Good practice when making occupational health referrals

What are the do’s and don’ts when making referrals? In the first of a series of articles on the interface between HR and OH, Dr John Cooper advises on best practice.

The main reason for referring an employee to occupational health is to help a manager resolve a situation where an employee’s health might be affecting their fitness to carry out their job, or their job may be adversely affecting their health in some way.

And in doing this, a manager can seek advice from HR on policy, employment law and how to deal with employees who might have personal problems, as well as asking for help from OH on matters of health relating to an employee’s fitness for work.

While medical details are private and confidential to every person and no manager has the right to know an employee’s medical details, doctors and nurses are bound by the principles of patient confidentiality.

However, the employer does have a number of responsibilities relating to health for which they can ask specific questions of an OH service. In this scenario, the OH practitioner acts as a filter between the employee and their medical details and the employer and their specific questions.

Employers are not responsible for all aspects of their employees’ state of health, but they are charged with a duty of care, ensuring the employee is medically fit for a certain job (for example, driving a bus), and that the work conditions do not cause adverse health effects on one of their workforce (such as an occupational illness).

There are seven vital steps in this process, and the principles apply equally to telephone as much as to face-to-face consultations.

Step one

The first step is for the manager to be clear as to the reason for the referral and, consequently, the questions to ask the OH practitioner. The more specific the questions, the more likely they are to get answers that help them move the situation forward. Valid questions seeking an occupational health opinion include the following:

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  Is this employee medically fit to work in this role?

• When, if absent, are they likely to be able to return to work?
• Is a phased return recommended?
• Is a review appointment recommended?
• Would the employee’s condition be covered by the disability provisions of the Equality Act (2010)?
• Are any adjustments needed to help the employee in their work?
• Are there any restrictions in what the employee can do in their role?
• Is the employee receiving the appropriate medical care and support?
• Should the employee be considered for ill-health retirement?
• Is the employee’s illness caused or exacerbated by their work?
• If the employee is taking medication, is it likely to impair their ability to do their job safely and effectively?

Referrals to occupational health that are not appropriate and tend not to help include

• Please review – this is too vague. Review what: left ear? Right foot? Mental state?
• What are the details of this person’s illness? – this is confidential information.
• What medication is the employee taking? – this is confidential and irrelevant.
• Is the employee likely to be in regular attendance in the future? – this is impossible to predict as attendance depends on so many variable factors.
• And not as one referral simply stated: “Needs heart and lung transplant” – what is it exactly the manager wants from OH?
• Or: “What do you think is the diagnosis and prognosis?” in a complex case still undergoing investigations – no way of knowing until investigations are completed.

Step two

Having made the referral, the second step is for the manager to explain to the employee the purpose and procedure for the referral and obtain their consent to be referred to occupational health.

Examples of what the manager might say include the following:

• “I have recently become increasingly concerned about your performance at work. And I want to refer you to occupational health so they can explore whether or not you might have some illness that could be the cause of this and, if so, what can be done about it.”
• “We are aware that you have a health problem, and we want to make sure we are providing sufficient support for you.”
• “Your absence level is higher than average and we would like OH to advise on whether or not anything more can be done to help your health.”

Step three

The third step is for the manager to write the referral itself, which is frequently done on a pro forma template.

Details should be included about the employee’s job, their length of service, absence record (if appropriate), date of birth, and any conflicting interests at the workplace, such as grievances or complaints.

The specific reason for the referral should then be clearly stated, along with the questions to be answered by the OH practitioner.

Ideally, referrals should be limited to about four to six questions, as there is unlikely to be sufficient time for the OH practitioner to address more.

The employee should be able to see a copy of the form, and ideally should also sign it, giving their consent, before it is sent to arrange the appointment.

Step four

The fourth step is the consultation itself. The OH practitioner will need to take details of the employee’s medical history as well as their job and any potential hazards or stressors involved.

A medical examination may be required, subject to the employee’s consent, for conditions such as back pain.

Medical reports may need to be obtained from the employee’s doctor, once again only with consent, for more complex cases.

It has to be remembered that employees are primarily the patients of their own GP, and OH practitioners must not stray into areas that are the GP’s responsibility.

The OH practitioner is not usually able to carry out investigations, make referrals or treat employees, but some OH services do include extra resources such as counselling or physiotherapy for rapid assessment and treatment.

Where there is doubt as to what OH might or might not be able to do medically, it is best to contact the employee’s own GP to talk through the scenario and agree who does what.

Step five

The fifth step is the report prepared by the OH practitioner. Written and informed consent is needed from the employee for this report, and the General Medical Council guidance recommends that the employee has the right to see the report before it is sent to their manager.

In such cases, the employee may ask for a fact to be corrected, which should be done.  But if they disagree with an opinion in the report (perhaps, for example, in relation to when they could return to work) then the OH practitioner is not obliged to change the opinion. However, they may point out in the report that their opinion differs from that of the employee.

Typically, an employee will be given one to three days in which to comment on the report before it is sent to their manager.

The report itself should address the main reason for the referral as succinctly as possible and answer the specific questions, in order to help the situation in a way that will benefit both employee and manager.

Step six

The sixth step is for the report to then be sent to the manager, with a copy to the employee and HR. Some OH services also copy this report to the employee’s GP.

Step seven

The seventh step is for the manager to review the situation in light of the written advice and any recommendations in the OH report. Ultimately, the best reports enable the manager to at least move the situation forward, and ideally to resolve it completely.

Points to consider when making occupational health referrals

Although it may seem simple on paper, there are some crucial points to be bear in mind in the process of referring an employee to the OH department.

Doctors and nurses always have to work within their own set of medical ethics and guidelines. The most important of these is the preservation of patient confidentiality. The challenge then for an OH practitioner is to know how much medical information to put in the report.

Essentially, it is more useful for the manager to know about the employee’s functional abilities – what they can or cannot do in their job – rather than any medical details per se.

But sometimes it does help to report on some medical factors, such as an employee who is epileptic and may need first aid at times. This is always subject to the employee’s agreement for the information to be divulged.

Another crucial factor to consider is whether or not the reason behind the referral is more for assessment or for support.

Some managers just want their employee assessed for a specific purpose (are they fit to return to bus driving after their heart attack?). Others want to help and support an employee who is having a difficult time healthwise – for example, feeling stressed and struggling with their job.

It is also critical to get the timing of the referral right. There is no point in referring someone to OH while they are still under investigation to establish a firm diagnosis or waiting for the result of a scan.

Similarly, people who have undergone surgery need time to recover, and usually will see their surgeon for a post-operation review before being considered for a return-to-work referral.

On the other hand, people experiencing stress-related issues or mental health problems often benefit from an early referral.

If in doubt, therefore, the manager or HR should communicate with the OH service and discuss when would be the best time to make the referral.

The OH practitioner will always try in the report to answer the referral questions as accurately and fully as possible, but it should be understood that medicine, as with quantum physics, deals with probabilities and not certainties. OH practitioners do not have a crystal ball, and trying to foretell the future needs to be done with care and honesty.

Illnesses can affect different people in different ways, resulting in a wide variety of responses to a given diagnosis. It is often more important to know what sort of person has a disease than to know what sort of disease a person may have.

It also has to be recognised that the OH practitioner is often seeing an employee who is extremely anxious about the referral, especially if they think their job is at stake. OH is not, as one employee once feared, “the military police of the organisation”.

The OH practitioner needs to gain the trust of the employee in a very short space of time, otherwise the full details of the situation – medical and occupational – will not be apparent.

At the same time, they must stay completely impartial and objective – not on either employer’s side or that of the employee. The OH practitioner should be a bridge between the two, able to provide advice and guidance on how best to address the given situation.

The best OH practitioners have good knowledge of their workplaces – their hazards as much as their culture – and equally know their patients well and their state of health. They are then well placed to advise on the best solutions.

Key points

• • The clearer and more relevant the reasons behind the referral, the better the value from the referral.
  • The process needs to be done in a manner that meets medicine’s ethical guidelines.
  • The more supportive the referral, the more likely a beneficial outcome. Trying to “get rid of a difficult employee” via occupational health rarely works in practice.
  • Managers have the right to ask certain questions about their employees’ fitness to work, but not the right to enquire about all medical details.
  • The report from OH services should allow the manager to at least move the situation forward, and, ideally, to resolve it entirely.
  • Not all OH practitioners know everything about every disease, and at times it may be necessary to seek further reports or information.
  • Be clear when questioning whether or not an employee is “suitable for this job” about distinguishing skills and abilities to do the job (which is for the manager to assess) from medical fitness to work (which is for OH to assess).

• OH provides advice, but the decisions are made by the line manager on the basis of advice from OH and HR.
• It is up to the manager to decide if any recommended adjustments or restrictions can be accommodated. They may choose to ignore or change the advice from OH, but if things then go wrong, the manager may have to defend and justify their decision to a higher authority or an employment tribunal.
• If in doubt, a phone call and discussion with the OH practitioner is the best way forward. Honesty is vital in such discussions. There is no point in pretending to support an employee if really you are trying to get rid of them. Complete clarity about your real aims and intentions will help the OH practitioner have a better all-round picture of the situation.
• A collaborative approach between the line manager, HR and OH is ultimately the most favourable way to bring about a resolution of the underlying situation in which an employee’s health might be of relevance to their ability to carry out their occupation, and to bring the best potential outcome for both employee and employer.

Dr John Cooper MB BS FFOM is an experienced occupational health consultant who has worked internationally in both the private and the public sectors. He was educated at Oxford University and St Thomas’ Hospital London, and is a former medical director at Mobil Oil. He was also global chief medical officer at Unilever for 15 years. He has developed award-winning health and wellbeing programmes, lectured internationally and published studies on the business benefits of a healthy workforce.

References

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“Duty of care” is the legal requirement for an employer to act towards its staff and the public in a reasonable way, with watchfulness, attention, caution and prudence.

The General Medical Council (GMC) website has a section for employers, including information on how to check a doctor’s status on the register, registration and licensing, and the obligations of employers. There is also a section on good medical practice, the standards doctors need to demonstrate in their work.