Research and analysis

Employers’ motivations and practices: A study of the use of occupational health services

Published 2 April 2019

DWP research report no. 979

A report of research carried out by Ipsos Market and Opinion Research International (MORI) on behalf of the Work and Health Unit.

© Crown copyright 2019

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First published April 2019.

Views expressed in this report are not necessarily those of the Department for Work and Pensions (DWP) or any other government department.

The research was carried out in accordance with the requirements of the international quality standard for Market Research, ISO 20252:2012, and with the Ipsos MORI Terms and Conditions.

Executive Summary

This one-page summary presents the key findings from qualitative research with employers conducted by Ipsos MORI on behalf of the Work and Health Unit (WHU). Interviews explored employers’ practices and motivations for using occupational health (OH) services. Six interviews were also conducted with employers who undertook a range of health and wellbeing measures in-house, but who did not have formalised OH in place.

Employers had a shared, but basic, understanding of OH services. Fundamentally, they understood the benefits of consulting a qualified expert for situations they felt unable to handle alone, either through lack of expertise or due to a need for an independent third party. Beyond this, employers used OH services for various reasons and services.

Situations OH support was used for:

• supporting staff with mental ill health
• attracting and retaining talent
• verify medical statements and health surveillance
• supporting a return to work
• investigate underperformance or poor conduct
• supporting staff with physical ill health

OH service used:

• Employee Assistance Programme
• counselling
• physiotherapy
• Cognitive Behaviour Therapy
• workstation assessment
• physical health or screening or assessment

The research identified 3 employer typologies: reactive purchasers (sought ad hoc support, no contract), proactive purchasers in office-based environments (permanent contracts in place), and proactive purchasers in manual environments (permanent contracts, operating in sectors with higher health and safety risks). Permanent contracts allowed employers to provide more holistic offers.

Employers provided access to OH services for 3 reasons: to comply with legal and regulatory obligations (legal); to reduce costs and improve business efficiency (cost); and to support and improve employee health and wellbeing (moral). Whilst one of these motivating factors was a priority in certain cases, in general they were usually interlinked.

Employers’ wishes to retain employees emerged as the main, overarching reason why they sought OH support. Employee retention encompassed all 3 of the motivations for providing OH services: cost (having to replace staff members), moral (employers valued their employees), and legal (ensure actions complied with employment law). OH services were rarely used to manage a member of staff out of the organisation.

For employers without OH, but who were engaged in other health and wellbeing activities, the barriers to purchasing services were: financial, attitudinal, and a lack of knowledge or misconceptions as to what OH involved^{[footnote 1]}. Similar reasons were given by reactive purchasers for not having permanent contracts. Whilst all employers recognised the cost of sickness absence, not all employers understood or had considered the benefit of providing OH to reduce or prevent sickness absence. Employers were largely positive about their OH providers, and relied heavily on them to recommend services or treatments that should be a part of the package they received.

Acknowledgements

The authors at Ipsos MORI would like to thank the team at the Work and Health Unit (Gemma Comber, James Hudson, Lisa Schulze, and Maisie Payne) for their advice, guidance and enthusiasm throughout this project. Thanks are also due to our colleagues at Ipsos MORI who helped with recruitment, fieldwork and analysis, with a particular mention to Katrina Leary.

Last, but by no means least, the authors would also like thank all the employers who took part in the research.

The Authors

This report was authored by researchers at the Ipsos MORI Social Research Institute:

• Sarah Fullick, Associate Director
• Kelly Maguire, Senior Research Executive
• Katie Hughes, Graduate Research Executive

Glossary and Abbreviations

Agriculture and Energy	Includes: Agriculture, Forestry and Fishing; and Mining and Quarrying; Utilities, Waste Management and Remediation Activities.
Banking and Finance	Includes: Financial and Insurance Activities; Real Estate Activities; Professional, Scientific and Technical Activities; and Administrative and Support Service Activities.
Distribution, Hotels and Restaurants	Includes: Wholesale and Retail Trade; Repair of Motor Vehicles and Motorcycles; and Accommodation and Food Service Activities.
Employee Assistance Programme (EAP)	Designed to support employees with personal or work-related problems that adversely impact their ability to do their job, or their general health and wellbeing.
Human Resources (HR)	Describes the management and development of employees. This includes: recruitment, benefits, training, and employment law.
Long-term sickness absence (LTSA)	An instance of sickness absence from work lasting 4 or more weeks.
Large employers	Employers that have 250 or more permanent employees.
Medium employers	Employers that have 50 to 249 permanent employees.
Micro employers	Employers that have one to 9 permanent employees. However, for the purposes of this research, organisations with only one employee were screened out of the survey. Micro employers are here defined as those with 2 to 9 employees.
Occupational Health (OH)	For this research, the definition used with employers was: Advisory and support services which help to maintain and promote employee health and wellbeing. OH services support organisations to achieve these goals by providing direct support and advice to employees and managers, as well as support at the organisational level, for example to improve work environments and cultures[footnote 2].
Occupational Sick Pay (OSP)	Where an organisation chooses to provide a contractual sick pay that is more generous than the statutory minimum (i.e. Statutory Sick Pay).
Other Services	Includes: Arts, Entertainment and Recreation; and Other Service Activities.
Public Administration, Education and Health	Includes: Public Administration, Defence and Compulsory Social Security; Education; and Human Health and Social Work Activities.
Reasonable adjustments	Steps taken by employers to ensure workers with disabilities or health conditions are not substantially disadvantaged when doing their jobs. Examples include installing a ramp for a wheelchair user, or allowing someone with social anxiety to work from home[footnote 3].
Small employers	Employers that have 10 to 49 permanent employees.
Statutory Sick Pay (SSP)	The minimum amount an employer must pay employees who are too ill to work. SSP is currently set at £92.05 per week for up to 28 weeks[footnote 4].
Transport and Communications	Includes: Transportation and Storage; and Information and Communications.

Summary

Background and methodology

‘Improving lives: The Future of health, work and disability’^{[footnote 5]} outlined the role of good quality occupational health (OH) to help disabled people and people with health conditions stay, and thrive, in work, as well as preventing unnecessary sickness absence, presenteeism and health-related job loss.

The Work and Health Unit (WHU), commissioned Ipsos MORI to conduct qualitative research with employers to understand their motivations and practices when using OH support and to explore:

• how employers use OH services
• why employers use OH services as they do
• why engaged employers do not purchase OH services

WHU is a UK government unit which brings together officials from the Department for Work and Pensions and the Department of Health and Social Care, to lead the Government’s strategy to support working-age disabled people, or people with long-term health conditions enter, and stay in, employment.

Ipsos MORI conducted 35 in-depth telephone interviews with employers in October and November 2018. Participants were business owners, office managers, or HR representatives and quotas were set on size and sector (see Appendix 9.1).

What do employers think OH services are and when do they purchase them?

Employers had a shared, but basic, understanding of OH services. At a fundamental level, they understood the benefits of bringing a qualified expert into an organisation when a situation arose that they felt unable to deal with themselves, either through lack of expertise or because of a need for an independent third party. In practice, employers used OH services for a number of different reasons and services, including treatment.

The nature of OH provision was affected by a mix of size, sector and the working environment, and the research identified several typologies^{[footnote 6]}:

• reactive purchasers: sought ad hoc OH support, without permanent contracts. Their reasons for not having permanent contracts are covered in Section 2.2
• proactive purchasers in office-based environments: had permanent OH contracts and worked in sectors that did not pose major physical health and safety risks
• proactive purchasers in manual environments: had permanent OH contracts in order to manage the health and safety risks associated with the nature of their work/ workplace

Having permanent contracts in place meant that employers could respond quickly to new situations, as well as proactively support employees through access to services designed to prevent ill-health (such as 24-hour counselling and wellbeing and healthy living guidance).

Six interviews were conducted with employers who had not purchased formalised OH services, but in the past year had carried out a range of interventions to support employee health and wellbeing in-house.

What are the motivations for using different OH services?

Employers used OH to help deal with situations in which they were not sufficiently skilled, and were motivated to provide OH services for 3 reasons:

• to comply with legal and regulatory obligations (particularly important for employers in manual environments, where the nature of the work posed a risk to employee health and safety)
• to reduce costs and improve business efficiency (employers understood the costs associated with sickness absence and wanted to limit them)
• to support and improve employee health and wellbeing (employers felt they had a moral duty of care to their employees)

These 3 factors were usually interlinked when employers considered their motivations for using OH services. For example, employers who used OH services to mitigate health and safety risks did so in order to be legally compliant, but also to avoid (costly) sickness absences resulting from workplace accidents, and because they felt a (moral) responsibility towards their employees.

Whilst legal regulatory compliance may have initially formed the foundations of employers’ OH offers, those who felt they had a duty of care that exceeded their basic legal duties had expanded their OH offer to include wider health and wellbeing benefits in recent years.

In which situations do employers use OH services?

The diversity of situations that OH services could be used to support meant that, across the interviews, employers did not have a shared interpretation of what OH services could be used for in practice. However, across all the examples shared by employers, wanting to retain employees emerged as the main, overarching reason why employers sought OH support. The wish to retain employees encompassed all 3 of the motivating factors for seeking OH: cost (to avoid the cost of having to replace staff members), moral (because employers valued employees and wanted to keep them), and legal (to ensure any actions they took were carried out in accordance with employment law).

The situations that employers used OH services for, and the specific services, used are shown below.

Situations OH support was used for:

• supporting staff with mental ill health
• attracting and retaining talent
• verify medical statements and health surveillance
• supporting a return to work
• investigate underperformance or poor conduct
• supporting staff with physical ill health

OH service used:

• Employee Assistance Programme
• counselling
• physiotherapy
• Cognitive Behaviour Therapy
• workstation assessment
• physical health or screening or assessment

Why do engaged employers not offer OH services?

A small number of employers, who had not purchased OH, but were engaged in wellbeing activities, primarily stated they had tight profit margins and could not justify the expense of OH, preferring to signpost employees to free resources (such as the National Health Service (NHS) or dedicated charities). Lack of knowledge or misconceptions were also evident; these engaged employers had a more limited understanding of what OH services actually involved.

Finally, attitudes around employers’ responsibility towards their employees also presented a barrier. Some, in particular small employers, felt that a formal OH service ran counter to their ‘family culture’, whereas others felt that providing for their employees’ health and wellbeing was beyond their remit, and that employees should be taking responsibility for this themselves.

Given the small number of these interviews, these findings should be treated as indicative.

How do employers choose an OH package or provider?

The personnel involved in these decisions varied depending on the organisation’s structure, and included: internal HR teams, senior management, or external HR consultants. HR consultants were used by smaller employers who lacked the time and/or expertise to handle human resource issues.

For the most part, employers performed internet searches to choose their providers and, in some cases, the history of how or why they had chosen their OH provider was unclear or undocumented. Employers without a permanent contract in place often needed to find an OH provider quickly, and would make a shortlist of providers who offered the service(s) they required, were local and, all other factors being equal, chose the cheapest provider.

Reviewing OH provision was rare, and the examples were confined to large employers (Section 5.1). The factors involved in choosing and keeping a provider were:

• expertise: in resolving situations or finding workable solutions; understanding specific job roles and circumstances; understanding the nature of the working environment, and any restrictions on adjustments; and producing useful reports
• cost and efficiency: covering: speed of initial response; efficiency and speed of consultation; and regular communication

In most cases where employers had a contract in place, they relied heavily on their OH provider to recommend a package of support. Business needs, whether this linked to compliance or broader business objectives such as productivity, often shaped the type, size and frequency of the package purchased. Where employers had seen increased disclosures of mental ill-health, they had looked to expand their OH products to include services such as counselling and Employee Assistance Programmes.

How does the OH referral process work in practice?

The process of how an OH assessment (i.e. an assessment of an employee’s physical or mental health with a view to supporting employees to carry out their role to the best of their ability) worked in practice typically followed the 6 stages shown below^{[footnote 7]}. Employers reported some variation within these stages, depending on their size, relationship with their employees or whether they had an HR function, which are outlined in more detail in the main report (Section 6.2).

1. Decision: The suitability of OH is discussed, and employee consent gained. Interchangeable with Step 2.

2. Referral: Could be self-referral or referral from HR or Line Manager depending on organisational setup. Interchangeable with Step 1.

3. Assessment: OH practitioner carries out an assessment of the employee.

4. Report: A findings report is written, with the level of detail shared up to the employee.

5. Action: Any suitable changes may be made. Managed by HR or Line Manager depending on organisation.

6. Review: An informal or formal review is undertaken.

What do employers think about their providers?

Employers were broadly positive about their OH providers. As they used OH specialists for situations they felt they either could not or should not handle themselves, they saw their OH providers as a source of expert advice and guidance. When asked to consider improvements or tensions within the relationship, employers highlighted the following:

• slow turnaround or delayed responses
• vague or unactionable recommendations
• poor communication and information sharing

What policies do employers have in place?

Most employers did not have a dedicated organisational policy guiding their use of OH, rather it was included as part of a wider sickness absence, health and safety, or attendance management policy, reflecting the different uses of OH across different types of employers. The level of detail in employers’ policies was minimal (i.e. when to seek OH support) and, as such, guidance for line managers was not prescriptive. Employers explained that this enabled their OH-use to be more tailored and adaptable on a case-by-case basis. For others, the use of OH was so infrequent that they did not see the need for a more detailed, formal policy.

OH was often communicated through general all-staff channels. Some employers reported that line managers ought to have a greater awareness of OH policies than other staff members. This was because managers would need to know the policy to effectively supervise employees and/or the hazardous sites in which they may work.

1. Introduction

1.1. Background to the research

The ‘Improving lives: Future of health, work and disability’^{[footnote 8]} paper outlined the role of good quality occupational health (OH) to help disabled people and people with health conditions stay, and thrive, in work, as well as preventing unnecessary sickness absence, presenteeism and health-related job loss.

The Work and Health Unit (WHU) commissioned Ipsos MORI to conduct qualitative research with employers to understand their motivations and practices when using OH support. WHU is a UK government unit which brings together officials from the Department for Work and Pensions and the Department of Health and Social Care, to lead the government’s strategy to supporting working-age disabled people, or people with long-term health conditions enter, and stay in, employment.

Proactive management of ill-health and chronic conditions in the workplace is proven to help prevent long-term job loss^{[footnote 9]}. This includes employers seeking and acting on OH advice. Good quality OH support has the potential to improve health and work outcomes, by preventing work-related illness and unnecessary sickness absence, and supporting those with health conditions to remain in work. The government’s aim is for more individuals to have access to appropriate and timely OH advice, and enable people experiencing health conditions or disabilities to stay, and thrive, in work.

What is occupational health?

OH can be defined as advisory and support services which help to maintain and promote employee health and wellbeing. OH services support organisations to achieve these goals by providing direct support and advice to employees and managers, as well as support at the organisational level, for example to improve work environments and cultures^{[footnote 10]}. OH focuses on the physical and mental wellbeing of employees at work, and can cover^{[footnote 11]}:

• preventing work-related illness or injury through encouraging safe working practices, and helping employers to implement policies and health and safety compliance
• supporting employees to manage conditions and remain in work through reasonable adjustments (for example, ensuring the workplace is accessible, making changes to employees’ desks or chairs for more comfortable working, amending job roles, or sign-posting appropriate interventions)
• supporting the management of sickness absence, both long and short-term, and employees’ return to work (including amending job roles, or flexible/phased returns)
• preventing common health concerns from becoming a problem through monitoring the health of the workforce (trying to proactively prevent sickness absence), including conducting pre-employment health assessments, or supporting health promotion and education programmes
• providing advice and counselling to employees around non-health or non-work related problems

OH providers are professionals that employers use to support their employees, or to support their management of employees. OH was not included in the NHS’ remit when it was formed in 1948. This has led to a private market of OH providers which specialise in the provision of OH services to employers. In recent years, the OH market has adopted a multidisciplinary workforce which includes, but is not limited to, healthcare professionals (doctors or nurses), physiotherapists, hygienists, psychologists, occupational therapists, or ergonomic experts^{[footnote 12]}.

1.2. Research aims

The WHU commissioned Ipsos MORI to conduct qualitative research with employers to understand their motivations and practices when using OH support. Specifically, the research sought to answer 3 questions:

1. How do employers use OH?

• range of support sought: nature of OH provision, determinants of shape/scope of OH support, criteria in employers’ purchasing choices, what is OH used for?
• determining need: who is eligible for support and what determines OH use in specific cases? What determines whether an employee is offered rehabilitative treatment like physiotherapy, or more costly interventions?
• responsibility and role clarity: who is responsible for making OH referrals and acting on advice? Is there clarity to make referral decisions, or it is mainly discretionary?

2. Why do employers use OH as they do?

• business objectives or policies that relate to OH? For example, to what extent is OH offered to support other company policies such as sickness absence management, or talent management?
• where would employers seek advice when deciding on OH and how much are they influenced by other employers and providers? Are their decisions based on financial considerations, or duty of care?

3. Why do engaged employers not purchase OH?

1.3. Method

HR representatives within organisations that had taken part in the ‘Sickness absence and health in the workplace: Understanding employer behaviour and practice’ research with Ipsos MORI during the summer of 2018. The survey was representative by size and sector of employers across Great Britain and the report is due to be published later in the year, with an interim report to be published in April.

Interviews were conducted with OH-users (29 interviews) and employers without OH services (6 interviews). The latter were ‘engaged employers’ that were sampled on the basis of having stated they did not provide access to OH services, but provided a range of other services that were akin to the services of an OH provider. They were included within the research to explore their reasons for not seeking OH support, despite having recent experiences in areas where OH support could be helpful, such as:

• managing employees’ return(s) to work after long-term sickness absence
• making efforts to prevent employee ill-health, or
• making efforts to improve the general health and wellbeing of their workforce

Quotas were also set on:

• size: micro (2 to 9 employees^{[footnote 13]}); small (10 to 49); medium (50 to 249) and large employers (250+)
• sector: Agriculture and Energy (ABDE); Manufacturing; Construction; Distribution; Hotels and Restaurants (GI); Transport and Communications (HJ); Banking and Finance (KLMN); Public Administration, Education and Health (OPQ); and Other Services (RSTU)

Please see the Appendix (9.1) for the full quota table and detailed methodology.

1.4. Interpretation and representation of qualitative data

Qualitative approaches are used to explore the nuances and diversity of views, the factors which shape or underlie them, and the ideas and situations in which views can change. The results are intended to be illustrative of the range of views, not statistically representative.

Verbatim comments have been included in this report to illustrate and highlight key points and common themes. Where verbatim quotes are used, they have been anonymised and attributed by sector and size.

2. What affects the nature of employers’ OH provision?

This chapter explores what employers think occupational health involves, and the nature of their OH contracts. The chapter introduces 3 employer typologies which help to describe how the nature of OH provision varies depending on employer characteristics, in addition to engaged employers without formal OH contracts.

2.1. What do employers think OH is?

OH-users looked to purchase services from OH providers as professionals whose expertise they could draw on for support in situations:

• involving employee health and wellbeing that they did not feel they could manage effectively on their own due to a lack of expertise, or
• they felt were better handled by an independent third party (for example, where mediation or distance between employer and employee might be required)

Employers understood the concept of OH – as support from an expert to look after the health and wellbeing of employees – regardless of size, sector, or experience. However, there was a lack of shared understanding across the interviews in terms of the different ways that OH services could be delivered. For example, some thought that private health cover offered as a staff perk counted as OH use, and there was a lack of consensus over whether OH-use necessitated employers paying for support or treatment. In one case (shown below), despite using OH services on an ad hoc basic, an employer did not count themselves as an OH-user.

Case study: OH as an ‘administrative exercise’ rather than employer provision

One medium-sized construction firm did not consider themselves to be an OH-user as they only used OH services when required to by a client. When they won contracts with multinational firms or government clients, they were required to provide certification for all employees due to work on the contract, carried out by an OH professional, that they were fit to work.

As these OH assessments were a contractual requirement for certain types of clients, this employer saw their use of OH as more of an administrative exercise, rather than something they had introduced, as an employer, for the benefit of their employees.

We have to get a medical assessment by an OH provider when we win certain contracts, but we don’t single it out as OH use. We don’t use it ourselves, only when we’re told to. I suppose we do use OH, technically, but we see it as being under a different heading – we’re using it for our health and safety arrangements.

(OH-user, Medium, Construction)

Overall, those who did not purchase OH services had a more limited understanding of what OH services involved and could offer them (covered in more detail in Section 2.2).

2.2. Employer typologies associated with OH provision

Employers used OH in a number of different ways, and what support they required depended on the specific situation. Analysis of the data uncovered different typologies of employers in terms of the nature of their OH provision and how this is affected by size, sector and working environment. Details of these 3 typologies are discussed below.

The following typologies, referred to throughout the remainder of the report, are not intended to be a comprehensive segmentation of employers. Instead, they are all subgroups of employers emerging from the interviews who tended to have similar characteristics affecting the nature of their OH provision, or lack thereof. It is also important to note that these typologies exist within the study population, which may not be representative of the wider employer population.

Reactive purchasers had bought OH services but did not have a permanent contract in place. Instead, they used OH services in reaction to specific events that they felt unable to handle within their existing structures. For example, an employee might develop a health condition and the employer may need support to manage their sickness absence, return to work or amend their job role.

Whilst most of the reactive purchaser examples did relate to dealing with sickness absence, it is important to note that OH services were not always purchased for this reason. Reactive purchasers sought specialist support when they could not handle a given situation. In addition to sickness absence management, situations identified were performance management issues, or the need to amend an employee’s job role or working environment.

We have not considered a permanent package, because we only need to use OH every few years … It’s an extra cost, but we’ve looked at OH as a necessity in those cases where we’ve felt unable to make a proper judgement and needed a third-party professional.

(OH-user, Medium, Manufacturing)

Employers purchased OH services reactively rather than proactively because:

• they believed they did not have the volume of cases for which a permanent OH contract was required. If employers saw an increase in need for OH services among their workforce, then it would become more cost-effective to have a permanent contract. A permanent contract would reduce both the direct costs of the services and the indirect costs to the employer, namely employer time in organising individual OH transactions. Recognising when the number of cases had reached the point at which a permanent contract became more cost-effective was generally the result of employers analysing sickness absence data, or if it was found that employees were disclosing conditions/requesting support in greater numbers
• of historical reasons (i.e. employers who have always purchased OH services on an ad hoc basis and see no reason to change)
• of attitudes towards health and wellbeing and the role of the employer (particularly influential in small and medium businesses where negative attitudes about these topics can have more traction). There were examples of new HR or senior personnel coming into organisations and instilling a culture of health and wellbeing, where this did not previously exist, therefore enhancing the understanding of OH and how OH services could be used

The factors above were largely correlated with size and sector. Whilst it is not accurate to say that all reactive users were smaller in size, smaller employers were less likely to have the volume of cases to make investing in a permanent OH contract more cost-effective than purchasing OH services on an ad hoc basis.

Likewise, smaller employers were more likely to experience financial barriers (perceived or otherwise) to purchasing permanent OH contracts. Across the interviews, there was evidence that this was due to both lack of capital (some employers said they lacked the upfront funds to be able to purchase a permanent OH contract), and an inability to justify the expense, as it would eat into their profits. Two attitudes emerged amongst reactive purchasers who felt they could not afford to engage an OH provider on a permanent contract:

• cost was a prohibitive factor but employers understood the benefits of OH services (in terms of reducing sickness absence and associated cost) and how the benefits could outweigh the cost of paying for a permanent contract. Whilst they understood this in principle, these employers still felt their margins were too tight to be able to afford the upfront cost of OH services
• employers who had not considered, or did not understand the cost nor the benefits of providing comprehensive OH services (OH services that also addressed any underlying drivers of sickness absence or poor employee health and wellbeing). Attitudes and lack of knowledge/understanding usually shaped this perception. For example, these employers either did not believe or understand how OH services could reduce sickness absence (and therefore reduce cost to the employer), or they did not think it was their duty as an employer to take an active role in employee health and wellbeing^{[footnote 14]}

Proactive purchasers in office-based environments had a permanent contract in place with their OH provider(s). These employers worked in non-manual environments, and were associated with sectors that did not pose major health and safety risks, and so staff were less likely to suffer workplace injuries. They also tended to be medium or large employers (though not exclusively, as shown by the below verbatim), as in most cases they required the critical mass of employees who could present with health concerns in order to justify a more proactive approach.

Having permanent contracts in place meant that these employers could respond quickly to new situations that required OH support, as well as proactively supporting employees through access to services such as 24-hour counselling^{[footnote 15]} and preventative measures (such as wellbeing and healthy living guidance).

Across the interviews, there were examples of employers who used to be reactive purchasers but decided they needed to engage with a supplier on a more permanent basis. These employers set up permanent contracts as a result of their employees coming to them and asking for more support; employers felt that disclosures of mental ill-health, in particular, had increased in recent years and thought this was due to wider societal conversations around mental health and the topic’s stigma beginning to lessen.

I think, really, we were reactive at first, because of one employee’s situation and not knowing how best to handle it. But as people have disclosed more and more mental ill-health, we’ve become more aware of it and more proactive as an employer to put things in place for them.

(OH-user, Small, Other Services)

Proactive purchasers in manual environments had a permanent contract in place with their OH provider(s) in order to manage the risk associated with the nature of their work/workplace. These employers operated in sectors where health and safety was paramount, such as Manufacturing, Construction, Agriculture and Energy, and organisations involving working offshore, with machinery, chemicals, or food handling or production.

As a result, the nature of their provision was geared more towards employees’ fitness to work. These employers mostly used OH services for medical screening, fitness to work assessments and to fulfil legal obligations, such as health and safety legislation, specific to their sector, but also for services outside of this (such as managing sickness absences and supporting returns to work). Given the regularity with which employers in such environments required these services, it was more cost-effective for them to engage a permanent supplier than continually arrange ad hoc OH contracts.

However, there were examples of proactive purchasers in manual environments who had expanded their OH offer beyond health and safety to include things like counselling, Employee Assistance Programmes (EAPs), and wider health and wellbeing support. These employers had decided to expand their provision for one or both of the below reasons:

• they had seen an increase in the number of staff disclosing mental health conditions, or
• new senior or HR staff had come into the business and driven forward the health and wellbeing agenda (example below)

When I first started, medicals were seen as a necessity for sea-farers. There wasn’t previously a qualified HR person here, so when it came to someone returning to work it was very much like, ‘get yourself back on the tug[boat]’. I started saying that OH can provide a lot more than we are using them for … We saw a lot more engagement from the crews, and it certainly reduced the amount of time the guys were having off.

(OH-user, Medium, Transport and Communication)

Across the interviews, we did not find any instances where employers had decreased their offer. Where OH users explained that certain services were less commonly used by staff, they felt it was important to maintain them as part of their overall offer – just in case a situation arose in the future.

Other employer groups

Engaged employers without OH services were those who did not have formalised OH in place, and instead managed sickness absence, return to work and supported employee health and wellbeing internally. These 6 employers were from a range of different sizes – not only small or micro (please see Appendix 9.1 for the full sample breakdown).

Overall, these employers had a more limited understanding of what OH services involved and offered, with the exception of participants who had experience of OH services from previous employers. These employers felt that OH services were something that would be used by larger or more profitable companies to help ensure a healthy workforce, but could not easily provide concrete examples of how this support might be delivered in practice in their organisation^{[footnote 16]}. Several also had the misconceptions that OH was only for people with disabilities or long-term health conditions.

Despite these misconceptions, most understood that the support offered by OH services was different to the support they provided in-house as it was a formalised arrangement that involved a healthcare professional or some kind of qualified specialist. This meant that, across the interviews, employers without OH understood, in a basic sense, OH ‘the discipline’ but did not always understand the role that OH services could play in enabling or improving some of the functions and behaviours they already exhibited in-house.

I’m not really sure … I think we can be responsible for occupational health as well, it’s not just something that we could do externally … So we had a lady with terrible anxiety issues that we knew about when she started and it kept getting worse and worse until it was preventing her from working. I spoke to her about it, just to reach out to her really and show her we cared, and helped her get in touch with a couple of local facilities – the NHS, private and Mind – to see what would be in her price range or what could help.

(Engaged employer without OH, Small, Banking and Finance)

These employers made decisions around employee health and wellbeing internally, usually involving the owner(s), directors and office manager. Their reasons for not purchasing formal OH services included: lack of need, cost and time barriers, and feeling that staff would disclose any issues due to the ‘family-like’ nature of the business. The reasons employers choose not to offer formalised OH will be covered in more detail in Chapter 4.

We’re a small business, so it’s just prohibitively expensive to have someone there all the time. If we had more regular sickness absences then we might ask GPs to refer staff to OH, but we’re just not big enough to merit any kind of ongoing contract.

(Engaged employer without OH, Small, Agriculture and Energy)

As only 6 interviews were conducted with employers without OH services, we are unable to draw any meaningful conclusions about their characteristics.

The research also found employers whose staff had access to an NHS OH offer. In these cases, the NHS was providing OH services to its employees as an employer, not as an OH provider. Having access to high-quality OH provision, for free, essentially meant that these employers did not need to make decisions around which provider or services to use^{[footnote 17]}.

3. What are the motivations for using OH services?

Employers provided access to OH services for a number of reasons that varied according to their size, sector, and whether they had designated HR personnel. These reasons are discussed in turn throughout this chapter and are as follows:

• to comply with legal and regulatory obligations
• to reduce costs and improve business efficiency
• to support and improve employee health and wellbeing

3.1. Complying with legal and regulatory obligations

One reason employers used OH services was to fulfil their legal obligations, such as health and safety and employment legislation. Employers used OH services to fulfil their statutory responsibilities to do what was reasonable and practicable to protect the health, safety and welfare of their employees.

Safeguarding the workforce was particularly important to employers in high-risk industries, such as Manufacturing, Construction, or Agriculture and Energy, and using OH services for reasons of legal and regulatory compliance was therefore more common amongst proactive purchasers in manual environments.

If their [the employee] health and wellbeing is not correct, it’s a high-risk job they’re doing, so it’s a priority.

(OH-user, Medium, Construction)

Using OH services in this way was also a vital part of their corporate governance. Employers explained that non-compliance could potentially result in financial penalties, civil litigation, prosecution and reputational damage, which could be a substantial threat to the financial health of businesses.

These employers used OH services to assist them in satisfying their legal duties to assess and control the effect of work on employee health; ensure workers were fit to perform their job roles; and ensure people with health conditions and disabilities were not discriminated against^{[footnote 18]}. The most frequently purchased services and assessments are shown below.

OH services to support legal and regulatory compliance

• pre-employment health assessments
• regular, ongoing assessments and health surveillance
• statutory medical examinations and statutory reporting
• advice and guidance on managing workplace health and safety risks

Health assessments, surveillance and medical examinations were carried out by OH providers at regular intervals to support employers to:

• manage exposure to situations that would present health risks
• report accidents, occupational diseases and specified dangerous occurrences
• ensure staff were still fit to carry out their core functions
• identify specific needs and arrange or provide suitable adjustments if required

Employers looked to their OH providers for clear and actionable advice and guidance to effectively manage risk. The type of advice and guidance ranged from legal regulatory compliance to general day-to-day operations.

3.2. Reducing costs and improving business efficiency

Employers saw their workforce as an important resource for their business to run effectively. Across all sizes and sectors, employers identified that sickness absence presented their business with considerable costs, including:

• sick pay
• reduced productivity
• purchasing and arranging temporary cover
• time spent by the employer managing the sickness absence and above related costs

Employers of all sizes found it difficult to cover work internally as a result of sickness absence. For smaller employers, the absence of a key member of staff impacted the organisation’s ability to complete workloads, with time lost and reduced efficiency potentially having serious consequences for the bottom line. Larger organisations had to manage sickness absence at scale, with high sickness absence rates leading to significant direct and indirect costs. Whilst size had little bearing on an organisation’s ability to cover work internally, larger employers were more easily able to absorb the direct costs associated with sickness absence.

A key motivating factor for employers who used OH services was therefore to reduce the costs associated with sickness absence management.

3.3. Improving employee health and wellbeing

The third reason why employers were motivated to provide OH was simply that employers felt they had a moral duty to their employees. Employers across organisations of all sizes and sectors explained that they used OH services to make sure their employees were healthy, as it was the right thing to do, and they cared about their wellbeing.

It’s just part of our culture, we go above and beyond for our customers, so we must go above and beyond for our employees, too.

(OH-user, Large, Transport and Communications)

3.4. Providing OH: How legal, cost, and moral motivations are linked

The 3 reasons why employers provided OH services were legal (to ensure they were compliant), cost (to reduce costs associated with sickness absence or lost productivity), and moral (looking after employees was the right thing to do), however, these motivating factors were usually interlinked.

For example, employers who used OH services to mitigate health and safety risks did so to ensure they were legally compliant, but also to avoid (costly) sickness absences resulting from workplace accidents, and because they cared about their employees (and did not want them to suffer injury or other ill-health at work).

Likewise, where employers were motivated primarily by reducing avoidable costs associated with sickness absence, they wanted to ensure they were doing this in a legally compliant manner, and in a manner that best supported their employees.

Using OH services out of a duty of care to employees and to reduce costs arising from sickness absence ultimately had the same eventual outcome, of improving organisations’ financial health, as summarised below.

Employers’ responsibility towards their employees and cost-benefit of OH provision

OH provision is about responsibility, and business efficiency:

• responsible employers: feel they have a duty of care for their employees’ health and wellbeing
• morale boost: staff feel valued and supported which improves wellbeing, increases workplace productivity and improves retention
• productivity: more productive staff led to increased financial benefits
• sickness absence: sickness has a range of direct and indirect costs on the organisation
• impact of OH services: can prevent or reduce (cost of) sickness absence
• improve bottom line: reduced costs improves organisations’ financial health

Employers indicated that employees with a good state of health and wellbeing significantly contributed to successful business outcomes. Therefore, improving the health and wellbeing of employees was seen as a way to have a more productive workforce, which in turn would lead to greater financial performance, whilst also enhancing other strategically important factors such as their profile and credibility.

Employers, regardless of size, recognised that looking after the health, wellbeing and welfare of their employees made the workplace a more attractive place to work, producing a ‘win-win’ situation that benefitted all. Employers tended to feel that employees who were recognised, supported and valued were more productive and more engaged in the workplace. Proactive purchasers used their OH provision to this effect by providing preventative and ongoing services (such as 24 hour Employee Assistance Programmes, or healthy lifestyle information). They felt that their OH provision reduced avoidable costs associated with sickness absence, whilst also tackling costs associated with staff turnover and subsequent recruitment fees. Employers perceived creating a culture of health and wellbeing, by preventing risk and promoting good health and positive wellbeing, as pivotal to increasing retention rates and enhancing the loyalty of employees.

Offering GP Choices to all our staff helps them to be at work and keeps them fit and well. Ultimately, it helps the business, because people are at work or can get back to work quicker, and it helps our staff for the same reason, or if they’re struggling with something at home.

(OH-user, Small, Public Administration, Education and Health)

Beyond health and safety

Shifting the scope from occupational safety to occupational health and striving to improve all aspects of the working environment was seen by many employers as key to fostering a workforce that was ‘healthy, happy and here’. Employers of all sizes generally recognised that their employees were a fundamental resource and investing in their welfare, health and wellbeing, yielded tangible and intangible returns.

It was nice to be able to offer something - when someone came to me with a problem, to be able to say, ‘well we actually now have this service where you might be able to get more help’, rather than trying to support them as a manager would anyway, or telling them to try their GP. We can offer this to them courtesy of us, it’s easy, it’s free.

(OH-user, Small, Other Services)

They are good staff and I want to look after them…I want to be a good employer.

(OH-user, Micro, Agriculture and Energy)

Whilst legal regulatory compliance may have initially formed the foundations of some employers’ OH offers, those who felt they had a duty of care that exceeded their basic legal duties had expanded their OH offer to include wider health and wellbeing support in recent years. However, cost remained a limiting factor. Across the interviews, there were examples of employers who wanted to broaden their offer, but lacked the financial means to do so. Awareness of incentives such as tax exemption on certain health services was very low, but were welcomed by those with tight profit margins who cited cost as a reason for not engaging a permanent OH supplier.

Because we’re a catering company, we don’t have huge margins and we’re always looking for where we should be spending our money and where there’s cost implications we can’t always go forward with those, unfortunately.

(OH-user, Large, Distribution, Hotels and Restaurants)

Companies with dedicated HR personnel, teams or departments tended to have a greater understanding of the value and impact of OH services, beyond health and safety management. For smaller organisations, having key individuals in the organisation (or supporting roles such as employment or HR consultants) who understood and valued the wider benefits of OH, was key to driving the use of OH services.

3.5. What do employers use OH for?

Employers drew on the support of OH professionals for a wide variety of situations. The diversity of situations that OH services could be used to support meant that, across the interviews, employers did not have a shared interpretation of what OH services could be used for in practice. However, across all the examples shared by employers, wanting to retain employees emerged as the main, overarching reason why employers sought OH support. The wish to retain employees encompassed all 3 of the motivating factors for seeking OH services: cost (to avoid the cost of having to replace staff members), moral (because employers valued employees and wanted to keep them), and legal (to ensure any actions they took were carried out in accordance with employment law).

Across the interviews, employers’ desire to retain employees took 6 main forms, in terms of their use of OH services (shown below). In most cases, employers’ use of OH services focused on certain aspects of the below (i.e. not all OH packages offered by employers were comprehensive enough to cover all of the below, or not all employers had used their OH provider in all of the below ways).

How employers use OH services by typology and motivation

	Legal	Cost	Moral
Attracting and retaining talent: Used mainly by proactive purchasers in both hazardous and non-manual environments		Important motivation	Important motivation
Verifying medical statements and health surveillance: Used by all, but most regularly among proactive purchasers in hazardous environments	Most important motivation	Most important motivation	Important motivation
Supporting an employee with a mental health condition: Used mainly by proactive purchasers. Rarely used by reactive purchasers or micro/small employers with attitudinal barriers to OH	Important motivation	Most important motivation	Important motivation
Supporting an employee with a physical health condition: Used by all employers. This was the most common reason that reactive purchasers sought OH support for their employees	Important motivation	Most important motivation	Important motivation
Sickness absence management: Used by all employer types and, along with supporting employees with physical health conditions, was the most common use of OH	Important motivation	Most important motivation	Important motivation
Investigating underperformance or poor conduct: The rarest use of OH services across the interviews, therefore difficult to comment on the types of employers who use OH in this way	Most important motivation	Important motivation	Important motivation

Each of these uses of OH services are discussed below, with illustrative case studies.

3.5.1. Attracting and retaining talent

Employers who shared these examples saw OH services as a means of retaining employees they valued and showing staff that they cared. Valued employees were not necessarily the most senior; rather, value was determined by skill (how indispensable they were) and loyalty (length of service, longstanding hard work and commitment to the organisation). Employers also spoke about their OH offer as an additional perk for both existing and prospective employees – particularly those who were unable to match competitors’ higher salaries – and as a way to boost morale of staff overall.

Employers who used OH services to attract and retain talent were mainly proactive purchasers in office-based or manual environments, who could use their permanent OH contract as either a recruitment tool or to proactively attempt to mitigate high staff turnover. This use of OH was therefore associated with cost (not having to replace employees, and/or finding it easier to recruit new employees) and moral (OH services being a way to show employees their employer carer about their wellbeing) motivating factors of providing OH services.

Case study: Using OH services to mitigate staff turnover

One medium fundraising agency explained that they suffered from high staff turnover. The majority of their workers were students, who tended to work for the business for a short period of time in-between other roles, though staff turnover was also higher than they wanted for other staff members.

The employer used OH to show their employees they were valued. They made a high number of referrals, particularly for employee counselling, for advice as an employer on supporting individuals with mental health conditions, and for private physiotherapy.

It’s mainly a way for us to retain staff. We have very high staff turnover and we offer little in the way of financial incentives, so offering things like OH is a way of letting staff know they’re valued.

(OH-user, Medium, Other Services)

The employer had received positive feedback from staff and retained all but one staff member they had referred to their OH provider.

3.5.2. Verifying medical statements and health surveillance

OH services were used by employers to verify or clarify information provided by an employee, including information provided by their General Practitioner (GP). This could be the case where further evidence was needed to support a medical claim. For example, where an employer needed proof of a condition that required an employee to have time off work. OH assessments were also used to find out more about how the employer could best support the employee in the workplace.

Case study: Using OH services to uncover falsified medical claims

One micro construction company in the commercial carpentry industry explained how they used OH services to investigate a physical illness when there was a lack of evidence to support the case. The employee told the employer that he had chipped bones in his knee and shoulder at work, but there was no evidence of this on CCTV, no witnesses and he appeared physically fine. The employer referred him to their OH provider who, after conducting an assessment, could not find any evidence of injury. The employer felt they had avoided a potential lengthy absence by using the right channels to investigate the employee’s claim.

There were people who were obviously blagging it, it was ridiculous. Even when we hear that they were out skateboarding the night before, but have been telling us they can’t walk and have injured themselves at work. We get a lot of that. So we use OH to go down the right channels and surprise, surprise, they find that there’s either nothing wrong with them, or they injured themselves outside of work.

(OH-user, Micro, Construction)

This type of support also included health screening exercises, either pre-employment to identify any health concerns the employer should be aware of, or regular screenings to either certify continued fitness for work, or as part of the employer’s health and wellbeing package.

Case study: Regular health surveillance services

One meat processing factory used OH services to ensure their employees were fit for work. As part of their package, they offered staff annual medicals. In one case, the nurse suspected an employee had diabetes following a urine test. She recommended that the employee should see a doctor, and it was later confirmed that the employee did have diabetes.

If she hadn’t spotted that, they would have continued with these signs that they weren’t aware of, and it could have been a more long-lasting, serious outcome had it not been detected that early.

(OH-user, Medium, Manufacturing)

As the diabetes was detected early, the employee was able to take medication to manage their condition and minimise its severity.

For these uses, OH services were adopted by all employers, in particular proactive purchasers in manual environments who had more need to regularly screen their employees. Using OH in this way was driven by all 3 motivating factors for the providing OH services:

• cost – identifying any potential health concerns and taking action
• moral duty – offering health screenings as a way to support employee health and wellbeing
• legal obligation – to ensure employers were mitigating any workplace health and safety risks, and were going down the right channels if they suspected employees of disingenuous sickness absence claims

Across the interviews, the legal and cost motivating factors were the most important to employers, given the potential risks they faced as a result of being non-compliant, or not picking up on employee conditions for which they later required sickness absence.

3.5.3. Supporting an employee with a mental health condition

Employers felt that OH referrals for employee mental ill-health conditions were becoming more common. Employers used OH services to understand how conditions such as anxiety or depression, or wider health and wellbeing issues which were non-work related, were affecting employees’ ability to work, and to understand how they could be supported.

Across the interviews, there was only one example of a recommended adjustment, relating to a mental ill-health condition. An employee suffered from anxiety and worked for a catering company in a range of venues, including offshore sites. The OH assessment recommended that the employer adjust their role to work onshore only for a temporary period. The employee’s confidence eventually increased and they felt able to return to their previous role after a few months. The employer was happy with the adjustment as the employee’s confidence had improved, and they did not need to take any time off sick.

In this respect, the use of OH was driven by all 3 of the motivating factors for providing OH services. Whilst all 3 were important, employers emphasised how costly sickness absences were for their organisations, making cost the primary motivating factor.

Case study: Using OH to support an employee’s mental health condition

At a medium-sized company, one employee developed depression following the death of his wife. His GP signed him off work and offered him anti-depressants, but he did not want to take them, so the employer discussed an OH referral with the employee. The OH specialist recommended a course of Cognitive Behavioural Therapy, which the employer paid for. The employee was able to remain in work.

He was in a very bad state and didn’t seem to be progressing, so we were concerned about him. We sat him down and said we could refer him to OH to see what they could offer… I think OH just knew how to deal with him. He is now back at work, and whilst he no doubt has a long way to go, he is doing much better.

(OH-user, Medium, Transportation and Communications)

Referral to OH for staff with mental ill-health was more common amongst proactive purchasers, and was rarely used by reactive or micro/small employers, particularly those with attitudinal barriers to using OH or towards mental health support. Across the interviews, there was evidence of employers who felt that mental ill-health should not be discussed in the workplace, or who questioned the impact that mental health conditions had on an employee’s ability to do their job.

3.5.4. Supporting an employee with a physical health condition

A common reason that employers used OH services was to support employees with physical health conditions, either pre-existing or those they had developed during employment. They wanted to understand what they could do to help employees, for example making physical workplace adjustments (for example, ergonomic chairs to support employees with back problems), a change of role within the same organisation, or other treatment options (for example, physiotherapy).

Employers saw OH services in these instances as a way to retain employees where possible, and to reduce sickness absences. All types of employer used OH services in this way, and this was the main reason for OH use by reactive purchasers. As with supporting employees with mental health conditions, this use of OH was driven by all 3 of the motivating factors. Again, whilst all 3 were important, employers emphasised how costly sickness absences were for their organisations, thereby making cost the key motivating factor.

Case study: Making adjustments for a physical condition

One employee working for a medium-sized construction firm developed a shoulder injury which affected their ability to do their job.

We worked with our OH provider who brought in a consultant, and we looked at what he could and couldn’t do on site, and what adjustments we needed to make. They were really good at intervening and making sure we all had the information we needed.

(OH-user, Large, Public Administration, Education and Health)

The employee took some time off, and came back to work on reduced hours and a different location (to reduce his travel time) initially. He is now back working full-time and does not need any adjustments to his role.

3.5.5. Sickness absence management

Using OH providers to support sickness absence management encompassed:

• preventing sickness absence from arising in the first place
• managing sickness absence by keeping in touch with employees
• supporting return to work
• retiring employees through ill-health, as a last resort

Each element is discussed in turn below. Employers of all types used OH services for sickness absence management. In this respect the use of OH was primarily driven by:

• cost – ensuring sickness absence is managed effectively so that employees come back to work as soon as they are able, and to reduce the chance of further sickness absence
• moral duty – wanting to support employees
• legal obligation – to ensure employers were fulfilling their legal obligations to their employees

Whilst all 3 motivating factors were important, employers emphasised how costly sickness absences were for their organisations, making cost the key motivating factor.

Preventing sickness absence

Employers with permanent OH contracts in place better understood the benefits of using OH services to prevent ill-health that could lead to sickness absence. These employers drew on both their OH providers and in-house expertise to improve employee health and wellbeing generally. Proactive purchasers took steps to ensure a healthy workforce by:

• identifying emerging patterns and causes of ill health, sickness and injuries
• providing accessible health and wellbeing interventions
• enhancing communication and working relationships between employers and employees

As a result, proactive employers saw OH services, along with other health and wellbeing measures they undertook internally, as essential for preventing common causes of ill-health (such as stress, fatigue, or poor diet). The cost savings associated with a proactive approach were viewed by employers as a strong value proposition for continued investment in OH services.

Case study: A proactive approach to wellbeing

One company had regular health screening sessions that had a wider focus than occupational health and safety. In one case, a skin specialist came to the company and checked employees for skin damage and signs of cancer. The specialist identified a few employees who had early stage skin melanoma, who then received treatment through the NHS.

(OH-user, Large, Manufacturing)

Managing sickness absence

Employers turned to their OH providers for their expertise and support in handling situations they felt unable to, and managing sickness absence was one of the most common reasons employers sought OH services. Employers used OH services to manage sickness absence in order to:

• reduce the amount of time employees would have off sick (thereby reducing cost)

Services are expensive; however, we are paying for medical opinion, and medical opinion isn’t cheap… and long term it’s beneficial as a member of staff being off for 2 days costs more than a doctor’s appointment, so paying £200 for a doctor vs. having a staff member off for a week it’s actually cheaper.

(OH-user, Large, Public Administration, Education and Health)

• show they valued the employee
• ensure they were handling the sickness absence properly (i.e. in accordance with employment law)

OH support, advice and guidance services procured by employers to manage sickness absences included: understanding the GP Fit Note and associated requirements; understanding the mode and frequency of keeping in contact with employees during sickness absence; and understanding how best to document and record processes to safeguard both the employer and employee.

Return to work after long-term sickness absence

Given the costs associated with sickness absence, employers wanted to ensure that returns after periods of sickness absence were managed effectively. This meant:

• not returning to work until they were fit and able to (employers required a fit note in some circumstances), or
• returning in a reduced capacity if they were not able to return to their full role (for example, returning part-time or to a reduced work load)

Employers of all sizes, including those without OH services, recognised the adverse consequences that improperly handling a sickness absence and return to work could have.

If she tackled something and she had a setback, another injury, from an employer’s point of view that’s not good! To have even more time off work.

(Engaged employer without OH, Small, Distribution, Hotels and Restaurants)

Employers explained that well-managed returns to work helped both the employee and the organisation. Employees felt supported by the employer, did not feel overwhelmed at returning too soon or to duties beyond their current capacity, or did not feel frustrated at not being able to return to work soon enough (as long as they were cleared for work). For the employer, having an employee return to work in a timely manner meant that the risk of further sickness absence (resulting from a poorly managed return) was reduced.

OH services encompassed keeping in touch with employees during sickness absence, interviews after the return to work, and support preparing and managing return to work plans. This included an assessment from the OH provider about any reasonable adjustments that needed to be made to the employee’s role before they could return to work. Reasonable adjustments included:

• reduced hours or returning to work part-time
• performing different duties or tasks, or
• providing specialist equipment (such as a desk or chair designed to minimise back pain)

Our main goal is for our employees to be able to return to work as soon as they’re fit and able to do so, or for us to be able to offer alternative roles or adjustments before they can return to their current position.

(OH-user, Large, Banking and Finance)

Case study: Using OH services to manage a return to work

One fruit-packing company had 2 sites and over 300 employees, mostly in manual roles. They used OH services predominantly to screen employees who drove forklift trucks, but had expanded their OH contract to include wider health and wellbeing measures in recent years. Staff and management see the OH package as a positive.

In one instance, an employee had been on a long-term sickness absence following an operation. They had been referred to OH who determined they would not be able to return to their previous role. OH worked with the employer and the employee to shape a new role for the employee, and reintegrate them slowly to their new position. The employer felt the return to work was managed very well, and the employee had remained in their post.

(OH-user, Large, Agriculture and Energy)

Retiring through ill-health: The last resort

Where return to work and reasonable adjustments were not possible, OH providers were used to assist employers in retiring employees from their position sensitively and legally. In these cases, employees had developed a health condition and taken a period of sickness absence. Their conditions affected their ability to return to their previous role, and so employers had brought in OH services to see what they could do to help the employees remain in work. In both the examples highlighted below, the aim of the employer was to retain the employee, but unfortunately no adjustments were feasible in practice and the situations ended in retirement through ill-health and resignation respectively.

Case study: Retiring through ill-health

One private care home for the elderly had a long-serving and highly valued staff member who had developed arthritis. The organisation sought specialist OH services to see if any adjustments could be made, or a role could be found elsewhere for the employee. Other roles that the employee was suited for were too physically repetitive and so the OH provider advised that there was nothing more that could be done for the employee. The OH advisor worked with the employer to support the employee to retire due to ill-health.

(OH-user, Medium, Public Administration, Education and Health)

Case study: Employee resignation

One manufacturing company sought advice from an OH provider about an employee who had developed multiple sclerosis (MS). The employee worked with machinery and tools which posed a potential health and safety risk, and the employer could see the employee was struggling. The OH provider recommended a change of role, but the employee would not accept the effect his condition was having on his work, and refused. This led to the employee resigning.

(OH-user, Medium, Manufacturing)

3.5.6 Investigating underperformance and poor conduct

Employers did not just use OH services to help employees with known health conditions or on sickness absence, though this was the main motivation. There were also cases of employers using OH services to investigate performance management issues, which fell into 2 categories:

• underperformance due to ill-health: where an employee’s health condition (either pre-existing or that developed during their employment) negatively affected their ability to do their job to the level expected. Employers were either not aware of the condition/circumstances of the employee, or that it had developed and was affecting their job role. Employers therefore became aware when employee performance dipped, or employees disclosed their condition to employers; and
• underperformance due to poor conduct: where employers wanted to investigate the root cause of an employee’s poor conduct (for example, turning up late to work or not doing the job to the specification expected) by bringing in an independent arbitrator. Employees with this type of underperformance issue either did not have a verifiable health condition, or employers suspected they were using a health condition that had little bearing on their ability to do their job as an excuse

Underperformance due to ill-health

OH providers were used by employers as competent and independent arbitrators to determine underlying issues and causes of underperformance. If OH providers indicated that underperformance was a product of unreported ill-health, then employers looked to providers for clear advice and recommendations on how best to support their employee back to full health, or to a better state of health. Employers were generally clear on the importance of ensuring that all employees who were present at work were well enough to function effectively, from a productivity, health and safety and broader wellbeing perspective.

Underperformance due to poor conduct

Examples of poor conduct included; false claims of a workplace illness, accident or injury; regular patterns of absenteeism (for example, having the same 2 weeks off sick every year); or false claims of a general illness, sickness or accident outside of work that required leave of absence. These employers explained that there were certain cases that they did not feel were genuine and they used OH as a way to confirm their suspicions, without having to directly challenge the employee.

There have been employees who have been off work repeatedly, and we’ve sat them down and offered them OH, but they always say, “Oh no, no I don’t need that!” and then they come back to work. To be perfectly honest with you, I think they’re blagging it, and in a way, the OH is quite useful as a way of getting that to come out in the wash.

(OH-user, Micro, Construction)

In some cases, employers explained that simply by asking underperforming employees if they would like to be referred to OH (which they refused), the poor conduct rapidly improved. In contrast, where employees were found to have made false claims regarding sickness or injury, employers used evidence produced by their OH suppliers to constructively and lawfully challenge and manage this behaviour. In the example below, one employer used an employment law consultant to support in an employment tribunal.

Case study: OH services as evidence of going down the right channels

One small employer had an apprentice with both performance and capability issues. They had called in sick on their first day, and had regularly missed training sessions and assignment deadlines ever since. The employer challenged the apprentice on their conduct, who subsequently told them they had suspected Crohn’s disease.

The employer referred the apprentice to their OH provider as well as taking advice from a separate employment advisory company. They wanted to ensure they were acting in a legal manner should the situation result in dismissal.

The OH provider had recommended a large number of adjustments, which the employer did not think were reasonable. Whilst they did not doubt the impact of the employee’s condition on some aspects of their work, they felt that it did not fully explain the employee’s consistent performance and capability issues.

The employee took their employer to an employment tribunal, as they felt the necessary adjustments had not been made for their condition. Acas upheld the employer’s decision, as they had been able to demonstrate all the steps they had taken, as recommended by the employment law advisor.

They gave us the reassurance we were following the necessary steps. They weren’t cheap, but they’ve got the best reputation and Acas would’ve known they’d’ve done all the right things … There are no tensions between us and OH; I think they were influenced by a particularly vociferous family member who accompanied the apprentice in their appointments.

(OH-user, Small, Public Administration, Education and Health)

Employers who used OH services to investigate underperformance or poor conduct were driven by all 3 of the motivating factors for using OH services. In cases where poor conduct and health concerns were connected, the legal motivating factor was the most important for employers, whose primary concern was that they were taking the right steps to resolve the issues they faced.

4. Why do engaged employers not offer OH?

This chapter examines the perceptions, barriers and challenges that influenced employers not to purchase formalised OH services. These employers had, in the previous year, actively supported employees with existing health conditions or provided a range of inhouse interventions to support employee health and wellbeing.

Throughout the chapter, common themes and key points are explored by employer characteristics. However, given the small number of engaged employers who did not use OH services interviewed, these findings should be treated as indicative and we are unable to comment on how their behaviours and attitudes might compare to employers who did not provide anything. These employers highlighted a range of reasons for not purchasing OH services, summarised in below.

Reasons why employers did not offer OH services

• cost of providing services
• hard to determine value for money
• lack of cases
• attitudinal barriers
• lack of knowledge

4.2. Financial implications and lack of awareness of incentives

The main reason cited by these employers for not having OH services was cost. Engaged employers without formalised OH services explained that they had tight profit margins, meaning that every expense had to be justified. Where they needed to support employees above and beyond what they could handle in-house, they would direct them to free to use services such as the NHS, or dedicated charities. For these employers, providing a paid for service above and beyond their legal obligations was a cost that could not be validated.

We just stick to legal obligations. The drivers have to have eye tests, we have check that they can see and send them for a test if there’s an issue. Otherwise, we just do the normal Health and Safety rules and deal with everything else as it comes up.

(Engaged employer without OH, Medium, Transport and Communications)

Awareness of financial incentives through the tax system to encourage the use of OH services was very low – only one employer from all 35 employer interviews had any awareness of the incentives available. Given the lack of legal imperative, coupled with the low levels of awareness of financial incentives, some employers indicated that there was no real impetus for them to invest in OH.

Unlike the reactive purchasers, some of whom understood the benefits of OH services but still felt cost was a prohibitive barrier, employers without OH services did not appear to understand or have considered the value for money or cost-benefit arguments of using OH services^{[footnote 19]}. Whilst several of these employers explained that return on investment was an important feature of their organisation’s management decisions, few of them appeared to have considered this in the context of OH use. Several engaged employers explained that they did not have the volume of employee disclosures or sickness absences to justify an investment in OH services, though these employers were still unable to articulate the wider benefits of OH services in terms of maintaining a healthy workforce overall.

4.3. Lack of knowledge or misconceptions of OH services

Engaged employers appeared not to have considered the non-financial benefits of OH when explaining that that the costs were too prohibitive, and management decisions were based on return on investment. Overall, these employers had a more limited understanding of what OH involved than OH-users, and there were notable misconceptions about how it was used:

• services used by larger companies
• only for people with disabilities or long-term health conditions, or
• used to ‘force people out of the business

This lack of knowledge around what OH services might involve, or what they could be used for, appeared to indicate that engaged employers had not fully considered the wider or more indirect benefits of providing OH services.

The senior directors want to see the ROI [return on investment] on anything we spend money on. We only have fairly basic HR processes here and there’s a real lack of knowledge around OH and its possible benefits. We’ve realised recently that we aren’t doing enough and we need to ‘see people as people’ and take care of them and their mental health and wellbeing.

(Engaged employer without OH, Medium, Banking and Finance)

4.4. Attitudes and employers’ responsibility towards their employees

Some engaged employers felt that a formal OH service was counterintuitive to their ‘family culture’, and there was evidence of this amongst some smaller OH-users, too. These employers liked to think their employees had a strong enough relationship with them to talk directly about their problems and issues in order to work as a collective to provide the necessary support. This informal approach was assumed to be more effective in strengthening the employee-employer relationship than formalised OH.

I feel we’re close enough to our employees that we could talk directly to them about any problems they may be having, and signpost them to support. We’re like a family, and we actually employ quite a lot of family members, so we’re very tight-knit.

(Engaged employer without OH, Small, Agriculture and Energy)

In addition, some employers had the perception that OH had traditionally been used for dismissals and managing staff out of the organisation (even amongst individual participants who had used OH services in the past). These perceptions had created negative attitudes towards OH, with these employers viewing OH as a purely reactive mechanism with little strategic gain for a business outside of employment law. In some cases, employers had heard directly from their employees that they too had this perception.

The staff associate any kind of outside medical help or intervention with ‘being got rid of’ and they think ‘I’m going to lose my job’. It makes them more apprehensive, even if you explain that these are the steps we need to go through to help you.

(OH-user, Medium, Public Administration, Education and Health)

There were also examples of employers without OH services who felt that providing for employees’ mental health and wellbeing was beyond their remit as an employer and sat outside of the work environment. These employers felt that employees should be taking responsibility for their own health and wellbeing and should not allow health and wellbeing issues to affect their work. In these instances, the needs of the employer appeared to take precedence over employee health and wellbeing, which was generally viewed by the employer as appropriate, as staff were replaceable.

Case study: Employee health and wellbeing not an employer’s responsibility

One employer explained that they could not provide OH due to lack of ability to pay for these services, but their attitudes towards work and health and wellbeing, and whether an employer ought to be responsible for this certainly contributed to lack of OH provision. Below are some excerpts from the interview.

Many years ago, we had a guy with ‘yuppie flu’, I think it’s known as ME these days, some kind of tiredness thing. When he got signed off, we thought ‘how long do we have to pay this guy?’ We terminated his employment as soon as we could and put SSP into contracts from then on to protect ourselves.

We have a member of staff with a terminal illness, he has 5 years to live. He assured us he would carry on as normal and we expect he will just leave at some point before it becomes an issue for us.

We are starting to wonder about mental health, young people seem to be having an issue with keeping it together and we’re seeing more of that… I don’t really see mental health as being our problem. We have had staff who have told us they were going to counselling and we are always worried about that. We had one guy who had some kind of problem and people didn’t want to work with him, he made people uncomfortable, so we just pushed him out because he’d been with us less than a year and we were able to just get rid of him.

[We would only offer OH] if we felt that something we were asking for were causing the problem. But in all the cases we’ve had, we’ve not been the problem. It’s almost always a personal issue, something physical, something going on at home, something wrong with them.

(Engaged employer without OH, Medium, Transport and Communications)

In addition, employers (both OH-users and those without OH) explained that age, gender and workplace culture all contributed to attitudes towards employee disclosures and the role of the employer in supporting health and wellbeing at work. Employers highlighted that the number of disclosures tended to be less in male employees (particularly in maledominated or manual workforces), and younger generations tended to be more open to proactive approaches, such as OH services.

[Mental health] is very important and we do our best to look after you, however once you cross the line over to being ill all the time and it can’t be fixed very quickly then you are viewed as a bit of a nuisance… In honesty, I don’t know what to do if people have things like anxiety, you’re a bit of a wussy if you’re off for stress… You’re a man, just sort yourself out!

(Engaged employer without OH, Large, Banking and Finance)

5. How do employers choose an OH package or provider?

This chapter covers the processes and practices that employers used when considering which OH provider and package to purchase.

5.1. Who is involved in choosing an OH provider?

How employers chose their OH provider varied according to their size, sense of urgency, and the nature of their HR function (whether they had one internally, used an HR consultant, or had no HR function).

A number of smaller employers and some medium organisations acquired HR expertise through a consultant or consultancy company. Employment consultants were used by employers who required support in expert functions to run their business^{[footnote 20]}. Employment consultants were used for support with recruitment, payroll, wellbeing, and particularly for their expertise in employment law. These employers described how, as small businesses, they had neither the time nor expertise to adequately stay abreast of developments in employment law (mentioning changes to automatic enrolment, minimum wage, and workers’ rights as examples), and therefore saw outsourcing their HR needs to a consultant as a means of reducing burden^{[footnote 21]}.

HR outsourcing allowed smaller businesses to delegate employee management tasks that would otherwise be subsumed within management roles, where HR knowledge and experience may be minimal. In such cases, employers looked to their HR consultants to advise, guide and direct their choice of OH provider, package and service (across both reactive and proactive purchasers). Employers explained that some of their consultancy companies had internal OH services as part of their offer, whereas others recommended their preferred OH suppliers to employers. As such, there were examples across the interviews of employers discussing cases with their employment consultants, who would advise whether OH services were required. The consultants would then recommend an OH provider, and arrange an introduction.

Reactive purchasers, who often needed to find an OH provider quickly, tended to perform simple internet searches, though there were examples of proactive purchasers, employers looking for long-term contracts, who also followed this process to find their chosen provider. These employers would make a shortlist of providers who provided the services they required, were local, and all other factors being equal, chose the provider with the lowest price (though employers noted that there was little variation in this).

Word of mouth recommendations were also important. For example, employers relied on resources like online HR forums to review their peers’ experiences of specific OH providers, or on employment/HR consultants, if used. How rigorous the procurement process was depended on access to HR resources, the involvement of key decision makers who usually had financial or budgetary oversight, and the procurement sign-off procedure.

For some employers, regardless of size, the history of how or why an OH provider had been chosen was unclear or undocumented. For these employers, if they felt that the OH service was positive, then they would maintain the contract, as opposed to scoping the market for additional offers. For some, this was a result of not knowing exactly what they wanted or needed as an organisation, as well as lacking knowledge on what made a ‘good’ provider.

We have not considered a permanent package because we only need to use OH every few years [and] there is not enough information out there. We are not big enough to be approached by OH providers and because we don’t have an internal HR professional, we have not built up that knowledge on what’s out there and where to find them. It would be helpful to know more but I wouldn’t know where to look.

(OH-User, Medium, Manufacturing)

Larger employers invested in internal HR resources, ranging from a single designated person to a designated HR team or department. Their roles covered managing the contract and services of existing providers, reviewing services provided by the existing OH supplier and overseeing the commissioning process. Reviewing OH provision was rare, but several large employers described their review and commissioning processes, as shown below.

Large employers’ reviewing and commissioning process

1. Monitoring and reviewing provider employer relationships, identifying what works, what does not work and why.
2. Developing OH provider tender specifications based on the review(s), their needs and requirements.
3. Facilitating an open and competitive tendering process or conducting a market review and inviting a number of suppliers to competitively tender, which normally included the existing OH provider.
4. Shortlisting preferred suppliers and inviting them to interview with key decision makers, such as HR managers, business directors, senior managers and in some cases board of directors.
5. Key decision makers confirm their choice and commission the provider. Back to Step 1.

5.2. Which factors are involved in choosing a provider?

Employers, regardless of size, complexity, sector or HR capacity sought OH services to minimise the disruption and cost associated with sickness absence and to resolve situations they felt unqualified to handle themselves. Whilst there were several factors involved in choosing a provider, these broadly fell under 3 categories: expertise, cost and employee demand.

5.2.1. Expertise

Employers sought OH providers for their expertise, in particular their:

• ability to resolve situations, or finding workable solutions
• ability to understand the specifics of an individual’s job role and circumstances
• ability to understand the nature of the working environment, workplace culture, and any restrictions on reasonable adjustments (such as the employer’s ability to implement and pay for recommendations)
• ability to produce effective and useful reports

Employers wanted OH providers who could help them to resolve the situations that presented barriers to their employees doing their contracted work. Employers did not want ‘off the shelf’ products, rather they wanted providers to tailor any services or recommendations to their organisation and specific needs of their workforce. Employers expected providers to have a sound and far-reaching understanding of the company and the sector in which they operated. This included knowledge of day-to-day operations, business drivers, internal resources available for OH, legislative regulations and the implications these may have on the type and range of services offered to employers and employees.

For example, a number of employers wanted their OH providers to understand any internal restrictions that might prevent certain treatments or adjustments being possible for employees returning to work. Examples included, employers being unable to pay for interventions (such as physiotherapy), or unable to accommodate changes to shift patterns (from night shifts to day shifts). Other employers required OH providers to offer interpreters or translation facilities, as well as providing information to employees that was clear, concise, and relevant to their requirements.

For me it is about accessibility to the service as we have quite a few Eastern Europeans working for us, so language is important. [The OH practitioner] certainly provides the service that we need. She allows for prevention and offers a peace of mind.

(OH-User, Medium, Manufacturing)

This tailored approach and understanding needed to extend to any reports made by the OH provider. Employers wanted reports to be useful, timely and have feasible and relevant recommendations that balanced employee need with employer capability and resources. Useful reports were those that included precise, actionable recommendations, as well as highlighting scenarios that the employer may need to be aware of and manage. For example, if an employee had been signed off work due to anxiety, highlighting specific situations or interactions that should be avoided, as they may adversely affect the employee on their return to work.

OH really helps the line managers understand, because they don’t always understand how people’s illnesses can affect their behaviour or the way they react to certain situations. Their advice helps them to see it’s an effect of their condition and to proactively think about how certain tasks might affect them.

(OH-user, Large, Banking and Finance)

Having timely information was key to informing decisions about individual employees, but for proactive purchasers, it was also important to support the strategic direction of employee health and wellbeing across the organisation. Proactive purchasers, more so than reactive purchasers, wanted to know how they could provide a broader OH offer that went beyond statutory requirements and managing absences.

5.2.2. Cost and efficiency

Whilst cost was a key factor in engaged employers’ reasons not to provide OH services and also in reactive purchasers’ reasons for not having a permanent OH contract, the cost of the service required was rarely the most important factor for OH-users in choosing a provider. It was not the direct cost of the service that they considered, but rather the:

• speed of initial response (this included locality or mobility, and ability to get a quick appointment)
• efficiency and speed of consultation (to support employees to return to work in a timely fashion, thus reducing time and cost associated with sickness absence)
• regular communication (to keep employers up to date with progress and expected timescales for internal planning and resource management)

For OH-users, the speed with which providers could respond and be seen to be putting measures in place to resolve situations, and the expertise they brought in supporting employers and employees were more important driving factors than the cost when it came to choosing a service or provider. This was the case for both employers with permanent and ad hoc contracts. Those with permanent contracts understood that investment in OH services was preferable to the costs they faced as an organisation as a result of extended sickness absence, and those with ad hoc contracts recognised that they faced losing valuable employees without external support. In addition, employers mentioned that most OH providers seemed to charge similar rates, making the cost for a given service a less discriminating factor as opposed to speed and accessibility.

Employers needed flexible and adaptable providers that responded effectively to changing environments and working conditions. Speed was important as unnecessarily extended absences caused by avoidable delays and inefficiency were costly in terms of time and money, as well as being frustrating for employees (and employers). Therefore, local providers or those with mobile resources such as travelling healthcare professionals or occupational health vans were thought to be able to respond more rapidly to demand. However, face-to-face consultations were only expected where needed (for example, for physical assessments).

In addition to making access quicker, locality and mobility also reduced disruption to the working day for employees and employers. This was particularly important for employers that required health surveillance and assessments at regular intervals, and where employees worked across multiple sites such as those in Construction, Manufacturing, and Public Administration, Education and Health.

With the boys working on the site all day, and moving around all over the country it works really well that the company sends a doctor up to us on a Saturday morning and he’ll see 10 workers one after the other. We just make sure those that need their health assessments are there at the right time.

(OH-user, Medium, Construction)

Effective and regular communication was also important. Employers required regular updates on cases so they were aware of timescales to help plan things like budgeting and cover. Employers preferred providers who could offer communication through multiple channels, being able to pick up the phone at short notice, as well as sending emails and having web-based communications (such as a dedicated portal). Providers who restricted communication of results and advice to emails or online platforms were generally seen as less effective.

5.3. Choosing an OH package

In the majority of cases where a long-term contract was in place, employers relied heavily on their provider to understand their business and workforce needs and to suggest a package of support. OH providers were contracted to act as competent experts that guided and informed the choices employers made when purchasing OH services (such as which situations necessitated an OH referral). Nevertheless, sector requirements and job role/core duties were key considerations for employers of all sizes and complexities. Packages that were consistently used across the sector or in similar sectors (for example, providers that specialised in their sector, or were used widely across the industry) and that directly supported the fulfilment of a job role were viewed positively by employers. Examples of the specific OH interventions that employers had used are shown below.

OH interventions utilised by employers

OH treatments:

• Employee Assistance Programme
• counselling
• Cognitive Behaviour Therapy
• physiotherapy
• physical health screening or assessment
• workstation assessment

Business needs, whether this linked to compliance or broader business objectives such as productivity, often shaped the type, size and frequency of the package purchased. In instances where employers had seen increased disclosure of ill-health or injury and/or an increased need and demand for OH services from employees, they would discuss the need to extend their provision internally and with their providers. Examples included the provision of broader services, increased frequency or accessibility of services, and better communication of what services were available to employees.

Range of factors involved in choosing an OH provider and package

Range of factors when choosing a provider:

• locality to employer
• mobility and accessibility
• cost effectiveness
• dissemination of information to inform decisions
• effective and regular communication
• speed and efficiency
• knowledge and understanding of sector
• effective and useful reports
• multiple communication channels

Factors in choosing an OH package:

• sector requirements
• employee demand
• increased disclosure
• job type, roles and responsibilities
• business need
• cost

6. How does the employer-provider relationship work?

This chapter provides an overview of how OH services were delivered and managed, how OH worked in practice through the typical process of referral, and employers’ views on their relationships with their providers.

6.1. How are OH services delivered and managed?

The management of OH schemes (permanent contracts) or individual transactions (ad hoc contracts) were handled differently according to the structure of the organisation. Those with HR departments had an individual or team responsible for managing the contract, reviewing services and overseeing any referrals. In smaller organisations, the provideremployer relationship was either managed by an individual such as a company secretary or office manager, by the owner, or external HR consultants.

Across the interviews, there were 3 different models through which OH was delivered:

• in-house by specialist OH teams employed by the business (this was very rare and occurred in specialist environments where participants felt strongly that an external professional would not be able to provide the level of support required)
• by an external specialist contracted directly by the business, either on a permanent or ad hoc basis. In these situations, the employer or HR department would facilitate the process of referral, or where employers had permanently engaged OH suppliers, employees could self-refer, or
• by an employment consultant with OH capability, or through an external specialist who had been recommended by an employment consultant. In these instances, the employer together with the employment consultant would be involved in referring employees (see Section 5.1 for more detail)

6.2. The process of OH referral

The process of how an OH assessment (i.e. an assessment of an employee’s physical or mental health with a view to supporting employees to carry out their role to the best of their ability) worked in practice typically followed the 6 stages shown in below^{[footnote 22]}. However, employers reported some variation within these stages (depending on their size, relationship with their employees or whether they had an HR function), which are outlined in the following narrative.

Typical OH process

1. Decision: The suitability of OH is discussed, and employee consent gained. Interchangeable with Step 2.

2. Referral: Could be self-referral or referral from HR or Line Manager depending on organisational setup. Interchangeable with Step 1.

3. Assessment: OH practitioner carries out an assessment of the employee.

4. Report: A findings report is written, with the level of detail shared up to the employee.

5. Action: Any suitable changes may be made. Managed by HR or Line Manager depending on organisation.

6. Review: An informal or formal review is undertaken.

Step 1: Decision

Employers sought OH services when health and wellbeing situations arose that they felt unable to manage with their existing support structures, and the first step was often deciding that external, specialist support was required. Discussions around whether OH support was needed applied to the following uses of OH services:

• supporting an employee with a mental health condition
• supporting an employee with a physical health condition
• supporting a return to work
• investigating underperformance

Employers became aware of issues that might warrant the use of OH support through: line managers (who had identified and/or discussed an issue with an employee), HR personnel (who had noticed patterns in sickness absence, for example), or through employees disclosing issues (or referring themselves to OH services, where this was an option). In some cases, discussions amongst management would also take place without the employee, though a referral would only ever be made with the employee’s consent.

Deciding whether or not to use OH services for a given situation was particularly important for reactive purchasers, who did not have a permanent contract in place. There were examples of these employers discussing cases with OH specialists to determine whether a referral was needed, before a formal referral was made. Decision-making was also the first step for employers with existing OH contracts who faced situations they had not previously encountered, or where employees disclosed new conditions or issues that necessitated support.

Across the interviews, employers stated that an initial referral to OH would be considered for all employees, regardless of seniority or length of service, if the employer felt it was the appropriate step to take. In other words, access to OH advice was not restricted or prioritised.

Step 2: Referral

Once employers had decided that OH services were required, the next step was referral. In certain situations, referrals were made without decision-making or internal discussion: to verify medical statements (a service commonly required by proactive purchasers in manual environments), or where employees could self-refer (where proactive purchasers’ contractual arrangements included a self-referral service).

In most cases where self-referral was possible, employees could do so confidentially, without permission or involvement from the employer. Outside of self-referral, referrals could be made by line managers, HR personnel, or the individual responsible for managing the OH contract, depending on the structure of the organisation.

Step 3: Assessment

Once the referral had been made, an OH professional would carry out an assessment of the employee, to understand more about their circumstances, condition(s) or the barriers they faced to performing their current role to specification, if relevant. As this was undertaken confidentially, employers generally knew very little of what occurred at this stage. However, where referrals were made by the employer (i.e. employees had not selfreferred), they would usually maintain communication with OH to keep informed of timescales and progress.

Step 4: Report

Once assessed, the OH provider would write a report, outlining the assessment and any recommendations. The content of the reports depended on the reason for referral:

• in instances where employees were referred for a physical or mental health condition, to retain employees, or to support a return to work, reports would include a summary of the assessment and next steps. This included suggestions for reasonable adjustments, further tests, or return to work plans
• in instances where employees were referred to verify medical statements, reports would include an assessment of whether the employee was fit for work

Using OH reports to inform decisions about potential dismissal was rarely the initial reason employers sought OH support. Rather, they brought in OH services to try to resolve issues that were preventing employees from doing their work, or to confirm their suspicions of poor conduct. As such, reports in these instances gave employers:

• a better understanding of the challenges faced by their employees, and how best to support them, or
• grounds for fair dismissal (where the report gave conclusive proof of poor conduct). In these cases, employers felt that the OH referral also protected them in the event the employee challenged the dismissal

The level of detail within the report varied, depending on whether the employee gave consent to share more detail to help with adjustments (see Section 6.3 for more detail). Where reports were shared, the findings were reviewed by the employer to see if the recommendations were feasible in practice. This was particularly important for smaller businesses in cases where further treatment or adjustments came with a cost. Reviewing recommendations was typically more important for reactive purchasers as they did not have an established relationship with an OH provider who understood the constraints on their organisation to implement certain recommendations.

In addition to whether recommendations were feasible, employers considered whether the suggested treatments or adjustments were justified in order to retain the employee. This was particularly the case where recommendations or further tests/treatment would incur a cost; valued employees were more likely to receive more costly adjustments, even where budgets were tight. An employee’s value was not solely determined by their seniority but rather how important they were to the business: either through their skill or their length of service (in these cases, employers wanted to retain long-serving and loyal employees).

Case study: Justifying more costly treatments

One large tele-communications company had a permanent contract with an OH provider which included employee access to a free and confidential Employee Assistance Helpline.

The employer explained that if their OH provider made a recommendation, they would always put it in place. This also applied to offering support above and beyond their basic package, if it was recommended by the OH provider. For example, the employers’ Employee Assistance Helpline covered 6 sessions of counselling for employees, but if their provider recommended that employees should continue to have sessions, then they would consider it (rather than immediately rule this out on the basis of cost).

The employer explained that these decisions would be made by the HR team, with eventual sign-off provided at board-level, and long-standing employees would be more likely to receive additional treatment.

(OH-user, Large, Transport and Communications)

Once employers had decided that the recommendations were feasible, they were discussed with employees (HR would be present where there was an HR function).

Step 5: Action

Following discussion with the employee about the report, either reasonable adjustments, signposting to interventions, or other supportive requirements were put in place. Employers took more of a role at this stage, with HR, senior staff or line managers (depending on the organisational set-up) ensuring the changes were actioned. The level of involvement of HR, the manager or others would depend on the changes needed, for example ordering in a new office chair or more complex changes to the role (such as temporarily moving from full-time to part-time hours). Sometimes the advice could be more focused on the employee, for example lifestyle changes, meaning the employee would decide whether to make those changes. In cases of poor conduct amongst employees, employers described using the OH report to dismiss employees, citing lack of evidence of a health condition to justify their conduct.

Where employers could not afford the support recommended (for example, physiotherapy), they would signpost employees to relevant treatments available on the NHS, or provided by relevant charities.

Step 6: Review

Once the recommendations were actioned, some employers would schedule timelines for reviewing how the employee was doing, supported by their OH providers (where packages covered this, or where employers felt their support was necessary). The employer and employee would monitor the adjustments and the situation was typically reviewed around 6 to 8 weeks after the assessment or whenever recommended by the OH provider (as the context merited).

The formality of the review process varied. Larger employers, proactive purchasers, and employees with more serious cases were formally reviewed, with the OH provider involved. Smaller employers, reactive purchasers, or those with less serious cases tended to have more informal reviews, such as conversations between the line manager and employee about how they were finding the changes and anything that needed to be improved.

6.3. What do employers think about their providers?

Employers were broadly positive about their providers, across all key characteristics: size, sector, whether they had an HR function, the complexity of health and wellbeing requirements and whether they were proactive or reactive purchasers. Employers used OH specialists for situations they felt they either could not or should not handle themselves, and so saw their providers as a source of expert advice and guidance.

This perception applied to both the individual circumstances for which employers sought support, and to the broader employer-provider relationship. As covered in Section 5.3, proactive purchasers tended to refer to their providers to help shape the OH package of support they eventually bought, and reactive purchasers often consulted with OH professionals or employment consultants (if used) about whether an OH referral was necessary for a given situation.

Employers were largely positive about their relationships with their OH providers. When asked to consider what could be improved about the relationship, employers highlighted 3 consistent tensions:

• slow turnaround or delayed responses
• vague or unactionable recommendations
• poor communication and information sharing

Slow turnaround or delayed responses

Employers understood the need for providers to have adequate time to produce high quality reports and actionable recommendations, but timeframes that were perceived as unnecessarily long caused frustration. Employers explained that waiting for referrals, treatment or reports had both direct and indirect cost implications on their businesses.

Slow turnaround times had a particular impact on reactive purchasers who, by their nature, were using OH because they were reacting to a situation that required an urgent response. However, there were also cases where proactive purchasers would look elsewhere if their contracted provider could not offer an immediate appointment.

We use OH to reduce sickness absence. We pay enhanced OSP [Occupational Sick Pay] and lose out on employees’ chargeable hourly rate to clients if they’re off sick. We also have to pay for agency staff to cover, and it impacts on team morale, as well as the level of service we can provide to clients… We will approach other providers if we can’t get an appointment quickly with our main one.

(OH-user, Large, Banking and Finance)

Vague or unactionable recommendations

Employers wanted clear and concise details outlining both the issues the employee faced and recommendations to manage the situation. Tensions arose when reports did not provide employers with clear and deliverable steps and actions, or offered off-the-shelf solutions that were not tailored to meet the needs of both the employee and employer. Whilst examples were relatively rare, reports that showed the provider’s lack of understanding of employer and employee needs, and specific sector demands, were particularly ineffective and seen as unnecessarily costly.

Case study: The problem with unactionable recommendations

One catering company mostly used their OH provider to ensure health and safety compliance and fitness to work. They had 2-weekly calls to discuss their sickness absence cases. Whilst the OH service was open to all employees, the employer was unable to fund any treatments (such as physiotherapy, private counselling, or cognitive behaviour therapy) due to budgetary restrictions. Early on in their relationship, the OH provider recommended a course of physiotherapy for one employee, and told the employee that the employer would pay for it.

It can be really quite damaging to us, because we don’t have an unlimited pot of money. As much as we would like to support our employees, if we set a precedent for doing that… we just don’t have the money to offer it to everyone. So it can be unhelpful when that’s been discussed as an option.

The employer discussed the situation with their provider and they agreed that, going forwards, the provider would make recommendations for treatment via the NHS.

(OH-user, Large, Distribution, Hotels and Restaurants)

The (few) employers who had actively changed their OH provider did so based on their dissatisfaction in the time taken to produce and release reports with an appropriate level of detail.

We really need to know not just the background of the employee but also be really clear on what adjustments (for example) we need to make, what hours they can do, are they fit to return to work and in what capacity. It’s really understanding our requirements and ensuring they cater their response to answer our questions.

(OH-user, Medium, Construction)

Poor communication and information sharing

Supporting employees in a timely fashion was vital to both employees and employers. To be able to plan resources effectively, employers needed to be kept abreast of timescales when OH providers were working with employees. Poor communication and information sharing from providers further complicated issues relating to slow turnaround; having to ‘chase’ providers to find out the stage of the process, or having an unresponsive provider unnecessarily absorbed staff time, as well as adversely affecting the credibility of the OH provider.

In addition, proactive employers wanted regular updates on the general OH landscape relevant to their sector and workplace. Having timely and regular information was key to informing decisions about employees but also to support the strategic direction of employee health and wellbeing across the organisation. Employers wanted to remain up to date with legal requirements and any changes that might be on the horizon. Most employers wanted to know how they could provide a broader OH offer that went beyond statutory requirements and managing absences, and they expected their OH supplier to provide this.

7. What policies do employers have in place?

This chapter covers the policies that employers had (or did not have) in place, relating to their OH use that mentioned OH services and guided their use within the organisation. OH-users were asked about their policies’ content and levels of awareness and training on these policies, during the interviews. At the end of the interviews, Ipsos MORI asked participants whether they would be willing to share their OH-related policies. Six employers consented to this, and their policies were reviewed to explore any common themes in terms of how their OH provision was referenced (or not). The low number of policies provided means the ability to draw any meaningful conclusions is limited but this exercise does give some insight into how OH is described.

7.1. Policy content

Most employers did not have a dedicated OH policy that they used in their workplace. Where employers’ use of OH was included in a policy, it was nearly always part of wider sickness absence, health and safety or attendance management policies. This again reflected the diversity of situations for which OH services were used. Amongst the policies reviewed, there was either a fleeting reference to OH, simply stating that the services existed, or brief guidance on when to use OH services. The exception to this was amongst NHS employers; in these cases, there were different policies exclusively dedicated to OH between NHS trusts and authorities.

As OH did not usually form a substantial policy, the prescriptiveness of the guidance for line managers tended to be limited. There was no evidence in the interviews that this reflected an employer’s unwillingness to make OH services available but was described as enabling OH to be more tailored and flexible on a case-by-case basis. Employers who used OH services infrequently and/or those without permanent contracts in place, did not feel the need for prescriptive guidance or, in some cases, a policy at all.

[OH] doesn’t have an official policy. It’s so rare [that we need to use it] that it’s handled on an ad hoc basis.

(OH-user, Medium, Banking and Finance)

All of the reviewed policies showed that employee consent was required before an OH referral was made, or medical reports were accessed. However, one policy highlighted that disciplinary action would be taken if employees did not comply with the OH process after initial consent was given.

The reviewed policies commonly described OH as a means to facilitate returns to work. For example, they mentioned terms such as ‘Fit for Work’ (including in relation to the former government service), ‘Fit for Return’ or other consultations and return to work plans that could be undertaken through an occupational health provider. This supports the finding that one of the main reasons why employers used OH was to retain employees^{[footnote 23]}. Some policies described the roles of GPs, HR personnel and line managers as key actors that may be involved during the OH process, and these roles were typically described as shown below.

Key actors in the OH process

GPs:

• could issue a fit note that the employee ‘may be fit for work’
• could recommend OH referral
• agreed return to work plans
• employee medical reports could be used in conjunction with OH (with consent). One policy stated that OH reports took precedence over GP advice

HR personnel:

• administrative functions (for example, providing forms)
• liaising with OH provider and/or healthcare professionals (for example, booking referrals)
• maintaining contact with the employee, including answering any queries

Line managers:

• policies tended to be directed as guidance for managers
• line managers were described as assessing the suitability of OH after an absence
• employees might raise OH with their line manager

There were 2 examples of policies that discussed OH as a preventative measure to help create a healthy and productive workforce^{[footnote 24]}. In one example, an employer’s Health and Safety policy stated that it was their duty to provide a healthy working environment for all of their employees, meaning they would take steps to monitor and prevent the occurrence of any work-related disease. They went on to mainly frame this in relation to their hazardous working environment, health risks, safety and regulations such as the Health and Safety at Work Act 1974.

A finance and banking organisation also described OH within a wider framework of workplace wellbeing but orientated this towards mental health. This was the only policy provided that explicitly mentioned mental health and work-related stress as part of their OH policy, which aligned with their attitudes in the qualitative interview around wanting to provide a supportive culture.

Communication and awareness of policies

Employers who clearly communicated their policies and their OH provision, for example through posters, emails, online platforms, inductions and meetings, assumed that staff awareness of the policies was high. This included those in hazardous environments where awareness of policies relating to Occupational Health and Safety tended to be higher. These employers explained that they regularly communicated with employees about Health and Safety regulations, including spreading awareness of OH visits, screenings and check-ups, due to the risks associated with their work. Organisations who used NHS policies attributed high awareness amongst staff to the communication campaigns and handbooks that were disseminated, together with the need to comply with Care Quality Commission requirements.

Staff get [OH policies] at inductions, they link into the website, they are given a leaflet to keep with them etc.

(OH-user, Large, Manufacturing)

Other employers generally reported that their staff would be aware that the policy existed and would know where to access this, for example the intranet site, their contract or staff handbook. However, employers indicated that typically staff would not be able to recall the OH policies in any level of detail – implying that policies were not widely-read. In addition, there was no evidence of any employer providing training sessions on their OH policy for all staff members, but policy information was sometimes given during job inductions in manual working environments.

If I just picked someone at random and said ‘do you know what our occupational health policy is?’, I don’t think they’d know.

(OH-user, Small, Distribution, Hotels and Restaurants)

Some employers reported that line managers should have a greater awareness of OH policies than other staff members. This was because managers would need to know the policy to effectively supervise employees and/or the hazardous sites in which they may work. Some employers reported that line managers would receive more extensive training on OH policies compared to the basic induction training provided to staff in some organisations. This was to help managers assess where an OH service may be needed for whoever they managed.

8. Conclusions

8.1. What does OH mean to employers?

Employers had a shared, but basic, understanding of what OH services involved. At the fundamental level, they understood that OH involved bringing a qualified expert into an organisation, when an employer encountered a situation they felt unable to deal with. This could be due to a lack of expertise, or a feeling that a situation would be better handled by an independent third party. Fundamentally, employers wanted to do the right thing and sought the expertise and reassurance that an OH professional’s involvement brought.

OH aims to keep the workforce healthy and thriving, has many practical applications (taking a proactive or a reactive approach, or focusing on mental or physical ill-health), and encompasses a huge range of different services. Because of this, engaged employers without formalised OH often lacked a clear understanding about what OH could offer or typically involved, and had misconceptions about OH services as a result. For example, where employers had little or no experience of using OH services, they primarily associated OH services with informing dismissals. These employers often also lacked knowledge and awareness around the organisational benefits of OH services.

However, lack of understanding of the benefits of OH, or awareness of the full range of OH services was also evident amongst some OH-users, as many used OH in a fairly limited way, i.e. in the form of OH assessments. This was particularly the case for reactive purchasers who purchased OH services on a case-by-case basis. As a result, they had a more limited understanding of the organisational benefits of OH services, such as such reductions in the level and length of sickness absence.

In contrast, employers with long-term contracts were more likely to offer holistic and integrated services, such as Employee Assistance Programmes (EAPs) and general health screenings, and had the ability to trigger referrals more quickly than those who bought OH advice on an ad-hoc basis. These employers felt their OH services helped address, or even prevent, health-related issues (including sickness absence) at the earliest possible opportunity.

Overall, this suggests that examples of how OH services can be used, along with the potential benefits of investing in OH services, could encourage more employers to purchase OH or invest in a broader range of services.

8.2. What motivates employers to use OH services?

On the one hand, employers used OH services in order to satisfy their legal obligations, such as health and safety, and employment legislation. This was particularly important for employers working in manual environments, where the nature of the work posed potential risks to the physical health and/or wellbeing of employees.

Employers who had actively considered OH as an investment, broadly concluded that the cost of OH and the direct financial benefits (in terms of reductions in level and length of sickness absence, retention of employees, and increases in organisational performance) outweighed the alternative of not investing in OH services. Employers saw their employees as an important resource for the organisation to run effectively, and had a clear understanding of the costs associated with sickness absence.

There were also employers, especially those with tight profit margins, who had concluded that they could not afford the costs associated with purchasing an ad hoc or permanent contract. These employers welcomed any financial support or incentives. However, amongst all bar one employer interviewed, awareness of tax reliefs for purchasing OH services was very low.

Across the interviews, OH-users said they provided access to OH services for all permanent employees, without discrimination. However, whilst referral was open to all employees, it was not the case that they would pay for recommended treatments, or make adjustments suggested by the OH provider, as a rule, for all employees. Rather, the decision to pursue costly treatments or adjustments depended on the value of the employee to the organisation. Value was not purely restricted to seniority, and also included how important the employee was to the organisation: both in terms of how difficult they would be to replace, and as a way of rewarding loyalty or long-service.

Finally, employers were motivated to use OH services out of a sense of responsibility towards their employees’ health and wellbeing.

Whilst all 3 motivating factors, i.e. legal, cost-benefit ratio, and sense of responsibility, were important, employers were typically motivated by a combination of the 3 when they sought OH services. Across the situations for which employers sought an OH professional’s support, they primarily used OH services to help employees stay in work. Whatever the precise nature of the reason for referral, employers’ desired outcome was to have an employee who was mentally and physically healthy, and therefore able to work productively.

Employers’ provision of OH services therefore operated in the space of being a responsible employer, and balancing cost and benefit, both motivations underlined by a need to comply with employment legislation. Being a responsible employer and balancing cost were not mutually exclusive: employers thought about both their responsibilities to their employees and cost-benefit analyses of providing support, when deciding whether to offer OH services.

OH provision is about responsibility, and business efficiency:

• responsible employers: feel they have a duty of care for their employees’ health and wellbeing
• morale boost: staff feel valued and supported which improves wellbeing, increases workplace productivity and improves retention
• productivity: more productive staff led to increased financial benefits
• sickness absence: sickness has a range of direct and indirect costs on the organisation
• impact of OH services: can prevent or reduce (cost of) sickness absence
• improve bottom line: reduced costs improves organisations’ financial health

8.3. What does the provider-employer relationship look like?

Employers who had experience with OH professionals were positive about their interactions. However, generally, employers were not aware of the full range of OH services available and the services they did use tended to be limited to those they had purchased in the past. Whilst employers knew what they wanted from OH providers in terms of the practicalities of the relationship (responsiveness, multiple communication channels, tailored and actionable reports), they knew very little about what was needed in terms of the detail of services. Employers therefore relied on their chosen provider to help shape their OH offer.

There was limited evidence of employers shopping around for OH services, or undertaking detailed procurement exercises to inform their decisions to appoint a given provider. The few examples of systematically reviewing or commissioning of services were confined to large employers with dedicated, internal HR teams.

Proactive purchasers felt one of the benefits of a permanent contract was being able to build a relationship with an OH provider who had the time and capacity to understand the nature of their working environment in more detail. This allowed them to adequately tailor their package to their workforce needs. Tailoring was less common amongst reactive purchasers who sought OH services for specific needs on an ad-hoc basis.

9. Appendix

9.1. Sampling and recruitment

Employers were recruited from those who had agreed to be recontacted during the ‘Sickness absence and health in the workplace: Understanding employer behaviour and practice’ survey, conducted by Ipsos MORI during the summer of 2018. Quotas were set on variables including: OH use (or non-use), size, sector, country (Great Britain), and urbanity. The table below shows achieved interviews compared to quota:

Table 9.1: Sampling matrix (achieved v. quota)

OH-user (29 interviews)

Employer size	Quota	Booked/completed
2 to 9	Min 5	5
10 to 49	Min 5	5
50 to 249	Min 8	11
250+	Min 8	8

Sector	Quota	Booked/completed
Agriculture and Energy (ABDE)	Min 2	2
Manufacturing	Min 5	5
Construction	Min 2	3
Distribution, Hotels and Restaurants (GI)	Min 5	5
Transport and Communications (HJ)	Min 2	2
Banking and Finance (KLMN)	Min 5	5
Public Admin, Education and Health (OPQ)	Min 5	5
Other Services (RSTU)	Min 2	2

Geographical area	Quota	Booked/completed
England	Mix and monitor	25
Scotland	Mix and monitor	4
Wales	Mix and monitor	-

Urbanity	Quota	Booked/completed
Rural	Mix and monitor	8
Urabn	Mix and monitor	21

Employers without OH services (6 interviews)

Employer size	Quota	Booked/completed
2 to 9	× 1	3
10 to 49	× 2	1
50 to 249	× 2	1
250+	× 1	1

Sector	Quota	Booked/completed
Agriculture and Energy (ABDE)	Mix and monitor	2
Manufacturing	Mix and monitor	-
Construction	Mix and monitor	1
Distribution, Hotels and Restaurants (GI)	Mix and monitor	1
Transport and Communications (HJ)	Mix and monitor	1
Banking and Finance (KLMN)	Mix and monitor	2
Public Admin, Education and Health (OPQ)	Mix and monitor	-
Other Services (RSTU)	Mix and monitor	-

Geographical area	Quota	Booked/completed
England	Mix and monitor	5
Scotland	Mix and monitor	1
Wales	Mix and monitor	-

Urbanity	Quota	Booked/completed
Rural	Mix and monitor	4
Urabn	Mix and monitor	2

OH-users were those who said they used occupational health services during the survey, in response to the below question (which was confirmed during recruitment):

Does your [business] [organisation] provide access to occupational health services for your employees?

Add if necessary: By occupational health services, I mean advisory and support services which help to maintain and promote employee health and wellbeing. OH services support organisations to achieve these goals by providing direct support and advice to employees and managers, as well as support at the organisational level for example, to improve work environments and cultures.

Do not read out. Single code only.

1. Yes
2. No
3. Don’t know

Employers without formalised OH were those who said they did not provide access to occupational health during the survey. However, they were purposively selected as they did provide a range of other services, and the Work and Health Unit wanted to explore their reasoning behind offering these other measures, but not a formalised OH scheme. To be eligible for the research, these employers had to achieve a certain number of ‘points’, based on their provision.

Participants had to ‘score’ 3 points to qualify as an engaged employer without OH. Points were applied as follows: one point for doing at least one action from codes 1 to 3, one point for one action at code 4, and two points for two or more actions at code 4. The codes related to the following questions from the survey:

(1) Have you used any of the following to manage employees’ returns to work after a long-term sickness absence?

• regular meetings
• develop return to work plans
• external, specialist support to manage the employee’s return

(2) Seek an independent assessment of employees’ work capacity to manage employees’ returns to work after a long-term sickness absence.

(3) Which, if any, of the following do you currently provide to prevent employee ill-health or improve the general health and wellbeing of your workforce?

• health and wellbeing promotion programmes to improve employees’ physical activity or lifestyle (for example, healthy food choices, subsidised gym membership)
• interventions to prevent common health conditions becoming a problem (for example, smoking or weight loss support, free health checks)
• training for line managers on ways to improve employee health and wellbeing
• an Employee Assistance Programme (EAP) or staff welfare/counselling programme provided by an external organisation

(4) In the last 12 months, have you used any of the following to support employees with health problems to remain in-work or support in returning to work?

• phased returns to work from sickness absence
• amending employee workload or job role
• opportunities for employees to return to work in a flexible manner
• workplace adjustments (for example, different chair, building modifications)
• additional external support or advice, for example psychological or physio therapy)

9.2. Topic guides

Two topic guides were used: one for OH-users and one for employers without OH.

Topic guide: OH-users

Background

Ipsos MORI has been commissioned by the Work and Health Unit (a joint unit between the Department for Work and Pensions and Department for Health and Social Care) to understand employer motivation and practices when using Occupational Health (OH) support.

OH providers are professionals that employers use to support their employees. They can be medical professionals (doctors or nurses), physiotherapists, hygienists, psychologists, occupational therapists, or ergonomic experts. OH focuses on the physical and mental wellbeing of employees in the workplace, and aims to prevent work-related illness and injury by^{[footnote 25]}:

• encouraging safe working practices
• making workplace adjustments (for example, ensuring the workplace is accessible, studying how individuals work and adjusting accordingly, for example, the height of their desk or chair)
• monitoring the health of the workforce (and trying to prevent sickness absence)
• supporting the management of sickness absence (and employees’ return to work)

OH services can be used by employers in different ways. In addition to the above, OH providers may work with employers to:

• implement policies and ensure health and safety compliance
• conduct pre-employment health assessments
• support health promotion and education programmes
• provide advice and counselling to employees around non-health related problems, or
• help employers with dismissals (for example, if the nature of the work is not suited to an employee)

Aims and objectives

The aim of these interviews is to explore the different types of motivations employers have for using OH and other forms of similar support. Specifically, the research aims to:

• explore how and why employers decide to use OH, and which package to choose
• explore how the OH is used in practice, including the management of the scheme
• explore which policies employers have in place relating to OH

OH versus OH-related support

We will explore employers’ wider offer to support employee health and wellbeing, though the primary focus is on OH. Throughout the guide, we refer to this as ‘OH-related support’, and this includes:

Category	Examples of support
Manage employees’ returns to work after a long-term sickness absence	- regular meetings - develop return to work plans - external, specialist support to manage the employee’s return
Seek an independent assessment of employees’ work capacity to manage employees’ returns to work after a long-term sickness absence
Prevent employee illhealth or improve the general health and wellbeing of your workforce	- health and wellbeing promotion programmes to improve employees’ physical activity or lifestyle (for example, healthy food choices, subsidised gym membership) - interventions to prevent common health conditions becoming a problem (for example, smoking or weight loss support, free health checks) - training for line managers on ways to improve employee health and wellbeing - an Employee Assistance Programme (EAP) or staff welfare/counselling programme provided by an external organisation
Support employees with health problems to remain in work or support in returning to work	- phased returns to work from sickness absence - amending employee workload or job role - opportunities for employees to return to work in a flexible manner - workplace adjustments (for example, different chair, building modifications) - additional external support or advice (for example, psychological or physio therapy)

1. Introduction

2 to 3 mins

Thank participant for taking part. Introduce self, and explain nature of interview: informal conversation; gather all opinions; all opinions valid. Interviews should take around 45 minutes. Introduce research and topic – the Work and Health Unit (a joint unit between the Department for Work and Pensions and Department for Health and Social Care) has commissioned Ipsos MORI to conduct research with employers to understand their reasons and practices when using Occupational Health (OH) or similar support. They have been asked to take part in this interview because they took part in a survey on a similar topic over the summer. Role of Ipsos MORI – Independent research organisation (i.e. independent of government), we adhere to the Market Research Society (MRS) Code of Conduct. Confidentiality – reassure all responses anonymous and that identifiable information about them will not be passed on to anyone, including back to Work and Health Unit (WHU) or any other government department. Consent – check that they are happy to take part in the interview and understand their participation is voluntary (they can withdraw at any time). Ask for permission to d igitally record – transcribe for quotes, not detailed attribution. Only non-identifiable information will be passed back to WHU. Any questions before we begin?

Orientates interviewee, prepares them to take part in the interview. Outlines the ‘rules’ of the interview (including those we are required to tell them about under MRS and General Data Protection Regulation (GDPR) guidelines).

2. Context

2 to 3 mins

To start off with, I’m going to ask a few broad questions about your role and the nature of your organisation. Can you tell me a bit about what the organisation does? - sector (confirm) - size/financial turnover (confirm) - length of time in operation - single site versus multiple site - briefly explore the nature of the work and range within the business (for example, manual versus office based) And can you talk me through what your role involves? - specific HR role / senior management / owner or director / Occupational Therapist or Wellbeing professional - explore their responsibilities/experience/qualifications in relation to employee health and well-being - length of time at the organisation

Provides contextual background information about the participant and their organisation.

3. Overview of OH offer

10 mins

I understand, from the survey that you took with us over the summer, that your organisation provides Occupational Health services, and I’m interested in hearing about the services you provide. By Occupational Health services, I mean advisory and support services by qualified professional to help employers to maintain and promote employee health and wellbeing. Before we look at what your Occupational Health services look like, I’d like to understand why you decided to offer OH in the first place. Can you talk me through the decision? How did the idea to provide OH come about? Was it in response to something that happened at your workplace (for example, in response to increase in long-term sickness absence) or something else (for example, employee demand etc.)? Why did they decide to offer OH? Prompt using the answers they gave in survey (H3) and the following: - as a source of information / professional advice - as a legal requirement - to support employee health and wellbeing / employee health and wellbeing is an employer’s responsibility - normal for the sector - help to attract / retain staff - prompted by an individual employee’s case (reactive approach) - to inform dismissal or to manage employees out of the business - to verify medical statements - for advice on adaptations and adjustments - occupational health and safety - to inform return to work plans - cost/benefit analysis (benefit outweighed the cost) - prevention – reduce long-term sickness absence - reintegration – to support employees back to work What would you say is the main reason? Why? At the time of purchase, were you aware of any financial incentives available for the purchase of OH? Prompt if necessary: - health services provided by registered doctors, dentists, opticians, pharmacists and other health professionals are VAT exempt - additional tax reliefs for some health promotion interventions, for example, health screening - cost of OH-recommended medical treatment to help Return to Work after Long Term Sickness Absence (< £500 per employee) exempt of National Insurance contributions (NIC) and direct tax What, if any, impact did these have on your decision to buy OH services? Can you talk me through what OH services you provide? Ask if not mentioned by participant: Does your OH cover expert advice services? For example, 3-way conversation between line manager (LM)/employee/expert to aid Return to Work or an independent assessment of work capability Does it cover intervention services> For example, Physiotherapy, Cognitive Behaviour Therapy (CBT). How long have you provided OH services? Which service do you most commonly use as an employer? Which service is most commonly requested by employees? If provide more than one service: Did you start by offering this package of support, or build it up over time? - why did you decide to offer this package from the outset? Or - why did you build up your offer over time? What effect do you hope this support has on your employees? What effect do you feel this support has on your employees in reality? For each aspect of the OH offer: Is [aspect of OH] open to all, or only to some? - who/why? - can you talk me through how you decided to offer this service to these employees?

Establishes, the reasons why they introduced OH (generally) and what the employers OH offer covers.

4. Decision-making on OH

10 mins

I’d now like to move on and find out about how your organisation decided to provide this particular package of support. Why did you choose this particular OH package? Probe on: - sought specialist advice/support - cost – probe: how did you determine good value for money? - employee demand - industry standard - off the shelf/easy Can you talk me through the process of choosing this particular package of support? Who was involved in developing the package – employees, management, the provider, Board? What role did each play? Probe on employer-led versus provider-led versus collaborative. What information or advice did you seek to implement your plan? Why did you choose these sources? How useful were they? What did you find especially useful / not useful? Was there anything you wanted to know but did not get? What types of OH providers did you consider? Did you want to consult more but were unable to? What is your view on the range/choice/diversity of providers available? How did you compare providers (price, range of services, recommendations, evidence on the outcomes or success of using OH, provider accreditation, ease or convenience)? - what was the most important factor that led you to choose your provider(s)? - if use multiple providers, explore reasons for this Thinking about your provider(s) now, do you think you have made the correct choice? Would you say you have a broadly positive or broadly negative relationship with them? Can you explain why this is? Probe: any situations where OH provider recommended one thing and your organisation wanted to do another? What are you particularly pleased about? What would you like to change about them? If cost was a factor in choosing provider(s): How do you feel about the value for money you’re getting from your OH provider? To what extent do you feel you are seeing a return on your investment? To what extent do you feel you are saving money as a result of providing OH? How? Reflecting back on your initial reasons to provide OH services to staff, how have they changed, if at all? What would you say are the main reasons why you have continued to provide OH services to staff? How much would you say your organisation values the OH services you use? Why?

Explores how employers arrived at their decision to offer OH, including advice sought and discussions held. Establishes why employers decided to use their provider in particular.

5. Management of the OH scheme

5 mins

I’d now like to find out more detail about how your OH is managed in practice. How are OH services managed in your organisation? Who has responsibility for some/all of your provisions? How often, if at all, do you review the level of support you provide? I’d like to find out a bit more about how your OH works in practice. Interviewer: for each aspect of their OH provision, explore: How do employees access [OH services]? What process do you have in place? Probe on: - who requests OH in the first instance? (Line Manager, HR, employee?) and at what stage is OH requested? - typically, how involved would the employee be in the decision? - what determines how much support an employee receives? Probe: any professional advice/support (for example, Line Manager, HR, employee) - what determines whether an employee is offered more costly interventions, (for example, seniority, length of service, working pattern, temporary/permanent staff) for example, rehabilitative treatment/physiotherapy - who is responsible for acting on the advice of the OH provider? Is advice always followed? Probe for an example of a situation where advice hasn’t been or wouldn’t be followed. - are there any tensions between your organisation and your OH provider? What do these look like? - what happens after somebody goes to OH?

Overview of how the OH contract is managed, including who is responsible for it and a description of the process of OH-referral.

6. Reasons for using OH

5 to 10 mins

I’d now like to discuss why you use OH in the way you do. When OH is used, what kinds of things is it used for? - inform recruitment - inform dismissal/manage people out of the business - verifying medical statements - advice on adaptations/adjustments - occupational health and safety - inform return to work plans - managing sickness absence - keeping the workforce healthy - what do you mainly use OH for? Could you talk me through an example of when OH services have been particularly effective? How was it effective? Probe: what do they see as a positive outcome and for whom? Could you talk me through an example of when OH services have been ineffective? Why was it ineffective – what outcome were you hoping for that did not materialise? Why did it not happen in the way you’d wanted?

Explores in more detail how OH is used in practice, and what happens after an employee visits OH.

7. Policy

2 to 3 mins

Finally, I’d like to explore the policies you have in place that relate to OH. Do you have specific policies that cover your OH provision? - which policies cover your OH provision? - in these policies, how prescriptive is the guidance for Line Managers in regard to OH? How aware are… - line managers; and - employees … of these policies? How have these policies been communicated to line managers and/or employees? Have they had any training on these policies? What does this training look like? If an employee wanted to know more about these policies, how easy or difficult would it be for them to find out? As part of this project, we reviewing organisations’ OH policies to draw out common themes and comparisons. Would you be willing to share the relevant policy documents with us in confidence? Reassure if required: we will be reporting themes only. It will not be possible to identify any organisation in the report. Add if necessary: - the documents will only be viewed by the research team at Ipsos MORI - the documents will be fully anonymised, so that your name or the organisation’s name will be removed and it won’t be possible to identify either in our report - the documents will be kept on a secure network at Ipsos MORI - the documents will be securely destroyed once the project has come to a close - should you change your mind at any time, you can let us know that you’d like to withdraw the documents

Overview of which policies employers have in place that relate to OH, and seeking permission to view these policies for review.

8. Summing up

2 to 3 mins

We are coming to the end of the interview, but I have a few final questions before we finish. Is there anything else you would like to mention that we have not had the opportunity to discuss? Thank and reiterate confidentiality. Incentives = a ‘thank you’ from Ipsos MORI for their time and contribution. £50 donation to a charity of their choosing. Explain next steps for the research and close – report will be published in summer 2019.

Brings the conversation to a close, and allows participants time to mention anything that has not already been covered.

Topic guide: Engaged employers without OH

The briefing notes were the same for the OH-users’ and employers without OH guides and have therefore not been included below.

1. Introduction

2 to 3 mins

Thank participant for taking part. Introduce self, and explain nature of interview: informal conversation; gather all opinions; all opinions valid. Interviews should take around 45 minutes. Introduce research and topic – the Work and Health Unit (a joint unit between the Department for Work and Pensions and Department for Health and Social Care) has commissioned Ipsos MORI to conduct research with employers to understand their reasons and practices when using Occupational Health (OH) or similar support. They have been asked to take part in this interview because they took part in a survey on a similar topic over the summer. Role of Ipsos MORI – Independent research organisation (i.e. independent of government), we adhere to the MRS Code of Conduct. Confidentiality – reassure all responses anonymous and that identifiable information about them will not be passed on to anyone, including back to WHU or any other government department. Consent – check that they are happy to take part in the interview and understand their participation is voluntary (they can withdraw at any time). Ask for permission to digitally record – transcribe for quotes, not detailed attribution. Only non-identifiable information will be passed back to WHU. Any questions before we begin?

Orientates interviewee, prepares them to take part in the interview. Outlines the ‘rules’ of the interview (including those we are required to tell them about under MRS and GDPR guidelines).

2. Context

5 mins

To start off with, I’m going to ask a few broad questions about your role and the nature of your organisation. Can you tell me a bit about what the organisation does? - sector (confirm) - size/financial turnover (confirm) - length of time in operation - single site versus multiple site - briefly explore the nature of the work and range within the business (for example, manual versus office based) - ease to recruit/retain staff (confirm from recruitment info) And can you talk me through what your role involves? - specific HR role / senior management / owner or director / Occupational Therapist or Wellbeing professional - explore their responsibilities/experience/qualifications in relation to employee health and well-being - length of time at the organisation Can you talk me through how the organisation makes decisions about staff health and wellbeing policies? By ‘health and wellbeing’ we mean all things to do with employee health and wellbeing, including the management of ill-health, LTSA, retention of employees and disability. - who is involved in making these decisions? (for example, director, senior management, owner). PROBE on specific health and wellbeing roles: HR, external professionals - does the organisation have dedicated HR staff? If not, who handles this work? How important would you say employee health and wellbeing is to your organisation? Do you have business objectives related to employee health and wellbeing? - what are these? Why do you have them? - why not?

Provides contextual background information about the participant and their organisation.

3. Overview of OH-related support

In this section, I’d like to understand more about what your organisation does to support employees and their health and wellbeing. Interviewer refer to recruitment information for this section and explore the following ways of supporting employees: - managing employees’ return to work after long-term sickness absence - if applicable: seeking an independent assessment of employees’ work capacity - preventing employee ill-health or improving the general health and wellbeing of the workforce - supporting employees with health problems to remain in-work or support in returning to work For each method of support, explore: - what does this involve? - who is responsible for managing this support option? - who is responsible for delivering the offer? Probe: in-house or contracted out? - are these options available to all, or only to some? Who/Why? - how is eligibility decided? - can you talk me through how you decided to offer this service to these employees? - how do employees access this support? Probe on whether they are referred, or they have to request it - what effect do you hope this support has on your employees? - what effect do you feel this support has on your employees in reality? - why does the business use this type of support? - as a source of information / professional advice - as a legal requirement - to support employee health and wellbeing / employee health and wellbeing is an employer’s responsibility - normal for the sector - help to attract / retain staff - prompted by an individual employee’s case (reactive approach) - to inform dismissal or to manage employees out of the business - to verify medical statements - for advice on adaptations and adjustments - occupational health and safety - to inform return to work plans - cost/benefit analysis (benefit outweighed the cost) - prevention – reduce long-term sickness absence - reintegration – to support employees back to work - what would you say is the main reason? Why?

Description of other support that employers provide to manage return to work, prevent ill-health and support employees with health problems to remain in work.

4. Reasons for not providing Occupational Health

I’d now like to talk about Occupational Health services, and what you think about them. I understand, from the survey that you took with us over the summer, that your organisation does not provide Occupational Health services. Just a reminder that there are no right or wrong answers, and that I’m interested in your opinions. Can you describe to me what you understand by the term ‘Occupational Health’ services? Interviewer: Reassure participant that ‘don’t know’ is a valid response - what are your thoughts on Occupational Health (in terms of how necessary it is, how useful it is for employers/employees)? - do you feel that Occupational Health is something different to the support that we have just discussed? - how/why is it different? Can you think what other employers might use Occupational Health services for? Can you tell me why your organisation does not use Occupational Health services? Interviewer use their answers from the survey to probe and explore further (H5) - cost/too expensive – explore whether they feel they can do it cheaper in-house - unable to get funding for it – explore whether they feel they can do it cheaper in-house - too complicated/too much administration involved - too few cases to justify the expense - no employee demand/employees not disclosing they are in need of OH - does not help solve the issues that the organisation faces - lack of knowledge – what services to buy, who to buy services from/who are good suppliers - lack of time to investigate - negative experience of OH services in the past - lack of awareness or support amongst senior management/no ‘champion’ to take forward - general make-up of the workforce doesn’t make it worthwhile, for example mainly part-time or temporary staff, high levels of staff turnover - not a priority for this organisation Which is the main reason why you don’t use OH services? What, if anything, might prompt you to start using OH services? Refer back to specific reasons identified above and ask whether and how these might be overcome. Have you ever used or considered using OH in the past? If used before: - what were your experiences of using OH? - what made you decide to offer the services you have now (refer to specific services) rather than OH services? - needs of staff? - cost? Are you aware of any financial incentives available for the purchase of OH? Prompt if necessary: - health services provided by registered doctors, dentists, opticians, pharmacists and other health professionals are VAT exempt - additional tax reliefs for some health promotion interventions, for example health screening - cost of OH-recommended medical treatment to help Return to Work after Long Term Sickness Absence (< £500 per employee) exempt of National Insurance contributions (NIC) and direct tax What, if any, impact would these have on your decision to use OH services? What else might encourage you to use OH?

5. Summing up

2 to 3 mins

We are coming to the end of the interview, but I have a few final questions before we finish. Is there anything else you would like to mention that we have not had the opportunity to discuss? Thank and reiterate confidentiality. Incentives = a ‘thank you’ from Ipsos MORI for their time and contribution. £50 donation to a charity of their choosing. Explain next steps for the research and close – report will be published in summer 2019.

Brings the conversation to a close, and allows participants time to mention anything that has not already been covered.

1. These findings should be treated with caution due to the small number of interviews in this group. ↩

2. As defined in ‘Sickness absence and health in the workplace: understanding employer behaviour and practice’ due to be published later in the year. ↩

3. For more information, see Reasonable adjustments for workers with disabilities or health conditions. ↩

4. For more information, see Statutory Sick Pay (SSP). ↩

5. DWP and Department of Health and Social Care (DHSC), ‘Improving Lives: The Future of Work, Health and Disability’, 2017. ↩

6. These typologies are not intended to be a comprehensive segmentation of employers. They are subgroups emerging from the interviews, with similar characteristics affecting the nature of their OH provision. These typologies exist within the study population, and may not be representative of the wider employer population. ↩

7. This process was highlighted during the interviews, and is also a widely-used/accepted process (outside of the research findings). ↩

8. DWP and Department of Health and Social Care (DHSC), ‘Improving Lives: The Future of Work, Health and Disability’, 2017. ↩

9. DWP and Department of Health and Social Care (DHSC), ‘Improving Lives: The Future of Work, Health and Disability’, 2017. ↩

10. As defined in ‘Sickness absence and health in the workplace: understanding employer behaviour and practice’ due to be published later in the year. ↩

11. See, for example: How occupational health can help businesses. ↩

12. See, for example: How occupational health can help businesses. ↩

13. Micro employers are defined as having one to nine permanent employees. However, for the purposes of this research, organisations with only one employee were screened out of the survey. Micro employers are here defined as those with 2 to 9 employees. ↩

14. We can infer from this that employers who do not think it is their duty to provide for employees’ health and wellbeing may not fully understand the benefits of investing in OH services (benefits such as reducing the costs associated with long-term sickness absence). This hypothesis would merit exploration in further research. ↩

15. Some employers had counselling services as part of their OH offer. There were also employers without OH services and employers whose OH packages did not include counselling, who supported their employees with mental ill-health and/or personal problems by signposting them to external support (such as NHS mental health support or charities). ↩

16. For example, these employers were unable to articulate or think about what OH services could have offered them where they needed to manage long-term sickness absences, return to work, manage employees with long-term health conditions, or to maintain a healthy workforce more generally. These employers are discussed in more detail in Chapter 4. ↩

17. Ipsos MORI conducted 2 interviews: one with an NHS subsidiary company (operating facilities on behalf of an NHS hospital), and the other with a General Practitioner (GP) practice. Due to the limited data on decision making with these types of employers, Ipsos MORI and WHU decided not to recruit any more employers in the healthcare sector, and these employers’ are only lightly touched on throughout the report. ↩

18. However, employers were not solely using OH services for legal reasons. See Section 3.4 ‘Providing OH: How legal, cost, and moral motivations are linked’ for more detail. ↩

19. As this is only based on 6 interviews, this finding should be treated as indicative only, and would merit further exploration. ↩

20. HR services accounted for around one-fifth of all outsourcing deals in 2014 (see: HR outsourcing: a sophisticated, innovative future?) and 29% of businesses outsourced payroll, 35% outsourced training and 12% outsourced recruitment (see: The 2011 Workplace Employment Relations Study). ↩

21. We see similar attitudes among small businesses in relation to their tax affairs, with both businesses and self-employed individuals preferring to use accounts rather than manage their taxes themselves – due to lack of time, and fear of making mistakes. For an example, see: Making Tax Digital for Business: Survey of small businesses and landlords. ↩

22. This process was highlighted during the interviews, and is also a widely-used/accepted process (outside of the research findings). ↩

23. See Chapter 3 for more detail. ↩

24. In these cases, it appeared that employers were referring to OH as a broader aim, objective, or discipline, rather than as a service. This was not explicitly stated by the participants but could be inferred from the data. ↩

25. How occupational health can help businesses

    The role of occupational health. ↩