral steroids3.
c.
Those who have required more than one nebulisation since the age of 5.
d.
Those who have had a single admission to Intensive care or high dependency, or
multiple admissions to hospital.
6.
All others with a history of wheeze, particularly those with an atopic tendency require
investigation by the protocol below.
1 Includes oral steroids, repeated courses of antibiotics and other oral asthma treatments.
2 BTS Guidelines
3 Past treatment is used as a proxy for severity. Those treated abroad may have been given more aggressive therapy than in usual in
UK, which might unnecessarily debar some individuals. If there is concern this may have been the case, efforts should be made to
obtain the medical records from the event to gauge severity, and a candidate may be assessed by the protocol at 6.
Return to Contents Page
4-D-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Candidates identified as requiring
further assessment for wheeze
(JSP 950 6-7-7 Section 4 Annex D)
Examining doctor to send respiratory
questionnaire to GP and start 4 week
peak flow diary
Concerns raised from clinical
examination or respiratory
questionnaire?
no
Peak flow diary greater or equal to 15% diurnal variability?
(To calculate variability, divide the difference between the highest and lowest recorded
PEFR values by the highest recorded value X 100).
yes
no
borderline
Referral to single-Service Entry
medical authority for consideration of
assessment/formal respiratory function
un
satisfactory
testing
satisfactory
In accordance with single service policy, individual services may require additional
respiratory function testing for specific occupational groups.
Return to Contents Page
4-D-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Pneumothorax
7.
Spontaneous pneumothorax. If left untreated, ipsi and contra-lateral recurrence rates of
this condition are high4. Therefore, candidates who have had a spontaneous pneumothorax
at
any time without definitive treatment are normally UNFIT. Candidates who have had definitive
treatment (normally bilateral open or Video-Assisted Thoracostomy (VAT) pleurectomy5 ) may be
determined FIT provided there is no evidence of subpleural blebs or bullae and they have
achieved activity compatible with military service for a period of at least 3 months6, subject to
approval from the single-Service occupational physician responsible for recruiting.
8.
Traumatic pneumothorax. Candidates who have suffered traumatic pneumothorax are at
no greater risk of recurrence than the normal population. Therefore once these candidates have
made a full clinical recovery, they may be determined FIT provided lung function is normal.
Chronic bronchitis, emphysema and bronchiectasis
9. Candidates with chronic bronchitis, emphysema, bronchiectasis, cystic fibrosis or other
chronic pulmonary condition are UNFIT.
Tuberculosis
10. Candidates with active tuberculosis should be determined UNFIT7. Full details of those with
a history of confirmed, latent or suspected tuberculosis should be obtained and the candidate
referred to the single-Service occupational physician responsible for the selection of recruits.
Individuals with a history compatible with an increased risk of TB should be referred to their GP
for investigation prior to selection.
4 4 54.2% incidence of recurrence over four years following primary spontaneous pneumothorax . Sadikot RT,Greene T,Meadows
K,Arnold AG. Recurrence of primary spontaneous pneumothorax. Thorax, September 1997, vol./is. 52/9(805-9).
5 Pleurodesis is not considered definitive treatment for certain occupational groups (e.g. aircrew and divers). VAT is not acceptable for
aircrew.
6 See Section 4, Paragraph 3.
7 Health clearance for serious communicable diseases – Report from the Ad hoc Risk Assessment Expert Group, Dec 2002.
Return to Contents Page
4-D-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX E
GASTROINTESTINAL PRE-ENTRY
Upper GI Tract Disorders
1.
Oesophageal disease. Candidates with a current or past history of oesophageal disease,
including, but not limited to ulceration, varices, fistula or achalasia are UNFIT. Gastro
Oesophageal Reflux Disease (GORD) responding to lifestyle changes and not requiring regular
medication may be determined FIT.
a.
Motility disorders and oesophagitis. Candidates with a current history of
motility disorders, chronic, or recurrent oesophagitis are UNFIT.
b.
Hiatus hernia surgery. Candidates who have had any form of surgical correction for
hiatus hernia are UNFIT.
c.
Anti-reflux surgery. Those who have undergone surgery purely to resolve reflux and
who are asymptomatic and free of any complications1 12 months post-surgery should be
referred to the single-Service consultant occupational physician responsible for recruiting for
a final decision on fitness for entry.
2.
Dyspepsia. Those with a history of dyspepsia that has caused frequent disability, no matter
how long ago are UNFIT. Those with mild and infrequent symptoms not requiring any medication
may be determined FIT. The exception is where dyspepsia has been attributed to H pylori infection
which has been successfully eradicated. In this case, candidates may be accepted if symptom-
free for one year after treatment.
3.
Peptic ulcer disease. Candidates with a history of surgery for peptic ulceration or
perforation are UNFIT. Medically resolved peptic ulcer disease should be assessed as for
dyspepsia above.
4.
Pernicious anaemia. Candidates with pernicious anaemia may be determined FIT subject to
the following caveat. The history must be confirmed and an appropriate autoantibody screen2 and
fasting blood glucose should not show any abnormality (apart from the antibodies involved in
pernicious anaemia). Those with other antibodies or elevated fasting blood sugar should normally
be UNFIT (due to the risk of developing other auto-immune conditions).
Bowel conditions
5.
Irritable bowel syndrome. Candidates with a current or past history of irritable bowel
syndrome requiring medical follow-up/review, requiring medication within the previous two years
or of sufficient severity to interfere with normal daily activities3 are UNFIT. Those with mild
symptoms not requiring any medication, who are able to cope with a varied diet4 may be
determined FIT with a E2 risk marker. In cases of doubt an opinion should be sought from the
single-Service Occupational Physician responsible for selection of recruits.
6.
Inflammatory bowel disease. Candidates with a history of inflammatory bowel
disease, including but not limited to unspecified regional enteritis, Crohn’s disease, ulcerative
colitis or ulcerative proctitis are UNFIT, regardless of treatment (including surgery).
1 Complications include dysphagia, gas trapping (inability to belch) or return of reflux.
2 Associated with auto-immune thyroid disease, vitiligo, hypoparathyroidism, Addison’s disease and diabetes. As antibody tests can be
false positive, it may be necessary to refer for confirmation of diagnosis.
3 Examples include time off school or work.
4 The requirement to cope with the diet while deployed, at sea or on field rations, should be borne in mind.
Return to Contents Page
4-E-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
7.
Familial adenomatous polyposis (FAP). Opinion should be sought from the single-Service
Occupational Physician responsible for selection of recruits5.
8.
Hirschsprung’s disease. Candidates with Hirschsprung’s Disease are normally UNFIT 6.
Intestinal malabsorption syndromes
9.
Gluten sensitivity. Candidates with a history of gluten sensitive enteropathy (Coeliac
Disease) or gluten sensitivity are UNFIT.
10.
Lactose and other food intolerance. Candidates with a confirmed history of lactose
intolerance and/or any other food intolerance which requires an exclusion diet to prevent
symptoms and/or which require any form of medical intervention are UNFIT.
Herniae 11. Candidates are normally UNFIT if any hernia (inguinal, epigastric or incisional) is present.
However, those with an easily reducible periumbilical hernia that does not affect physical activity
may be determined FIT. Candidates with repaired and soundly healed herniae may be determined
FIT provided that they are able to tolerate activities comparable with military training/Service over
a minimum period of 3 months7. However, candidates with a repaired incisional hernia (especially
if originally extensive) should be referred for specialist surgical advice as this type of hernia is
more liable to recur.
Surgical procedures 12. Candidates with a history of open or laparoscopic abdominal surgery should be assessed
following the guidance below. Care should be exercised to ensure that the original reason for
such surgery is not disqualifying in itself.
a.
Candidates who have undergone surgery during the preceding 6 months are
normally UNFIT.
b.
Laparoscopy. Candidates who have had diagnostic laparoscopy and other
procedures such as appendicectomy and laparoscopic sterilisation with a low risk of late
complications may be assessed as FIT on return to full physical activity.
c.
Bariatric surgery. Because of the significant risks of complications, candidates who
have undergone bariatric surgery within the last two years are graded UNFIT. Where more
than two years have passed since surgery, candidates are to be assessed on a case-by-
case basis by the single-Service consultant occupational physician responsible for the
selection of recruits. Because of the high rate of complications, including slippage and
erosion, candidates who have undergone gastric banding are graded UNFIT. Candidates
who have undergone other procedures, such as sleeve gastrectomy, and gastric bypass
(requiring Roux-en-Y reconstruction), with stable weight and in whom there are no surgical
or metabolic complications, and no ongoing requirement for dietary supplementation, may
be graded FIT.
d.
Pouch surgery. Any applicant who has undergone colectomy and pouch surgery
should be considered UNFIT as they all require prolonged follow-up and have significant
long-term morbidity.
5 Practice parameters for the treatment of patients with dominantly inherited colorectal cancer (Familial Adenomatous Polyposis and
Hereditary Nonpolyposis Colorectal cancer). Diseases of the Colon & Rectum 2003;46 (8):1001-1012. http://www.acpgbi.org.uk/ -
Association of Coloproctology of Great Britain and Northern Ireland. http://www.acpgbi.org.uk/content/uploads/2007-CC-Management-
Guidelines.pdf
6 Even after surgery, perfect continence is unlikely and usually requires management with intermittent laxatives, enemas, and revision
surgery.
7 See Section 4 Introduction.
Return to Contents Page
4-E-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Anal and perianal conditions 13.
Pilonidal sinus. Candidates with active disease or a history of more than two planned,
definitive surgical procedures for pilonidal sinus are UNFIT. A past history of acute abscess
drainage does not on its own bar entry. Those who have had wide excision with healing by
secondary intention will not be accepted until 12 months have elapsed since complete healing of
the wound.
14.
Haemorrhoids. Candidates with active haemorrhoids (internal or external), when large,
symptomatic, or with a history of bleeding within the last 8 weeks, are UNFIT.
Liver, biliary tree and pancreas 15. Candidates with a developmental or chronic disease of the liver, biliary tree or pancreas
are normally UNFIT.
a.
Viral hepatitis. Candidates with a current acute or chronic hepatitis, hepatitis carrier
state, hepatitis in the preceding 6 months, or persistence of symptoms after 6 months, or
objective evidence of impairment of liver function are UNFIT8.
b.
Pancreatitis. Candidates with a single episode of acute viral pancreatitis with
complete recovery and no evidence of chronic pancreatitis or diabetes may be considered
FIT at least 1 year after recovery. However, candidates with a history of alcohol-induced
pancreatitis are UNFIT.
c.
Cholecystitis. Candidates with a current or past history of symptomatic cholecystitis,
acute or chronic, with or without cholelithiasis, or other disorders of the gallbladder and
biliary system are UNFIT unless surgically treated. Cholecystectomy is acceptable if
performed greater than 6 months prior to examination and the candidate remains
asymptomatic. Candidates who have had fibre-optic procedures to correct sphincter
dysfunction or cholelithiasis if performed more than 6 months prior to examination and
remain asymptomatic may be determined FIT.
d.
Metabolic liver disease. Candidates with a current or past history of metabolic liver
disease, including, but not limited to haemochromatosis, Wilson's disease and alpha-1
anti-trypsin deficiency, are normally UNFIT.
e.
Hepatosplenomegaly. Candidates with hepatosplenomegaly from whatever cause
are UNFIT.
f.
Gilbert’s syndrome. Gilbert’s syndrome affects 5% of the population and may
present as jaundice under a variety of stressors such as minor illness and reduced calorie
intake. It can also be discovered as an isolated hyperbilirubinaemia (<100umol/l)9 .
Candidates with Gilbert’s syndrome may be determined FIT if asymptomatic.
Splenectomy
16. Policy on splenectomy is at Annex N - Other Conditions.
8 See also Section 4 Annex N Miscellaneous Conditions.
9 Davidson’s Principles & Practice of Medicine 19th Ed; p. 843.
Return to Contents Page
4-E-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX F
RENAL AND UROLOGICAL PRE-ENTRY
1.
Where not otherwise stated in the text, Glomerular Filtration Rate (GFR) can be either
measured or calculated (eGFR)1.
2.
Abnormalities of urinalysis. A persistent abnormality of urinalysis is defined as painless
haematuria ≥1+ and/or proteinuria ≥1+ (trace can be ignored). For the management of proteinuria
and painless non-visible haematuria see fig 1. The candidate is UNFIT until pathology has been
excluded to satisfaction of the single-Service occupational physician responsible for recruiting.
Any episode of clot colic is UNFIT.
3.
Nephritis. Candidates with a history of nephritis are normally UNFIT. However, they may be
accepted subject to review by the single-Service Occupational Physician responsible for selection
of recruits providing that:
a.
There is no persisting abnormality on urinalysis.
b.
Blood pressure is normal.
c.
There is a GFR or eGFR of at least 60ml/min.
Those having made a complete recovery from acute glomerulonephritis or a single attack of
pyelonephritis (without predisposing factors) more than two years earlier, may be determined FIT.
If urinalysis shows proteinuria, then this should be assessed objectively. If protein excretion
exceeds 400 mg/24 hours2 then the candidate should be rejected unless specialist consultation
determines the condition to be benign orthostatic proteinuria. Those with a history of asymptomatic
haematuria for several years and are normotensive, have no pathological proteinuria and normal
renal function may be acceptable subject to formal nephrological assessment. [DCA Medicine]
4.
Urinary Tract Infection. Candidates with a history of recurrent infection in childhood, or one
proven infection in a male or two in a female since puberty should not be accepted until a full report
from their GP confirms that they have a normal urinary tract (such patients will require urological
assessment). If an abnormality is discovered then referral to the single-Service Occupational
Physician responsible for selection of recruits is indicated. A history of mild vesicoureteric reflux
(Grades I-III) where an individual has been discharged from follow-up, has been free of infection3,
has no requirement for antibiotic prophylaxis, normal urinalysis and normal blood pressure may be
determined FIT. Those with Grades IV-V that required surgical correction and have been
discharged from follow-up, should additionally demonstrate a GFR or eGFR of at least 60ml/min.
5.
Urethral abnormality. Candidates with unsuccessful or continuing treatment for urethral
abnormalities are UNFIT. Those who have been successfully treated for minor urethral stricture
may be determined FIT on the condition that they have been discharged from follow-up.
Candidates with genital piercing (excluding the urethra) that has fully healed without complications
may be determined FIT. Due to the risk of developing urethral stricture at a later date, candidates
with history of genital piercing involving the urethra may only be accepted as FIT on a case by
case basis after obtaining the relevant urologists opinion. Those deemed at unacceptable risk by
the Service urologist are UNFIT.
1 If calculated then the preferred method is the CKD-EPI Calculator Levi A.S, Steven L.A et al A new equation to estimate glomerular
filtration rate Ann Intern Med 2009; 150 (9) 604-612 (Calculator found at http://touchcalc.com/e_gfr
2 Or equivalent albumin/creatinine or protein/creatinine ratio.
3 There is no published time period, but 12 months is suggested by military urology adviser.
Return to Contents Page
4-F-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
6.
Urinary incontinence. Candidates with a history of diurnal urinary incontinence, or of
nocturnal enuresis in the two years preceding entry are UNFIT and barred from entry regardless of
the presence of normal neurological and psychological investigations.
7.
Genital infections. Candidates with a current or past history of genital infection or
ulceration, including, but not limited to herpes genitalis or condyloma acuminatum, if of sufficient
severity to require frequent intervention or to interfere with normal function, are UNFIT.
8.
Congenital Abnormality. Candidates with known polycystic disease, mega-ureter or other
congenital anomalies are normally UNFIT. The following exceptions apply:
a.
Polycystic kidney disease. Candidates with a family history of polycystic kidney
disease require screening ultrasound after the age of 16 years before being accepted.
b.
Hypospadias. Candidates with current hypospadias, when not accompanied by
evidence of urinary tract infection, urethral stricture, or voiding dysfunction, may be
determined FIT after urological assessment.
c.
Pelviureteric Junction (PUJ) Obstruction. Candidates with surgically-corrected PUJ
obstruction may be determined FIT provided there is evidence of correction and preservation
of good renal function (as assessed on isotope renography, no earlier than 12 months post-
surgery). Candidates with unilateral PUJ obstruction with a non-functioning kidney or those
treated with nephrectomy should be regarded as having a single kidney (see 09).
d.
Mega-ureter. Candidates with a history of surgically corrected mega-ureter may be
determined FIT if the GFR exceeds 60ml/min4 and they have been discharged from follow-up.
All candidates should be referred to the single-Service Occupational Physician responsible
for selection of recruits.
9.
Absence, loss or malfunction of a kidney. Candidates with only one functioning kidney
may be acceptable provided that there is no evidence of disease in the remaining kidney, i.e. no
persistent abnormality on urinalysis and a GFR or eGFR of at least 60ml/min, in the absence of
raised blood pressure. All cases meeting the above criteria and potentially acceptable should be
referred to the single-Service Occupational Physician responsible for selection of recruits.
Candidates with renal transplants are UNFIT.
10.
Urolithiasis. Candidates who have a confirmed history of calculus formation are UNFIT. A
candidate with a history of a single episode of ureteric spasm (renal colic), which has been
investigated without demonstration of underlying pathology, may be determined FIT. Those with a
history of recurrent (more than one) ureteric spasm are UNFIT.
11.
Urological malignant disorders. Candidates with successfully treated malignant disease of
the bladder or kidney should be referred to the single-Service Occupational Physician responsible
for selection of recruits. Candidates with malignant urological diseases are normally UNFIT but
those with Wilms’ tumour treated in early childhood may be determined FIT.
12.
Other painful urological conditions. Candidates with non-specific groin or pelvic pain or
undiagnosed loin pain are unsuitable for service and UNFIT. Candidates may re-apply after being
symptom-free and off treatment for one year. the presence of normal neurological and
psychological investigations.
4 Total residual GFR/eGFR.
Return to Contents Page
4-F-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX G
NEUROLOGICAL PRE-ENTRY
1.
Candidates with a history of some nervous system diseases may be acceptable for service
but be excluded from employments that require more stringent medical standards including aircrew
and occupational diving. Where there is doubt about either the diagnosis or suitability for entry,
cases should be referred to the single-Service Occupational Physician responsible for the selection
of recruits.
2.
Candidates with diseases of the nervous system with a progressive or recurrent course are
normally UNFIT.
Seizures and epilepsy
3.
Candidates diagnosed as having epilepsy1 or who have had more than one seizure after their
sixth birthday are UNFIT. The following should be noted:
a.
Febrile convulsions. Candidates with febrile convulsions before their sixth birthday2,
and with no subsequent seizures, may be determined FIT.
b.
Single seizures. Candidates with a single seizure less than 5 years prior to entry are
UNFIT. Candidates who
have had a single seizure more than 5 years before entry, and who
have not been on treatment during this interval, can be determined FIT (in accordance with
DVLA Group 2 entitlement standards3). They may still be unable to enter some trades or
branches, subject to single-Service regulations. Such candidates must be referred to the
single-Service Occupational Physician responsible for the selection of recruits.
c.
Provoked seizures. Those with a history of provoked seizures should be assessed on
a case by case basis and advice sought from the single-Service Occupational Physician
responsible for the selection of recruits. Consideration will also need to be given to fitness for
service in relation to the provoking stimulus. It must be clear that the seizure had been
provoked by a stimulus that does not carry any risk of recurrence and does not represent the
unmasking of any underlying vulnerability.
d.
Petit Mal (absence seizures). Candidates with a history of typical childhood absence
seizures with onset before the age of 10 years4, who have had no such seizures for 5 years
(without treatment) may be determined FIT.
e.
Benign rolandic epilepsy of childhood. Candidates with a confirmed diagnosis of
typical rolandic epilepsy of childhood, who have been seizure-free for 5 years (without
treatment) may be determined FIT.
Headache
4.
Headaches are common and those who have infrequent mild headaches may be accepted as
FIT. Candidates with headaches with any of the following features in the last 2 years should be
determined UNFIT:
1 Diagnosis of epilepsy must be made by a medical practitioner with expertise and training in epilepsy (NICE Clinical Guideline 20)
2 Advice from Consultant Adviser in neurology to the RAF.
3 DVLA Current medical guidelines: DVLA guidance for professionals
https://www.gov.uk/government/collections/current-medical-guidelines-dvla-guidance-for-professionals
4 Advice from Defence Consultant Adviser in neurology.
Return to Contents Page
4-G-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
a.
Are severe enough to disrupt normal activities, including loss of time from school or
work.
b.
Require treatment by pharmacy (GSL) or prescription only medicine.
c.
Are aggravated by lack of sleep, missed meals or anxiety and occur more often than
once every six months.
d.
Require prophylactic treatment.
Migraine
5.
The diagnostic criteria for migraine5 without aura are at least 5 attacks fulfilling criteria a-c:
a.
Headache attacks lasting 4-72 hours (when untreated in adults).
b.
Headache has at least two of the following characteristics:
(1)
Unilateral location
(2)
Pulsating quality
(3)
Moderate or severe pain intensity
(4)
Aggravation by or causing avoidance of routine physical activity
c.
During the headache, at least one of the following is present:
(1)
Nausea and/or vomiting
(2)
Photophobia and phonophobia
(3)
Not attributable to another disorder.
6.
The following are known trigger factors for migraine that should be sought in any candidate
presenting with recurrent headaches:
a.
Relaxation after stress.
b.
Missing meals, sleep deprivation, long distance travel etc.
c.
Bright light and loud noise.
d.
Dietary e.g. alcohol, cheese, citrus fruits, chocolate.
e.
Menstruation.
7.
Candidates with any of the following criteria should be considered UNFIT:
a.
One episode of migraine in the last two years with any of the following associated
history:
5 Diagnostic criteria for migraine (from ICHD-II3).
Return to Contents Page
4-G-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
(1)
Moderate to severe pain6 (score of 5 or more on the WHO step ladder pain
scale7).
(2)
Photophobia8, phonophobia and/or other neurological features.
b.
Two or more episodes of migraine in the last 2 years irrespective of their severity or
trigger.
c.
Use of prophylactic medication for migraine in the last 2 years.
Head Injuries9,10
8.
Candidates with a past history of head injury who show any evidence of persisting intellectual,
psychiatric or neurological symptoms or signs should be considered UNFIT. 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.
(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 haematoma11
(4)
Depressed skull fracture
(5)
Brain contusion.
9.
The risk of seizures following head injury is directly related to the severity of the head injury.
Seizures occurring within 7 days of a head injury are considered to be provoked seizures. As a
result of the significant risk of continuing seizures following head injury:
a.
Candidates with a history of mild head injury may be determined FIT as long as they are
free of post-concussion symptoms.
6 Pain intensity is a strongest indicator of disability at work (Steward WF, Lipton RB, Simon D. Work related disability: results from the
American Migraine study. Cephalalgia 1996; 16: 231-8. Oslo. ISSN 0933-1024).
7 WHO step ladder pain scale: 1 to 10 where 1 = No Pain and 10 = Intense Pain.
8 Photophobia will limit ability to work in, for example, bright light and possibly whilst driving.
9 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
10 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.
11
All intracranial haematomata, including epidural, subdural and subarachnoid.
Return to Contents Page
4-G-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
b.
Candidates with a history of moderate head injury may be determined FIT providing 2
years have elapsed since the head injury and during this interval they have been seizure and
medication-free and have no long term neuro-behavioural sequelae.
c.
Candidates with a history of severe head injury will normally be UNFIT, however, be
determined FIT providing 5 years have elapsed since the head injury and during this interval
they have been seizure and medication-free and have no evidence of long term neuro-
behavioural sequelae
Hydrocephalus
10. Candidates with a history of hydrocephalus or intra-cranial shunt (working or blocked) are
normally UNFIT. However, candidates with a history of resolved infant hydrocephalus may be
determined FIT but are to be referred to single-Service Occupational Physician responsible for the
selection of recruits.
Neurosurgery and tumours
11.
Neurosurgery. Candidates with a history of neurosurgery are normally UNFIT because of the
risk of post-surgery seizure. Such candidates should be referred to the single-Service Occupational
Physician responsible for the selection of recruits for further assessment.
12.
Tumours. Candidates with a history of intracranial tumour are normally UNFIT.
Loss of Consciousness/altered awareness
13. A full history should be taken including note of any pro-dromal symptoms, length of
unconsciousness, degree of amnesia and any confusion on recovery. Candidates with symptoms
suggestive of a cardiovascular or neurological aetiology must be fully investigated. The results of
any cardiological and neurological investigations must be normal or any underlying abnormalities
fully treated before acceptance can be considered.
14.
Simple faint. These have definite provoking factors, are unlikely to occur whilst lying or sitting
and are benign in nature. Candidates with non-recurring faints may be determined FIT. Candidates
with recurring faints are normally UNFIT.
15.
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 determined FIT providing 12 months have elapsed since
the episode and they are considered to be at low risk of recurrence12 .Candidates with recurring
episodes where no underlying cause can be found should normally be determined UNFIT.
16.
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 candidates should only be accepted after 5 years with no
recurrence13.
Involuntary Movements/Tics
17. Candidates with significant involuntary movement disorders, including Tourette’s and other
similar syndromes, should be determined UNFIT.
12 Based on DVLA medical standards criteria.
13 DVLA requirements for Class 2 licensing. See also Hart et al. National General Practice Study of epilepsy: recurrence after first
seizure. Lancet Vol 336 pp 1271-1274.
Return to Contents Page
4-G-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
18. Candidates with slight involuntary movements (including mild tics) may be determined FIT
after appropriate functional assessment. Advice should be sought from the single-Service
Occupational Physician responsible for the selection of recruits.
Return to Contents Page
4-G-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX H
ENDOCRINE PRE-ENTRY
1.
Disorders of the endocrine system frequently result in the need for continuous medication,
the withdrawal of which may lead to severe or even life-threatening consequences, and the
requirement for regular medical review, often at secondary care level. Many such disorders are
associated with other medical conditions, themselves necessitating treatment and follow-up. For
these reasons, candidates suffering from endocrine disease will normally be UNFIT. Specific
guidance is given for the following conditions:
2.
Diabetes mellitus. Diabetes mellitus is a heterogeneous condition in which hyperglycaemia
is the hallmark. Both the disease and its treatment can lead to disabilities and complications1 which
affect the employability of individuals in the Armed Forces. Candidates with a history of diabetes
mellitus or impaired glucose tolerance (including gestational diabetes2) according to WHO criteria
are, therefore, UNFIT. If glycosuria is found on urinalysis, a normal glucose tolerance test is
required before the candidate can be accepted.
3.
Pituitary conditions. Hyper and hypo-secretory conditions of the pituitary gland are likely to
result in long -term treatment and follow up, with potentially life-threatening effects resulting from
non-compliance with medication. Candidates with an established diagnosis are UNFIT.
4.
Adrenal conditions. Due to the life-threatening nature of failure to comply with therapy, e.g.
when the supply of medication cannot be guaranteed, candidates with an established diagnosis of
adrenal conditions requiring treatment are UNFIT. Candidates with a previous history who have not
required treatment for a year and who have been discharged from follow-up should be referred to
the single-Service Occupational Physician responsible for the selection of recruits.
Thyroid conditions 5.
Hypo-thyroid disease. Successfully treated hypothyroidism poses little health risk from
short-term failure to take medication3. Its association with a number of health risks in the longer
term4 and the requirement for continuous medication and regular monitoring would normally result
in a grading of UNFIT. However, after consultation with a single-Service consultant occupational
physician responsible for the selection of recruits, candidates may be determined FIT if they are
euthyroid on a stable dose of medication for at least 1 year and following exclusion of associated
autoimmune conditions5.
6.
Hyperthyroid disease. Candidates with a hyperactive thyroid may be accepted as FIT
following successful definitive treatment with radioactive iodine or surgery, provided at least a year
has elapsed6 and the candidate is euthyroid without therapy. Candidates who have received
treatment with carbimazole or thiouracil are UNFIT because of a high risk of recurrence of
hyperthyroidism7.
Other Endocrine Conditions
7.
Candidates with carcinoid tumours, thymic tumours and multiple adenomata are UNFIT
because of the need for continuous monitoring and regular medication.
1 For example: hypoglycaemia, infections, metabolic disturbance, retinopathy, peripheral vascular disease, coronary heart disease,
neuropathy and renal disease.
2 Approximately 50% develop DM in 15 years.
3 Functional impairment (including muscular fatigue, cold intolerance and slowing of cognition) would develop over 1-2 months.
4 For example: cardiovascular disease, obesity, hypertension, depressive illness, menstrual disorders.
5 For example: Addison’s disease, coeliac disease, pernicious anaemia and some cases of primary ovarian failure.
6 Following RAI, approx 5% of patients per year will become hypothyroid (dose dependent) and require replacement therapy.
7 e.g., 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.
Return to Contents Page
4-H-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
8.
Candidates with a history of other endocrine disease should be discussed with the single-
Service Occupational Physician responsible for the selection of recruits to determine the need for
specialist opinion.
Return to Contents Page
4-H-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX I
DERMATOLOGICAL PRE-ENTRY
General
1.
When assessing a candidate’s fitness for entry, the potential for military service to either cause
or aggravate existing skin disease must be evaluated. Chronic skin disease may require frequent
and extensive periods of treatment during which the individual would not be fit for unrestricted
service. Skin disease may affect the ability to wear military clothing or the ability to operate military
equipment. Further restrictions may be required dependent on the individual’s intended Service or
Career Employment Group, in which case guidelines are available in single-Service publications1 or
opinion should be sought from the single-Service Occupational Physician responsible for the
selection of recruits.
2.
Acne. Candidates with acne that may affect the ability to wear military clothing or to operate
military equipment should normally be considered UNFIT, or entry should be deferred until the
disease has been successfully treated. Candidates under treatment with isotretinoin may be
determined FIT eight weeks after completing successful treatment by which time most adverse
effects will have settled. Candidates using topical treatments and/or oral antibiotics may be
determined FIT providing the pre-treatment severity of acne would not have affected the ability to
wear military clothing or the ability to operate military equipment.
Dermatitis
3.
Candidates with a history of mild episodes of skin irritation that is not atopic or contact
dermatitis, is not affecting the hands or affecting function, and with no history of childhood atopic
dermatitis (eczema), may be determined FIT. Candidates with active dermatitis of any type are
normally UNFIT.
4.
Atopic dermatitis (or eczema). A history of atopic dermatitis is considered to increase the
likelihood of irritant contact dermatitis on exposure to irritants (such as oils, greases, detergents).
Candidates who have a history of severe atopic dermatitis are normally UNFIT. Severe atopic
dermatitis (or eczema) is defined as having required or caused ANY of the following:
a.
Secondary care involvement whether inpatient or outpatient.
b.
Occlusive dressings.
c.
Systemic immunomodulatory therapy.
d.
Phototherapy.
e.
Intense scratching.
f.
Insomnia.
g.
School/work absence.
h.
Maintenance therapy (other than emollients).
Furthermore, candidates who have a history of atopic dermatitis with any of the following,
regardless of severity, are also normally UNFIT:
1 BRd 1750A Handbook of Naval Medical Standards PULHHEEMS Administrative Pamphlet (PAP) AP 1269A Royal Air Force Manual
of Medical Fitness.
Return to Contents Page
4-I-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
i.
Involvement of the hands.
j.
An episode within the last 1 year.
k.
Prescription-only topical immunomodulatory2 treatment in the last 3 years.
5.
In candidates with atopic dermatitis, who do not have any of the above exclusions, the
presence of the following known risks factors should be enquired after:
a.
Functional impairment such as difficulty with school/work, sleep disturbance, inability to
do sport or other social activities or inability to wear certain footwear due to dermatitis.
b.
Previous episodes of non-atopic dermatitis of the hand(s).
If none of these risk factors are present, the candidate may be determined FIT. If any of the above
is present, the candidate should be referred to the single-Service Occupational Physician
responsible for the selection of recruits.
6.
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. Candidates with a confirmed history of irritant contact
dermatitis are normally UNFIT. However, where a candidate has experienced isolated
episodes of irritant contact dermatitis as a result of an defined exposure, unlikely to be
encountered during military Service, they should be referred to single-Service Occupational
Physician responsible for the selection of recruits.
b.
Allergic contact dermatitis. Candidates with history of allergic contact dermatitis
confirmed by patch testing should be referred to the single-Service Occupational Physician
responsible for the selection of recruits.
7.
Pompholyx. Candidates with a history of pompholyx type dermatitis (recurrent vesicular
eczema affecting hands and / or feet) are normally UNFIT.
Psoriasis3
8.
Non-cutaneous manifestations. Candidates with non-cutaneous manifestations are UNFIT.
9.
Active psoriasis.
a.
Candidates who have active psoriasis with any of the following are normally UNFIT:
(1)
Affecting >5% Body Surface Area (BSA)
(2)
Have required treatment with phototherapy or systemic agents.
b.
Candidates with active psoriasis may be determined FIT provided that:
(1)
The extent of the disease has always been <5% BSA.
(2)
The disease has not involved hands4 and/or feet.
(3)
The disease would not affect the ability to wear military clothing or the ability to
operate military equipment.
2 Including prescription-only topical steroids and topical calcineurin inhibitors. Emollients are acceptable.
3 See also Fig 1 Psoriasis flow chart.
Return to Contents Page
4-I-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
10.
Previous history of psoriasis.
a.
Candidates with a previous history of psoriasis affecting <5% BSA may be determined
FIT if it did not involve hands4 and/or feet.
b.
Candidates with a previous history of psoriasis affecting >5% BSA may be determined
FIT only if:
(1)
They have remained free from symptoms whilst off treatment for 5 years.
(2)
They only required topical treatments.
(3)
The disease has not involved hands4 and/or feet.
(4)
Would not affect the ability to wear military clothing or the ability to operate
military equipment.
11. In all cases, candidates who meet the criteria for entry but require topical treatment to sustain
function and skin integrity should be referred to the single-Service Occupational Physician
responsible for the selection of recruits for consideration of the requirement for an E2 medical
marker.
12.
Submarine service. Psoriasis, even mild, can be particularly problematic in the enclosed
environment of a submarine. If being selected for submarine service, candidates with past or
present evidence of psoriasis who are otherwise considered fit for entry are to be referred to the
single-Service Occupational Physician responsible for the selection of recruits to the Royal Navy.
13.
Guttate psoriasis. Candidates with a history of a single episode of guttate psoriasis which
has fully resolved (irrespective of treatment) may be determined FIT. Candidates with more than
one episode of guttate psoriasis should be referred to the single-Service Occupational Physician
responsible for the selection of recruits.
Other skin diseases
14.
Cysts, scars and keloids. Candidates are normally UNFIT if the size or location of cysts,
scars or keloids (from whatever cause) could affect the ability to wear military clothing or the ability
to operate military equipment.
15.
Birthmarks. Consideration should be given to the potential that a birthmark may be a
cutaneous manifestation of a genodermatosis such as neurofibromatosis, or a neurological
condition such as Sturge-Weber. Candidates are normally UNFIT if the size or location of
pigmented or vascular lesions could affect the ability to wear military clothing or the ability to
operate military equipment.
16.
Bullous dermatoses. Candidates with any immuno-bullous disease such as dermatitis
herpetiformis or any genetic bullous disease such as epidermolysis bullosa are UNFIT.
17.
Fungal infections. Candidates with extensive or recalcitrant fungal disease or disease that
could affect the ability to wear military clothing or the ability to operate military equipment are
normally UNFIT.
18.
Viral warts and veruccas. Candidates with extensive or recalcitrant viral warts and or
veruccas that could affect the ability to wear military clothing or the ability to operate military
equipment are normally UNFIT.
4 Mild nail involvement is acceptable.
Return to Contents Page
4-I-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
19.
Folliculitis. Single-Service policy5 should be considered when a candidate has had a
condition such as folliculitis barbae or pseudofolliculitis which may prevent them from shaving.
Candidates with extensive or recalcitrant inflammation of the hair follicles that could affect the
ability to wear military clothing or the ability to operate military equipment are normally UNFIT.
20.
Lichen planus. Candidates with generalised disease that is not responsive to treatment are
normally UNFIT.
21.
Cutaneous leishmaniasis. Candidates undergoing treatment are UNFIT. Following
successful treatment, candidates who have been discharged from follow-up may be determined
FIT.
22.
Hyperhidrosis. Candidates with disease affecting function are normally UNFIT.
23.
Malignant skin disease. Candidates with a history of malignant skin disease, which has
been successfully treated and who are regarded as cured, may be considered for Service entry
provided that they have been discharged from regular follow-up and that no treatment is required.
A clinical report is to be obtained in all cases. A decision on medical fitness for entry and the
requirement for an E2 medical marker is to be made by the single-Service Occupational Physician
responsible for the selection of recruits.
a.
Malignant melanoma. To be considered for Service entry candidates with a history of
malignant melanoma must have completed treatment and been discharged from follow-up in
accordance with national guidelines6. Candidates with a history of more than one malignant
melanoma are normally UNFIT.
b.
Squamous cell carcinoma. To be considered for Service entry candidates with a
history of squamous cell carcinoma must have completed treatment and been discharged
from follow-up in accordance with national guidelines7. Candidates with a history of more
than one squamous cell carcinoma are normally UNFIT.
c.
Basal cell carcinoma. Candidates with a history of a single episode of basal cell
carcinoma may be determined FIT, but must have completed treatment and been discharged
from follow-up. Candidates with a history of more than one basal cell carcinoma may be
considered for Service entry following referral to the single-Service Occupational Physician
responsible for the selection of recruits.
24.
Pre-malignant skin conditions. Candidates with a history of pre-malignant skin conditions
who remain under active dermatological review are normally UNFIT.
a.
Candidates with a history of keratinocyte derived disease such as actinic keratosis,
Bowen’s disease, vulval or penile intra-epithelial neoplasia who remain under active
dermatological review are normally UNFIT. Candidates who have completed treatment and
have been discharged from follow-up may be determined FIT.
b.
Candidates with a history of melanocyte derived disease such as atypical mole
syndrome or dysplastic naevi who remain under active dermatological review are normally
5 Single-Service policy on facial hair is detailed in: RN BR3(1), Part 6, Chapter 38. Army AGAI, Volume 2, Chapter 59 Annex B. RAF
AP1358, Chapter 1. Beards are permitted on religious ground. Muslim, Sikh and Rastafarian men are permitted to wear uncut beards
in normal circumstances. For occupational or operational reasons, where a hazard clearly exists, individuals have to be prepared to
modify or remove their beards, for instance to enable the correct wearing of a respirator or breathing apparatus.
6 Royal College of Physicians and British Association of Dermatologists (Sep 07) Number 7 The prevention, diagnosis, referral and
management of melanoma of the skin Concise Guidelines http://www.bad.org.uk/shared/get-file.ashx?id=793&itemtype=document.
NICE (Jul 15) NG 14 Melanoma: assessment and management https://www.nice.org.uk/guidance/ng14.
7 British Association of Dermatologists (Nov 09) Multi-professional Guidelines for the Management of the Patient with Primary
Cutaneous Squamous Cell Carcinoma http://www.bad.org.uk/shared/get-file.ashx?id=59&itemtype=document.
Return to Contents Page
4-I-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
UNFIT. Candidates who have a history of complete excision of dysplastic naevus, who have
been discharged from follow-up may be determined FIT.
25.
Photosensitivity. Candidates with any condition sensitive to or aggravated by exposure to
sunlight not adequately controlled by sunscreens, are normally UNFIT.
26.
Vitiligo. Candidates with vitiligo have a comparable risk profile for photosensitivity and skin
cancer as those with Type 1 skin8. Candidates with vitiligo not associated with any other auto-
immune disorder may be determined FIT.
27.
Scleroderma. Refer to JSP 950 Part 1 6-7-7 Section 4 Annex K Musculoskeletal.
28.
Urticaria and angio-oedema.
a.
Acute urticaria and angio-oedema. Refer to JSP 950 Part 1 6-7-7 Section 4 Annex N
Other Conditions.
b.
Chronic spontaneous urticaria. Candidates who have a history of chronic
spontaneous urticaria (symptoms > 6 weeks) requiring regular medication are normally
UNFIT. Candidates with chronic spontaneous urticaria which has fully resolved and free
from treatment for 2 years may be determined FIT.
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.
8 The Fitzpatrick skin type scale type 1 Ivory: pale skin, light or red hair, prone to freckles. Burns very easily and rarely tans.
Return to Contents Page
4-I-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Fig 1 Psoriasis flow chart
Non-cutaneous
manifestation(s) Yes
UNFIT
psoriasis?
No
A single episode of
Yes
May be determined FIT
guttate psoriasis which
has fully resolved
Guttate psoriasis
Yes
(irrespective of
treatment)?
No
Refer to the single-Service Occupational
Physician responsible for the selection of recruits.
No
Affecting >5% Body Surface Area
Yes
Normally UNFIT
Active psoriasis?
Yes
and/or required treatment with
phototherapy or systemic agents?
No
No
Has it involved hands
Previous history
<5% BSA
(mild nail involvement is
Yes
Normally UNFIT
of psoriasis?
acceptable) and/or feet?
>5%
BSA
No
Symptom-free
UNF
whilst off treatment
IT
No
for 5 yrs?
Would it affect the ability
to wear military clothing
Yes
or the ability to operate
Yes
Normally UNFIT
military equipment?
Only required
UNFIT
No
topical treatments?
No
Yes
May be determined FIT
Refer to the single-Service
Occupational Physician responsible
Is topical treatment to
Has it involved hands
sustain function and
Yes
for the selection of recruits for
UNFIT
Yes (mild nail involvement is
skin integrity required?
consideration of the requirement for
acceptable) and/or feet?
an E2 medical marker.
No
No
Would it have affected
the ability to wear military
UNF
IT
Yes
clothing or the ability to
May be determined FIT
operate military?
equipment?
No
Submarine Service
Psoriasis, even mild, can be particularly problematic in the
enclosed environment of a submarine. If being selected for
May be determined FIT
submarine service, candidates with past or present evidence
of psoriasis who are otherwise considered fit for entry are to
be referred to the single-Service Occupational Physician
responsible for the selection of recruits to the Royal Navy.
Return to Contents Page
4-I-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX J
REPRODUCTIVE PRE-ENTRY
1.
A careful menstrual, obstetric and gynaecological history must be taken and recorded. In
every case the date of the last menstrual period must be recorded. Where a positive history of
menstrual or pelvic disorder is elicited, then full details must be sought. It should be noted that:
a.
Examination of the genitalia, external or internal,
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.
b.
Similarly, breast examination is not required. However, a history should include
enquiry with particular reference to chronic mastalgia, cyclical or otherwise. Candidates with
this problem should normally be UNFIT. Enquiry should be made of ergonomic difficulties
encountered or discomfort should gross hypertrophy be apparent. Such difficulties should
be considered on a case by case basis, in particular whether she can perform the required
duties.
Gynaecological conditions 2.
Pelvic Inflammatory Disease (PID)1. Candidates with an established diagnosis of chronic
PID are normally UNFIT. However, a candidate with a single, confirmed episode that has not
recurred within 12 months may be FIT 2. A past history of pelvic Chlamydial infection should not in
itself preclude service. Suggestive but unconfirmed histories of PID should result in more detailed
enquiry being made and advice from a single-Service Consultant Occupational Physician
responsible for the selection of recruits sought in doubtful cases.
3.
Menorrhagia. Candidates with menorrhagia sufficient to warrant time off school or work
are normally UNFIT.
4.
Amenorrhea. Amenorrhea can usually be disregarded provided there is no serious
cause3 and pregnancy has been excluded4.
5.
Dysmenorrhoea. Candidates with dysmenorrhoea sufficient to warrant time off school or
work are normally UNFIT. Those with mild or moderate dysmenorrhoea manageable with mild
analgesia may be FIT.
6.
Endometriosis. This condition is recurrent, progressive and causes chronic ill health in up
to 50% of patients5. Therefore, candidates with symptomatic endometriosis confirmed by a
Gynaecologist are normally UNFIT. However, candidates with endometrial deposits discovered
incidentally at laparoscopy may be FIT provided they are symptom-free.
7.
Chronic pelvic pain syndrome. Chronic pelvic pain is a common indication for referral
to a gynaecologist6 and has a multi-factorial aetiology. Candidates with chronic pelvic pain
syndrome are difficult to manage and should be determined UNFIT.
1 The best means of definitive diagnosis of PID is visualisation of the Fallopian tubes by laparoscopy.
2 If clear for 12 months, PID is highly unlikely to become chronic unless there is a fresh infection. 20% of PID patients get chronic pelvic
pain and this will become evident before 12 months. All cases should be carefully assessed by obtaining evidence from the candidate’s
gynaecologist. (No audited evidence is available, but consensus opinion provided from Birmingham Women’s Hospital).
3 Including but not limited to anorexia (3.14.24) and PCOS (11).
4 Referral back to the candidate’s GP is recommended to exclude pregnancy. Pregnancy testing is not to be performed at the recruit
medical examination.
5 Evidence from Birmingham Women’s Hospital.
6 Annual incidence of 38 per 1000 between ages 12 –70 years. Evidence from Birmingham Women’s Hospital.
Return to Contents Page
4-J-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
8.
Uterine and ovarian tumours. Candidates with symptomatic fibroids, other uterine tumours
or ovarian tumours are normally UNFIT. However, asymptomatic small fibroids, ovarian cysts and
recurrent follicular cysts are common. These are unlikely to affect full operational fitness7.
Candidates with incidentally discovered asymptomatic8 benign tumours in which the uterus is not
enlarged or causing encroachment on the uterine cavity may be graded FIT.
9.
Uterine prolapse. Candidates with symptomatic prolapse are normally UNFIT. Those who
have undergone satisfactory surgical repair may be determined FIT.
10.
Cervical Intraepithelial Neoplasia (CIN). The following guidelines9 should be applied:
a.
Borderline smears10. Women with smears that show borderline changes may not
have proceeded to histological investigation but should have had colposcopic examination
(evidence of which must be obtained). Those with no abnormalities on colposcopy can be
returned to routine follow-up after normal smears have been demonstrated at the 6 and 12
month point. Therefore candidates with a normal smear at both these points may be
determined FIT.
b.
CIN 1. It is recommended that women with CIN 1 are returned to the routine
screening programme once they have had normal follow-up smear results at the 6 and 12
months. Therefore candidates with a normal smears at both these points may be
determined FIT.
c.
CIN 2 and 3. It is recommended that these women undergo annual screening for at
least ten years because of clear evidence of persisting risk of invasive carcinoma.
However, provided there is evidence of a normal follow-up smear result at the 6 and 12
month points, these candidates may also be determined FIT.
d.
Invasive carcinoma. Candidates with a history of invasive carcinoma are UNFIT.
e.
Other. Those with other cervical abnormalities, including viral changes, may be
determined FIT following two consecutive normal smears at least six months apart.
11.
Polycystic Ovary Syndrome (PCOS)11. PCOS is not an acute problem and often goes
completely undiagnosed. The mainstay of treatment for PCOS is weight loss which may be
assisted by metformin. Candidates whose symptoms have been adequately controlled (i.e. regular
menses) and whose BMI has been maintained at = 29 for at least 12 months by oral
contraceptives or metformin12 may be determined FIT.All other candidates are UNFIT.
Obstetric conditions 12. Candidates who declare pregnancy prior to entry13 are unfit for service until at least three
months after the end of a pregnancy involving vaginal or Caesarean delivery. Provided that
evidence is available of a satisfactory post-natal examination, requiring no subsequent follow-
up, and breast feeding has ceased, candidates may then be determined FIT. Those who
become pregnant after acceptance14 should be re-graded P4 in accordance with current single-
7 Consensus opinion from Birmingham Women’s Hospital.
8 Pain and bleeding must be excluded – gynaecological evidence is recommended especially to determine the reason for the
investigation during which the diagnosis is made.
9 Based on Colposcopy and Programme management: Guidelines for the NHS Cervical Screening Programme NHSCSP Publication
No.20. (April 2004). http://www.cancerscreening.nhs.uk/cervical/publications/nhscsp20.pdf with confirmed advice from Birmingham
Women’s Hospital.
10 The term “dyskaryosis” is no longer used – contemporaneous advice from Birmingham Women’s Hospital, whose unit were
instrumental in preparing the guidelines at footnote 124.
11 Evidence provided by Birmingham Women’s Hospital.
12 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 no sequelae and if BMI = 29 there is no increased incidence of NIDDM.
13 Entry as defined by single-Service administrative policies - usually, before a provisional date of entry has been assigned.
14 Provisional entry date assigned.
Return to Contents Page
4-J-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Service policies. The extant policy on pregnant workers is detailed in Section 5 Annex J.
Account should be taken of the following:
a.
A woman may be determined FIT and accepted for service four weeks after a
spontaneous or induced termination of pregnancy provided there is full recovery.
b.
In candidates with a history of ectopic pregnancy either with or without salpingectomy,
a report is to be obtained from the GP giving information on the history and any
predisposing factors. Candidates treated by salpingectomy which is not associated with
pelvic inflammatory or other disease may be determined FIT. Other cases are to be
discussed with single-Service Occupational Physicians responsible for the selection of
recruits.
c.
Candidates with a history of underlying malignancy (e.g. gestational trophoblastic
disease – including hydatidiform mole, invasive mole, choriocarcinoma, placental site
trophoblastic tumour) should be determined UNFIT.However, candidates who have been
disease-free and treated simply by evacuation of the uterus and whose ßHCG levels have
been normal for 2 years may be determined FIT 15. Because of adverse effects on other
systems, candidates who have required treatment with methotrexate are normally UNFIT
unless the candidate can provide evidence that other system function16 has returned to
normal.
15 Absence of disease should be confirmed by a consultant in gynaecological oncology. There is no increased risk of recurrence in this
group unless pregnancy occurs. The risk of recurrence is increased for 3 months after each pregnancy and with each subsequent
pregnancy. (Evidence provided by Birmingham Women’s Hospital).
16 Especially bone marrow suppression.
Return to Contents Page
4-J-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX K
MUSCULOSKELETAL PRE-ENTRY
1.
This Annex must be used in conjunction with the guidance in Section 3, Section 4
Introduction and any issued by single Services.
Introduction
2.
Candidates require a robust physical frame to cope with the physical demands of military
training and subsequent Service. Musculoskeletal injury remains the greatest single cause of
medical discharge from training and service, so it is essential to identify and assess any conditions,
inherent or acquired, that might predispose to injury. Conditions are grouped as follows:
a.
General (including fractures).
b.
Conditions affecting the function of the upper part of the body (including cervical spine)
and conditions affecting lower limb and spine function.
3.
Enquiry about level of physical activity comparable with military service is especially
important in the assessment of these conditions including recovery from previous injury or surgery.
See also Section 3 paragraph 3. To determine the impact of any musculoskeletal condition the
following aspects are to be assessed:
a.
Structure. The candidate must not have any deformity or anatomical derangements
that might interfere with function or the use of standard issue military equipment e.g. clothing
(especially gloves and boots).
b.
Function. The candidate must not have any limitation of range of movement (ROM),
dexterity, strength or endurance likely to interfere with military training or Service (formal
assessment advised in certain cases, eg weapon handling)1.
c.
Symptoms and signs. The candidate should be assessed for any pain, or instability,
particularly on or exacerbated by activity comparable with military training or Service.
4.
Referral for specialist opinion. Initial referral for advice on employability of candidates with
orthopaedic/rheumatological conditions should be to the single-Service Medical Entry staff
(SSMES) for occupational medicine (OM) opinion. A clinical assessment may be sought to inform
the OM opinion.
General
5.
Amputation. Candidates with amputations are normally UNFIT. For single-digit amputation
see paragraphs 32 and 56.
Arthropathies and connective tissue disorders
6.
Ligamentous laxity (hypermobility). Generalised ligamentous laxity (hypermobility) may be
responsible for locomotor symptoms or future joint problems. Candidates with a formal diagnosis of
hypermobility syndrome made in adulthood are normally UNFIT. Candidates with hyperextension
of >10 degrees2 in either knee are normally UNFIT3 but if asymptomatic, have good knee control
1 Care must be taken to assess for a level of compensatory measures.
2 Examine the knee and measure hyper-extension with goniometer with patient supine.
3 A candidate with >10 degrees of hypermobility is unlikely to be able to lock their joints to achieve the required level of function.
Return to Contents Page
4-K-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
and undertaking exercise comparable with military activity may be referred to SSMES for
consideration of referral for specialist assessment.
7.
Ehlers-Danlos Syndrome.
If a candidate has a formal diagnosis, they are UNFIT due to the
associated medical risks and complications.
8.
Septic arthritis.
A fully functional candidate with a history of a brief episode of infection more
than 12 months ago which was not complicated by any of the following are FIT.
a.
Secondary osteo-arthritis.
b.
Functionally-significant deformity.
c.
Significant imaging changes that are likely to impact on future service.
9.
Candidates with a history of septic arthritis complicated by secondary arthritis, functionally
significant deformity, decreased ROM or imaging changes are normally UNFIT. Candidates with a
history of septic arthritis without these complications must be referred to SSMES for a decision on
fitness for entry.
Chronic arthritis
10. Arthritis occurring in candidates younger than 30 years of age is a poor prognostic sign.
Candidates with an incidental finding of minor age-related osteoarthritis that does not affect
function and are asymptomatic are normally FIT.
11.
Other arthritidies. A candidate of any age with a history of rheumatoid arthritis, anklyosing
spondylitis or psoriatic arthritis is normally UNFIT.
12.
Inflammatory arthritis. Candidates with a
single episode of reactive arthropathy, with no
symptoms for 2 years or more, not on any treatment, and with no underlying joint damage, may be
FIT following referral to the SSMES. Candidates with a family history of inflammatory arthritis and
who are known to be HLA B-27 positive are FIT as long as they meet functional requirements.
13.
Gout. Candidates with a history of gout with no symptoms for 2 years or more, not on any
treatment, and with no underlying joint damage, are normally FIT.
14.
Connective tissue disease and vasculitis causing arthritis. Candidates with these
conditions are UNFIT.
15.
Juvenile Chronic Arthritis (JCA). JCA can be a systemic disease. Candidates who have
been disease and symptom-free for a minimum of 2 years, with no evidence of joint damage or
systemic disease, with activity comparable with military training for 3 months, may be suitable for
entry subject to referral to SSMES. Candidates with a history of confirmed systemic involvement
(e.g. cardiac/respiratory/neurological/ophthalmological involvement) are UNFIT.
16.
Osteomyelitis. An episode of osteomyelitis from which the candidate has recovered with full
asymptomatic function and no deformity may be FIT after referral to SSMES. Candidates with
evidence of active disease are UNFIT.
17.
Osteochondritis dissecans. If the defect has been shown to have fully resolved (following
medication and/or surgery) with no other lesion and no symptoms the candidate may be FIT
following referral to SSMES. Candidates with a residual defect, loose bodies or abnormal imaging
are UNFIT.
Return to Contents Page
4-K-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
18.
Osteochondral defects.
In weight bearing joints, the location and size of the defect is critical
to determine whether this affects the weight bearing surface. Candidates with osteochondral
defects are to be referred to SSMES who may seek a specialist opinion as to the significance of
the defect.
19.
Connective tissue disorders. Candidates with a history of systemic lupus erythematosus,
scleroderma, polyarteritis nodosa, polymyositis and other connective tissue disorders are normally
UNFIT.
20.
Myopathy and myositis. Those with minimal post-traumatic wasting, causing no significant
loss of function, are FIT provided functional assessment is normal. All cases of myopathy with
muscle wasting are UNFIT.
Fractures
21. General guidance about previous fractures of all appendicular skeletal bones is provided
below. Specific guidance may also be found under conditions affecting the upper limb and lower
limb and back assessment.
22.
Previous traumatic fractures without surgical fixation. For those with normal function and
with no deformity, a period of at least 12 months must have elapsed since the fracture before
selection. This is due to remodelling following fracture which often takes up to 12 months. In cases
of doubt, consult the SSMES. Specific guidance is given below.
a.
Long bones. Candidates with fractures where union is confirmed without a deformity
affecting function, who have been asymptomatic for 3 months while undertaking activity
comparable with military training and have full function of the joints above and below the
injury are FIT. If there is deformity with no symptoms and full function, referral to SSMES
should be considered. Candidates with any symptoms or deformity resulting in dysfunction
are UNFIT.
b.
Flat bones (e.g. pelvis, scapula). Fractures with union confirmed, no deformity, and
where the candidate is asymptomatic having undertaken exercise comparable with military
training for 3 months are FIT.
c.
Patellar fractures. Whilst technically an intra-articular fracture, candidates who are
able to perform activity comparable with military training for 3 months, should be assessed on
a case-by-case basis by SSMES.
d.
Intra-Articular fractures involving the upper and lower limb joints. Early
osteoarthritis is the norm. Candidates must have normal function and have demonstrated the
ability to undertake exercise comparable with typical military activities. Modern trauma
surgery aims to minimise the risk of post-traumatic degenerative changes, but it cannot undo
damage at the time of injury.
(1)
If the candidate has abnormal alignment or remains symptomatic, they are
UNFIT.
(2)
If the candidate has normal alignment and is asymptomatic they may be FIT
subject to referral to a SSMES. Fitness will depend on many factors including function,
the type of injury, type of fracture, type of fixation and any subsequent complications.
(3)
Intra-articular fractures of toes, other than the great toe, are normally FIT.
(4)
Those of the fingers are normally FIT.
Return to Contents Page
4-K-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
e.
Candidates with the following simple (non-fixed) fractures may be considered FIT after
6 months. In cases of doubt consult the SSMES.
(1)
Metacarpal and phalangeal fractures.
(2)
Clavicular shaft fracture, not involving the acromioclavicular or sternoclavicular
joints. Where these joints are involved the candidate should be referred to SSMES.
(3)
Extra articular distal radial fracture.
(4)
Un-displaced distal fibular4 Weber A fracture.
23. All pathological fractures are normally UNFIT.
24.
Previous traumatic fracture with surgical fixation5. For those with normal function and
with no significant deformity, a period of at least 12 months must have elapsed since the fracture
before selection due to remodelling following fracture which often takes up to 12 months. In cases
of doubt consult SSMES.
25.
Upper limb fractures. Candidates with upper limb fractures where:
a.
Union is confirmed.
b.
There is no deformity.
c.
There is no tenderness over the area of metalwork / fracture site.
d.
There are no symptoms with exercise comparable with military training over the last 3
months.
e.
There is full function of the joints above and below the injury are FIT.
26.
Lower limb fractures. The same conditions apply to candidates with lower limb fractures. If
surgery has resulted in restitution of anatomy, candidates are normally FIT provided they are
symptom-free with activity comparable with military training for 3 months and should be referred to
SSMES. Candidates who have undergone complex surgery involving joints or surgical fixation of
major upper and lower limb joints are normally UNFIT as early osteoarthritis is the norm..
27.
Stress fractures. Candidates recovered from uncomplicated, single stress fractures who are
symptom free with proven activity comparable with military training for a minimum of 3 months and
radiological confirmation of healing are FIT. Candidates with any femoral neck stress fracture or
multiple or recurrent stress fractures at any site are normally UNFIT. Previous pre-disposing factors
should be considered.
28.
Medial tibial stress syndrome (MTSS) and tibial stress injuries. Acute conditions should
be deferred for a period of at least 6 months and reassessed following rehabilitation. Candidates
must have full function and be asymptomatic with exercise comparable with military training over
the last 3 months in order to be found FIT.
4 Fractures at, around or proximal to the syndesmosis must be referred to the single-Service Occupational Physicians responsible for the
selection of recruits.
5 In general, asymptomatic metalwork does not need to be removed - M Townend, P Parker. Metalwork Removal in Potential Army
Recruits. Evidence Based Changes to Entry Criteria.
J R Army Med Corps 2005; 151: 2-4).
Return to Contents Page
4-K-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
29.
Joint replacements. Candidates who have had joint prostheses (including articular
resurfacing) are normally UNFIT.
30.
Osteopenia and osteoporosis. Candidates with a current diagnosis6 of osteopaenia or
osteoporosis due to any cause, are normally UNFIT. Candidates with a past history of osteopaenia
which has fully resolved with confirmation of normal bone mass using DXA (Dual Energy X-Ray
Absorptiometry – whole body, lumbar spine and hip) may be considered FIT following referral to
SSMES.
Conditions Affecting the Upper Body and Limb
31. Deformities of individual parts of the upper limbs, such as loss of any finger or parts of a
finger or other parts of the hand are assessed according to functional capacity. Particular
consideration must be given to manual dexterity. To assist examiners, the following guidance is
provided.
32.
Fingers and hands. Candidates with loss of any finger of either hand should be assessed
according to residual functional capacity and are normally FIT. Those with more extensive loss
affecting function are UNFIT. Candidates with loss of an opposable thumb are UNFIT. However,
those who have had a finger reconstructed to replace a thumb at an early age should be
functionally assessed (including the use of CBRN gloves) and can be found FIT if fully functional.
Candidates with any other deformity if symptom-free with full function including firing weapons and
compatibility with clothing (especially CBRN gloves) are FIT.
33.
Wrist. Candidates with significant loss of function of wrist movement are UNFIT. Those with
non-union of fractures of the carpal bones or a painful wrist with limitation of movement are UNFIT.
Candidates with good function are FIT. In cases of doubt candidates can be referred to SSMES for
a functional assessment.
34.
Elbow. Candidates with less than 15 degrees loss of extension7 and, or flexion (usually
following injury) with normal pronation and supination and able to hold a prolonged (more than 20
seconds) press-up position (elbows flexed, in accordance with Section 3) symptom-free are FIT.
Those with greater loss are normally UNFIT. Candidates who have lost more than 20 degrees of
either pronation or supination are normally UNFIT. Varus or valgus angulation should not preclude
entry provided that normal function can be demonstrated.
35.
Shoulder. Candidates with any functional limitation of shoulder movement are UNFIT. The
following guidance is provided for candidates who have suffered shoulder dislocation. Subluxation
requiring acute medical intervention should be considered as for dislocation. Each shoulder should
be reviewed separately. Clinical evaluation should include an assessment looking for full ROM,
with resisted assessment of the shoulder in external rotation and abduction. If this causes pain or a
feeling of instability (where symptoms improve when the clinician supports the candidate’s shoulder
by placing a hand on the anterior aspect), then the candidate is UNFIT.
a.
In all cases, at least 12 months must have elapsed since the dislocation/surgery.
b.
Candidates with a single episode of dislocation, who have full shoulder function, are
asymptomatic, and with negative apprehension test8 be FIT subject to referral for further
assessment.
6 Osteopaenia is defined as a T Score of between -1 and -2.5 SD http://www.iofbonehealth.org/diagnosing-osteoporosis.
7 Some degree of loss of full extension of the elbow (up to 15 degrees) without significant loss of function is not uncommon in the young
active general population (DCA Orthopaedics opinion).
8 Shoulder apprehension test: candidate’s elbow is flexed to 90 degrees and the shoulder is abducted to 90 degrees. 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.
Return to Contents Page
4-K-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
c.
Candidates with two or more dislocations (in the same shoulder), who are symptomatic,
have evidence of early arthritic change or have a positive apprehension test are UNFIT.
d.
Candidates with multiple dislocations (in the same shoulder), who subsequently
undergo a stabilisation procedure and full rehabilitation and who go on to be asymptomatic
and fully functional with a negative apprehension test are normally FIT.
36.
Clavicle fractures and clavicular joint disruptions. The interaction between load carriage
equipment and mal-union or un-united fracture of the clavicle often results in pain. At least 12
months must have elapsed since the fracture/dislocation/surgery with the exception of a simple
fracture of the clavicular shaft that may be considered for assessment after 6 months. The
following guidance is provided for fractures and sprains:
a.
Fractured clavicle. Candidates with a deformity from a fractured clavicle that is
asymptomatic9, allows full shoulder movement and does not cause symptoms with load
carriage during activity comparable with military training for 3 months are FIT. Candidates
with deformity that causes symptoms, restriction of movement or interferes with load carriage
or the wearing of restraint harnesses are UNFIT.
b.
Sternoclavicular and acromioclavicular dislocations. Candidates with deformity
that is asymptomatic, allows full shoulder movement and does not cause symptoms with
restraint harnesses or load carriage during activity comparable with military training for 3
months may be FIT10.
Candidates with deformity that causes symptoms, restriction of
movement or interferes with load carriage are UNFIT.
c.
Acromioclavicular sprain. Candidates with a Grade I/II sprain who are asymptomatic
with normal function are FIT. Candidates with Grade III sprains are to be referred to SSMES.
Candidates with Grade IV-VI sprains are normally UNFIT.
37. Candidates with a chronic history of pain related to overuse (e.g. para-tendonitis crepitans),
or of upper limb disorders, such as a proven carpal tunnel syndrome, bursitis and epicondylitis, are
normally UNFIT. In cases of doubt the advice of the SSMES should be sought.
Conditions affecting the lower limb and spine
38. Service life places great demands upon the lower limbs and spine. Even minor abnormalities
and conditions can be exacerbated by and may break down during training. Lower limb injuries
(especially knee) are the main cause of medical discharge during training and of early medical
discharge from service. Searching enquiry must be made to elicit any history of injury or symptoms.
This should include particular reference to physical activity (see paragraph 2), sports undertaken
and symptoms arising in association with footwear of any kind. Decisions on FIT or UNFIT should
take into account functional capacity and prognosis.
Spinal conditions
39.
General. Normal structure and function of the spine is an essential requirement for military
service. The following spinal conditions must be given careful consideration.
40.
Abnormality of the spine11. Candidates with minimal abnormal scoliosis12, kyphosis or
lordosis with no associated back pain with full and free movement of all spinal segments (cervical,
9 The effect of any plates must also be considered as they could be a rub point for load carriage.
10 Function is often restricted and specialist assessment may be required.
11 No symptomatic structural abnormality fares well in military training.
12 Adams' forward bend test (forward bending at the waist, viewed from anterior, posterior, and lateral aspects) provides a good
prospective for identifying thoracic, thoracolumbar, or lumbar paraspinal and thoracic cavity prominences (which result from abnormal
Return to Contents Page
4-K-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
thoracic and lumbar) are FIT. Candidates with more than minimal abnormality and normal function
should be discussed with SSMES. Candidates with scoliosis or other curvature requiring treatment,
that is associated with an on-going disease process/neuromuscular or neurological dysfunction or
back pain are UNFIT13.
41.
Radiological abnormalities of the spine. Incidental radiological abnormalities of
questionable or no clinical significance should be discussed with the SSMES as they may be
compatible with a grading of FIT.
42.
Scheuermann’s disease. This must be a radiological diagnosis. Candidates who have
achieved 3 months activity comparable with military training (especially load-carrying ability)
without symptoms are to be referred to SSMES. Candidates who are currently symptomatic are
UNFIT.
43.
Spondylolysis and spondylolisthesis. All candidates who have been diagnosed with these
conditions (whatever the degree of slip for spondylolisthesis) but are now asymptomatic during
activity comparable with military training for a minimum of 3 months are to be referred to SSMES
responsible for the selection of recruits; it should be noted that those with a slip of grade II or more
are normally UNFIT. Candidates who are currently symptomatic are normally UNFIT.
44.
Spina bifida occulta. This condition can only be diagnosed with imaging. Candidates with
an incidental finding, without history of symptoms and in the absence of other abnormality may be
FIT. Candidates with either present or previous symptoms are to be normally UNFIT.
45.
Spinal fracture. Candidates with resolved spinous and transverse process fractures, or
functionally insignificant fractures, are FIT. Any history of other spinal fractures, including wedge
fractures of the vertebral body, are normally UNFIT14.
46.
Previous spinal surgery. Candidates with a history of any orthopaedic spinal surgery are
normally UNFIT. However, candidates who have had a single-level discectomy (e.g. for
sequestered disc) may be FIT subject to referral to SSMES responsible for the
selection of recruits
providing the candidate is at least 12 months post-operation, is asymptomatic when undertaking
activity comparable with military service and has been doing so for at least 3 months and there is
no evidence of treatment or injury related secondary effects.
47.
Cervical spine. Those with insignificant non-bony neck injuries that resolve fully and quickly
with minimal clinical input may be assessed FIT once fully functional. Candidates with more
significant previous non-bony neck injury (e.g. whiplash or muscular sporting injury) are FIT
provided they have been asymptomatic for at least 6 months including during exercise comparable
with military training for 3 months. Those with any ongoing symptoms or chronicity are normally
UNFIT.
vertebral rotation as well as from a combination of abnormal spinal curvature in the coronal and sagittal planes). Bending forward
accentuates paraspinal and rib prominences, which is suggestive of scoliosis. This is the hallmark examination finding that leads to a
suspicion of scoliosis during screening evaluation. A positive result is observation of an asymmetric paraspinal prominence. The
presence of an asymmetric scapular prominence may suggest an upper thoracic curve. A scoliometer is used to quantify right- and left-
sided asymmetries (paraspinal prominences) identified on Adams' forward bend test. A positive result is one of >5 degrees at any
paraspinal prominence (thoracic or lumbar). Patients with scoliometer values of 5 degrees or greater correlate with Cobb angle
measurements of at least 10 degrees which represents a commonly agreed-upon cut-off point used to direct treatment decisions.
http://bestpractice.bmj.com/best-practice/monograph/979/diagnosis/step-by-step.html.
13 Altered biomechanics will affect load-carrying ability.
14 DCA Orthopaedics: Approximately 30% of individuals with a wedge compression fracture will become symptom free in 2-3 months
with no residual disability and no risk of late complications; another 40% will have occasional back pain when the back is stressed but
this will not affect function; the remaining 30% will continue with back pain that will restrict any heavy work. However, the prognosis is
not entirely proportional to the degree of deformity. The reason for this is not established but a change in the general shape of the spine
affects its mechanical performance and such candidates are likely to suffer recurrent episodes of back pain.
Return to Contents Page
4-K-7
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Back pain
48. There is strong evidence15 that a history of back pain is the best predictor of future
problems. When assessing candidates with a history of back pain it is important to consider the
nature of the pain, frequency and duration of symptoms, their effect on function and what
treatment, if any was needed. What has happened since the episode(s) is more important than the
episode itself. There is no evidence to support the determination of fitness for service based on the
number of episodes of back pain alone.
49. Episodes where a candidate has been unable to work, attend college etc, for a period of
time, should be explored in detail. If the episode relates to an acute injury (e.g. during sports or
road traffic collision), then the recovery and subsequent function is more important than the
specifics of the initial injury (except where the injury sustained would exclude for other reasons i.e.
spinal fracture).
50. Recurrent non-specific mechanical lower back pain (LBP) should be assessed carefully
considering current function and requirement for healthcare professional support. There may be
many reasons why candidates are now fully functional with no recent episodes. Effective reasons
include loss of weight and appropriate conditioning etc. Exercise history can be useful, and the pre-
Service Medical Assessment will allow a judgement on conditioning to be made. Referral to
SSMES can be made for candidates where the examining clinician requires further advice.
a.
Those with isolated episodes of LBP, that resolve fully and quickly with minimal clinical
input may be assessed FIT once fully functional.
b.
Candidates with longer isolated episodes of pre-existing LBP, that may have required
greater clinical input, are normally FIT provided they have been asymptomatic for at least 6
months (where history includes exercise comparable with military training for 3 months).
c.
Candidates with any episode of chronic back pain lasting 12 weeks or more are
normally UNFIT.
d.
Candidates with a history of sciatic pain with or without back pain are normally UNFIT.
e.
Those who have had a successful single-level discectomy should be assessed in
accordance with paragraph 46.
Leg length discrepancy
51. Leg length should be measured in accordance with Section 3. Candidates with a discrepancy
of <1.5cm may be FIT provided the functional assessment is normal. Those with a discrepancy of
1.5-2.5cm who can achieve activity comparable with military training for a minimum of 3 months
are to be referred to the SSMES for further assessment. Those with a discrepancy of >2.5cm, are
normally UNFIT. This degree of discrepancy will cause functional decrement.
Feet and toes
52.
Hallux rigidus. Candidates with Hallux rigidus are normally UNFIT.
15 a. Occupational Health Guidelines for the Management of Low Back Pain 2000 - Evidence Review and Recommendations. Waddell,
G, Burton, K https://pdfs.semanticscholar.org/dff9/5228f2572c83fb7c1c3022e3e83ef38aef15.pdf. b. Acute low back pain: systematic
review of its prognosis Pengel LHM, Herbert RD, Maher CG, Refshauge KM. BMJ 2003;327:323-7. c. Predicting who develops chronic
low back pain in primary care: a prospective study. Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MIV, Macfarlane GJ.
BMJ 1999;318:1662-7.
Return to Contents Page
4-K-8
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
53.
Hallux valgus. Candidates who are asymptomatic with no over-riding or callosity of the
second toe; or who have had hallux valgus osteotomy, have normal function and are asymptomatic
during activity comparable with military training are to be referred to SSMES. At least 12 months
must have elapsed since the surgery. Candidates with existing hallux valgus are normally UNFIT.
54.
Foot deformities. Candidates with minor conditions that allow the usage of normal footwear
(with orthotics if necessary) and are asymptomatic during activity comparable with military training
for 3 months are FIT.
a.
Candidates who use custom-made footwear are normally UNFIT.
b.
Those who require an orthotic but can use issued boots are normally FIT.
55.
Hammer, mallet and clawed toes. Candidates with mild conditions without history of
symptoms are FIT. Those with fixed clawing of toes, hammer or mallet toes are normally UNFIT.
56.
Loss of toes. Those with loss of terminal phalanx of great toe with no painful stump may be
FIT. Those with total or sub-total loss of other toes are FIT subject to normal outcome on functional
testing. Candidates with total loss of either great toe are normally UNFIT.
57.
Flat feet. Candidates with flat feet causing no symptoms are FIT. Those with mobile flat feet
causing symptoms or with rigid flat feet are normally UNFIT.
58.
Claw feet. Candidates with a deformity that has not caused symptoms in the past, where the
foot is mobile, without pressure areas or fixed clawing may be FIT if the condition is considered
compatible with the demands associated with training and the wearing of boots and if there is no
associated neurological disorder (such as peroneal muscular dystrophy, etc). Candidates with a
positive past history, or limitation of movements or evidence of pressure areas are normally UNFIT.
59.
Club-foot and talipes. Those with any degree of clubfoot, corrected or otherwise, are
normally UNFIT. Those who are confirmed to have positional talipes which has resolved with
physiotherapy are normally FIT.
Ankle joint
60. Candidates with previous ankle sprain or fracture may be FIT provided that they have made
a full recovery, have no limitation of movement, and are asymptomatic during activity comparable
with military training for 3 months. Candidates who have had a ligamentous repair (e.g. Brostrom-
Gould Repair) or ligamentous replacement (e.g. Evans Tenodesis) are to be referred to SSMES
when at least 12 months has elapsed post-surgery, normal function has been restored and there
are no symptoms during activity comparable with military training for 3 months. Candidates with an
unstable or stiff ankle are normally UNFIT. Candidates with limitation of ankle movement are
normally UNFIT.
Knee joint and anterior knee pain/overuse patellofemoral pain syndrome
61. Knee problems account for a large proportion of the medical discharges that occur during
recruit training. Candidates with chronic symptoms of the knee(s) are normally UNFIT.
a.
Those with insignificant isolated episodes of knee pain that resolve fully and quickly
with minimal clinical input may be assessed FIT once fully functional.
b.
Candidates with more significant episodes of previous knee pain may be FIT provided
they are asymptomatic for at least 6 months and having undertaken exercise comparable
with military training for 3 months.
Return to Contents Page
4-K-9
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
c.
Candidates with any episode of chronic (at least 12 weeks duration) knee pain are
normally UNFIT.
62.
Osgood-Schlatter’s Disease. Candidates who have been symptom-free for at least 12
months for Osgood-Schlatter’s disease during activity comparable with military training for 3
months may be FIT.
63.
Knee injuries. Candidates with confirmed meniscal tears who are at least 12 months post-
injury and are fully functional after conservative management while undertaking exercise
comparable with military training for 3 months may be FIT after referral to SSMES. Candidates who
are at least 12 months post-surgery for an arthroscopic partial or sub-total meniscectomy and who
are asymptomatic during activity comparable with military training for 3 months are FIT. Those who
have had complete or open meniscectomy16 or meniscal transplantation (including autologous
chondrocyte transplantation17) are normally UNFIT.
64.
Knee ligaments.
a.
Candidates with any history of complete anterior cruciate ligament (ACL) or posterior
cruciate ligament (PCL) rupture whether managed conservatively or surgically are UNFIT.
b.
Candidates with a history of partial tears of the ACL or PCL are to be referred to the
SSMES.
c.
Candidates with a history of partial or complete rupture of any other knee ligaments are
to be referred to the SSMES.
d.
Candidates with slight laxity of the ACL or other ligaments without a history of injury
and without any loss of function are FIT.
Hip joint
65. Any symptomatic hip condition is UNFIT. Candidates with any history of hip disease or
fixation, regardless of apparent recovery, are to be referred to the SSMES.
66.
Slipped femoral epiphysis. Candidates with a history of slipped femoral epiphysis where
the hip has been remodelled to normality, have a full range of internal and external rotation and are
asymptomatic during activity comparable with military training for 3 months may be FIT subject to
referral to the SSMES.
67.
Congenital dislocation of the hip (CDH). CDH predisposes individuals to early
degenerative changes. Candidates with CDH are UNFIT unless there is substantial evidence to
support a physically active childhood and adolescence and imaging confirms normal anatomy.
68.
Dislocation of the hip (other than congenital)18. This condition requires careful
assessment as in 95% of cases there are also associated injuries (especially if the original
reduction took place more than 6 hours post injury). Posterior dislocations are more likely to have
poorer outcomes. There must be confirmation of normal anatomy, no evidence of osteoarthritis and
no sciatic nerve injury. Candidates who have normal function, have undertaken activity comparable
with military training for 3 months, are more than 5 years post injury may be FIT subject to SSMES
referral and orthopaedic assessment.
16 This technique is out-dated and does not leave sufficient “bridging” for the opposing meniscus for military activities.
17 There is insufficient current evidence on this technique.
18 KE Dreinhofer, Bone & Joint J, Vol 76, 1 Jan 94. P Kellam, J Orth Trauma 2016.
Return to Contents Page
4-K-10
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
69. Candidates with associated ligamentous disruption (except ligamentum teres, which is
disrupted in all dislocations), intra-articular fracture, labral tears, chondral defect or osteochondral
fragmentation or open surgical reduction are UNFIT. Candidates who have had a perfectly reduced
fracture fixed with open reduction and internal fixation, with normal function and no signs of osteo
or avascular necrosis at 5 years, may be FIT pending SSMES and military orthopaedic consultant
referral.
70.
Perthes disease. The affected hip is almost always abnormal. Candidates with Perthes
disease are UNFIT if there is any abnormality on the most recent imaging. If imaging confirms
normal anatomy and the candidate is asymptomatic with a full range of hip movement and a
satisfactory functional assessment, the candidates is to be referred to the SSMES. Enquiry should
be made as to exercise comparable with military training that has been undertaken e.g. running,
sport, hill-walking and this information should be included in the referral19.
19 Candidates should not be deferred to undertake an exercise programme prior to referral since, as most will not be acceptable as
military training and service will accelerate degenerative change in an abnormal hip, there is a risk that the candidate could
subsequently argue that the exercise programme resulted in a deterioration of the condition of the affected hip.
Return to Contents Page
4-K-11
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX L
PSYCHIATRY PRE-ENTRY
Special Conditions Affecting the M Grading
1.
The M grading is a clinical quality distinguishing those whose mental capacity makes them
suitable for normal training and posting, from those of limited intellectual capacity who necessitate
rejection.The recruit selection test procedures will usually provide an objective assessment of
mental ability to facilitate grading.
2.
The M grading is dependent not only on the candidate’s innate ability, but also on their
capacity to use that ability. No formal clinical assessment is practicable or required during the
examination. A history of head injury, indications of learning difficulties and a practical application of
knowledge gained should be sought by exploring the candidate’s school career, literacy, nature of
employment since leaving school, hobbies and interests, etc before grading M2.
Special Condition Affecting Fitness for Service
General
3.
Examining medical officers should have a good knowledge of mental health matters and in all
cases, a critical examination of the candidate’s psychiatric history is imperative to determine
suitability for military Service. For candidates with a previous mental health diagnosis, identifying
vulnerabilities which may contribute to the presentation of a further disorder during Service wil be
helped by ensuring that:
a.
the diagnosis of a mental health disorder was correct and made by a suitably qualified
professional;
b.
the aetiology or perceived stressor preceding the onset of the disorder was identified;
c.
timely evidence-based therapy was provided.
4. It is important to differentiate between conditions representing understandable emotional and
behavioural responses to significant life events (e.g. parental divorce, bereavement) and those
disorders with a hereditary or complex aetiology (e.g. depression). Whilst the former may settle
within acceptable time frames and with no psychiatric input, the latter are more likely to have a
significant effect on function and greater risk of relapse. Candidates with a diagnosis made during
adolescence require particular scrutiny. This is to ensure that individuals who have presented at a
time of normal and understandable emotional turmoil are not unnecessarily declared UNFIT if they
are symptom free and have developed coping strategies adequate for Service life.
5. If there is insufficient evidence presented at the pre-employment medical examination (or prior
questionnaire screening) to enable a decision, additional clarifying evidence (e.g.
contemporaneous medical records) should be requested from the candidate or the candidate’s GP.
When specified within this policy or where uncertainty remains, the case should be referred to the
single Service occupational physician responsible for Service entry.
6. Candidates with current psychiatric disease or dysfunctional behaviour are always UNFIT. In
certain circumstances they may become FIT after a prescribed period of time once the condition
has resolved.
7. The guidance given in this section is based on evidence for prognosis and recurrence rates for
most of the mental health conditions listed in the ICD-10 classification of mental and behavioural
Return to Contents Page
4-L-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
disorders1. Advice is provided for all relevant diagnostic groups and the ICD Code is given for ease
of reference.
Dementias (F00-F03)
8.
These are rare in the recruit age group although in theory variant Creutzfeldt – Jakob disease
could occur. Candidates are UNFIT.
Organic Amnesic Syndrome (F04)
9.
Recovery from this condition is extremely rare. Candidates are UNFIT.
Delirium (F05)
10. The causes of delirium are numerous though, in the recruit age group, delirium is most likely
to have been due to high temperature associated with severe infection. In such cases there should
be no bar to recruitment provided the infection was acute and single and has completely remitted. If
this was not the case, then the cause should be determined and the case discussed with the sS
occupational physician responsible for Service entry.
Other Mental Disorders due to Physiological Conditions (F06-F09)
11. This group of conditions are caused by a variety of aetiological factors. Most of the conditions
have a serious underlying cause and candidates are normally UNFIT. In cases of doubt, the
examining physician should seek the opinion of the single Service occupational physician
responsible for service entry.
12. Candidates with a history of post-concussion syndrome (F07.2) may be determined FIT
provided that the candidate has been symptom-free, including from vestibular disturbances and
mental health co-morbidities, for 1 year prior to application. (See 6-7-7 Section 4 Annex G 4G.08
for the neurological assessment of head injuries.)
Mental and Behavioural Disorder due to Psychoactive Substances (F10-F19)2
13.
Illicit Drugs. Discovery of the use of any il icit drugs is not a clinical matter per se. It
becomes a clinical matter when illness, most particularly drug dependence, has occurred.
Examining medical officers are not obliged to inform recruiting staff if a history of substance
abuse not resulting in clinical illness is volunteered during the course of an examination.
14.
Drugs. Candidates with
current drug related health problems are UNFIT. Before accepting
anyone with a previous history of drug-related health problems, referral to the single Service
occupational physician responsible for Service entry is recommended as the risk of relapse must be
carefully considered.
a.
Candidates in whom there is evidence of drug dependence in the 3 years prior to
application are normally UNFIT. If there is unequivocal evidence from an addiction clinic that
the candidate has been clean3 for more than 3 years prior to application then recruitment may
be permitted.
b.
Candidates that have been diagnosed with harmful use of drugs not amounting to drug
dependence in the 2 years prior to application are normally UNFIT. If there is good evidence in
the candidate’s medical history that the individual has been clean3 and symptom free for more
1 Some categories are not included either because they are only used by mental health researchers or because they are irrelevant for
military candidates.
2 F10 relates to alcohol. F11 to F19 relates to opioids, cocaine, cannabis and other drugs.
3 Defined as absolutely no drug use.
Return to Contents Page
4-L-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
than 2 years prior to application with no ongoing treatment, then recruitment may be
permitted.
c.
A history of infrequent recreational use without evidence of damage to health is not a
medical bar to entry.
15.
Alcohol misuse. If there is good evidence that prior to application the candidate has been
symptom-free and has not been undergoing any treatment, then recruitment may be permitted. It is
advised that corroborative evidence is sought and in cases of doubt, the examining physician
should seek the opinion of the single Service occupational physician for service entry.
a.
Candidates with a history of alcohol dependence (F10.2) with or without associated
problems (F10.3-F10.7) are UNFIT4. 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.
b.
Candidates who have been diagnosed with harmful use of alcohol (F10.1) in the 2
years prior to application are normally UNFIT. The prognosis of those who have been
diagnosed with harmful use of alcohol not amounting to dependence (F10.1) is variable and
the risk remains.
Schizophrenic and Delusional Disorders (F20-F29)
16. With the exception of acute and transient psychotic disorders (F23), all candidates with
diagnoses in this category are UNFIT. These disorders represent a variety of ill-understood
conditions whose relationship to schizophrenia and other psychotic disorders is uncertain. Even
though such conditions often have many of the qualities of “good prognosis” schizophrenia there is
still a significant relapse rate of up to 30%. If there is very clear evidence that the illness was short-
lived, i.e. fully abated (with or without treatment) within 1 month of diagnosis, and due to an obvious
cause, the candidate should be discussed with the single Service occupational physician
responsible for Service entry. Where an organic cause (such as a toxic reaction to a drug or an
acute severe infection5) is evident, candidates may be determined FIT but where the cause is found
to be functional, i.e. resulting from a mental health condition, candidates wil be UNFIT.
Mood (Affective) Disorders (F30-F39)
17. Disorders of mood, especially depression, are not confined to this category as diagnoses may
also be classified in the anxiety and stress-related categories (F41 and F43). Disorders in this
group range from the profoundly disabling psychotic affective disorders (e.g. mania) to less
distressing, mild and transient lowering of mood secondary to a minor life stressor. In some
individuals the genetic predisposition is so strong that the condition may become overt with no
triggering stressor. However, in most cases of affective disorder, an episode of illness is
precipitated by a stressful life event.
18. Candidates with a diagnosis of a single episode of mild or moderate depression (F32.0, 32.1)
with a clear precipitating stressor may be determined FIT provided that all treatment, including
medication, has been completed and the individual must be free from symptoms and off medication
for 1 year.
19. A diagnosis of a single episode of severe depression without psychosis (F32.2) suggests a
greater impact on functioning, a requirement for more extensive therapy and higher risk of relapse.
To be determined FIT, al treatment (including medication) must be completed and the candidate
must be free from symptoms and off medication for 2 years. The episode of depression itself and
the treatment pathway should not be more than 24 months in total6.
4 Alcohol is a legal drug and lifetime risk of relapse is high.
5 i.e. similar to delirium.
6 DCA Advice - the natural recovery of depression is about 2 years and with treatment around 6-9 months with some needing
maintenance medication for 6-12 months.
Return to Contents Page
4-L-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
20. A candidate with a history of two of more episodes of depression or a recurring or persistent
depressive disorder (F33), severe depression with psychosis, manic disorder (F30) or bipolar
affective disorder (F31) wil be UNFIT. If there is a doubt about the diagnosis the case should be
referred to single service occupational physician responsible for Service entry.
Phobic Anxiety Disorder (F40)
21. In these disorders, severe physiological arousal occurs which is markedly disproportionate to
the seriousness or danger of the triggering stimulus. Phobias may be classified into 3 major
groupings of specific phobia, social phobia and agoraphobia. Specific phobias developing in
childhood have a poorer prognosis than those starting in adult life and if untreated, can persist for
many years. However, phobias are very amenable to treatment and a candidate may normally be
determined FIT provided that al treatment, including medication, has been completed and the
individual has been free from symptoms and off medication for 1 year. Candidates presenting with
a history of 2 or more episodes wil be UNFIT.
Other Anxiety Disorders (F41)
22. As discussed in paragraph 3, it is important to differentiate short term anxiety presenting as
part of a normal reaction to a clear trigger, such as exams, from a more significant presentation
meeting the diagnostic criteria for a condition such as panic disorder or generalised anxiety
disorder. Even with a clear diagnosis of an anxiety disorder candidates may present with a history
ranging from a single brief stress-related episode to a longstanding condition, seemingly more
related to a vulnerable personality than to external stressors. In those cases where it is clear that
the condition was brief and triggered by significant life stress then the candidate may be determined
FIT as long as they have been symptom and treatment-free for at least 1 year. Candidates with two
or more episodes of anxiety or with a longstanding history of panic or generalised anxiety disorder
are UNFIT.
Adjustment Disorders (F43.2)
23. Adjustment disorders are characterised by excessive emotional and behavioural symptoms
in response to a perceived stressor, however the presence of symptoms of depression or anxiety
often make diagnostic distinction uncertain. The emotional response, any maladaptive coping
strategies and reduced functioning would be expected to develop within 3 months of the stressor
and settle within 6 months; if the latter is not the case the diagnosis should reflect the enduring
symptoms of anxiety and depression. Understanding the aetiology of the disorder is imperative in
deciding whether the emotional response was commensurate with the stressor and thus the
individual’s capacity to withstand further stress.
24. Candidates with a diagnosis of adjustment disorder may normally be determined FIT provided
that all treatment, including medication, has been completed and the individual has been free from
symptoms and off medication for 1 year. Candidates with two or more episodes are UNFIT.
Obsessive Compulsive Disorder (OCD) (F42)
25. Candidates with a history of OCD are UNFIT.
Post-Traumatic Stress Disorder (PTSD) (F43.1)
26. A previous history of PTSD, diagnosed by a consultant psychiatrist or clinical psychologist, is
a significant risk factor for the development of further PTSD. Because of the likelihood of Service
personnel being involved in stressful operational environments, the candidate should normally be
determined UNFIT, even if previously treated. In cases where the diagnosis is uncertain or not made
by a consultant psychiatrist or clinical psychologist, the examining physician should seek the
opinion of the single service occupational physician responsible for Service entry.
Return to Contents Page
4-L-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Dissociative Disorders (F44)
27. These disorders include dissociative fugue where the sufferer goes into a trance-like state,
and conversion disorders, where there is loss of sensation or loss of function of limbs or loss of
vision or similar incapacity. All candidates with this diagnosis, whether from an organic or
psychological7 cause, should normal y be determined UNFIT.
Somatoform Disorders (F45)
28. Candidates with a somatisation disorder diagnosed by a consultant psychiatrist or clinical
psychologist, including somatisation and hypochondriacal disorder, are normally UNFIT.
Eating Disorders (F50)
29.
Candidates with a confirmed diagnosis of anorexia nervosa (F50.0) or the atypical form of this
condition (F50.1) are UNFIT. For anorexia nervosa it is not currently possible to reliably distinguish
between the 20% of sufferers who make a full recovery and do not relapse in the future, from the
remainder who relapse and remit or who remain severely ill.
30. Candidates with a diagnosis of bulimia nervosa (F50.2) without co-morbidity such as
anorexia, atypical eating disorder patterns or personality disorder, may be determined FIT one year
after recovery provided they are fully functioning and symptom-free. Candidates meeting this
criteria and candidates for whom the diagnosis is uncertain should be discussed with the single
Service occupational physician responsible for Service entry. Candidates with two or more discrete
episodes are UNFIT.
31. Candidates with Other Specified Feeding and Eating Disorders (F50.9) are UNFIT.
Mental Disorder Associated with the Puerperium (F53)
32. Candidates with a history of puerperal psychosis (F53.1) from which they have fully
recovered, should be discussed with a single Service occupational physician responsible for
Service entry.
33. Candidates with a history of puerperal depression have an increased risk of developing a
depressive episode outside of the puerperium. The guidelines to be followed are the same as
those for mood (affective) disorders (F30-F39) (Paras 17 - 20).
Disorders of Personality (F60-F69)
34. ICD-10 lists a number of categories under this heading. All of these conditions indicate deeply
ingrained and enduring patterns of behaviour, and candidates with a diagnosis in this group must be
determined UNFIT. In cases of doubt, the examining physician should seek the opinion of the single
Service occupational physician responsible for Service entry.
35. Disorders of sexual preference (F65) e.g. fetishism, exhibitionism, voyeurism, paedophilia and
sadomasochism are listed with the personality disorders. Such cases should be discussed with the
single Service occupational physician responsible for Service entry.
Gender Identity Disorders (F64)
36. Candidates with Gender Identity Disorders may present untreated, during treatment or having
completed all hormonal and surgical treatment. In each case the candidate is required to meet the
same physical and mental entry standards as any other candidate. JSP 889 ‘Policy for the
7 Even in cases in which there is clear causative stressor.
Return to Contents Page
4-L-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Recruitment and Management of Transgender personnel in the Armed Forces’8 gives the
overarching MOD policy with the medical aspects of recruiting covered in Annex A.
37. Candidates who have completed transition (and, where appropriate, have been stabilised on
hormone medication and fully recovered from surgery) may be determined FIT, subject to fulfil ing
the normal medical standards according to the individual’s legal gender, including any time periods
required in this Annex to allow for the resolution of psychological problems encountered before or
during the transition process. Any ongoing hormone therapy must be compatible with world-wide
Service and have been stable for at least 6 months. Refer to JSP 889 Annex D for further guidance.
38.
Candidates in transition. Transition is an extremely stressful period and may involve regular
treatment (surgical or hormonal) and follow-up. It is likely that the requirements for treatment and
review, as well as the psychological stresses of this period, will normally be UNFIT.
a.
Candidates who are undergoing surgical procedures should normal y be considered
UNFIT until those procedures are complete and the normal recovery times for surgery laid
out in the appropriate Annexes9 of this JSP have been achieved and then assessed in line
with para 37 above.
b.
Candidates undergoing hormone treatment must be stable for at least 6 months on a
medication regimen and the medication and review requirements must not preclude world-
wide service before they can be determined FIT. If the hormone therapy is a prelude to
surgical procedures then the candidate should normally be UNFIT until that surgery and
appropriate recovery is complete.
c.
Whilst gender identity disorders themselves are not a reason for referral for psychiatric
assessment, candidates in transition should be carefully assessed for previous and ongoing
psychiatric conditions or distress which should be graded in accordance with the relevant
paragraph of this Annex.
d.
Where any doubt exists about the suitability of a candidate for military service the
examining physician should seek the opinion of the single Service occupational physician
responsible for Service entry.
e.
For assessment of the risks of musculoskeletal injury in military training see Section 4
Annex K.
39. Candidates currently experiencing gender dysphoria are normally considered UNFIT in line
with para 6 of this Annex.
Disorders of Psychological Development (F80-F89)
40. Candidates diagnosed with autism (F84) or similar disorders by a specialist autism service are
normally UNFIT. Candidates diagnosed with Asperger’s syndrome (F84.5) by a specialist autism
service may appear unremarkable on examination but should normally be UNFIT. If there is doubt
about the diagnosis or the condition is mild and does not cause disability, candidates should be
referred to the single Service occupational physician responsible for Service entry. In cases of mild,
entirely non-disabling Asperger’s Syndrome, the single Service occupational physician may advise
single Service recruiting staff psychiatric assessment is not required. This because pre-entry tests
of suitability for military life (e.g. selection interviews and tests) are as good a form of assessment as
a psychiatric assessment.
8 JSP 889 'Policy for the Recruitment and Management of Transgender Personnel in the Armed Forces' (V1.1 Aug 19).
9 Annexes E, F and J.
Return to Contents Page
4-L-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
The Hyperkinetic Disorders (F90)
41. Attention Deficit Hyperactivity Disorder (ADHD) is the most common diagnosis to present in
this category. There is a large spectrum of behaviour in children and adolescents that attracts this
diagnosis. Symptoms suggestive of this disorder may also be part of normal adolescent behaviour
or be presenting features of anxiety or depressive disorders. For an unambiguous diagnosis there
must be an early onset (prior to the age of 7 years10) with impaired attention and overactivity, both
of which occur in all kinds of locations (e.g. home, school, sports centre, doctor’s surgery). This is
because the impaired attention and hyperactivity is excessive when compared with other children
of the same age and IQ.
42. ADHD can be associated with co-morbid common mental disorders (CMD) and substance
misuse. In cases where a CMD or substance misuse is present, the prognosis is poor and
candidates should be determined UNFIT.
43. Candidates with ADHD but without co-morbidities may be determined FIT if the candidate has
been stable without evidence of dysfunctional behaviour for one year prior to application11 without
medication. Corroborative evidence should be sought to confirm that the individual has been
functioning normally (e.g. maintenance of regular employment, attendance at school or college)
and where there is doubt the case should be referred to the single Service occupational physician.
44. Candidates with a diagnosis of hyperkinetic conduct disorder with evidence of violent and/or
delinquent behaviour should be determined UNFIT as current evidence indicates that these forms of
the condition are unlikely to improve with time.
Intentional Self-Harm (X60-X84)
45. The spectrum of intent in respect of intentional self-harm ranges from stress relief by cutting,
through manipulative behaviour or emotional blackmail of others to serious suicidal intent. It is often
difficult to tell from a candidate’s recorded history where past episodes lie on this spectrum.
Candidates with a history of self-harm may have taken a medication overdose. Superficial cutting,
typically of the arms, thighs or abdomen, is also common.Evidence suggests that cutting is often a
maladaptive way of relieving stress and is more appropriately termed self-mutilation.It may be
linked to acute stressors but might also be indicative of long term personality problems or a history
of past childhood abuse.
46. Candidates with a single episode of self-harm or self-mutilation occurring more than 2 years
before application in response to a stressful event may be determined FIT provided the 2 year
interim has been free from all symptoms. If there was no precipitating stressful event then the
candidate should normal y be considered UNFIT, as this indicates an enduring endogenous risk of
further self-harm.
47. Candidates with a history of 2 or more episodes, even with clear stressors, should normally
be considered UNFIT, as repetition indicates a substantial risk of further repetition and a significant
increase in risk of later death by suicide. If multiple episodes occur over a short period of time
(weeks rather than months), and can clearly be ascribed to the same single stressful event, then
for the purposes of selection these may be regarded as a single episode. Additionally, if 2 or more
episodes are attributable to independent stressors but there is robust evidence that the candidate
has subsequently developed coping strategies adequate for Service life, the case may be referred
to the single Service occupational physician with responsibility for Service entry in line with para 5.
10 Developmental course of ADHD symptomatology during the transition from childhood to adolescence: a review with
recommendations. Willoughby MT. Journal of Child Psychology and Psychiatry 44.1 (2003), pp 88-106.
11 This is developed from an overview of all available prognostic evidence.
Return to Contents Page
4-L-7
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX M
DENTAL AND ORO-MAXILLOFACIAL PRE-ENTRY
General
1.
Candidates with dental diseases or other oral conditions that are treatable by a general
dental practitioner, are not normally rejected. Candidates should have:
a.
An acceptable and functional occlusion of either natural teeth or well-fitting standard
prostheses.
b.
Healthy gums and oral mucosa, with no obvious soft tissue disease or deformity.
Oral neglect and/or dental caries 2.
If gross oral neglect is found1, candidates would not normally be fit to enlist. In cases of
doubt, the opinion of the sS Occupational Physician responsible for the selection of recruits is to be
obtained. Where doubt regarding dental fitness for Service entry exists, the candidate may be
referred to a Service Dental Officer2.
Amelogenesis Imperfecta and Dentinogenesis Imperfecta
3.
Candidates with a history of hypocalcified Amelogenesis Imperfecta (AI) and Dentinogenesis
Imperfecta (DI) will require further assessment by the sS Occupational Physician responsible for
the selection of recruits. Whilst the dentition may be treated or remediable3, the possibility of
osteogenesis imperfecta must be considered in candidates presenting with DI.
Dental Phobia
4.
Candidates
who cannot tolerate routine primary care dentistry under local anaesthetic and
require conscious sedation or general anaesthesia are normally UNFIT. In cases of doubt, the
opinion of the sS Occupational Physician responsible for the selection of recruits is to be obtained4.
Cleft lip and/or palate 5.
Candidates with uncorrected cleft lip and/or palate are UNFIT. Candidates with corrected
cleft-lip and/or palate, or any gross abnormalities of the dento-facial complex and associated soft
tissues, should be referred to the sS Occupational Physician responsible for the selection of
recruits5 if the condition is likely to affect wearing protective headgear and/or respirators.
Facial Fracture and Orthognathic Surgery
6.
Candidates with a history of facial fractures, including those who have undergone
Orthognathic Surgery and who continue to have symptoms should be considered UNFIT until these
are resolved. Candidates with retained metalwork may be determined FIT if asymptomatic, with
confirmation of fracture healing and no residual deformity. In cases of doubt, the opinion of the sS
Occupational Physician responsible for the selection of recruits is to be obtained4.
1 Gross oral neglect includes multiple open carious cavities. 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.
2 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)/ARTD 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.
3 Further advice/assessment by a Service Restorative specialist may be required.
4 Further advice/assessment by the sS Dental/Oral Health SO1 may be required.
5 Further advice/assessment by a Service Oro-Maxillo-Facial specialist may be required.
Return to Contents Page
4-M-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Orthodontic treatment
7.
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.
8.
Active Orthodontic Treatment. Candidates who are undergoing active orthodontic
treatment will normally be UNFIT until treatment is complete, as confirmed by a report from the
treating practitioner. This is because of the difficulties of continuing with orthodontic treatment
during initial training.
a.
Active Appliances. The removal of active appliances simply to facilitate Service entry
is not to be undertaken or advised. Candidates presenting having had appliances removed
simply to facilitate entry shall be considered UNFIT until the treatment for which the
appliance was fitted is complete.
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 will not preclude entry to the service.
Orthodontic Treatment for Army Foundation College Harrogate and Defence Sixth Form
College Wellbeck Candidates
9.
Entry to these establishments is constrained by age. Recruits to these establishments must
be considered on a case-by-case basis by the sS Occupational Physician responsible for the
selection of recruits and may be accepted if treatment can be managed within the constraints of the
training timetable. Individuals applying to either establishment must make arrangements to
continue orthodontic treatment with their civilian orthodontist/dental practitioner for the duration of
their studies.
Return to Contents Page
4-M-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
ANNEX N
OTHER CONDITIONS PRE-ENTRY
Blood diseases
1.
Candidates with a known history of chronic blood disease, such as G6PD deficiency,
homozygous or double heterozygous sickle cell disease, hereditary spherocytosis, homozygous α
or β thalassaemia, haemoglobinopathy, or any haemorrhagic disorder resulting in abnormal
coagulation are UNFIT (Below Entry Standards).
Sickle cell trait (Hb A/S).
2
This usually benign condition is associated with normal development and exercise tolerance.
All candidates1 should be asked about sickle cell trait (SCT). The following applies:
a.
Individuals with SCT have a higher risk of exertional rhabdomyolysis and other
conditions such as hyposthenuria (a reduced ability to concentrate urine), DVT and splenic
infarction. In a candidate with SCT, any demonstrable history of exertional rhabdomyolysis or
other significant complication related to SCT, will result in the candidate being UNFIT.
Therefore, a history of passing black urine (likened to ‘flat cola’) after exercise should be
sought in all candidates. Its presence is likely to indicate myoglobinuria secondary to
rhabdomyolysis and such candidates are UNFIT.
b.
A rare complication of SCT is Exertional Collapse Associated with Sickle Cell Trait
(ECAST). This can result in serious illness and death. Candidates with a history of ECAST
are UNFIT.
c.
Candidates with a history of heat illness and SCT must be assessed as per heat illness
at paragraph 14 and JSP 5392.
d.
Candidates with SCT are to be awarded an E2 marker (where a deployable SP should
normally be graded A4 L1 M1 E2). This is to be reviewed on completion of Phase 1 (and if
retained, Phase 2) training.
Heterozygous α or β thalassaemia.
3
The heterozygous α or β thalassaemia traits are usual y asymptomatic with a hypochromic,
microcytic blood picture and little or no anaemia. These and other haemoglobinopathy traits are
unlikely to produce significant clinical or haematological abnormalities. Candidates with
asymptomatic trait conditions may be determined FIT. Double heterozygotes with Hb S/C
thalassaemia, Hb S/C or Hb S/D have disease of varying clinical severity. Candidates with a history
of these double heterozygous conditions must be carefully assessed and referred to the sS
Occupational Physician responsible for the selection of recruits.
Blood Borne Viruses (BBVs)
4.
Routine pre-employment blood test for screening for BBVs is not required. For those who
declare a relevant history:
a.
Human Immunodeficiency Virus (HIV):
(1)
Candidates known to be infected with HIV are UNFIT for at least 12 months
following diagnosis.
1 SCT is present in 1 in 4 West Africans, 1 in 10 Caribbean and 1 in 76 of all babies born in UK. https://www.sicklecellsociety.org/about-
sickle-cell/.
2 JSP 539 ‘Heat illness and cold injury: prevention and management’.
Return to Contents Page
4-N-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
(2)
Candidates known to be infected with HIV who are on Antiretroviral Therapy
(ART) may be considered FIT with an E2 marker, subject to approval by the Military
Advisor in Sexual Health and HIV Medicine (MASHH) and approval by the relevant sS
Entry Board, if they have:
(a)
been diagnosed for at least 12 months
(b)
are on a stable treatment regimen
and for at least 6 months have consistently maintained:
(c) a CD4 count of at least 350 cells/mm3
(d) a viral load below 50 copies per ml
(3) Candidates 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 are
UNFIT.
b
. Viral hepatitis. Candidates known to be chronically infected with hepatitis B or
hepatitis C is normally UNFIT. To be determined FIT, those who have a past history of
hepatitis B or hepatitis C must provide the following:
(1).
Hepatitis B. Evidence that they are hepatitis B surface antigen (HBsAg) negative
and Hepatitis B surface antibody (anti-HBs) positive.
(2).
Hepatitis C. Evidence that they have undetectable hepatitis C viral load by
polymerase chain reaction (PCR). If antiviral therapy has previously been used to cure
Hepatitis C, this PCR must be taken at least 6 months after finishing antiviral therapy.
Pre-Exposure Prophylaxis (PrEP) 5.
Candidates who are on PrEP are normally FIT, with an E2 marker, subject to review by
SSMES. Specific guidance applies to certain employment groups such as aircrew3.
6.
Defence Medical Services (DMS) Healthcare Workers (HCWs) screening and
immunisation on entry. DMS HCWs must have standard and additional health checks during the
first week of Phase 1 training and 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 Management4. Candidates with a history of BBV infection or failure
to respond to hepatitis B vaccination should be referred to the single-Service Occupational
Physician responsible for the selection of recruits
Venous thromboembolic disease
7.
A past history of Venous Thromboembolism (VTE) is the strongest predictor for a future
thrombotic event5. Candidates with a past history of VTE, whether on treatment or not, should
normally be UNFIT because of the unavoidable risks associated with service that can predispose
personnel to thrombotic events6.
Thrombophilia
3 PrEP policy for aircrew and controller recruits is detailed in AP1269A Lft 5-10.
4 Candidates should be informed
during the pre-Service recruitment process that they will be required to undergo screening for TB
and BBVs in accordance with this policy.
5 Baglin T Author, Management of Thrombophilia: Who to Screen? Pathophysiology of Haemostasis and Thrombosis 2003/2004, Vol.
33, No. 5-6. https://pubmed.ncbi.nlm.nih.gov/15692251/.
6 Enforced prolonged immobility (e. military transport), relative dehydration in hot environments.
Return to Contents Page
4-N-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
8.
Thrombophilic gene mutations, including but not limited to Factor V Leiden and Prothrombin
20210A, expressed either in heterozygote or homozygote form and present individually or in
combination, have previously been thought to be predictive of future thrombotic events. However,
current expert opinion5 is that family or personal medical history of a DVT or PE is the strongest
predictor for a future thrombotic event and that asymptomatic single heterozygote thrombophilic
gene mutations do not have any predictive value. The evidence for the predictive attributes of
homozygous or complex heterozygous mutations is less clear. Consequently, candidates with
asymptomatic thrombophilic gene mutations, in the absence of an adverse family history may be
determined FIT. Complex cases (including those where there are difficulties defining the presence
of a significant family history) should be referred to the single-Service Occupational Physician
responsible for the selection of recruits.
9.
Anti-coagluation therapy7. Personnel who require anti-coagulation therapy (including
warfarin and direct oral anti-coagulants8) are UNFIT.
Irradiated blood products
10. Personnel who require irradiated blood products9 should be determined UNFIT as such
blood products are not routinely available when deployed. 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 emerges.
b. Hodgkin's lymphoma (lifelong following diagnosis).
c.
Aplastic anaemia patients receiving immunosuppressive therapy with anti-thymocyte
globulin and/or Alemtuzumab.
d.
Immunoglobulin A (IgA) deficiency.
COVID-19 infection
11. COVID-19 infection ranges from asymptomatic to severe clinical illness requiring
hospitalisation and ventilation for prolonged periods. The sequelae of this infection will vary
significantly between affected individuals and the extent and duration of these are not yet fully
understood. In candidates with a history of COVID-19 consideration should be given to the
presence of any underlying chronic condition that may have resulted in increased susceptibility to
COVID-19, in accordance with the relevant section of this JSP. Candidates with recent COVID-19
infection must be deferred until free from symptoms for four weeks.All candidates must be back to
their baseline exercise tolerance following COVID-19 infection (see para 3 in the ‘Introduction’ to
Section 4). The following applies:
a.
Asymptomatic. Candidates who have had asymptomatic infection can be considered
FIT (including fit to undertake physical selection tests).
b.
Mild. Candidates who had mild symptoms (breathlessness on significant exertion, e.g.
2-3 flights of stairs) over 4 weeks ago and who are back to their baseline exercise tolerance
can be considered FIT (including fit to undertake physical selection tests).
7 This excludes anti-platelet medication (e.g. aspirin, clopidogrel).
8 Including apixaban, dabigatran and rivaroxaban and other analogous variants.
9 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
4-N-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
c.
Moderate. Candidates who have had moderate COVID-19 symptoms (breathlessness
on mild exertion/activities of daily living, chest pain, fast palpitations or pre-syncope) are to
be considered temporarily UNFIT for a period of 6 months from the point of infection. When
baseline exercise tolerance is recovered, the candidate can then be considered FIT.
d.
Severe. Candidates who have had severe COVID-19 symptoms (breathlessness at
rest, chest pain, syncope) or have been hospitalised have a high risk of significant sequelae
are UNFIT.
Chronic fatigue syndrome and associated disorders
12. Candidates diagnosed as suffering from chronic fatigue syndrome or the group of associated
disorders e.g. fibromyalgia (FM), myalgic encephalomyelitis (ME), or post-viral fatigue syndrome
(PVFS), are UNFIT. Those with a history of this disorder lasting no more than 6 months, who have
been certified by their GP or specialist to have had no further symptoms and have been
undertaking activities compatible with military training and service for more than two years, should
be referred to the single-Service Occupational Physician responsible for the selection of recruits
before acceptance10.
Congenital, chromosomal and genetic disorders
13. There is a wide spectrum of congenital disorders. The following list is not exhaustive and
advice should be sought from the single-Service Occupational Physician responsible for the
selection of recruits in the case of those with genetic disorders not covered below. Guidance on
candidates with specific conditions is detailed below:
a.
Huntington’s disease. Candidates known to be carriers of the gene associated with
this condition are NORMALLY graded UNFIT11. Candidates with a proven, immediate family
history of this condition are NORMALLY graded UNFIT unless known not to carry the gene7.
Genetic testing should not be initiated solely for the purposes of recruitment.
b.
Phenylketonuria. These candidates 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. Dietary restrictions are still generally necessary with
protein supplements normally required and the military cannot guarantee that specialist diet
will be available12.
c.
Malignant hyperpyrexia. Candidates known to be carriers of the gene associated with
this condition are UNFIT due to the risk of a patient with this condition obstructing the critical
pathways associated with casualty treatment and evacuation.
d.
Neurofibromatosis Types 1 and 2. Candidates known to be carriers of either of the
genes associated with these conditions are UNFIT. There are associated conditions 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 x higher
than that of the general population13.
10 Professor Simon Wessely’s observations on CFS: ‘Those who have fully recovered and been symptom free for 6 months to a year - in
other words regard this as something that they have had, recovered from and put behind them, tend to do well. This may be due to
simple passage of time, or receiving treatment such as cognitive behaviour therapy or antidepressants. Of more concern are those who
are still symptomatic and/or consider themselves still to be particularly vulnerable to the effects of viral infections/stress or other
precipitants. The key, therefore, should be first whether or not they have recovered, and second, whether or not they consider
themselves still vulnerable to relapse’ – personal communication 11 Dec 06. Also see Cairns R, Hotopf. M. (2005): "A systematic review
describing the prognosis of chronic fatigue syndrome."
Occupational Medicine; 55: p2 0-31.
11 The genetics of Huntington’s disease are complex and the likelihood of a candidate developing Huntington’s and the likely age of
presentation are dependent on the number of gene repeats. In some cases, it is possible to predict these with a high degree of
certainty, based either on genetic testing of immediate relatives or of the candidate themselves. If there is clear evidence that a
candidate is unlikely to develop Huntington’s disease during a Service career, then they may, on a case by case basis, be considered
FIT. Supporting evidence must be endorsed by an appropriately qualified and experienced specialist. Any successful candidate will
require an appropriate medical marker.
12 From National Society for PKU ‘Management of PKU’ Feb 2004.
13 Adams & Victor: Principles of Neurology.
Return to Contents Page
4-N-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
e.
Familial Adenomatous Polyposis (FAP). Candidates with a family history of FAP are
at risk of developing this condition and its associated consequences. Individual assessment
is required on employability and an opinion should be sought from the single-Service
Occupational Physician responsible for the selection of recruits14.
f.
Suxamethonium sensitivity. Candidates who are homozygous for the atypical
cholinesterase gene who have been identified as requiring special anaesthetic precautions
are to be determined UNFIT due to the risk of those with this condition obstructing the critical
pathways associated with casualty treatment and evacuation. Those who are heterozygous
of the atypical cholinesterase gene should be subject to SSMES opinion15.
Malignant disease
14. Candidates with a history of malignant disease are normally UNFIT. In cases which have
been successfully treated and are regarded as cured, candidates may be determined FIT provided
that they have been discharged from regular follow-up and that no treatment is required16. A clinical
report is to be obtained giving risks of recurrence over time, risks of present or future complications
from treatment given, and is to be forwarded to the single-Service Occupational Physician
responsible for the selection of recruits for consideration. However, some drugs, particularly the
anthracyclines17 and bleomycin, and trans-thoracic radiotherapy are associated with cardiac and
lung side effects respectively. All such candidates require appropriate cardiological or respiratory
assessment. The following also apply:
a.
Acute Lymphatic Leukaemia (ALL). Candidates with ALL may be determined FIT if
they have remained free of recurrence for a period of 5 years from the completion of
treatment.
b.
Acute Myeloid Leukaemia (AML). AML has a high rate of relapse within a 5-year
period. Candidates who remain disease-free for 5 years may be determined FIT following
referral to the single-Service Occupational Physician responsible for the selection of recruits.
Conditions affected by climate
15.
Heat illness. Candidates who have suffered an episode of heat illness (with or without
physical exertion) are UNFIT unless they have been shown to thermoregulate normally during an
exercise-in-heat stress test18. Candidates who suffer from any of the disorders associated with
malignant hyperthermia, including an isolated abnormal ryanodine test, are UNFIT.
16.
Disorders of sweating. Candidates with hypohydrosis or anhydrosis affecting more than 5%
of the body surface area should be determined UNFIT unless they are shown to thermoregulate
normally during an exercise-in-heat stress test.
17.
Cold injury. Candidates who have previously been discharged from Service due to non-
freezing cold injury should be determined UNFIT. Those who suffered an episode of freezing or
non-freezing cold injury in the past but were not discharged due to this episode and who are now
asymptomatic are to be referred for assessment at the Cold Injuries Clinic at the Institute of Naval
Medicine. Following assessment, a decision on suitability for recruitment will be made by the
single-Service Occupational Physician responsible for the selection of recruits.
18.
Raynaud’s disease or phenomenon. Candidates diagnosed with Raynaud’s disease or
phenomenon are UNFIT (also refer to Section 4 Annex C Cardiovascular).
14 Practice parameters for the treatment of patients with dominantly inherited colorectal cancer (Familial Adenomatous Polyposis and
Hereditary Non-polyposis Colorectal cancer).
Diseases of the Colon & Rectum 2003;46 (8): pp1001-1012. Also see
http://www.acpgbi.org.uk/.
15 CBRN opinion highlights that this should not generate a concern with respect to work in a CBRN environment.
16 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.
17 Particularly used in leukaemias, malignant lymphomata and other myeloproliferative disorders.
18 Such as those available at the Institute of Naval Medicine.
Return to Contents Page
4-N-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Tropical disease
19. Candidates with a history of tropical disease who have made a full recovery and are
considered cured may be determined FIT. Enquiry should be made about previous foreign travel
and residence and those with an equivocal history of tropical disease should be referred to the
single-Service Occupational Physician responsible for the selection of recruits.
Splenectomy
20. Candidates who have had a splenectomy, or have reduced splenic function, are more
susceptible to a number of potentially life-threatening infections i.e. haemophilus influenzae,
neisseria meningitidis, malaria, capnocytophaga canimorsus and babesiosis. Therefore,
candidates who have had a splenectomy for any reason are UNFIT. Candidates with reduced
splenic function (e.g. partial splenectomy or splenunculus) who require regular prophylactic
antibiotics or specific immunisations are also UNFIT.
Transplantation of organs
21. Candidates with transplanted organs are UNFIT. Candidates who have donated a kidney and
are otherwise well may be graded P2 MFD not earlier than 6 months post-surgery, providing they
meet the requirements of paragraph 9 in Section 4 Annex F Renal and Urological.
Immune system disorders
22.
Anaphylaxis. Anaphylaxis is an increasingly common diagnosis and refers to a severe
allergic reaction in which prominent dermal and systemic signs and symptoms manifest which may
include urticaria, angioedema, hypotension and bronchospasm and which require treatment with
adrenaline or hospitalisation. A candidate with a past history of anaphylaxis is UNFIT.
23.
Allergy. This includes a past history of Type 1 (immediate IgE mediated reaction), regardless
of trigger. Candidates are to be assessed on a case by case basis. The following points are to be
considered in all cases:
a.
Although it is not entirely possible to predict the severity of subsequent reactions based
on previous history19, assessment must include clinical history, speed of onset, severity of
response, frequency and the need for and level of treatment received.
b.
IgE levels should be interpreted with caution as they are not independent predictors of
symptom severity. There are no tests with adequate sensitivity and specificity to indicate who
might be at risk of a fatal reaction.
c.
In cases of Oral Allergy Syndrome (Birch Pollen Food Syndrome) if reliance on
medication is absent/low, the deliberate avoidance of allergen is not required, and the
candidate has very mild symptoms with British Society for Allergy and Clinical Immunology
(BSACI) considered risk of incapacitation as being very low; then they may be assessed as
FIT. (For further information about BSACI, see sub-paragraph g.)
d.
In cases of Seasonal Allergic Rhinitis (Hay fever), if reliance on medication is
absent/low, the deliberate avoidance of allergen is not required, and the candidate has very
mild symptoms then they may be assessed as FIT.
e.
Cross-reactivity often exists within groups of allergens (e.g. ground nuts and tree
nuts).
19 Pumphrey: Anaphylaxis: can we tell who is at risk of a fatal reaction?; Curr Opin Allergy Clin Immunol 4: pP2 85-29. DOI:
10.1097/01.all.0000136762.89313.0b.
Return to Contents Page
4-N-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
f.
The nature of Military Service is such that it is not possible to guarantee an individual’s
ability to self-police an allergy to the triggers above thorough labelling or identification of
trigger constituents.
g.
In cases of doubt over the history of allergy or where self-administered adrenaline
injection has been prescribed but there is doubt over its necessity, candidates may wish to
ask their general practitioner to refer them to an allergist for opinion. Referral should be made
to the Lead Consultant at one of the clinics shown in Table 1, which are approved by the
British Society for Allergy and Clinical Immunology20. In the case of food allergy, allergic
response could be assessed by serum or skin tests followed by a sequential challenge test
(e.g. eating up to 10 peanuts). No reaction to the tests would equate to the same risk as an
individual without a history of food allergy. Wasp and bee sting desensitisation may be
undertaken although future anaphylaxis cannot be ruled out; however, those who had
previously reacted to stings, but then went on to have further stings without problem could be
considered to have no greater risk than the general population if they then sustain multiple
stings.21
h.
Candidates with a history of allergy to drugs should have a careful history taken,
including whether the allergy has been formally confirmed. Candidates with an allergy to
morphine, drugs used in prophylaxis or treatment in a CBRN environment or anaesthetic
agents likely to be used on operations should be referred to the single-Service Occupational
Physician responsible for the selection of recruits and are likely to be UNFIT.
24. Candidates with other immune system conditions that makes the candidate more vulnerable
to developing infections are UNFIT due to the risks of worldwide deployed service.
25. Advice in all cases of doubt should be sought from the single-Service Occupational Physician
responsible for the selection of recruits.
Table 1 – Recommended allergy and immunology clinics for military referrals.
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
20 https://www.bsaci.org/.
21 Professor Frew, Joint Committee on Immunology and Allergy, presentation to MES WG Mar 11.
Return to Contents Page
4-N-7
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Sleep disorders
26.
Insomnia. 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. Candidates
with any history of insomnia within the last 2 years, having no discernible underlying cause,
causing significant dysfunction or requiring prescribed hypnotic medication22 must be referred to
the single-Service Occupational Physician responsible for the selection of recruits and are likely to
be UNFIT.
27
Hypersomnolence disorders. As for insomnia, candidates with a current or past history of
other hypersomnolence disorders 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
28.
Parasomnias. Parasomnias are episodic disorders of arousal, partial arousal or sleep-stage
transition that may be initiated or worsened by sleep. Candidates suffering Common parasomnias
include:
a.
Non-Rapid Eye Movement (REM) sleep arousal disorders. This includes sleep
walking and night terrors23. Candidates with any non-REM sleep arousal disorder who are
dependent on strict sleep hygiene measures or hypnotic medication to remain symptom-free
are UNFIT.
(1)
Sleep walking. Candidates with a history of sleep walking experienced after the
age of 13 are UNFIT. A childhood history of sleep walking (up to age 13) should be
referred to the single-Service Occupational Physician responsible for selection of
22 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
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.
23 Epidemiological evidence shows that these arousal disorders are common in childhood: 25% in under 5 year olds; but prevalence
drops with age: up-to 6.5% in 13 and under; 2.3 – 2.6% in age group 15 – 64. Reference: International Classification of Sleep
Disorders. 3rd Edition. American Academy of Sleep Disorders 2014; pp 233-239.
Return to Contents Page
4-N-8
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
recruits24 and those candidates who have not required specialist medical assessment
or intervention may be determined FIT.
(2)
Night terrors. Candidates with a history of night terrors experienced after the age
of 13 are UNFIT. A childhood history of night terrors (up to age 13) should be referred
to the single-Service Occupational Physician responsible for selection of recruits24 and
those candidates who have not required specialist medical assessment or intervention
may be determined FIT.
b.
REM sleep behaviour disorder. REM Sleep Behaviour Disorder is characterised by
the intermittent loss of [the usual] REM sleep electromyographic (EMG) atonia and by the
appearance of elaborate motor activity associated with dream mentation. Candidates with a
history of REM sleep behaviour disorder are UNFIT.
c.
Nightmare disorder. 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 current history of nightmares causing significant dysfunction
in daily activities are UNFIT. Candidates with a past history of such nightmares should have
no underlying psychiatric cause affecting fitness elsewhere in this policy, and should be
symptom free for a period of two years before being accepted as fit for entry.
29.
Circadian rhythm sleep-wake disorders. Candidates with a sleep specialist confirmed
history of circadian rhythm sleep-wake disorder are UNFIT.
30.
Narcolepsy. Candidates with a sleep specialist confirmed history of Narcolepsy, current or
past, are UNFIT25.
31.
Breathing related sleep disorders. Candidates with obstructive sleep apnoea/hypopnoea
syndrome are UNFIT. Candidates with a past history should be referred to single-Service
Occupational Physician responsible for selection of recruits.
32.
Restless leg syndrome. This condition is common (general population prevalence is 15%),
and in majority of cases is mild and causes little dysfunction. Candidates with a history of restless
legs syndrome causing any disability should be referred to single-Service Occupational Physician
responsible for selection of recruits. Underlying causes, including anaemia, chronic neck or spine
pathology should be excluded.
24 To check for presence of any current sleep or other mental health symptoms, or history of hereditary factors, and consideration of
employment group suitability with respect to functional requirements.
25 Narcolepsy is a life-long condition; it can be managed but not cured. Reference: Narcolepsy Fact Sheet. National Institute of
Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/All-Disorders/Narcolepsy-Information-Page
Return to Contents Page
4-N-9
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
5.
Certain categories of employment (e.g. Special Forces, Submariners, Parachutists, Divers
and, Aircrew) require more stringent standards, which are promulgated separately.
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.
Return to Contents Page
5-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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.
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.
Return to Contents Page
5-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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).
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.
Return to Contents Page
5-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
(4)
Operation of cranes, hoists, and fork lift trucks2.
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 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.
Return to Contents Page
5-A-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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
Return to Contents Page
5-A-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-A-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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.
Return to Contents Page
5-B-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
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) Hypertension in adults: diagnosis and management NG136.
Return to Contents Page
5-C-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
include 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 Cardiology 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”.
Return to Contents Page
5-C-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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:
1 Further details contained in BRd 1750A Handbook of Naval Medical Standards, AP 1269A Royal Air Force Manual of Medical Fitness
Return to Contents Page
5-D-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 70 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.
Return to Contents Page
5-D-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
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 countries1 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
1 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.
Return to Contents Page
5-E-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
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
service2.
2 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.
Return to Contents Page
5-E-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-E-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-F-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
(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.
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.
Return to Contents Page
5-G-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
(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.
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.
4 All intracranial haematomata, including epidural, subdural and subarachnoid.
Return to Contents Page
5-G-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-G-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
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.
Return to Contents Page
5-H-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-I-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
REPRODUCTIVE IN-SERVICE
ANNEX J
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.
(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.
Return to Contents Page
5-J-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-J-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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
Return to Contents Page
5-J-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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
1 Subject to single-Service procedures on medical grading.
Return to Contents Page
5-J-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Return to Contents Page
5-J-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-J-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-J-7
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-J-8
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-J-9
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-J-10
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-J-11
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-J-12
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
5-J-13
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
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.
Return to Contents Page
5-J-14
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Agents
Human Reproductive Hazard
Scientific Evidence
Recommendation for MO
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.
Return to Contents Page
5-J-15
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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.
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.
Return to Contents Page
5-K-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
(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.
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.
Return to Contents Page
5-K-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
Return to Contents Page
5-K-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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 practices1.
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.
Return to Contents Page
5-K-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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.
Return to Contents Page
5-K-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
32. Asymptomatic spina bifida occulta, failure of fusion, spondylosis and spondylolisthesis which
is detected incidentally only on imaging does not require re-grading.
Return to Contents Page
5-K-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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).
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.
1 Further details on definition and award in JSP 950 Leaflet 6-7-7 Section 2 Annex A and sS policy.
Return to Contents Page
5-L-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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).
Return to Contents Page
5-L-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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).
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 This term encompasses all consultant psychiatrists working for the MOD, uniformed or civilian.
Return to Contents Page
5-L-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
(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 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.
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.
Return to Contents Page
5-L-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
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.
7 Further information can be found in JSP 889 'Policy for the Recruitment and Management of Transgender Personnel in the Armed
Forces'.
Return to Contents Page
5-L-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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.
Return to Contents Page
5-L-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
Appendix 1
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.
Return to Contents Page
5-L-A1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Return to Contents Page
5-L-A2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 at 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:
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
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 available here).
4 Beyond single Service restricted duties timeframes.
5 R1 to R5.
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.
Return to Contents Page
5-M-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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
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.
Return to Contents Page
5-M-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
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.
13 This may last up to two years.
Return to Contents Page
5-M-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 the Defence Medical Services (DMS) should be
screened in accordance with Section 4 Annex N Other Conditions Pre-Entry.
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
5-N-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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)1, 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 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
1 MASHH On-call email: xxx.xx@xxx.xxx On-call phone: 07929 788873 or Sec: 0121 424 2358
Return to Contents Page
5-N-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
fragments from the infected person1. 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 publications2.
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 products3 should normally be graded no higher than MND,
as such blood products are not routinely available when deployed. RN and RAF SP 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 Prof Mutimer (Head UBHNHSFT Hepato-Biliary Team) agrees you cannot exclude infection whatever the viral load given ballistic
injury.
2 PrEP policy for In-Service aircrew and controllers is detailed in AP1269A Lft 5-10.
3 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
5-N-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
(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 pathway1. 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 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
Medicine2. Grading should reflect the functional level during this rehabilitation phase. Final
outcomes are variable and consideration may have to be given to medical discharge.
1 JSP 950 COVID Lft 002 ‘Clinical and occupational assessment prior to return to duty and training post-COVID-19’.
2 Occupational Aspects of the Management of Chronic fatigue Syndrome – a national guideline.
Return to Contents Page
5-N-4
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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.
Return to Contents Page
5-N-5
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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.
Return to Contents Page
5-N-6
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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
Return to Contents Page
5-N-7
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 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.
Return to Contents Page
5-N-8
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
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.
Return to Contents Page
6-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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 board1 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 policy2 .
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.
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 SPPol3.
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
1 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.
2 SGPL 05/04 – Role of Secondary Care Consultants in Medical Board Procedures.
3 DD SPPol (Pensions) letter reference ‘AFCS 75/Attributable’ dated 23 Mar 05.
Return to Contents Page
6-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
FMed 23 Completion Instructions.
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.
Return to Contents Page
6-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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)
Return to Contents Page
6-A-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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
Return to Contents Page
6-A-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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
Return to Contents Page
6-B-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
Return to Contents Page
6-B-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
Return to Contents Page
6-B-3
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
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.
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.
Return to Contents Page
6-C-1
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
MDG(N) Med Legal
All Personal Medical Records
To deal effectively with any legal
(FMed 4) and
any 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.
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
Return to Contents Page
6-C-2
JSP 950 Lft 6-7-7 (v2.4 Oct 22)
