DrLinda Lazarus

Departmentof Health

Room631B

SkiptonHouse

80London Road

LONDON

SE16LH

28April 2003

DearDr Lazarus

Consultation on DraftGuidance on Health Clearance for Serious Communicable Diseases: New Healthcareworkers: joint CHMS and UKUHF response

We are writing in response to the CMOs invitationto comment on draft guidance. We feelthat it is timely to take a fresh look at this important issue and are pleasedto have the opportunity to offer our views.

The Council of Heads of Medical Schools comprisesDeans or Heads of all Medical Schools or Faculties in the UK. The UK University Hospitals Forum comprisesthe Chief Executives of the main UK teaching hospitals. The two organisations are key partners inthe provision of undergraduate medical education and training and we felt thatit would be appropriate if we provided a joint response on the important anddifficult issue of medical students who have serious communicable diseases,including blood-borne viruses.

It might be helpful to begin with a brief historicalcontext. Between 1975 and 1990 in England, Wales and Northern Ireland, therewere 12 outbreaks of Hepatitis B infection associated with infected surgicalhealthcare workers and these resulted in a total of 95 cases of Hepatitisinfection in patients. Transmissionrates range from 1% to as high as 20% following major surgery. In April 1991 the NHS management executiveissued guidance that included the statement:before admitting a medicalstudent to a hospital Health Authorities and Trusts should make enquiries intothe health of students and may request and arrange for them to undergo amedical examination as a condition of their attendance in hospital if they aresatisfied that the interests of patients require it. Following a good deal of debate, the Committeeof Vice Chancellors and Principals (now Universities UK) wrote a letter on 22^ndMarch 1994 to Universities with Medical Schools and their Deans including thestatement: all students who are Hepatitis B carriers and shown to be infectiousshould be excluded from the clinical stages in medical and dental courses. Thisled to all medical schools excluding, at the point of admission, students whowere Hepatitis B, e-antigen positive.This was because the award of the degree entitles graduates automaticallyto apply for provisional GMC registration and to obtain a PRHO post andimplies, with no further certification, that they are fit to practise.

The General Medical Council Education Committee hasrecently published a new edition of Tomorrows Doctors, describing theknowledge, skills and attitudes that must be demonstrated by new medicalgraduates. As you say in your draft,these outcomes which should be regarded as the core of undergraduate medicaleducation can be achieved without recourse to exposure prone procedures. The GMC has also recently published revisedguidance on Student Health and Conduct which includes the statement: Subject to meeting a Universitysregulations, anyone can graduate provided

that they meetall the outcomes and curriculum requirements in Tomorrows Doctors. The view ofthe GMC is that students with a wide range of disabilities or health conditionscan achieve the prescribed standards of knowledge, skills, attitudes andbehaviour. Each case is different and has to be viewed on its merits. Thesafety of the public must always take priority.

Thus, at one level the way is open to take a moreliberal view of medical students with BBVs.However, all medical curricula include not only core but also optionalclinical experience and it is possible that during this phase of training either in the UK or during electives overseas medical students could beinvolved in EPPs. We are aware, ofcourse, that dental students and midwifery students are required to have experienceof EPPs and would be unable to graduate without these skills. Dental and midwifery students who would putpatients at risk should therefore not be admitted to those courses, butarguably a more flexible approach is possible in relation to medical, nursingand other AHP students.

The question of whether to admit medical studentswith BBVs was discussed at a joint meeting of CHMS and the UK UHF in October2002. The following options weredebated:

1. Maintain the status quo. The current position of themedical schools clearly protects the public, but could be the subject ofchallenge under the Disability Discrimination Act and possibly Article 6 of theEuropean Convention on Human Rights. Abalance may therefore need to be found between the rights of the HBV e antigen(or other BBV) positive student and the protection of the public.

2. Students to be screened and vaccinated against HBV as atpresent, but e-antigen positive students to be admitted under the supervisionof the Occupational or Student Health Service.Occupational Health or SHS would with the students consent liasewith the medical school and partner NHS Trusts to ensure that the student didno EPPs, with supervising hospital staff being informed on a need to knowbasis.

3. Medical Schools require students to know their HBV (andperhaps other BBV) status and to confirm that they will act in accordance withOccupational or Student Health Service advice with respect to not becominginvolved in EPPs. This would maintainthe students right to confidentiality, but their BBV carrier status couldstill become apparent through deductive disclosure.

A range of views on these suggested approaches wasexpressed by those present, but option 3 was rejected. There was a broadly equal split betweenoptions 1 and 2.

Admission to Medical School implies a clearexpectation that students will be allowed to complete their clinical studies.It is essential therefore that Medical Schools and their partner Trusts act inharmony and with consistency throughout the UK.

Our view at present is that further discussionsbetween the Medical Schools, their NHS partners and the UK Health Departmentsare needed before the wording of paragraph 7 can be finalised. The protection of patients, for which TrustChief Executives are accountable, must take priority. For their part the universities and their medical schooladmissions selectors also have a responsibility to ensure that patient safetyis a priority. However, they also aimto be fair and transparent in operating their student selection criteria, andit is their view that it should be possible to admit students who are carriersof BBVs, provided they emphasise everyone, including especially the studentsthemselves, act responsibly. It is already the case that doctors who arecarriers of BBVs can continue to practise provided their careers are managedappropriately by themselves and by occupational health services.

If a decision is taken to relax the restrictions onthe entry of students with potentially serious communicable diseases accepting that students may beinvolved in EPPs there will have to be detailed discussions, leading torevised guidance to Medical Schools and their NHS partners relating to eachspecific disease, as they are variably treatable. However, it is essential that the duty of care to patients isaccorded the highest priority and that the differences between the healthprofessions in relation to exposure prone procedures are recognised andunderstood by all concerned.

Yourssincerely

Professor Robert Boyd

Chairman, CHMS

Dr Jonathan Michael

Chairman, UK UHF