We all know occupational health (OH) is changing, and changing fast. The ‘fit note’ is an innovation that has the potential to bring about far-reaching changes in how work-related health and absence are viewed and managed. It is set to go live from next month [April], so there is no better time to be looking at how current thinking about managing long-term and short-term absence is evolving, and what people and employers think works most effectively.
Since 2008, when the Department for Work and Pensions (DWP) awarded a five-year, £5m OH contract to Atos Healthcare, it has shaved 1.8 days’ absence per person per year off its total – a significant reduction in an organisation employing about 110,000 people, points out David Wright, chief OH physician at Atos Healthcare.
“Our experience is that early intervention and a quick turnaround helps people to reduce sickness absence,” he says. “It has been just by getting to grips with when people go off sick and ensuring that interventions, when they are needed, are carried out quickly, and that return-to-work is managed. A lot of it does now revolve around the use of IT systems and telephone discussions, with referrals coming in through a web portal,” he adds.
For employers, however, the range and complexity of options on offer can often be somewhat baffling: ‘triaging’, first-day contact and call centres, phone support, technology, and ever-more varied software packages, for example. Alongside this, of course, in an economic climate that remains tough, there is a heightened appetite among employers to ensure they are getting value for money and a return on their investment, as David Prosser, strategic development manager at Axa Icas makes clear.
“Very often, employers simply do not have enough detailed absence intelligence on which to make a robust before-and-after comparison of the effect of a particular intervention,” he says.
Day- and nurse-led call centres started to become popular about five years ago, and were, for a time, one of the more popular outsourced solutions among employers. However, while it would be going too far to call it a backlash, among many employers there has now been something of a re-evaluation of their worth, he contends. “Initially they had quite a superficial attraction, but employers are coming to see that this is not always the best way to deal with absence,” explains Prosser. “It may have a good initial effect, but good absence management is really just about good people management, not about having someone speak to a nurse on day one. So the model is flawed.
“If you are already an absence basket-case, then speaking to a nurse over the phone is not going to have any effect,” he adds.
Lack of trust
If you are someone who only takes the occasional day off, and for obviously genuine reasons, having to phone in and go through the rigmarole of speaking to a nurse can be irritating, as well as giving a negative impression, suggesting your employer doesn’t trust your commitment and attendance record, he suggests. “Some employers are starting to see the effect flattening off. They might have seen some improvement in absence but the rate has still remained higher than it ought to be – you still get 3%, which is quite common, but still probably too high. So some more enlightened employers are now saying: ‘Can we deal with absence in a different way? Can we take it to the next stage?’,” says Prosser.
But Aaron Ross, chief executive of FirstCare (which now includes Active Health Partners since a merger in November), argues that this sort of early, outsourced contact can still be an important absence management tool for many employers.
“Absence starts the minute someone goes off and it is about getting that early intervention. An employer may have good policies, but the way managers are resourced these days means their immediate focus is going to be on replacing that person within their workforce, so by outsourcing it you can take the management of and focus on the person who is absent off the managers.
“The line manager should be involved in managing absence, of course, but the tools need to be provided to them,” he adds.
Triaging, too, can be a beneficial approach, depending on the size and complexity of the organisation involved and the health challenges it faces, with, for example, fast-track physiotherapy triaging often leading to much quicker appraisals of musculoskeletal conditions and the most appropriate next course of action, suggests Prosser.
“Getting someone in to treat them quickly is obviously beneficial. Referring them in after they have already been off for 20 days is simply too long, so why wait?” he asks.
In the current climate, one of the biggest challenges for OH professionals is simply ensuring that they remain relevant and in tune with the wider business and operational aims of their organisation, agrees Ingolv Urnes, principal of psHealth. “There is an increasing realisation that OH as a whole has to be like anything else delivered into the business – it has to fit into the whole corporate landscape and, so, has had to become more quantitative,” he says.
Technology has also been radically changing the way OH professionals operate and ‘see’ patients. “Ten years ago, almost all OH activity, perhaps 90%, was face to face. Now, I’d say perhaps 40%-50% is not. There may, in fact, sometimes not be that much value, or incremental value, in a face-to-face meeting between a person and the OH adviser,” argues Urnes.
“A well-trained OHA or OHN on the phone with the person after day five or seven days will be as valuable as nurse seeing them face-to-face in week two. You could then have a face-to-face meeting later on if need be.
“If the triage, say, by an OHN cannot establish which way to go, then how likely is it that it will have been able to establish that with any more certainty in a face-to-face meeting. Phone triage in my experience cuts down the process by on average 10 days,” he adds.
But this heightened use of technology is creating its own challenges, most notably around data management, mining, confidentiality and security.
“Trying to automate whatever you can is probably a good idea. There has been, in the past, some resistance to the use of technology. But, particularly in the current climate, the use of technology can be cost-effective, and so we are seeing more employers being willing to look at technological solutions. I wouldn’t say the dams have opened yet, but it is something that is becoming more attractive,” says Prosser, pointing out that since 2007 Axa has had its SAM telephone and software-based absence reporting and recording service.
“It is quite clear from discussions with employers that they often do not have very good data, or not good enough. And even if they have good data, there is a question of whether they know what to do with it and how to interpret it properly,” he adds on a more general note.
“Line managers are the fundamental building block for reducing absence. But employers are crying out for evidence-based approaches to work-based healthcare, something our industry has not been very good at doing. A lot of it often makes good intuitive sense, but there is not a lot of good, case study evidence that is very robust,” he says.
Within this, and as the use of more sophisticated (and therefore expensive) technology becomes the norm – expected, even – there is a question about where it will leave the smaller, perhaps single-handed OH practitioner who, inevitably, will have a smaller budget to compete with.
“Over the next 10 years, I do think a lot of the smaller players might disappear, simply because they are not going to be able to invest in the technology to the same extent,” predicts Urnes. “OHNs as time goes on are, I think, less likely to be sticking in needles and it is more going to be around their communication skills. It is not a quantum leap, but employers are going to want to see real-time information about where a case is,” he adds.
What we may therefore see more of as time goes on, predicts Wright, is more remote case management, phone and remote consultations, training, and even innovations like online cognitive behavioural therapy.
“It is becoming more about sickness absence management rather than an OH-based, transactional-based issue. So it is more about discussion and management rather than poking or prodding around a person,” says Urnes. “It is less diagnosis and treatment, although that still remains important, and more discussion about how ill health can be managed in relation to the workplace.”
Similarly, the fact that more vision and hearing screening tests, for example, can now be done in a high-street setting, is likely to change the need for this sort of activity to be done in the workplace, although there is a limit to how far it can go before it loses touch with the issues of a particular workplace.
There will also need to be a greater understanding of security and confidentiality issues, such as, for example, not leaving data on USB sticks or laptops which can be lost. And there will also need to be greater recognition of the potential of all this wonderful functionality for data mining and interpretation, something that many organisations have still not fully grasped, argues Wright.
“Merging or matching data sets, for example, can make a big difference in helping you see where any gaps are or whether anything, good or bad, is happening in a particular location and so on. A lot of data mining that could be done is not being done, but it can lead to significant improvements on a short-term basis, because it allows you to discover what has been previously hidden. We often find, too, that people sometimes disappear off the radar completely and, by pooling data sources and managing it all properly, this sort of problem can be resolved,” he says.
Of course, in an ideal working environment, where people were managed well and had responsibility for their work and challenging jobs, it could well be that organisations in the future would barely need to be physically managing short-term absence, says Prosser.
But we don’t live in an ideal world and so organisations, for both long-term and short-term absence management, need to take a step back before buying in services or technology, to look at what the investment is going to achieve, holistically, for their organisation.
“Employers need to stop thinking about buying services piecemeal and think more widely about their people strategy and what services they need that will make a difference. Rather than looking at solutions in product silos, you need to step back and understand the nature of your business and its objectives. What is your growth strategy, and how can a provider like ourselves help you on the way? So it needs to involve finance and operations as well as HR,” Prosser says.
“You need to be mapping out a journey of where you want to go, rather than simply parachuting in solutions,” he adds.
Return-to-work survey: phased return favoured by most employers
For most employers, a phased return to work is still considered the most effective way of getting long-term absent staff back to work, according to research.
The study of 173 employers by IRS has suggested more than 40% of employers rate this as the most effective intervention, followed by just over one-third who say preparing a return-to-work plan is the most effective option. Phoning the employee was favoured by just under 30%, and commissioning a report from a specialist about the employee’s condition by 28%.
The research also, by and large, validates and echoes the changes outlined by OH experts, with the employers polled saying that they used a multi-faceted approach to get people back to work, normally including making prompt contact and maintaining regular contact, taking medical advice, using procedures already laid out, making adjustments to the workplace and, where need be, offering the option of early retirement.
Responsibility for long-term absence tended to be split between line managers and HR, with nearly two-thirds doing this, and just over half of employers offering their managers training in this area. Almost three-quarters provided line managers with guidance on managing long-term absence, such as a printed or online manual. Most employers also now made use of case management, albeit only selectively.
The lack of access to OH expertise was also highlighted within the survey, with just one-quarter of employers polled saying they involved OH in long-term absence management, with the task also usually being shared with either HR or line managers.
More positively, more than nine in 10 said they had policies or procedures in place for the management of long-term sickness absence cases, though just one-quarter were flexible enough to be applied to individuals who were expected to become long-term absent, but had not yet reached this point.
When it came to making or maintaining contact with employees, just one-fifth admitted to making contact at the point at which an employee moves from short to long-term absence, with one in four doing so before this. The most common answer was: “varies with the individual”.
Most of the employers also used a range of methods to manage long-term absence, including: