Editorial

660 www.thelancet.com Vol 382 August 24, 2013

Health-care workers with HIV: free to work againOn Aug 15, 2013, the UK Department of Health recommended that restrictions on procedures done by health-care professionals with HIV in England should be lifted. At present, UK health-care workers with HIV have been banned from doing exposure-prone procedures that would increase the risk of transmitting infection—eff ectively preventing any medical professional with HIV from practising dentistry or surgery, and aff ecting many other specialties, such as obstetrics and emergency medicine.

As it stands, the ban is “at odds with contemporary medical opinion and has no scientifi c basis”, according to the British Dental Association. Worldwide, only four cases of transmission of HIV from health-care workers to patients have ever been recorded, all of which involved health-care workers who were not receiving antiretroviral therapy. In the event of a breach of infection control, the risk of transmission of HIV from an untreated health-care worker to a patient is tiny; for a health-care worker whose viral load is under control, it

is so small (one in 5 million) as to be negligible. Beyond the small number of professionals directly aff ected, such restrictions have a pernicious eff ect on the entire medical system. They encourage fear, shame, and stigma towards providers of care and patients living with HIV.

The new measures proposed by the Department of Health are not perfect. The testing routine—once every 3 months—is burdensome, and central registration of health-care workers with HIV poses privacy concerns. Whether local occupational health services and the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses can provide adequate and timely implementation and oversight of these measures remains to be seen. The restrictions will be lifted in England only from April, 2014, although outcomes of similar consultations in Scotland, Wales, and Northern Ireland are awaited.

Stigma remains one of the major barriers to providing an eff ective response to HIV. The Lancet welcomes the overdue lifting of this ban. The Lancet

For the Management of HIV-infected healthcare workers

report see https://www.gov.uk/government/consultations/

management-of-hiv-infected-healthcare-workers

For the Health Committee report see http://www.

publications.parliament.uk/pa/cm201314/cmselect/

cmhealth/584/584.pdf

Inpatient mental health care in the UK is in crisis. As a new report by the House of Commons Health Committee shows, compulsory detentions under the 2007 Mental Health Act have increased—from 42 208 detentions in England in 2008–09 to 44 894 in 2011–12—leading to severe pressure on beds in mental health units. Furthermore, evidence given to the committee suggested that voluntary admissions to psychiatric wards are now so restricted that some patients are being detained under the Act to gain access to treatment in hospital.

The report assesses the Mental Health Act 2007 for England and Wales, which amended and updated the 1983 Act. One of the aims of the 2007 Act was to transfer as much care as possible to within the community, rather than in hospitals. The fact that the need for inpatient care is increasing, therefore, requires investigation.

The natural assumption might be that there are failings in community care, but the reasons are likely to be more complex. What should not be forgotten, however, is that there will always be individuals for whom formal admission to hospital is an unfortunate

necessity, because of a marked deterioration in health and the associated vulnerabilities and risks. And there will always be people who voluntarily might benefi t from care in an environment that is not their home. Sadly, however, an inpatient psychiatric ward in the UK today is unlikely to be the best place for such patients to recover. Many of these wards are in outdated buildings with crumbling decor, where there are serious problems with the levels of staff experience and training, safety issues, and where patients have few activities to keep them occupied during their stay.

Alternative safe spaces for people to recover, such as crisis houses or modern mental health centres (eg, the Redwoods Centre in Shrewsbury, UK) that have been designed with the input of service users and carers, do exist: but it is surely the right of every person requiring inpatient care to have access to such spaces. Improving the quality of inpatient care should be a priority for government. If patients are in need of compulsory treatment, the place where they receive it should do more good than harm. The Lancet

Improving inpatient mental health care in the UK

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