Too often, occupational health follow-up appointments are suggested inappropriately by clinicians. Often this is due to a lack of diligence in the initial consultation – occupational clinicians should have a good reason for recommending a follow-up appointment.
In many instances, follow-ups are very much required. In safety critical industries such as railway transport, declaring an employee temporarily unfit for their role often requires a subsequent appointment to clarify their fitness to return to duties. This makes sense – you don’t want a driver at risk of a heart attack driving a train with a thousand people on it. If a health condition could have a safety implication for the employee, their colleagues or the public, it’s important to be clear that health no longer compromises safety before the employee returns to work.
However, it’s depressingly common to see follow-ups being recommended because the OH clinician didn’t make a plan in the initial appointment, isn’t sure what to do, and hopes things might have changed in a few weeks. This isn’t good enough, for several reasons.
First, employers often pay per appointment for OH reviews. It’s a waste of their resources, and the employee’s time and energy, to have repeated appointments that add minimal extra value. It compromises the reputation of the occupational health clinician, and the trust that both employer and employee have in the OH process. Even if there is not a direct financial cost (for instance if the OH service is provided on a flat-fee basis or is an in-house service), unnecessary appointments are clearly best avoided.
Second, it keeps the employer and employee in limbo. A follow-up without a clear purpose implies that something is wrong, but doesn’t explain what’s going to change. An example might be an employee experiencing a first episode of depression. An OH report noting the depression, saying they’re speaking with their doctor, and suggesting a follow-up in 8 weeks, doesn’t really help. Is the employee coming back to work after 8 weeks? Will it take longer? The lack of clarity or a plan creates a mystery for employee and employer which supports neither. I’ll talk below about how to provide this clarity.
Third, a poorly conceived follow-up creates all sorts of logistical issues. A weak follow-up recommendation without a plan creates a marker in time around which employer and employee must navigate. If the 4 week follow-up can’t happen for 6 or 8 weeks, what should everyone do? If the employee feels better after 2 weeks, can they go back to work? When someone is ‘under review’ by occupational health without good reason, the focus shifts away from the employee/employer working together to support a successful return to work, and towards an expectation that occupational health may somehow provide the solution. Most of the time when good OH advice is provided, the solution comes from the employee (working where necessary with their treating clinician) and the employer.
Follow-ups, done properly
This being said, follow-up appointments can be enormously useful if used judiciously. A follow-up should be suggested only as part of a plan to support the employee and employer with health in relation to work.
The plan should be clear, wherever possible, on the following:
Why a follow-up is recommended
What is expected to change between the initial appointment and the follow-up
How the follow-up fits with the OH advice to management, and the impact upon the likely resolution of the case.
Let’s return to our employee experiencing a first episode of depression. We can add value by adding context and timescales that help employee and employer understand the likely course of events. An example report excerpt might read:
The employee has consented to my disclosing that they have depression. I’ve advised them that counselling is likely to help them, and they can access this through their company private medical insurance. We have discussed additional measures they can consider to aid their recovery. Although they aren’t fit to be at work at the moment, I anticipate that counselling will significantly aid their recovery, and I expect they will be able to return to work in 4 weeks’ time. If they have returned by this point, a follow-up appointment is not required. If they have not returned to work by 8 weeks, management may wish to consider referring them back to me for further review. This will help us determine if the recommended support is effective and if any additional suggestions can support a return to work.
Some cases require multiple follow-up appointments over a longer period. People with long term or severe illness may benefit from follow-up appointments with occupational health while their condition stabilizes. Someone who has had a stroke for example may experience significant early functional recovery before a plateau over time. Occupational health can advise of what to expect, and the benefit of early active engagement in rehabilitation work, even if it is impossible initially to predict the eventual level of functional recovery. Giving a framework to the uncertainty can be extremely valuable to employee and employer, assisting both with an understanding of how recovery can work.
A follow-up appointment is not a replacement for a plan or a clear explanation of what the most likely course of an illness will be. As always in occupational health reports, recommendations should be made with careful considerations of their benefits and risks, and should be considered as part of a holistic assessment and planning framework to support the employee and employer as effectively as possible.