Reflecting on the role, and value, of ‘good’ occupational health

Reflective practice is vital to the effective delivery of occupational health and wellbeing interventions

New to the profession, and as part of her BSc in occupational health, Rikki Scott researched and wrote this article outlining what, for her, were the key concepts of absence management. This helped to crystallise her thinking around what constitutes “good” day-to-day OH practice, a process of reflective practice that, she argues, is invaluable whatever your experience or seniority within OH.

The effects of sickness absence on the health and wellbeing of employees and the performance of a business are devastating, and it is estimated to cost the UK as much as £12bn a year. However, it is also widely recognised that working in a well-managed workplace can be part of the rehabilitation and recovery process and will result in benefits for employees and employers.

About the author

Rikki Scott is an occupational health adviser based in Southampton and works for Duradiamond

The National Institute for Health and Care Excellence (NICE) defines short-term sickness absence as lasting less than four weeks, and long-term as lasting four weeks or more, though it raises concerns at the lack of universal definition amongst literature.

Musculoskeletal injuries, along with mental health problems and back pain, are among the most common causes of long-term sickness absence. Given that much of this is preventable, there is a need to place high priority on tackling such common health problems in the workplace.

Health behaviours in the workplace

Work organisation and health behaviours in the workplace are being increasingly recognised as levers to effect improvements in sickness absence and there is a large onus on employers to determine and manipulate work-related factors to ensure at the very least they are not harmful to employees, and ideally make a positive contribution to their overall health and wellbeing. This article examines the key concepts of absence management, including legislation and policies, the use of occupational health (OH), and various interventions and strategies available.

It has been found that the longer individuals are absent from work due to sickness the less likely they are to return. Therefore there is a common theme amongst literature highlighting the importance and benefit of early intervention in sickness absence, though it is not universally agreed what constitutes “early” in terms of days, weeks or months.

The Advisory, Conciliation and Arbitration Service (ACAS) recommends involving OH from the earliest possible opportunity as we have an important role to play in helping to reduce absence rates and promoting a healthy workforce.

Similarly, the government encourages a proactive rather than reactive approach, as OH can prevent unnecessary sickness absence and its deleterious effects. This can be achieved by acknowledging and understanding the complex influence that biopsychosocial (BPS) factors have on health. OH therefore faces the challenge of designing preventative and rehabilitative programmes that address all these contributing dimensions, as there is little in the way of simple clinical tools to assess the psychosocial issues or interventions to address them owing to the complex nature of the BPS approach.

Involving OH has been found to be one of the most effective methods of managing sickness absence, especially when used in the rehabilitation of common health problems. Mental ill health and musculoskeletal problems are manageable and, with proper advice and support, recovery can be expected and long-term incapacity avoided.

Case management and vocational rehabilitation

There are a variety of strategies and approaches that OH can call upon, which should be decided following an initial detailed assessment and revisited throughout the rehabilitation period, as factors that influence recovery and their relative importance will vary over time, such as the strong likelihood of the development of co-morbidities. A stepped-care approach can be taken which starts with simple, low-cost, low-intensity interventions and are progressively increased for those who need additional help, thereby efficiently allocating finite resources to meet individual needs. Alternatively, the stratified approach may offer a more streamlined service by looking at their prognosis and deciding what services will be required at a specific time, thereby avoiding treatments which are unlikely to be of benefit.

Case management is defined as “a collaborative process which assesses, plans, implements, co-ordinates, monitors and evaluates the options and services required to meet an individual’s health care, education and employment needs, using communication and available resources to promote quality cost-effective outcomes”.

It is underpinned by a single set of core standards that reflect current legislation and policies, and lay out the minimum level of service expected. Although case managers are not required to be healthcare professionals, and therefore may not work under professional codes of conduct, there is a requirement under the Case Management Standards for case managers to base their practice upon the best available evidence.

Vocational rehabilitation enables people with impairments or health conditions to overcome barriers relating to employment. The idea is to use an activity, often the workplace, as rehabilitation by understanding the challenges caused by the condition and the job role.

In order to be successful, vocational rehabilitation depends upon active involvement from the employee, supported by healthcare and the workplace all working together towards a common goal. Techniques might include the use of rehabilitation technology, providing support for self-management of health conditions or implementing interventions to remove environmental, employment and attitudinal obstacles.

Despite the strong scientific evidence base underpinning vocational rehabilitation, there is an urgent need to improve interventions, particularly regarding support with mental health problems.

In order to improve the success of the return-to-work plan, OH should involve members of the multi-disciplinary team, such as human resources (HR), line managers, GPs, ergonomists and physiotherapists. It is also important to involve the employee, as it is likely to improve cooperation, given that a paternalistic approach, whereby the clinician makes the decision for the employee, is no longer considered acceptable.

Whatever return-to-work programme is decided, it is essential it is transparent for the employee and employer to help provide clarity and manage expectations, which should help address the issue that the workplace itself is often a barrier to returning to work.

Organisational factors and management style

The British Occupational Health Research Foundation has found that the presenting health issue is rarely a barrier to resuming work and that organisational factors and management style commonly have a large part to play. This suggests that efforts in absence management should include ensuring that the culture of the organisation is committed to the health and wellbeing of the workforce from the top down, and not only as a response to statutory requirement.

OH and HR have a significant contribution to make in promoting such a culture and ensuring it is embedded in workplace policies and initiatives.

Line managers should be aware that employee health and wellbeing is central to their role, and employees should be aware of what is expected of them when absent from work. It is therefore important to have a clear and thorough absence management policy that is easily understood and widely accepted. Involved in this should be the requirement for a thorough sickness absence recording and monitoring system which will allow employers to identify patterns and possible work-related or other causes.

It should also involve instruction for line managers to come to an agreement with absent employees about the method and regularity of contact while they are absent to keep both the employer up-to-date about the absence and the employee up-to-date about the organisation. Keeping regular and appropriate contact has been shown to reduce employee’s concerns about returning to work.

Furthermore, it is recommended that the absence management policy include the need to complete a return-to-work interview. This could be informal and brief but should be used to welcome back the employee, ensure a mutual understanding of the return-to-work plan and cover any concerns either party may have. Return-to-work interviews have been found to be extremely effective, more so than disciplinary measures, and are one of the most common methods used by employers for managing long-term absence.

However, this relies upon the interview being conducted sensitively, as it may negatively damage their relationship and impact the success of the rehabilitation plan if poorly handled.

Understanding the advisory role of OH

Occupational health should have a good understanding of the absence management policy, but should remember that it is management’s job to enforce it not the OH department. However, the obligation of absence management on line managers should not be underestimated, and their competency should be ensured by providing adequate training, something that OH should support.

Guidelines, such as those produced by NICE and the Health and Safety Executive (HSE), can help employers to promote workplace morale, increase productivity and support sustained employment by improving management systems, whilst working within the relevant legislation.

Although there is no law that requires employers to rehabilitate absent employees, there is legislation that will apply, such as the Health and Safety at Work etc Act 1974 and the Equality Act 2010.

For example, one of the most common types of disability discrimination is the failure by an employer to make reasonable adjustments for employees who are protected under the Equality Act. OH therefore has a critical role in the area of disability discrimination because it can suggest reasonable adjustments that may assist someone with a disability to secure, stay in, or return to work. However, in addition to following this advice simply because of legislative requirement, employers are increasingly recognising it also makes good business sense as it enables employees to stay in work or return to work more quickly.

Adjustments can often be simple and inexpensive, and should be applied even where an employee’s medical condition might not qualify under the Equality Act. However, if the help an employee needs is not provided by the employer making reasonable adjustments, the government’s “Access To Work” scheme may be able to provide further assistance to further support rehabilitation.

Finally, it is important for management to understand the advisory role that OH plays. It is not within the remit of OH to take responsibility for managerial decisions and whether an adjustment seems “reasonable” must be decided by the employer based on the advice from OH, the nature of the organisation and resources available.

This can raise ethical concerns for OH, as healthcare professionals have a duty of non-maleficence, just as businesses have the same duty under risk management. Yet, healthcare professionals also have a duty to “do good” or “do no harm”.

Just as GPs have a responsibility under the General Medical Council to remain current in their practice, so too do OH professionals under the International Code of Ethics. The code also expresses the need for informed consent to be gained from the employee throughout, and should be a continuous process which is valid only for the stipulated purpose.

Employees should be aware that although consent can be withdrawn at any time, the employer reserves the right to make decisions about the employee’s health and wellbeing based on the available information, so not providing relevant facts may not be in the best interest of the employee.

Conclusions

Overall, it is clear that the benefits of properly managing sickness absence by employers and healthcare professionals are numerous.

By taking a proactive approach and using tools such as case management, vocational rehabilitation, return-to-work interviews and OH, the devastating effect of sickness absence on the employee, employer and wider society can be minimised.

The government has taken a keen interest in absence management and has developed strategies in an attempt to tackle the problem, such as introducing the fit note. Organisations should have employee health and wellbeing embedded in their culture and ensure that absence management policies are thorough, not only to reap the benefits to their company but also to work within relevant legislation.

OH faces challenges in absence management when abiding by professional codes of conduct and ethical obligations which may not marry with the needs of the employer, but none the less are fundamental to its role.

At a glance

  • The benefits of properly managing sickness absence by employers and healthcare professionals are numerous.
  • By taking a proactive approach, and using tools such as case management, vocational rehabilitation, return-to-work interviews and occupational health, the devastating effect of sickness absence on the employee, employer and wider society can be minimised.
  • The government has taken a keen interest in absence management and has developed strategies in an attempt to tackle the problem.
  • Organisations should have employee health and wellbeing embedded in their culture and ensure that absence management policies are thorough, not only to reap the benefits to their company but also to work within relevant legislation.
  • Occupational health faces challenges in absence management when abiding by professional codes of conduct and ethical obligations which may not marry with the needs of the employer, but none-the-less are fundamental to their role.

The importance of reflective practice

This article was written as part of my studies contributing towards my BSc in occupational health, writes Rikki Scott.

As professionals, we have a duty to keep our professional knowledge and skills up to date through a continuous process of learning and reflection and, although I was not new to the concept of absence management, revisiting the basics has been invaluable in strengthening the foundation upon which I base my practice.

No matter any individual’s experience or competence, bad habits and/or complacency can emerge over time. Routinely reminding oneself of the fundamentals is invaluable in ensuring we all remain consistent and safe in the service and care we provide.

The hours of research that have gone into writing this article have enabled me to explore the topic thoroughly and therefore crystallise my thinking. Consequently, I have been able to implement changes and improvements into my everyday practice, whilst also fulfilling some of my duties under the NMC.

I initially trained as a midwife but, after spending two years in the profession, I found myself looking for a new challenge. I thought I would try my hand at an entirely new career and left healthcare – where I lasted only 10 months before deciding to return!

That was when I discovered occupational health and I haven’t looked back. Since commencing my occupational health career, I have gained my BSc with Robert Gordon University, and now continue to progress with Duradiamond Healthcare.

References
Health and Safety Executive 2019. “Managing sickness absence and return to work.” http://www.hse.gov.uk/sicknessabsence/index.htm

National Institute of Clinical Excellence 2019. “Workplace health: long term sickness absence and incapacity to work”. https://www.nice.org.uk/guidance/ph19

Lewis J, Thornbury G 2010. “Employment law and occupational health: a practical handbook”. 2nd ed. London: Blackwell Publishing

Palmer K T et al, 2013. “Fitness for work: the medical aspects”. 5th ed. London: Oxford.

Thornbory G 2019. “Contemporary occupational health nursing”. 2nd ed. Oxon: Routledge.
Gov.uk 2019. “Vocational rehabilitation: what works for whom and when”. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/2 09474/hwwb-vocational-rehabilitation.pdf

O’Driscoll M O, Brough P 2010. “Work organisation and health”. In: Leka S, Houdmount J (editors) Occupational Health Psychology. Chichester: Wiley Blackwell, 2010; pp. 57-86.

Case Management Standards 2009. “CMSUK standards and best practice guidelines”. http://www.cmsuk.org/userfiles/file/000Standards%202nd%20Ed%20Nov%20200 9.pdf

National Institute for Health and Care Excellence 2016. “Workplace health: management practices”. https://www.nice.org.uk/Guidance/NG13

Advisory Conciliation and Arbitration Service 2019, “Absence” http://www.acas.org.uk/index.aspx?articleid=2832

Chartered Institute of Personnel and Development 2016. “Absence management survey”. https://www.cipd.co.uk/knowledge/fundamentals/relations/absence/absencemanagement-surveys

Gov.uk 2019. “Fit Note”. https://www.gov.uk/government/collections/fit-note

Advisory Conciliation and Arbitration Service 2019, “Reasonable adjustments in the workplace”. http://www.acas.org.uk/index.aspx?articleid=6074

Gov.uk 2019. “Access to Work”. https://www.gov.uk/access-to-work

Equality and Human Rights Commission 2016. “What are reasonable adjustments”. https://www.equalityhumanrights.com/en/advice-and-guidance/what-arereasonable-adjustments

Department for Work and Pensions 2017. “Improving Lives. The Future of Work, Health and Disability”. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/663399/improving-lives-the-future-of-work-health-anddisability.PDF

Coole C, et al 2015. “Completion of fit notes by GPs: a mixed methods study”. Perspectives in Public Health, 135(5), pp.233-22.

General Medical Council 2014. “Good medical practice”. https://www.gmc-uk.org/-/media/documents/good-medical-practice—english-1215_pdf-51527435.pdf

International Commission of Occupational Health 2014. “International code of ethics; for occupational health professionals” http://www.icohweb.org/site/multimedia/code_of_ethics/code-of-ethics-en.pdf

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