Absence essentials: the when and why of employee medicals

Medical assessments of job applicants and employees can help reduce exposure to risk, but there are legal, ethical and good-practice considerations to take on board.

Assessing the health status of existing and potential employees has been an established practice for decades. The evaluations are rated highly by employers, particularly large-sized companies, but less so by trade unions who see them as a means of excluding workers.

Interestingly, those undertaking the medicals - the occupational health providers - rate them lower in terms of importance than other functions within an occupational health service¹.

The term "employee medical" is all encompassing. The assessment of suitability for a particular job may be undertaken by a self-completed questionnaire, by a questionnaire plus specific assessment of an area of the body or of fitness status.

Much more rarely, a "full" doctor-based medical is performed, and the heart, lungs and every other system of the body checked. The value of this "full" medical over and above a questionnaire-based approach was evaluated in the context of pre-employment health assessments in the pharmaceuticals industry. The researcher concluded that there was no added benefit in terms of assessment of fitness to work or in improving health².

Assessments of health status may take place at several stages of the employment cycle, at:

Pre-employment

Pre-employment medicals (PEMs) and pre-employment health assessments (PEHAs) are usually carried out to assess fitness to undertake a particular job at the time and for the foreseeable future. They may also be used to assess if expensive and long training programmes would be cost effective in terms of years of service in the role. PEM/PEHA can also used to identify adaptations to work or work organisation that may be required under the Disability Discrimination Act 1995. In addition, some organisations believe that it is good practice to have a "baseline" medical although, with some rare exceptions, they rarely find it has been of value when considered retrospectively.

Good practice is for PEMs/PEHAs to be undertaken after the job offer has been made and not used as a means of screening those for interview or offer. The assessment should focus on capability and ability to do the job, and requires an up-to-date and accurate job description to be available either at the time or preferably before the appointment so that any queries can be clarified.

Pre-placement

Pre-placement assessments are usually undertaken when individuals change jobs. They are often neglected but are viewed by occupational health providers as very important.

For example, good practice dictates that an individual employed as a warehouse operative who then transfers within the department to be a fork lift truck driver should be referred to the employer's occupational health provider. The person should then be evaluated for fitness to do their new job on the basis of the guidance on fork lift truck driver medical standards produced by the Health and Safety Executive³. An individual with one eye or who experiences episodes of loss of consciousness may be suitable for the former job but not the latter one.

In the same way, a marketing executive based in Europe who transfers to the same job covering Latin America may have to contend with changes in diet, frequent long-haul flights, an office located at high altitude, and customs and practices that may clash with personal values and beliefs. Such a placement could be an expensive disaster if the issues are not considered in advance.

Failing performance

Medical assessment is of value in the management of the failing employee in order to exclude a medical reason for the decline in performance.

Not only could the assessment reveal previously undiagnosed medical conditions, it can also ensure, through liaison with the person's GP, that the optimal treatment is being given. As the number of older workers in the workplace increases, we will need to be more aware of the possibility of dementia, manifesting itself by social withdrawal, reduced concentration, problem-solving and forgetfulness.

Ill health retirement

Assessments for ill health retirement are likely to consider medical evidence obtained from a variety of sources including the GP and treating hospital specialist. The doctor also needs knowledge of the rules and criteria set by the employer's pension fund.

Statutory health surveillance

Formal statutory health surveillance is required under a number of regulations such as COSHH (Control of Substances Hazardous to Health Regulations 2002), the Ionising Radiations Regulations 1999 and Control of Lead at Work Regulations 2002. Health surveillance for noise and hand arm vibration syndrome (also know as white finger) is carried out under the Management of Health and Safety at Work Regulations 1999.

Essentially, this usually means that if workers handle agents such as chrome, lead, or if they use solder or wear latex gloves, then they likely to need health checks, under law, unless the risk of ill health is determined to be sufficiently controlled. Guidance on what checks are appropriate for the agents can be obtained from the Health and Safety Executive's information line (0870 154 5500), its website (www.hse.gov.uk/stress) and in its publications.

Under the Health and Safety at Work Act etc 1974, workers have a duty to assist employers in their arrangements for health and safety, and this includes undergoing medicals and health surveillance. But no worker can be forced to undergo an examination, as this may be deemed to be assault by the doctor or nurse. However, the employer may have to decide in a case where a worker refuses to be examined whether or not they should carry on being exposed to a risk or should be moved to other work.

Thus, it is good practice, from both health and safety and also industrial relations points of view, to include the need for statutory examinations in individuals' contracts of employment.

The doctor or nurse carrying out the assessment will need to ensure that individuals have given their consent, and understand the purpose of the assessment and what information will be passed back to management.

Clinical information obtained at assessments is confidential and should remain locked away and not available outside the occupational health team. Management should be provided with statements of unfitness, fitness or fitness with restrictions, but not with clinical details unless specific consent has been obtained from the employee.

It is important that both employer and employee are clear about which medical examinations they must do (that is, they are required by law), what they should do (because it makes economic sense and is good practice, but is not a specific legal requirement) and what they could do (the "icing on the cake", not legally required but may be provided as a perk for staff, such as cholesterol screening).

At the cessation of employment

Increasingly, employers, sometimes at the suggestion of their insurers, are conducting exit medicals. This is usually with regards to audiometry for noise-induced deafness and is intended to ensure that future loss of hearing is not attributed to previous employment.

General good practice in employee medicals

Having a policy, prior to setting up arrangements for medicals, is essential and should be agreed after discussion with employees or their representatives. The policy should contain the purpose of the examinations, who is responsible for organising them and gaining consent and, most importantly, what information will be passed back to management and how that information will be used.

Prior to referral for a medical, the line manager should explain to the employee the purpose of the assessment, what feedback will be received and how that information will be used⁴. It is not good practice for the manager to make an appointment with the occupational health physician or nurse and for the employee to turn up not knowing why he or she is there or what is going to happen.

A current, accurate job description highlighting any specific and important demands is essential and can aid the identification of any adaptations that might be needed.

When the assessment is for sickness absence, the British Medical Association has published a model letter outlining questions that an employer could reasonably ask of an assessing doctor or nurse. These are:

1. When is the likely date of return to work?

2. Will there be any residual disability; if so. will it be permanent or temporary ? What duties do you recommend the employee does not do and for how long?

3. Will the employee be able to render regular and efficient service?

4. Will the employee require continued treatment or medication on return to work?

The answers may require the occupational health provider to request a medical report from the GP or hospital specialist. This should follow the requirements of the Access to Medical Reports Act 1988. The Data Protection Act 1998 also covers confidential medical information and, shortly, the government's Information Commissioner will publish its finalised guidance on the handling of data within occupational health programmes (to be available from www.informationcommissioner.gov.uk).

This article was written by Dr Nerys Williams, a Consultant Occupational Physician and a Medical Policy Advisor at the Department for Work and Pensions; email: nerys.williams@virgin.net.

Note: This article is not intended as a replacement for professional advice on individual cases.

¹"Comparison of perceived occupational health needs among managers, employee representatives and occupational physicians", N Williams, A Sobti and T C Aw, Occupational Medicine, vol. 44 no.4, 1994, pp.205-208.

²Pre-employment health assessments: an economic appraisal, B Cooper, thesis for Membership of the Faculty of Occupational Medicine, 1992.

³Safety in working with lift trucks, Health and Safety Executive the Stationery Office, 2000.

⁴"Legal aspects of fitness for work", G Howard, in Fitness for work: the medical aspects, edited by R Cox, F Edwards and K Palmer, OUP, 2000.