Collaborative Consent vs. Mandatory Confirmation: A Critical Analysis of Proposed Changes to Occupational Health Practice in England

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Occupational health clinicians in England are currently debating a change in the process by which an employee’s consent is obtained to send an occupational health report to their employer. The current procedure, which I will term "collaborative consent," is ethical, pragmatic, and serves the best interests of all parties involved. A potential alternative, which I will term "mandatory confirmation," would introduce an unnecessary and harmful layer of friction into the process. This article will outline why adopting mandatory confirmation as the default procedure would be detrimental to patients, employers, and the occupational health specialty as a whole.

The vast majority of occupational health consultations are collaborative and constructive, and the collaborative consent model acknowledges this reality. In these cases, the occupational health clinician and the employee reach a shared understanding of the health and work issues and the best way forward. The resulting report to the employer is a reflection of this collaboration, and the employee is typically happy for it to be sent to their employer to facilitate support and adjustments.

It works like this: The occupational health clinician obtains written consent from the worker at the time of the consultation to send the report. The completed report is sent to the employee for their review. If they have questions about the report, or wish to request corrections, the report is held until they actively agree for it to be sent to the employer. If they withdraw consent for the report to be sent, it is not sent. If the employee takes no action, after an agreed time (frequently 2-3 working days) the report is automatically sent to the employer. This approach ensures transparency while minimizing bureaucratic delays.

In the mandatory confirmation model, the report is sent to the employee who is then required to reply to the occupational health clinician and actively confirm in writing that they are happy for the report to be sent to the employer. If the clinician hears nothing further from the employee for a set period (often 7 working days), the employer is informed that the employee did not consent to the release of the report, and that the employee must make management decisions with the information available to them.

Crucially, the collaborative consent model already includes a mechanism for more complex cases. If a case is contentious, complex, or if the occupational health clinician or the employee feels that further clarification is necessary, mandatory consent is engaged for that case. For example, if there is a possibility of misunderstanding, or if the health issue is particularly sensitive, the clinician can require the employee to see and sign off on the full report before it is sent to the employer. This is an existing best practice that allows for the more involved approach of mandatory confirmation to be used exactly when it is needed.

Collaborative consent is designed to be flexible, allowing for increased scrutiny where warranted, without creating unnecessary barriers to employees and employers getting effective occupational health support.

Changing to a mandatory confirmation model for all cases carries with it a tacit implication that occupational health is an adversarial process, something to be feared or mistrusted. It suggests that a shared understanding of the consultation and outcome between a patient and a clinician is insufficient, and that the report is so likely to be contrary to the employee's interests that they must be required to actively intervene to release it. This worldview defaults the process to not sending a report at all, requiring a positive action to approve it and move forward.

Who is harmed?

The potential adverse consequences of this added friction are significant and widespread:

Patients/Employees: The burden of engaging with occupational health increases. The process becomes slower, delaying the employer's receipt of the report and the subsequent application of supportive advice and adjustments. This could lead to longer sickness absence times, potential financial stress for employees with less-generous sick pay terms, and a disproportionate impact on those in lower-income jobs who are already more vulnerable. Furthermore, an unwell employee who simply wants their employer to understand how to best support them now has an extra hoop to jump through. They must be vigilant for an email requiring them to "click to send," adding an unnecessary task to their list at a time when they are already unwell and in need of support.

Employers: Mandatory confirmation delays the receipt of occupational health reports, making it harder for employers to quickly implement recommended adjustments. There is also an increased potential for confusion, as an employer may interpret a lack of active consent from the employee as a refusal to engage in the process, rather than the scenario that the employee simply missed the email or did not manage to respond before the deadline. This could damage the relationship between employers and employees and slow down the return-to-work process.

Occupational Health: By making the management referral process slower and more cumbersome, mandatory confirmation makes occupational health a less attractive and less useful option for both managers and employees. This has a direct negative effect on the reputation of our specialty as a whole. Occupational health improves both health at work and workplace productivity; such a change risks compromising the value and utility of occupational health services.

Who benefits?

The primary beneficiaries of a move to mandatory confirmation would be occupational health providers that currently use this model by default for all reports. As their services are likely slower to release reports due to the 'baked in' waiting period, they are currently at a competitive disadvantage when compared to providers who use the more pragmatic collaborative consent model. An industry-wide move to mandatory confirmation would eliminate this disadvantage, but it would do so at the expense of patients, employers, and the specialty's effectiveness and reputation.

Conclusion

The current collaborative consent procedure, which is in line with current FOM guidance, GMC guidance, and the Access to Medical Reports Act (AMRA) 1988, is flexible, pragmatic, and puts the employee in control. It allows for increased scrutiny when needed, while ensuring that the overwhelming majority of non-contentious cases can proceed efficiently. Mandating an affirmative procedure for all cases is a solution in search of a problem. It adds friction where none is needed and ultimately harms the very people it purports to protect. Occupational health clinicians should resist any such change, and continue to advocate for a system that is collaborative, effective, and efficient and ultimately respects the dual responsibility the specialty has to employees and employers.