An Occupational Health report allows us to make more informed decisions about a myriad of different people challenges. Often when instructing OH, the questions asked and the way that they are asked fall short of giving us the answers we need to make better decisions.

So, how can we get the best from a referral to occupational health, and a report that gives us the answers we need to take that next step in the process?

We spent some time with Occupational Health Physician, Mike Coolican of Willis Towers Watson, an accredited Specialist Occupational Health Physician with over 15 years’ experience,  to discuss everything from when and why you should obtain an OH report, what makes a great occupational health referral and what the assessment and reporting process looks like. Over to Mike and Stephen…

What’s the difference between Occupational Health Advisors and Physicians?

Mike: Occupational Health Advisors (OHA) have nursing experience and have then undergone specialist training in occupational health, often to diploma level and sometimes degree level. They are known as either ‘specialist nurse practitioners’ or ‘senior specialist nurse practitioners’.

In general, both advisors and physicians do the same things; looking at the relationship between health and work. There are certainly a lot more OHAs than Occupational Health Physicians (OHPs), so the vast majority of cases are seen by OHA’s, but there are certain cases that tend to be seen by Physicians, and they tend to be cases that are more complex in nature: and that can be either complex in terms of medical conditions, if there’s very complex work issues or legal implications involved, for example where a more robust report from an Occupational Physician is potentially more defensible in an employment tribunal.

Sometimes, certain cases are mandated to be seen by an Occupational Physician. So for example, if there is a suspicion that work related ill health is present, so ‘hand arm vibration’ for instance, that can only be diagnosed by an Occupational Physician. So that case would then get escalated up to us.

Stephen: Generally at Vista we find there is a frustration from those that instruct that they are looking for a diagnosis. Are we right in saying that isn’t usually your remit?

Mike: Yes. I mean, we can diagnose. As doctors, we can say “look, I think that a certain condition may be present” but we would then tend to refer back to the General Practitioner because if someone has got an undiagnosed condition, they would need to see their own GP or be referred to a specialist.

And I see that as our role as OHPs, we look at:

• Are there unmet treatment needs?
• Are there unmet assessment needs?
• Is there potentially a condition here that hasn’t been diagnosed yet?

So we might suspect that is the case, and refer to that in a report, but the actual diagnosis does need to come from their GP or appropriate hospital specialist.

Stephen: So in short, it is the diagnosis that is sometimes important, and helps you to work with the specialist or GP to identify the needs for the individual, and for the business to consider what reasonable adjustments they can make.

What does a good OH referral look like? The million $ question…

Stephen: So you also mentioned the dreaded word of ‘tribunals‘, Vista’s bread and butter, but a lot of OH matters that we refer and that our clients refer, don’t often end up in tribunal. But, when they do – it’s worth remembering from a legal perspective that the instructions are disclosable. The employee may well see the report and lots of HR professionals don’t know this. So, what sort of things would you advise people to avoid doing when referring to OH?

Mike: Well, certainly what tends to make my heart sink is when there is a lack of detail in the referral. So, we don’t know what has been going on at work. Often we just get a diagnosis or a label, there is no indication of what the employer’s concerns are or what adjustments they’ve already put in place.

So detail is really important because that gives us a guide to meet the expectations of the referral. If that is not there, then we can only do the best with what we have got.

On the other hand, too many questions can complicate things. Often we see a list of questions ‘just for the sake of it’ and not well thought through. I have seen referrals where there are 15, 20 questions and a lot of them are just asking the same thing in a different way. That takes up a lot of our time in generating an Occupational Health report. I am not saying don’t write any questions, of course you need to ask us questions, but think about what you actually want answers to and we will give that to you as best that we can.

Another thing that gets my alarm bells going is, if there is information in the referral that has not been shared with the employee. Like you said earlier on, it is disclosable to the employee. So be careful to put in things that are objective and that you can justify, that you can defend, and you are not putting controversial things in.

This is important because when we consent someone for an assessment, we have to help them understand the reasons why they have been referred, and that includes the information in the referral. So beware of contentious statements!

Medicalising management issues is also something that we see often. If we get repeated referrals for the same things, and it is clearly not a medical issue, and we have said that it is a performance issue; management need to manage that.

Are Job Descriptions as Useful as they Seem?

Stephen: Often we see job descriptions included in OH referrals as a matter of course. But a long job description that might not be 100% accurate, how helpful is that to generating your report?

Mike: It’s nice to have a job description, but they are often not very accurate in terms of the demands of the job role. So I tend to go into detail with the employee during the assessment to dig into the detail on what is involved. That allows me to get more information from the employee about things like:

• What they do
• What their perceptions are of the work environment
• How they feel they’re being supported at work
• What support they feel they would benefit from

This gives me much more than I would get from a job description, so it is good to have it, but it is more important to talk to the employee.

At Willis Towers Watson, on our referral we have a section where there are job demands and the referring person can just tick those that apply, and I find that very useful. In fact, I look at that more than I do the job descriptions because then I can cross-reference that with the employee.

What is the general approach that you take after you receive a referral?

Mike: Firstly I would do a pre-clinic assessment. So before the clinic starts, I will look at the referral and see if the employee has been seen before for any previous reports, I will go through those as well. So I will get up to speed on the case and have an idea of what is expected from the assessment before I see the employee.

When I see the employee, I tend to then consent them for the assessment. So I will explain why they’ve been referred, and I will go through the referral with them. I’ll explain what my role is, what the assessment involves in terms of getting a more detailed history, and find out what their perceptions are. If necessary, I’ll do an examination, and then explain to them that at I will write a report back to the individual who’s made the referral, with my opinion and recommendations.

Mostly the employee will consent, or they might ask for further clarifications, and then I proceed with the assessment which includes:

• A full medical history
• Background into the health condition
• What investigations or treatments they are having
• Are there any other conditions that could potentially be impacting on their work capabilities?
• What medication they are currently taking? And any side effects
• Social history – we tend to adopt a bio-psychosocial approach: so we are looking at the social background, what’s going on at home, as well as what’s going on at work.
• Current symptoms and functional abilities: this is crucial to advising on fitness for work. So I do a functional assessment on what they can do, and what they are finding it difficult to do.
• Explore the job role: so I will ask them about what they do, and what difficulties they’re having at work, what they feel the work issues are.
• Examinations: either physical or mental state if necessary
• Conclusion: to summarise with the employee what my opinion would be, and the advice that I think needs to be given to the employer.

I do this so that there is a shared understanding in terms of fitness for work, adjustments, modifications – the employee needs to be on side there as much as possible. If they are happy, we conclude the assessment and I will generate a report to the employer.

After Covid-19, do face to face occupational health assessments still have their place?

Stephen: Judges used to have an approach (certainly before lockdown) that, particularly in cases where it may lead to termination, face-to-face assessments were necessary. Where are we now following multiple lockdowns and this new world of work?

Mike: During Covid we were forced to do remote telephone assessments and teams assessments. But we are back seeing people face-to-face and that is really important.

We can see people remotely, I think with remote Teams assessments you have got the non-verbal communication element which is really, really important. My least favourite probably is the telephone because you just don’t get that sort of visual assessment.

If a physical examination needs to be undertaken then you are right, I think the thinking was that with a potential tribunal case you would want to see the person face-to-face and do an examination. I am not sure if that is the case now. I think you could probably get away with seeing them remotely via Teams. I don’t know, I’ve never been to a tribunal – touch wood!

But my view is, yes, certain cases still face-to-face, particularly if clinical examination is required or very complex medical issues, where the employer’s concerned particularly about the appearance. If the employee is really unwell, or they’re worried about certain aspects of their health that they can observe, then I think, the face-to-face or remote would be required then.

Stephen: In our experience at Vista,  sometimes for initial consultations and background the telephone is absolutely fine, for speed as well, but when we are getting to the point of termination or where there is an assessment observation to be done, then face-to-face is something I know the Judges certainly check – and they have the similar view to you.

Mike: Yes. That reflects the change you mentioned, I mean we can do a limited video examination, you can get people to move their arms, you can do a mental state examination just from the observations, but you can’t listen to the heart, you can’t check their blood pressure and so I think a video assessment is good, but face-to-face is the gold standard.

The Occupational Health Report Itself

Stephen: So moving onto the report, what is the general structure and what sort of things do you care to ensure are in the report for the individual and for the employer?

At Vista we find something that certainly shocks the more junior members of HR community and some managers, is that not only will the employee see the instruction, but they get the opportunity to review the report before it goes to the employer. And they can withdraw the consent for that to go even at that stage. So what does a report actually look like?

Mike: People have different styles, but my style is:

• General introduction – why the person has been referred and that they’ve consented
• Background – so there is a medical background of the health issues that are relevant to their fitness for work, investigations, any of the relevant issues that may be present. We have a duty of confidentiality, which is important. Some employees don’t want their employers to know certain things and we can’t disclose confidential medical details without the employee’s consent. Most employees I find are fairly relaxed about it but I always check with them.
• Current situation – So in terms of their current symptoms and function, I think that is important, because if you are giving recommendations, the recommendation will make more sense if you can see that they’re relevant in terms of the employee could only sit for 10 minutes and has to get up and move around. And if you are recommending they need adjustments in terms of varying their posture frequently, a computer workstation risk assessment, the employer will understand – the adjustments make more sense if there is a reasoning for it.
• Work issues, work perceptions, demands of the job, any difficulties the employee has, what they feel has been going on in the workplace, what their concerns are, and how they are being supported by their employer.
• Conclusions and recommendations – usually a quick summary of everything and then occupational health recommendations, fitness for work, adjustments, modifications, both short and long-term, and long-term prognosis. We also look at whether there is an increased risk of sickness absences, whether the condition may relapse in the future, what the factors may be causing that etc, and if there are any work factors that may cause the condition to relapse.

There is usually always an opinion on the Equality Act in there too: so whether in my opinion it might apply or not, but I always put a disclaimer in because that ultimately is a legal decision.

Additional Guidance

We also give guidance as to where further information could be sought, or if there is funding or equipment available. We can recommend further assessments, so for example if there is a suspicion someone may have underlying, undiagnosed neurodivergent condition, then we can signpost to that.

We can advise on access to work, the support that is available to help people with disabilities in the workplace and we can also commission independent specialist assessment. So if someone has got complex mental health difficulties causing major issues at work, we can recommend a referral to an independent specialist for further evaluations, treatments, prognosis, etc. At Willis Towers Watson we also have resources that we can link into in terms of carrying out functional capacity assessment; so getting more objective evidence of what people can and can’t do.

We can arrange counselling, CBT inputs, physiotherapy inputs, we can help with risk assessments as well. So there are lots of things that we can do to help employers manage their employee and meet their obligations.

Stephen: Brilliant, sometimes there is a limit as to what information can be provided and I think that sometimes the most helpful point for an employer is guidance of where to go next.

The Vista website has got lots of guidance on neurodiversity, but the breadth of the conditions that may need an assessment, and knowing where to get that and how to get that, it’s tremendous to hear you’re able to provide that service.

Mike’s Top Tips when Making an Occupational Health Referral?

Stephen: In addition to thinking about how many questions to ask and what you really want to get out of an occupational health report, what else would you suggest?

Mike:

Be clear about why you are asking for an occupational health referral in your own mind.

Think about the reasons for the referral (not just a tick box exercise), we are there to support employers, help them meet their legal obligations. But also to facilitate health, wellbeing and attendance at work. So really think about the reasons why you are referring to occupational health, what you want from the assessment and what you need from it.

Communicate your expectations

If we don’t know what your expectations are, we’ve got one arm behind our back. So think about what questions you want answering, put some thought into it. What is going to help you in terms of supporting your employee?

Give us good background details

Make sure to include:

• What the concerns are at work
• What you have observed
• What support you have already given or put in place for the employee and how effective that has been
• An outline of the job role
• Stick to the facts – don’t put anything too emotive in there or anything that you’re not prepared to defend
• Before you refer, discuss and explain to the employee why you are referring

Stephen: From the legal side we often see a fear factor, or suspicions about objectives, so we always say to our clients, think about how you ask the questions to yourselves and your colleagues. Open questions are the way to go.

Well, thank you Mike on behalf of everybody, it is useful to get some clarity on the Occupational Health process and also the further support that is available following receipt of an OH report. I think there are only a couple of things that I would like add.

Ask for more if needed – If the report prompts further questions, don’t hesitate to go back and ask for more information. Otherwise you risk relying on incomplete information to base what could be significant decisions.

Only base decisions on up to date information – if an occupational health report was requested some time ago, you may not necessarily be able to rely on it now.

If you take anything away from this blog, let it be this formula; good quality input = good quality output. A valuable and detailed Occupational Health report will ensure you can make the right decision for both your employee and your organisation.

Willis Towers Watson have 35+ years’ experience of providing advice on employee health and benefits to UK organisations. They have an in-house team of medical professionals including registered nurses, occupational health advisors, physiotherapists and OH consultant physicians like Mike, so if you are looking for support in this area then please contact WTW here.

Vista provide practical employment law support for employers, we work in partnership with HR teams supporting them with employment law advice on anything from disciplinary hearings and grievances, to redundancy, TUPE, negotiation with trade unions and representation in the employment tribunal. We also provide training for HR teams and line managers in people management & employee relations issues and provide services to support diversity, equity and inclusion.  If you are looking for support in any of these areas please drop us a line.