Absence: Mind the gap

As absence continues to move up the political and workplace agenda, employers, OH professionals and HR need to rethink how they define absence and, in turn, reconsider how, and when, they intervene to get employees back to work.

That was the conclusion of some ‘blue-sky’ thinking put forward by health insurer and provider Axa PPP to the government’s health watchdog the National Institute for Clinical Excellence (NICE), which is drawing up new guidance for employers on managing long-term sickness absence and incapacity for work.

New category

Key to Axa’s submission over the summer was that the current two-tier definition of absence as either ‘short-term’ or ‘long-term’ should be reconsidered, and a new cate­gory of ‘medium-term’ absence introduced.

GPs and primary care, it also argued, needed to be given a more central role in deciding employees’ fitness to work.

The ideas are likely to feed into the wider debate about the future direction of workplace health interventions kicked off earlier this year by national director for health and work, Dame Carol Black, in her review of workplace health. The government’s res­ponse to this is now expected at the end of November – credit crunch and general economic turmoil permitting.

The NICE guidance, which is due to be published next March, is trying to answer four questions. These are prefaced around discovering what work or primary care-based interventions, programmes, policies or strategies are effective and cost-effective in:

  • preventing or reducing the number of employees moving from short-term (fewer than 20 working days) to long-term (20 working days or longer) sickness absence, including activities to prevent or reduce the reoccurrence of short-term sickness absence episodes

  • helping staff who have been on long-term sickness absence to return to work

  • helping to reduce the reoccurrence of long-term sickness absence

  • helping those in receipt of incapacity benefit to return to full- or part-time employment.

But Dudley Lusted, Axa’s head of healthcare development, argued in his submission that, while these were good questions, NICE was missing the point at a more fundamental level.

“To continue to define short-term absence as fewer than 20 days may, unwittingly, discourage employers from earlier identification of potentially long-term absences before they deteriorate,” he said.

What was needed instead was for short-term absence to be defined as up to five working days, long-term absence to remain as it was, and a third category of absence, medium-term, to be used for workers who were off for six to 19 days.


This would mean the vast majority of short-term absence could be, if not ignored, then at least thought of as self-limiting and requiring no intervention, as most workers with minor illness would come back by themselves. Of course, if it involved repeated absence, it could then become an attendance and HR issue.

When absence moved into the medium-term category, it would lead to a simple low-cost assessment, argued Lusted, and become the point (much earlier in the cycle than waiting 20 days) at which an employer could identify whether there was a risk of it developing into long-term absence. This would, in turn, mean that most of the rehabilitation and intervention resources could then be targeted at long-term absence.

“The desire to identify potentially long-term absences at an early stage should be tempered, however, by an appreciation of the pitfall of wasting resources on inappropriate (too early) assessments (that is, within the first week of absence),” Lusted suggested.

It ought to be pointed out that, while novel, this idea is not completely new. A category of medium-term absence is already used by some employers, notably within local government and local authorities. Sheffield City Council, for example, in a report for 2004-05, defined short-term absence as less than one week, medium-term absence as a week to six weeks, and long-term absence as anything above six weeks.

Early intervention

Intriguingly, the split between the categories in Sheffield’s report – about a quarter off short-term, a third off medium-term and 40% off long-term – highlighted just how many employees there might be who fall into the medium category. These employees might benefit from the sort of earlier intervention proposed by Lusted.

The Axa submission, which reiterated long-term demands for more financial incentives for employers that invested in health and wellbeing initiatives, plus the need to avoid over-medicalising absence, also called for GPs to be given a much more central role in assessing employees’ fitness to work.

Given that GPs were already the first port of call for most workers and managers (especially those working in small firms) and that there was already a physical network of premises in place, it made sense for primary care to be the primary setting for this kind of assessment. An obvious candidate for this would be a GP with a special interest in areas such as the government’s Increased Access to Psychological Therapies projects.

“Undertaking this new role (accountability for assessment of work capability) in a primary care setting will mean a big culture shift for GPs who, by and large, have not shown much of an appetite for becoming actively involved in sickness absence management,” conceded Lusted in his submission.

Useful incentives for GPs could therefore include making sickness absence management a targetable performance objective. In this scenario, patients’ sickness absence levels and GP-issued sicknotes could become a key performance indicator, for example.

“The latter will be more readily achievable if the electronic fit note envisaged by Dame Carol Black in her strategy for improving the health of the working age population becomes a reality,” said Lusted.

But he recognised that GPs would not accept such an extra burden on their workload without additional funding. This is something of a political hot potato at the moment, what with billion-pound bank bail-outs putting a spanner into the works of government spending – not to mention a general perception by the public that GPs have already got away with financial murder under their new contract.


Defining absence as short-, medium- and long-term may well be useful for employers, agrees Geoff Davies, chairman of the Commercial Occupational Health Providers’ Association. But the most important thing is simply for employers, HR and OH to sit down and agree a strategy on how they are going to manage absence within their organisation – however it is defined.

“The intervention strategy for OH has to be identified with HR upfront at the start, with particular reference points for referral,” Davies points out.

“If you have a process set up from the beginning and a service agreement between HR and OH in place, then whether absence is long-, short- or medium-term is not an issue. It is just about having an agreed strategy,” he adds.

Without this agreed strategy in place, what tends to happen is managers either intervene too early – as identified by Axa – or sit on their hands worrying until it is too late.

It is also important to work out what your objective is going to be in categorising absence in this way, advises NHS Plus chief executive Kit Harling.

“You need to pick the categorisation that works. When thinking about the underlying causes of absence or series of absences in your organisation, it may be that seven days is quite a useful marker point. Or it may be that 20 days is more useful,” Harling says.

“So it is important not to get too fixated with boundaries. Whatever you choose should be about your needs and about getting the best care for your employees,” he continues.

“You have to be clear about why you are doing it. You also need to evaluate it and make sure it works as you are going along,” Harling adds.

AXA’s key recommendations

  • There needs to be a change to the definition of absence to short-term (up to five working days), medium-term (six to 19 working days), and long-term (20+ working days).

  • Employee assessments should be undertaken by a healthcare professional who understands capability for work, ideally perhaps in the primary care setting by a GP with a special interest.

  • Tax incentives for employer participation in absence management should be introduced.

  • More consideration needs to be given to employee motivation (or wanting to recover) and psychosocial aspects of sickness absence.

  • Over-medicalising of often complex psychosocial situations can be counterproductive and lead to patient demotivation or even non-compliance.

  • There needs to be a spectrum of low- to high-intensity interventions to meet the spectrum of low- to high-grade conditions. Low-end ailments may be better self-managed through patient literature, DVDs, remote and home-learning tools etc. Fast-track assessment to identify employees who would benefit from low-intensity intervention would also avoid wasting resources on inappropriate referrals to OH specialists.

  • Employers should recognise that employees do not need to be fully fit to able to return to work, and this needs to be communicated to employees, employers, GPs and other care providers.

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