Absence management: Head counting

Absence management is undertaken too often in a vacuum, without examining the evidence for its effectiveness, according to many speakers at a recent gathering of public sector managers. Attendance management in the public and private sector needs to reflect good evidence, reinforcing the old adage that “you can’t change what you don’t measure”, delegates at the Public Service Partnership’s attendance conference heard.


Failing to consider the evidence for what works in attendance management partly explains the huge variation in sickness absence experiences of different organisations, both within and beyond the public sector, delegates heard.


Organisations achieving the greatest success in cutting absence are those that measure their own patterns and trends and use this data to tailor interventions, including actions targeted at particular groups, occupations or departments, speakers agreed.


The lack of a clear evidence base makes it difficult to prepare a business case for investing in employee health, and therefore, to secure senior management buy-in for any investment.


In her keynote address to the conference, Dame Carol Black, national director for health and work, stressed that one set of data – on the impact of worklessness and poor health on the life chances of future generations – is providing a powerful message to GPs in the context of current discussions about a switch from a “sick” to a “fit” note scheme. Returning to work does reverse health risks and improves an individual’s resilience, she added.


Black talked about how health professionals are not taught that employability is as important as an individual’s condition in determining care plans, and suggested that she had practiced “incomplete medicine” during her time in practice because she often did not consider an individual patient’s functional capacity.


Health professionals need to share good practice, Black said, adding that a series of seven leaflets providing advice on recovery following common operations produced by The Royal College of Surgeons is a good start, and one that looks set to be followed by similar communications covering gynaecology and emergency medicine.


Updating her audience on a series of initiatives, Black reported that:




  • 70 partnerships of primary care trusts, voluntary sector organisations and universities have applied for eight “fit for work” service pilots announced by the government in its response to her review, Working for a Healthier Tomorrow.


  • The new fit note has been piloted by 600 GPs in England and statutory regulations implementing the change are almost ready to go out for consultation.


  • A Business in the Community HealthCheck tool for employers is being updated for summer to make it easier to use; and


  • The government’s long-awaited mental health strategy is due to be published before the parliamentary summer recess.

Convention rather than evidence


Current absence management practice is based on convention rather than evidence, and managers fail to use data on trends to develop actions, even if such data is collected, according to David Palferman, senior occupational psychologist at the Health and Safety Executive (HSE).


Organisations need to understand and use a biopsychosocial (BPS) model to maximise attendance, he believes. A BPS model shows that, in any one organisation, individuals are off work for a combination of reasons, including a subjective assessment of their own health, diseases with a recognised pathology and social reasons not related to either an individual’s perception of illness or diagnosed disease, Palferman adds.


Different causes of absence are often associated with absences of either short or long duration, prompting different types of intervention, and employers need to use the data they collect to target this management action. For example, high-frequency, short- duration absences are more likely to respond to management interventions, while longer-term absences due to a specific medical reason may require occupational health’s involvement.


Organisations also need to take note of their particular workforce demographics, and use this information to design effective attendance strategies, the HSE spokesperson explained.


For example, younger employees tend to have a higher number of shorter absences, while older colleagues take fewer spells of longer duration. Women tend to have a higher number of absence spells than men, as do employees in lower grades.


Blanket absence management policies fail to take account of these factors, and organisations need to follow the example of employers that have developed “honest” policies to enable a true picture of sickness absence to emerge. One organisation cited by Palferman has introduced a “phone in stuck” policy that employees can use if they need to resolve an unexpected domestic crisis, and make up the time later in the week. “This is not a difficult thing to develop,” he adds.


The HSE stress management website is part of the executive’s attempt to make it easier for organisations to develop evidence-based practice, and has recently been relaunched. “The early signs are encouraging,” Palferman reports, with website hits more than trebling following the revamp.


Model mental health employer


Learning and sharing good practice, and using evidence to inform direction, is central to a coherent approach to work and health being adopted by the London Borough of Tower Hamlets. The borough is currently working with charity MIND to become a model mental health employer, according to its joint director of human resources, Deb Clarke, speaking at the attendance management event.


Tower Hamlets is also piloting a scheme in four GP practices involving a shift in approach to those presenting with the two most prevalent causes of work-related sickness absence, mental ill health and musculoskeletal disorders (MSDs).


Patients who have been off work due to these groups of conditions for 10 days or more are not issued with a sick note by their GP, but are referred to an individual counsellor, who will liaise with employers on fitness and return to work.


The counsellor also acts as a gateway to additional occupational health services and other allied interventions, including job adaptation, employment advice and mediation.


Absence iceberg


The underlying drivers prompting individuals to stay at home or come into work need proper examination to get to the bottom of intractable absence problems. This was the experience of a group of 10 local authorities employing 608 adult social care staff in northern England, according to a case study presented by Michelle Radcliffe of PricewaterhouseCoopers.


The group of employers had “done all the usual” absence management in adult social care, according to Radcliffe, but still faced problems, and decided to take a look at the root causes of absence, in particular, those related to reduced motivation and wellbeing, performance and resilience. Using data to explore “below the water line” reasons for absence in this way will become increasingly important, and indeed “business critical”, to retain rare and valuable skills in future, Radcliffe believes.


She developed a questionnaire tool to explore a range of factors and their link with absence, including non-work factors such as ease of access to a GP, sleep problems, and engagement with the work community and local community. The results are interesting and suggest clear associations between these hidden drivers and sickness absence from work:


There is a clear link between the time it takes to get an appointment with a GP and days taken off due to digestive disorders. For example, of those who took no time off for this reason, 71% said they could usually see a doctor within 48 hours, compared with only 58% of those with seven or more days off due to this reason.


Those employees working in larger teams tended to take more spells of absence due to MSDs, suggesting the involvement of a “small cog in a big machine” theme, Radcliffe added.


The extent to which an employee feels they fit in with the community where they live is inversely associated with the number of days taken off in hospital visits, suggesting the involvement of a sense of belonging, or engagement, she suggests.


Lifestyle and behavioural factors did not appear on the list of drivers linked to sickness outcomes.


Radcliffe recognises that these findings are currently only associations, and is working with the local authorities to produce time series data, which should enable some more robust data on causality to be produced. However, the results of the research are already triggering actions – a number of the authorities are talking to local primary care trusts about the time taken by some of their employees to gain a GP appointment in particular practices.


Wellness programmes need to be tailored to the real drivers of absence, as measured by a robust evidence-based approach. Employers should design approaches around what the data is telling them about these drivers, which could mean spending less on initiatives aimed at changing lifestyle behaviours and more on supporting employees in work and at home, Radcliffe suggests.


Absence costs remain hidden


Many local authorities fail to measure the total cost of sickness absence, with the result that the true cost remains hidden in financial accounting, according to Marc Bell of mutual healthcare provider, Benenden. Speaking to the conference, he reported on his research into the long-term absence experiences of 30 local authorities, an exercise made more difficult by the absence of accurate and consistent data, he added.


Absence management was seen as an HR issue by most of the line managers in the local authorities he examined, and often there was no consistent, strategic approach to the issue. Almost three-quarters of the authorities do not measure the full cost of absence and only 7% have director-level input into the issue.


The absence of data and clear responsibility lines makes it difficult to argue the business case for investing in absence management interventions, Bell argues, adding that making a business case “needn’t be complex”. He put forward a simple model based on a daily salary, the number of days’ lost by employees waiting for NHS appointments and treatment, versus the outlay on paying for faster intervention through a corporate healthcare scheme.


Making a business case


The business case theme was taken up by Jeremy Garman of Axa ICAS, who talked about how employers can use evidence to produce a business case for workplace health, for example, by producing a return on investment figure for a particular intervention.


Garman stressed that the costs of presenteeism (employees attending but working below capacity due to illness or disease) are usually more than those associated with absence.


He used the example of headaches to demonstrate the potential presenteeism costs of this single condition, estimating that a co-ordinated wellbeing programme could produce a return on investment of between 300% and 500%.


“Producing metrics like these is vital, both in securing senior management buy-in at an early stage, and sustaining programmes”, he concluded.


Using data is “challenging”


Making sense of the data on absence, even if you collect it, is “challenging”, according to Bruce Robinson, managing director of Active Health Partners. For example, faced with a set of data on headline absence rates in different organisations, it is hard to explain what is producing the variation.


Are the absence management policies in those organisations with relatively low absence more effective? Or are these organisations lucky with their workforce demographics, the sector in which they operate, or their size?


Calculating the total cost of absenceis also difficult. No single function in the organisation owns the metrics that make up the business case. For example, insurance premiums might be part of the risk management function, early retirement costs come under the pensions banner, and time lost to accidents is health and safety’s responsibility.


Effective strategy


Monitoring, measuring and understanding information about absence is top of the list in forming an effective sickness absence strategy, yet often there is no holistic approach to this vital task, Robinson argued. Many different functions in an organisation are recording different aspects of the costs of absence, but fail to think about the value of the data as a whole, or use it to change how they intervene.


Active Health Partners (AHP) operates a telephone, nurse-led absence management system, and Robinson presented the results of research based on 80,000 contacts with this service. AHP carries out risk-profiling for the different causes of absence reported to its service, looking at the incidence and duration of absence due to groups of conditions.


This data is used to design interventions most appropriate to the type of absence in a particular organisation. For example, if a particular cause has a high incidence, but low spell duration, case management might be triggered.


If spell duration is an issue, the organisation might be encouraged to consider fast-track occupational health referral or, in the case of mental ill health, to examine usage of an existing employee assistance programme.


It is also possible to produce risk estimates for different causes of absence by gender and age in an individual organisation, which enables benchmarking against other organisations.


Drilling down the data in this way also means interventions can be refined or targeted. For example, return-to-work interviews can be tailored according to the cause or duration of absence, or to patterns of absence in particular departments. “People are frightened of data, but it’s not a case of ‘Big Brother’, but rather an effective way of bringing about culture change in an organisation,” Robinson says.

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