Reflections on forum developments accommodating formal and informal referral models

 C van Selm


Occupational Health Swaziland, Matsapha Industrial Complex, Manzini, Swaziland

Correspondence: Dr Chris van Selm, PO Box 692, Ezulwini, Swaziland. e-mail:


Chris van Selm is a SASOM member.


Any person (an employee, employer or anyone in any capacity at a place of work) has a right to confidentiality with regard to health and medically-related issues. Exceptions might include an injury on duty (IOD), an occupationally-related exposure, and/or an illness/disease that requires consultations, discussions and actions that include both employers and employees.

Confidentiality involves complex issues, including those related to financial, moral, cultural and religious concerns. It is also subject to company- or site-specific policies or procedures, and other legal measures that require conformity to ‘good behaviour’. Where confidentiality is breached, ensuing actions by authorised persons must take into account appropriate procedural applications, varying from closed or personal discussions to formalised meetings, and more disciplined measures, such as hearings, forms of arrest or restraint, and temporary or permanent dismissal from site.

Absenteeism is often associated with physical, mental or emotional illness which can create concern or frustration in others (most commonly employers) because of reduced productivity or performance at work. The most common reason for absence from work is medical, hence the development of methodologies to manage the situation by applying high ethical and moral standards, as well as being aware of the statutory implications e.g. as described in the Labour Relations Act (Act no. 66 of 1995), the Employment Equity Act (Act no. 75 of 1997), the Basic Conditions of Employment Act (Act no. 55 of 1998), the Compensation of Occupational Injuries and Diseases Act (Act no. 95 of 1990), and the Occupational Health and Safety Act (Act no. 85 of 1993). This, in turn, addresses the question of referral, of which there are two methodologies or processes that have been tested comprehensively by the author.



Where a person seeks any medical (or emotive) help or guidance from the staff of the occupational health clinic (or any other qualified medical professional), those professionals are committed, by the Medical, Dental and Supplementary Professions Act (Act no. 56 of 1974), to a strict code of confidentiality. As such, any information relevant to the visit may not, under any circumstances, be disclosed to any other person, either directly or indirectly, without written informed consent from the person seeking the help.



This is a process that is related to a formalised policy or procedure, designed to embrace certain criteria that are relevant to the referral. A formal referral therefore has legal implications and precedence that require strict adherence to procedure, with correct approaches to avoid any complications that might arise out of any potential and/or real conflict.

As an example, a person is unable to attend work because of headaches, and his employer feels concerned, or even aggrieved,* by the fact that he is absent from work on numerous occasions. The employer might have reasonable grounds for concern, and might challenge the employee by noting the excessive sick leave in a defined period (e.g. by following procedures stated in the Basic Conditions of Employment Act. In this case, the employer should invite the employee to a meeting to address these concerns, together with any representative(s) of the employee’s choice (e.g. a union shop steward, colleague, medical professional, lawyer, or family member) who might contribute to the proceedings in a meaningful way.


Forum formation

An agenda is then formulated, which a designated discussion can follow. The onus is on all parties to keep the contents of the agenda confidential. An opportune date, time and locality are chosen to comply with all parties’ needs. Once the forum is convened, comprehensive discussion can take place, matters can be debated in confidence (respecting allegiance to confidentiality), and all arguments will be noted by an elected scribe. Should one or more of the conclusions identify visits/referrals to the occupational health clinic (OHC) as being appropriate (the most common outcome), or any other site on company premises or elsewhere, and be acceptable to the forum, this will be accommodated. Further visits to on- or off-site localities will also be considered.

It is imperative that the formal referral be in writing and that the relevance of the referral be clearly determined. Such terms of reference are essential, and the content should be limited, accordingly (contentious issues that often arise are that medical assessments may require further investigations and/or specialist referral, and consent for this needs to be clearly documented in the referral letters, etc.) On- or off-site visits might have similar considerations.

Once the assessment is finalised, the process of a formal referral allows relevant disclosure to be submitted, in writing, back to the forum for review and reconsideration. A follow-up meeting is then held, comprising the same parties as the first meeting.

The important difference between an informal and a formal referral is that the formal referral allows confidentiality to be breached and relevant disclosure to be made in writing, whereas the informal referral does not.

Disciplinary action might be one of several outcomes that is taken against an employee thereafter, but the aim of a formal referral and forum follow-up is to rekindle opportunity, and to provide relief and/or continuity of work, where possible.



Concerns surrounding health assessments include the following:

1.    Definition – the word forum means embracing equal status for all present, and offering equal opportunity to participate

2.    The aim of the forum has relevance to its outcome, given that collective responsibility as a measure of successful closure is paramount

3.    The protection of rights, respect for confidentiality, and gestures of goodwill should dominate proceedings

4.    The procedure follows the referral process, with formality taking precedence

5.    Structural assignment of evaluation and clarity of discussion should accommodate, in particular, those very person(s) who are most vulnerable in the forum. In practical terms, this invariably means addressing the concerns of the ill, the compromised, and/or the impaired

6.    Associated parameters guiding the approach to proceedings, the manner and attitude in which this is directed, and the collective information relevant to conclude outcomes, should all be accommodated

7.    The practical model has additional characteristics to include:

• Recording of medical history, family, and employment history

• Confidentiality: each person should sign the agreement

• Representation for the person to whom the discussion is addressed should be invited, as well as any other person considered relevant to the forum

• Professional components should include medical personnel with suitable professional standing

• Input from Human Resource personnel

• Additional technical and professional support, when and where needed

• Any other person who might be considered valuable to assist in reaching a conclusion

• Acceptability of persons present must be acknowledged and approved by all

8.    The forum will include a leader as a spokesperson, a strong personality, or any other person whom the forum finds acceptable

9.    Procedure is accompanied by a prepared summation of all evidence to be led, with medical and other industrial-related or technical professionals; the detail is aimed at avoiding delays and inconclusive discussions

10.  Proceedings should not be prolonged; discussions should be limited to one hour

11.  In closure, the proceedings should be summarised, together with the conclusions (even in disagreement), and the minutes signed by all parties

12.  Follow-up is arranged by consensus



Social interdependence

Industry has always played a major part in the lives of people working in South Africa, going back many years. Often, it is found that workers give most of their time to their places of employ. Because of changes in the country since 1994, people are now very mobile, and job opportunities have thus increased.


Legal changes

As the working environment changed, so the paradigms of health and safety became more relevant; occupational health itself became a statutory requirement in 1993 under the Occupational Health and Safety Act, after prolonged and long overdue recommendations were implemented. This was prompted by the findings of the Erasmus Commission in 19761 and stimulated by influence from union movements on Parliament.


Department of Labour

Together with the significant changes in statutory requirements, the approach to observe and police the laws relating to health and safety became a reality. Slowly at first, but with increasing momentum, the Department of Labour has directly exercised its rightful place in the monitoring and surveillance of industry in general. This has also been clearly observed in the mining industry and, more recently, in commercial and small to medium enterprises.


Chains of custody

This shift in growing awareness and responsibility inevitably leads to an awareness of ‘chains of custody’ now being pursued and practiced, with immediate and follow-up care from place of accident/incident to hospitalisation and aftercare.


Centres of excellence

Following the initial responses to injuries, there are ‘centres of excellence’ that have become dedicated to giving the best medical and related attention. Such centres are usually strongly recommended and supported by industry to facilitate the best of attention, at any given time, to all workers and others involved.


Best attention

The procedural changes that have come about are directed towards such ‘best attention’ services and centres, with support from all sectors of workers in industry, either directly or  indirectly implicated, who share the ‘pain’ and emotional trauma that surrounds people who are hurt or become ill as a direct result of their work.


Emotional dysfunction

This often leads to very difficult and complex emotional dysfunction, particularly when a colleague, friend or peer is involved. A death is the ultimate disaster emotionally, even if it is not injury-related.



To a large extent, this very intense concern and emotional experience is carried over into the community, which also has ties with the industry. The expectation is that industry will respond both timeously and appropriately when a loved one is injured, becomes ill or, worse, is deceased. It is because of this intense emotional experience that communities become part of relationship-building with industry, and also the operational risks that are involved.

Missing this awareness is often a fault of industry in general. While this is often evident in major cities, the more rural the industry, the greater the awareness of the community

Smaller communities know each other better and are closely linked, both emotionally and physically. This becomes even more imperative if the environment is implicated. Current scenarios are compounded by a long-standing history of high-risk perceptions, all of which have a magnified exposure in the lay press, as well as the community at large.


Disability and absenteeism

The concerns that we have established over the years through major involvement in industry have identified various processes of monitoring both absenteeism and disability. This is a particularly important aspect of managing companies, and it is strongly advocated that this be further reviewed in the future. Often neglected, disability management is becoming increasingly complex and, to some extent, confusing because of lack of comprehension of case management.



1. The right to confidentiality and privacy is entrenched, particularly in workplaces

2. However, where work places create adverse or complex issues/incidents, the legal interpretations can be compounded, and the complexities become paramount, when contracts of employment or injuries/incidents become evident, leading to challenges requiring specific legal processes and procedures to be implemented

3. Forum formation and methodologies to develop these are aimed at seeking closure

4. Respect for inter-personal relationships in forum sessions can become conflictual, and sensitivities are eminent; allowances should always be accommodated with ultimate direction of closure

5. Open-ended directives towards legal continuation still have a place

6. Commonly, these situations are medical in origin, and involve injuries or incidents/ exposures from an occupational cause

7. The complexities of dealing with this can become delicate in relation to confidentiality and disclosures

8. Documentation of minutes and follow-up are integral in such procedures



1. Report of the Commission of Enquiry into Occupational Health (Erasmus Commission). RP 55. Pretoria: Government printer, 1976.


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