Dr Mark Simpson, medical director, Axa Icas Wellbeing (chair)
Dr Paul Nicholson, associate medical director with Proctor and Gamble and chair of the British Medical Association (BMA) Occupational Medicine Committee
Ben Willmott, senior public policy adviser at the Chartered Institute of Personnel and Development
Katherine Ashby, researcher in the health and wellbeing team at the Work Foundation
David Prosser, strategic development manager, Axa
Geoff Taylor, consultant, Axa Icas specialist services department
Do absence policies work to promote attendance or police absence?
Nicholson: One problem is the name ‘absence policy’, because that means the focus is on absence, rather than improving attendance and performance. If the policy was about improving employee performance or productivity, say a ‘performance policy’, that might put the issues into a more positive light. It’s really got to be built around a foundation of trust between the employee and their direct manager.
Simpson: An absence policy has negative connotations that you’re only going to manage something once it has become a problem rather than take a broader organisational context to promoting attendance in the first place.
Ashby: If you have good quality jobs where people trust their employer, have good line management, some control over the work and their skills are used, then the other policies that you have around individual wellbeing are more likely to be effective.
Do organisations think enough from a strategic perspective about promoting engagement even in apparently monotonous, repetitive jobs?
Willmott: The Chartered Institute of Personnel and Development’s (CIPD) Employee Outlook survey is seeing an increase in the proportion of people who are now actively dissatisfied. Part of that will be around what sort of change has happened and how that change has been managed. Business in the Community has its Business Action on Health campaign and was looking to get 75% of the FTSE 100 reporting on wellbeing measures, and has exceeded its target. The challenge is to get that awareness spreading across different sectors, and then different sizes of organisation.
Too often management training is seen as a sort of sheep-dip. If you have some form of 360o feedback as part of that management development, you are more likely to have lasting behaviour change.
Ashby: Often when you talk to people about the underlying causes of absence, people don’t talk about workplace-related factors and job quality issues, trust and promoting better relationships in the workplace. It’s more about looking at individual causes or how you treat the symptoms, rather than looking at these cultural factors. So bringing together that agenda and looking at how it relates to productivity is something that needs to happen.
In the recession you have presenteeism – people going in to work when they feel ill enough to justify staying at home – and that is hidden because it’s not often formally measured or necessarily noticed by line managers or workers. Presenteeism has often been linked to mental health issues which have become more prevalent. Understanding that absence isn’t the only indicator is important.
Prosser: One of the problems we’ve got in changing employers’ attitudes is a lack of good measures, good data. Trying to demonstrate the benefit of a certain intervention or change programme is difficult because the underlying starting data isn’t there, and that needs to change.
Nicholson: Once you get into the business of reporting sickness absence, that gets onto the stock market and investors may think: ‘Well, we’re not investing in that company’. But if a company could demonstrate what it’s doing in terms of ensuring it has the right programmes in place to make sure that people are working in a safe and healthy working environment, and for assessing lifestyle risk and promoting good health, to turn it around to be positive, that might be a better solution than reporting absence. Companies also ought to be doing their own employee surveys. We should focus on small- to medium-sized enterprises because they don’t have the resources – they don’t have in-house HR or occupational health (OH). But there are ways that they can measure employee trends, and one good example is the Health and Safety Executive’s Stress Management Standard.
Taylor: Managers are often reluctant to tackle this because they don’t know how to do it. They don’t have the confidence to go and talk to the individual because they’re frightened that they may open up a can of worms that they can’t deal with, so they brush it under the carpet and, inevitably, it just gets worse.
Simpson: We’d rather have people with a mental health problem coming to work and recognising it and working with it. It’s having a safe workplace designed to minimise those problems and then an early awareness and early intervention.
Do attendance bonuses work?
Nicholson: Whether it’s Royal Mail or bankers’ bonuses, any type of award should be for contributions over and above the norm. And so putting out the message that you get a bonus for coming in on the days when you should be in is the wrong thing to do.
Prosser: With Royal Mail, it had a huge problem with absence anyway, so doing almost anything would have made a difference because it raised the visibility of it. But that wasn’t the only thing it did. It managed to get competition at board level among directors for monitoring the absence and actually being quite competitive about absence rates in different divisions. The key thing that made the difference was boardroom debate about different levels of absence across the business.
Simpson: I’ve heard of people with really quite serious injuries including amputations of digits and so forth being made to return to work that same day so that they could maintain their non-working time limit. So [these initiatives] can work in perverse ways.
What forms of absence notification work best, what doesn’t work, and what are the trends?
Prosser: The call centre approach was a model that came out six or seven years ago. It was seen as a Rolls Royce-type service and feedback increasingly is that they are very expensive. They probably did have an impact on absence, but it has reached a plateau level beyond which they cannot improve the position. Employers are now buying into the agenda that it’s about line management engagement. There’s nothing in any of these outsource solutions that actually prevents the line manager from having a conversation.
Willmott: In CIPD surveys the effective notification of absence and the involvement of the line manager come out very highly as being most effective. The key thing is that the line manager is notified at a very early stage during the day that someone’s taking time off, and the other key thing is data – that you can identify patterns in both departments and individuals. There should be an element in managers’ performance targets which is tied to their absence management role. Making sure that return-to-work interviews happen is important; making sure the manager’s employees are notifying absence in the way that the policy recommends; making sure that absence review meetings happen properly; and that, where necessary, disciplinary action is initiated. If it’s not measured, there’s a danger that it won’t be managed, so you’ve got to find some way of encouraging line managers through their performance appraisals to focus on absence.
Taylor: Having an automated system works – at least you know it’s going to be recorded.
How important is the line manager’s response to notification of absence?
Prosser: It’s got to be a mutual benefit for both employee and employer, because if a service is launched on the basis that it’s not about Big Brother watching you, but it’s actually to make sure that we’re capturing all absences, that we’re not letting individuals slip through support nets, then I think those are absolutely the messages that you’ve got to have. We know typically absence is under-recorded by 25% when line managers are called upon to record it, and in many organisations there are perverse disincentives for line managers actually to record the absence because they have a key performance indicator on absence.
Willmott: Return-to-work interviews are a missed opportunity to have a really positive conversation, a one-to-one between a manager and the employee, not just about attendance but actually about work and their job satisfaction, and to see it as an opportunity to really drive engagement.
What impact do work organisation, peer pressure and team working have on reducing absence?
Simpson: It’s about how much goodwill there is in the bank for an individual worker. And where I’ve seen that there is a lot of goodwill in the bank, people have gone to extraordinary efforts to actually help somebody back to work. The OH service actually has to be seen as a supportive tool for the line manager, rather than something that the line manager will just pass over the problem from. It goes back to the point that we want to equip managers to be empathetic human beings, not just experts.
Ashby: Line manager training around how to make adaptations for people who have mental health conditions, and more understanding among line managers about what that means, is really important, because if it is just outsourced to OH, then the line manager isn’t involved, and there is that risk that it’s not going to benefit the individual in the longer term. The idea that work can be good for certain conditions needs to be raised.
Is the fit note a solution, a cross to bear, or a path to revelation?
Nicholson: A classic example might be somebody who breaks their leg on a skiing holiday and works in a call centre. In the past they’d have been given a sick note because they couldn’t get to work – there’s never been any thought about what work they do, or whether their employer could arrange with a co-worker or a taxi company to get them in to work. A lot of the solutions would be simple ones like that.
Simpson: Work done in the US looking at return-to-work timeframes for identical injuries caused by sport and through occupational injury showed that people with occupational injuries took four times as long to return to work. It is about motivation, and the alignment of expectations.
What are GPs’ feelings about the fit note? Do they see it as an imposition?
Nicholson: There’s currently 100% alignment on the fit note and the Department for Work and Pensions guidance for GPs was devised in partnership with the Royal College of General Practitioners and the British Medical Association’s GP Committee. There was a concern about: ‘Well, we aren’t trained as OH physicians and therefore we’re not competent to make recommendations about workplace adaptations or advice along those lines’. But of course in many cases, the advice is quite simple. If somebody’s rehabilitating after a hysterectomy or coronary artery bypass, then it might be no more than saying, in an office job, it makes sense that they return to work gradually over the next three or four weeks.
One of the potential missed opportunities of the fit note was that the draft tick box that was there to recommend OH referral was removed. From my point of view, it would have raised the profile of that lack of access, and might have made important changes in the future in terms of improving access to OH.
Willmott: I think what it will do is prompt GPs to at least have a conversation about the possibility of a phased return to work. For those people who have no interest in going back to work, it won’t make any difference at all. They will just be signed off as usual, and they will lobby their GP about or exacerbate their symptoms. You can’t cater for those individuals.
Simpson: By and large, absence certification is the employee’s view of their fitness for work rather than the GP’s view, and rarely will a GP say to an employee who wants to go back to work that they shouldn’t actually do so.
Prosser: It is only going to be a good thing, because it will stop employers and employees hiding behind this document [the sick note], which I’m afraid some of them do.
Ashby: It does depend on what they come back to and that kind of joined-up approach between OH, where that’s available, and the manager, and looking at how they can make adjustments around people’s health problems, and changing the context of those conversations around functionality and what people can do, rather than what they can’t.