Historically, the UK has one of the worst records in Europe for returning to work after long-term illness, with mental health and stress being the biggest causes of long-term sickness absence.
A European Community survey of its members identified the UK as having the second highest number of workers suffering from long-term sickness. The UK level of absence was 27.2% compared with the EU average of 16.4%.1
The Health & Safety Executive (HSE)2 estimates that 14.1 million days were lost to stress and anxiety in 2001, with each new case of work-related stress, resulting in an average of 29 days off work.
Absences caused by mental health problems and other personal difficulties can have a significant impact on both employer and employee – an issue that has tended to be neglected and mismanaged by employers.
A commitment from the HSE to work with the Department for Work and Pensions (DWP) and others to strengthen the role of health and safety in getting people back to work through a greater emphasis on rehabilitation is an integral part of the strategy for workplace health and safety in the UK.3
Two HSE documents, Revitalising Health and Safety and Securing Health Together, both launched in 2000,4 foresaw the important role that managing sickness absence and return to work would make to improving health at work.
Preventing work-related accidents and ill-health and helping people who have been ill to return to work complemented the Department of Health’s (DoH) broad aim to take action to safeguard health and prevent illness and disease, promoting healthier and longer lives.
This article discusses the role of the OH practitioner in assessment and rehabilitation planning for staff who are off work with stress and other mental health problems. It introduces a bio-psychosocial approach to assessment and rehabilitation planning, and proposes a two-stage assessment process to facilitate effective case management and returns to work. A case study highlights the clinical and financial benefits of introducing a two-stage assessment approach.
People may be absent from work for a variety of physical, psychological or social reasons. Attitudes to mental illness can have a significant impact on employees attempting to return to work. One study found that managers’ attitudes were often discriminatory.5 However, being proactive about identifying staff who are experiencing problems and helping them to access support and assistance can limit or prevent the need for a period of sickness absence.
For practical purposes, long-term sickness describes absences lasting four weeks or longer. The inactivity and isolation that may accompany long-term absences from work have a negative impact on our physical, psychological and social health and well-being, so a well-managed return to work helps employees to manage their symptoms or reduce the impact.6 Because people in work have been found to be physically, psychologically and socially healthier than people who are unemployed,7 the best approach to supporting employees is to help them remain in work.
Rehabilitation is a process to overcome the barriers an employee faces in returning to employment following an injury, illness or disability. It encompasses the support that both an employee and employer need to ensure the worker remains or returns to work, or accesses employment for the first time.
Rehabilitation incorporates the approaches in place to enable employees to access help, which allows practical delivery of rehabilitation and covers the wide range of interventions available to help employees overcome health or disability related barriers to work.
Being proactive about employee recovery and rehabilitation is vital. Research has shown that after six months absence, there is a 50% chance that an employee will return to work. At 12 months, this falls to 25%, and after two years, there is practically no chance of a return to work.8 These findings emphasise the importance of beginning the rehabilitation process as soon as possible after the start of the period of absence.
Companies need to take responsibility for employee health and for developing the systems, policies, procedures and guidance for managing the return to work. Recovery, retention and rehabilitation policies should be part of an integrated employee well-being or OH policy. However, only 10% of UK employers offer rehabilitation policies and services.9
It is recognised that early interventions are designed to prevent acute problems from becoming chronic, and that rehabilitation can be a successful way of reducing long-term absences.
An integrated approach to rehabilitation takes into consideration the links with other policies, including risk assessment, absence management, trauma support, employee counselling, health education, training and development, equal opportunities and data protection.
Organisations have a duty of care to reduce, as far as is reasonably practicable, the physical, psychological and social hazards that have an impact on the health and well-being of their workforce. It is possible that a hazard or condition is not connected with the employees’ work or working environment. However, if an employee is incapacitated, the organisation needs to consider what can be done to support them.
This is particularly true when the employee is suffering from a physical or mental disability. In such cases, there is a statutory duty to ensure that reasonable adjustments are made to support them. The process begins with an employee being identified as experiencing difficulties in their work, and ends with them working normally in their existing or new role, or with their employment being terminated through medical retirement, resignation or dismissal.
OH has a role in working collaboratively with HR to develop rehabilitation policies and practices. They also have a clear assessment and advisory role to support the management of individual cases.
The importance of effective case management for employees who require retention and rehabilitation support cannot be over-emphasised.
It has been found in countries where it is common to have a dedicated case manager or rehabilitation co-ordinator, that there is a much lower level of long-term sickness and disability than in the UK. There are some organisational barriers to rehabilitation, including a lack of commitment within some organisations, resistance from line managers to spend time on the rehabilitation process, together with a lack of skill in handling rehabilitation, suspicious and ill-informed GPs, suspicious unions and employees, and the difficulty in getting the caring professions to work together.
Rehabilitation in practice
Rehabilitation is used to describe a variety of work-based initiatives, policies and practices designed to get people back to work. There is no commonly-agreed model of rehabilitation. Even members of the Faculty of Occupational Medicine have difficulty in agreeing a definition.10
However, a best practice report prepared for the Institute of Employment Studies in 2003 concluded that organisations use a wide range of strategies and techniques to rehabilitate an employee following a period of absence due to work-related stress. It appears that practice has developed on the basis of historical approaches, analysis of need, problems and priorities and the culture of the organisation.
What is missing is evidence of consistent evaluation of specific interventions, where focused and intentioned action has been taken to help people with stress-related problems get back to work. In short, a review of what works best and why, would help to demonstrate the clinical effectiveness and financial benefits of health interventions.
A new CIPD guide written by one of the authors of this article, chartered psychologist Noreen Tehrani, gives guidance and tools to assist HR to develop and introduce effective workplace policies and procedures.11
Helping staff to deal with physical, psychological and social stressors is an approach that focuses on what employees can contribute to their organisation after a period of sickness absence. The problem facing employees and organisations is the number of people who may be involved in the treatment and recovery of an employee.12 This is why case management plays such a crucial role in the outcome of successful rehabilitation. A case manager will co-ordinate support and represent both the needs of the employee and the organisation.
A bio-psychosocial approach recognises the necessity to adopt a holistic approach to rehabilitation where there are interactions between physical, psychological and social well-being.13
The term stress is often used to describe a wide range of physical and psychological symptoms, so the nature and effectiveness of any rehabilitation plan will of necessity be dependent on the way in which the employee is experiencing stress and pressure. For example, rehabilitating a person who has a negative psychological reaction to being bullied will be different to someone who is suffering migraines due to workload stress.
A Labour Force Survey highlights the fact that at least 15% of people with a mental health problem have a physical health problem.14 In addition, up to two-thirds of employees who have been off work for six months with a physical condition are likely to be suffering from anxiety and depression.15
Psychiatric problems may be more difficult to deal with in the workplace and may therefore require adjustments to help keep the person at work. Psychiatric problems include disorders of thought, perception, mood and behaviour.
Additionally, situations that may be difficult to manage include situations where there may be a lack of self-awareness, poor commitment to rehabilitation, secondary gain from being ill, a personality disorder, politically-inspired absence, hypochondria, or instances where GPs are not committed to supporting a rehabilitation programme.
Employee risk assessment
A well-being risk assessment is central to the recovery, retention and rehabilitation approach.
The two-stage approach incorporates an employee risk assessment, together with the need, in a smaller number of difficult cases, for psychosocial risk assessment and rehabilitation management, carried out by a counselling, health or clinical psychologist.
The problem assessment model was first developed and introduced in the Post Office, where it has produced good results in reducing levels of employee distress.
This first stage assessment is used to outline the problems faced by the employee, identify what they would like to have happen, and then to create an effective plan. The model was shown to be effective in supporting the recovery, rehabilitation and retention of employees by promoting a culture of respect and support focused on empowering staff to look after themselves and move forward with their problem solution.
Where there is a dedicated OH service, the case management role and initial employee assessment will be undertaken by the OH practitioner.
The purpose of the assessment is to develop a plan to maximise the likelihood of recovery and return to work. The assessment should look at a number of factors, including the nature of the job, the way it is organised and the impact of the work environment and culture on the employee, the employee’s health condition, and how that affects their ability to do their job and, finally, the resources, training and workplace adjustments that can be provided to support the employee’s return to work.
Some of the factors that may stop the employee from wanting to return to work include fear of being unable to cope, managing the change circumstances, the costs of working, lack of family support and a lack of knowledge or inflexibility on the GP’s part to support the rehabilitation process. Therefore, interventions may involve retraining, capacity building, return-to-work management, reasonable adjustments, disability awareness, condition management and medical treatment. Where there is a clear mental or physical health problem, there may be a need to request a GP or consultant’s report to find out the best way to help the employee’s recovery.
The rehabilitation plan should include effective strategies, realistic targets and support. A solution-focused approach that targets what employees can contribute to their organisations rather than what is keeping them away from work, is essential. Personal support may be available from a variety of sources through access to counselling services, the GP and support from the primary care team, community resources, self-help groups and mentors. Goals and milestones need to be specific, measurable and realistic, with a clear timetable for action.
Psychosocial risk assessment
For more complex cases, the case manager may decide to organise a private medical, OH or psychological rehabilitation assessment.
The purpose of the assessment at this stage is to identify a rehabilitation programme to help the employee recover or, where recovery is not possible, to provide an indication of what action the organisation should consider, including the possibility of a referral for further treatment or medical retirement.
A psychosocial risk assessment looks more deeply at the employee’s psycho-social problems and will involve a structured interview, clinical and occupational assessment, and a tailored report to support the employee in returning to work.
Referral to an appropriately-qualified specialist practitioner or psychologist is recommended where there is prolonged absence from work with no indication of a return, or employee resistance to returning to work, where an objective measure of clinical symptoms would be helpful. This is also advisable for more difficult cases where the employee has little insight into their part in their condition, and perhaps blames others, or for an employee who may have a personality disorder.
A referral is also useful where the organisation may have got things wrong and trust has broken down, if there are complications such as bullying or harassment, or if the employee has a key role and has for example, a vital part to play in a project.
As the debate about the management of attendance and the process of rehabilitation develops, it is becoming increasingly important for health professionals working in the field to demonstrate their effectiveness in the process of rehabilitating people with mental health problems back into the workplace. By taking a research-focused approach, OH practitioners will be able to demonstrate the value they add to their organisations.
Early intervention studies show that this two-phased approach has been successful in helping employees to remain in work and that there are significant financial benefits to be achieved from such a systematic process. The Royal and Sun Alliance introduced this approach to managing stress and other mental health absences in 2000.
The evaluation of the programme, which was presented at the Chartered Institute of Personnel and Development, has highlighted significant financial and clinical success with benefits both for the employer and their employees.
Early results have shown a 3:1 return on investment. Success was also reflected in the reduction of long-term sickness absence levels, and the satisfaction levels of staff, managers and HR.
Psychosocial risk assessments were found to have facilitated the resolution of many of their complex long-term absence cases, with 37% of participants successfully returned to work. Cases where employees had not returned to work were resolved through resignation, redundancy, early retirement or termination on the grounds of capability.
Clinically, these results demonstrate statistically significant reductions in levels of anxiety and depression within the participant group of employees.
Noreen Tehrani is a chartered counselling, occupational and health psychologist. She is the author of the CIPD guide Recovery, Rehabilitation and Retention: Maintaining a Productive Workforce published in 2004. Tehrani is the director of Assessment and Rehabilitation Consultants (ARC Ltd).
ARC associate Christie Rainbird has worked as a manager and practitioner in OH for more than 14 years, and has a particular interest in developing programmes to protect the mental health of people at work. For more information, e-mail firstname.lastname@example.org
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