Misuse of occupational health: Who’s responsible?

Employers’ attitudes to their employees have improved much since the early days of the Industrial Revolution, but there may be echoes of earlier times in some managers’ denial of responsibility for staff wellbeing.

The tendency for line managers to treat managerial problems as medical issues and refer them to the occupational health (OH) department may have its roots in an era when employees had few rights and responsibilities. Today, nearly 300 years since industrialisation began, one of the fundamental principles of OH nursing practice is “Make the care of people the first concern, treating them as individuals and respecting their dignity” (Nursing and Midwifery Council (NMC) Code 2008).

The NMC Code requires OH advisers to encourage employees to contribute to caring for themselves, using the wealth of health services currently available.

However, research into health psychology indicates that the quality of self-care among individuals decreases in line with decreasing job status.

There is even some indication that individuals in some types of work environments are neglecting their health so that they can justify taking sickness absence as a means to escape the pressures of the workplace.

Statistics published by the Employment Tribunal (ET) service from 2005-2007 may help to determine whether there is a link between sickness absence, management action and increased ET claims. A review of cases for unfair dismissals, breach of contract and those related to the Disability Discrimination Act (DDA) indicated that over the period, the proportion of cases struck out of court for breach of contract and ‘DDA-related’ cases had increased over the three years in relation to the corresponding number of cases submitted.

In other words, the number of claims deemed inappropriate for trial appears to have risen. In 2005-06 4,072 DDA-related claims were submitted and nearly 5% were dismissed. By 2007-08, 5,133 had been submitted, and nearly 6% of those were dismissed. In 2005-06, 21,444 breach of contract claims were submitted, and 5% of those were dismissed. In 2007-08, 22,516 claims were submitted, and nearly 8% of those were dismissed.

The percentage of inappropriate claims for unfair dismissal has not increased, but has more or less remained the same over the three years, along with the overall number of claims submitted.

It would be worthwhile to investigate how many of the claims for breach of contract and the DDA resulted from management action taken because of perceived unjustifiable sickness absence by the claimant.

These figures may also be an indication that some working environments are cultivating a ‘sick role with diminishing responsibility’, defined as a behaviour in which a person adopts the symptoms of a physical or mental disorder to be cared for, sympathised with, and protected from the demands and stresses of life.

Recently I devised a questionnaire to test the possibility that there was diminishing responsibility between the employer and employee relating to sporadic sickness absence. It was given to line managers before I delivered a training session on the role of OH. The purpose was to examine how managers perceive the role of OH in assisting them to manage their sickness absence issues more effectively. The questions and analysis of responses are as follows:


  • How do you believe that the information you supply on your referrals about the role and duties of your member of staff would be used by OH?

  • As a manager, how do you differentiate between a practical problem in the workplace and a health issue?

  • What, in your view, are the common non-medical barriers/obstacles to regular attendance among your teams?

  • How do you endeavour to provide assistance to your staff when work-related problems are presented to you?

  • As a manager, what tools/skills do you employ to obtain optimum collaboration from your members of staff?

Analysis of responses

  • Most managers were aware of the relationship between work and health.

  • Most managers were aware of what non-medical work-related problems existed in the workplace.

  • Despite this, most managers viewed work-related problems as medical issues.

  • Only half the sample was willing to try to resolve work-related problems, even though most managers seem to possess the people management skills required to resolve non-medical issues in the workplace.

Question 3 is of particular importance as it reveals the types of non-medical issues which contribute to sporadic absence in teams. The examples documented by the managers were:

  • Work pressure (real and perceived)

  • Change in workload

  • Inadequate training

  • Conflict within the team, including with the manager

  • Office closures

  • Bullying

  • Unavoidable caring issues

  • Lack of motivation

  • Job stagnation

  • Low morale

  • Role dissatisfaction

  • Feeling under-valued

  • Poor public transport links

  • Hangovers

  • Just fancied a day off

  • Oversleeping

  • Fatigue

  • Insufficient training

  • Sick pets

  • Domestic emergencies.

In most cases, these non-medical issues would eventually be presented to OH as ‘stress and anxiety’, with the expectation that adjustments to roles and duties be recommended in the report to management.

The respondents who said they were not likely to try to resolve the workplace issues indicated, on the other hand, that they did accept responsibility for allowing reasonable adjustments to help maintain a healthy work-life balance.

However, there seems to exist some degree of reluctance to proactively deal with the employment issues. Managers confirmed that they feel compelled to obtain ‘certified wellness’ from OH before attempting any form of reasonable adjustment or capability and performance procedure.

Although they reportedly maintain a healthy respect for health and safety policies and employment tribunal processes, they also maintain a need to obtain medical advice for non-medically related absences.

On the other side of the coin, one out of three members of staff tends to arrive at an OH appointment with a trade union representative and a ‘wish list’ of adjustments they would like to see implemented.

Much has been achieved over the past 300 years of industrialisation, and the relationship between employee and employer has developed a good degree of equality and mutual dependence. As OH practitioners, the ‘care of individuals’ would likely be best served by supporting the relationship of mutual dependence between employer and employee, rather than continuing the practices of the ‘workhouse’ era.

This will demonstrate the ability of OH services to respond to the changing needs of industry, and reduce the potential for OH practitioners to be manipulated by managers to contribute to a ‘paternalistic’ management style where employees are denied rights or responsibilities.

Is this really a problem for OH?

What employers and employees can do before seeking advice from OH on sickness absence:

  • Stress risk assessments

  • Mutually agreed improvement plans

  • Behavioural skills framework plans

  • Re-training

  • Team-building exercises

  • Adjustments to roles and shift patterns

  • Flexible adjustments for leave and special leave in emergencies.

Occupational Health in the early industrial revolution

During the UK’s industrial revolution of the 18th century volunteers were taken from among workhouse inmates to act as nurses. The life of the workhouse nurse was as impoverished as any other worker, and the role was unpaid and not recognised as a nursing role by the trained nurses who worked in hospitals. The availability of doctor services to the workers was mostly limited to visits to the workhouses.

Workhouse owners were responsible for caring for the health of workers in the early industrial revolution, but there was little legislation on public health. Although Bernardino Ramazzini, the Italian physician considered the Father of Industrial Medicine, showed links between working practices and health in his 1713 publication of the De Morbis Artificum Diatriba (The Diseases of Working Men), his findings were largely ignored by early industrialists. This may have been because of a belief that industrialisation would resolve much destitution.

In the 1800s laws were introduced to control working conditions and to introduce factory inspections and ‘certified factory surgeons’, although this had limited impact on improving the working conditions.

The introduction of the New Poor Law in 1834 brought with it some degree of medicine in the communities where workers lived, and some effort to determine which individuals in the community were fit to work in workhouses. The healthcare of workers improved from the 1830s and Poor Law Nurses also began to earn the respect of their peers, the trained nurses.

The first Medical Inspector of Factories was appointed in 1898 to investigate the causes of industrial disease.

Nikla Rai RGN, BSc. ROH is a specialist nurse practitioner at Capita Medical Insurance Services.


1 Nursing and Midwifery Council (2008) Code of Professional Conduct

2 Nys, T R V (2008) Paternalism in Public Health Care. Public Health Ethics. April, Vol 1, No 1. p64-72

3 Kirby, S (2002) Reciprocal Rewards; British Poor Law Nursing and the Campaign for State Registration. International History of Nursing Journal, Vol 7, No 2, pp4-13

www.employmenttribunals.gov.uk/publications Annual Statistics; 2005-2006, 2006-2007, 2007-2008.

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