Occupational health professionals have a role in managing bipolar disorder and work attendance. Catherine Carr explains how psychological flags can help in suggesting workplace adjustments for staff.
Research increasingly suggests that employers who manage attendance save money and improve effectiveness (Acas, 2014). The CIPD absence management report (2015) shows that the average level of employee absence is 6.9 days per year, however this varies across organisations and sectors. The median annual absence cost per employee is £554 (CIPD, 2015) and the cost to the UK economy is £17 billion annually (Acas, 2014). Some of these costs are associated with mental health-related absences. Individuals with bipolar disorder tend to have a higher rate of absenteeism than those without the condition (Bowden, 2005).
This case study explores current policies and the legal and ethical issues encountered in managing attendance for an employee with bipolar disorder. The role of OH is examined in undertaking assessment and providing recommendations, while being alert to the issues of patient confidentiality.
Outline of the case
Daniel is 52 and works as a warehouse supervisor. He lives with his long-term girlfriend and has a son from a previous relationship, who is in his 20s. Daniel is an ex-army soldier and left the military 22 years ago. He served in Iraq and Northern Ireland. The current issues are:
- Five episodes of absence over the past 16 weeks. Documented as being caused by migraines and stomach upsets.
- A pattern of absence on Mondays or following a bank holiday.
- Colleagues have observed Daniel is quieter recently, initiates conversation rarely and has failed to meet two important deadlines.
- Daniel’s manager has spoken to him in relation to the absence. Daniel explained that he has regular headaches and thinks this is trigeminal neuralgia and stomach upsets.
- Daniel has been diagnosed with bipolar disorder and has not disclosed this to family, friends or work colleagues. He has been taking lithium carbonate for two weeks at the point of referral to OH.
Policy drivers in attendance management
A number of reports and pieces of legislation have influenced current thinking and the development of policies to manage attendance. Dame Carol Black’s 2008 report, “Working for a healthier tomorrow”, urges that we change the perception that people should not be at work unless they are 100% fit. The report also advocates removing the stigma around ill health and disability, to enable people with health conditions to find and stay in work, stating that this is particularly important in the case of mental health conditions.
Occupational health assessment and psychological flags
Biomedical (red) and mental health (orange)
- Bipolar diagnosis – medication commenced.
- Effects of condition – concentration and memory may be affected. Communication/interpersonal skills, and mood.
- Effects of medication – may cause drowsiness.
- Trigeminal neuralgia/migraines? Is this a diagnosed condition? Symptoms and effects may be linked to bipolar or medication.
- Past medical history?
- Alcohol/drug use?
- Triggers for mental health problems? For example, sleep and stress
- Suicidal thoughts?
- Personal history? Service in the army, witnessed conflict.
- Health beliefs/attitude? Illness may be seen as a sign of weakness. This may explain non-disclosure of diagnosis to employer/family.
- Coping mechanisms? Use of alcohol? Denial?
- Expectations of recovery/management of condition?
- What tasks are involved in being a warehouse manager – use of vehicles/machinery?
- What are the hours of work? Shift work?
- Relationship with manager/colleagues? Why has Daniel not felt able to disclose his diagnosis?
- Is work enjoyable?
- Stressors – for example, demand/control?
- Social support? Lives with long-term girlfriend in a supportive relationship?
- Relationship with son? Friends?
- Beliefs/opinions of significant others?
- Financial issues?
- Policies/procedures at work – are these helpful/unhelpful?
Daniel has not disclosed his diagnosis of bipolar disorder to his employer. It is likely this is because of a fear of being stigmatised. Michalak et al (2007) studied the impact of bipolar disorder on work and found that only a minority of subjects had not experienced any stigma in the workplace. Several respondents believed that they had been dismissed from positions, or held back in their careers, due to their diagnosis of bipolar disorder. However, non-disclosure also resulted in problems with managing the condition at work.
The Equality Act (2010) has also driven the development of policy relevant to attendance management. In particular, outlining the duty on employers to make reasonable adjustments to allow the recruitment and retention of employees with disabilities. A person can be defined as disabled if they have a physical or mental impairment that has “a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities” (Acas, 2016). In the workplace, day-to-day activities may include interacting with colleagues, following instructions and keeping to a timetable.
With the information available regarding Daniel, he may be defined as having a disability covered by the Act as it is likely his condition will be long term and impact on his daily activities. However, OH professionals are not ultimately responsible for deciding whether or not an individual’s condition would be defined as a disability. This is generally a matter for an employment tribunal (Kloss, 2014). Nonetheless, the Employment Code of Practice (2011) advises that the possibility of adjustments should be explored in all cases, without the need for a definite answer as to whether or not the Equality Act applies.
Daniel has shown a pattern of regular, short-term absence. Many employers have created attendance management procedures to deal with short-term, intermittent absences (Kloss, 2013). The majority of these procedures involve trigger points, specifying that after a certain number of days absence, during a defined period, the employee will be referred to HR and/or OH (Kloss, 2013).
Under the provisions of the Equality Act, employers have a duty to positively discriminate in favour of employees with a disability (Kloss, 2013). The use of attendance trigger points in HR policies may be seen as unduly stressful for an employee with a disability and therefore constitute unfair treatment, in breach of the Act (Kloss, 2013).
According to Kloss, “a reasonable adjustment may be to extend the trigger point for someone whose disability means that they may take more absence”. This was clarified in a recent case brought before the Court of Appeal, Griffiths v the Secretary of State for Work & Pensions (2015). Although Ms Griffiths was unsuccessful in her case, the Court of Appeal ruled that there is a duty to extend triggers as far as is reasonable (Yeardley, 2016).
However, at the author’s place of work, the local HR policy (2014) states that: “Occupational health cannot advise that the attendance policy is modified [such as trigger points or process].”
In the author’s opinion, this policy should be reviewed, as it would be justifiable for OH to suggest that absence trigger points are adjusted in some cases. It would remain for management to decide whether or not the adjustment is reasonably practicable.
Bowden (2005) states that individuals with bipolar disorder tend to have higher rates of absenteeism compared to those without, therefore adjusting absence trigger points could be considered in Daniel’s case.
However, it is important to first identify all the factors that may be contributing to absence from work. Brown, Palmer & Hobson (2013) propose that diagnosis alone provides little information about fitness for work, as it does not take into account the individual’s experience.
Assessment of the case
The biopsychosocial model can be useful for OH professionals when undertaking an assessment. This approach takes a holistic view of health, taking into account the biological, psychological and social dimensions of illness (Borrell-Cario et al, 2004).
Psychosocial flags can be used to provide a framework for assessment and planning. These flags are designed to identify obstacles to being active and working. Yellow flags look at the person; blue flags focus on the workplace; and black flags examine the context, incorporating factors that are outside the control of the individual. Red flags can also be used to identify biomedical factors, and orange flags have recently been introduced to alert the clinician to serious mental health issues (Watson, 2010).
Once any of the flags have been identified, a number of professionals may need to be involved in action planning to facilitate return to work (Watson, 2010), or in this case, enabling the employee to stay in work.
Michalak et al (2007) state that one of the predictors of poor occupational functioning in patients with bipolar disorder is lack of social support. However, their study had limitations in that it involved a small, self-selected sample.
Nonetheless, these findings are supported by Bowden (2005), who found that employment is more likely for patients with bipolar disorder if they have access to tangible social support. Within the consultation, the OH professional would need to establish whether or not support for the individual is adequate and if this is impacting on the management of their condition.
A key issue that would need to be addressed in the consultation is Daniel’s reluctance to disclose his diagnosis to his employer. OH professionals should maintain confidentiality unless written permission to disclose information is received from the client (Carmel, 2012).
However, there are some important points that would need to be conveyed to the manager from a safety point of view. These are the need to undertake a workplace risk assessment with regards to the potential effect of the client’s condition and medication on his ability to drive and operate machinery, and to identify any potential occupational factors or stressors that may exacerbate his condition.
Brown, Palmer & Hobson (2013) point out that disturbed sleep can be a trigger for mania in individuals with bipolar disorder, and therefore shift work may be unsuitable. They also advise that suitability for safety-critical roles should be carefully considered.
Within the OH report to the manager, the diagnosis does not need to be disclosed, however it would be prudent for the manager to know that the client has a condition affecting their psychological health and what adjustments and interventions would be recommended.
If the client did not give consent for a report to be sent to the manager, the OH professional would need to consider whether or not there was an obligation to inform the manager of any potential health and safety risks – for example, due to the effects of medication.
This would need to be discussed with the client first to ascertain if he has experienced any drowsiness and whether or not the job involves operating vehicles or machinery. The key factors in deciding whether or not to share confidential information are necessity and proportionality (DOH, 2010).
The decision of the manager to refer the client to OH in this case was to ascertain if there was an underlying medical reason for the episodes of sickness absence.
Although the exact nature of the illness does not need to be disclosed, it would benefit the employer to know there is an underlying condition. This would also benefit the employee, as disciplinary action around the episodes of absence would then be unlikely.
The OH professional would need to consider whether or not any adjustments or interventions may aid the client in remaining at work.
Recommendations in this case could include: flexible working or a change in working hours; adjustments to tasks or more time to complete tasks; and regular meetings with the line manager and reviews of work.
Mental health disorders may affect concentration and memory (Thornbory, 2013), therefore, provision of written instructions and memory aids may be beneficial. Access to Work may be able to provide a grant to enable the employer obtain additional support for the individual, such as counselling services, if there is no provision for this in the workplace currently. Also, if alcohol is found to be a contributing factor to absence in this case, referral to a local alcohol support service would be prudent.
OH cannot enforce adjustments, it can only recommend what would be appropriate in the individual case and explain the rationale (Carmel, 2012). A timescale should be set if adjustments are being implemented, so that the manager and employee can review the effects of this on attendance.
It is also important for OH to identify anything the employee can do to reduce the risk of further absence (Carmel, 2012). For example, exercise has been shown to help reduce the symptoms of bipolar disorder, particularly depressive symptoms (Mahmood, 2013). This could form part of an intervention to reduce sickness absence.
Managing attendance can help employers to save money and increase effectiveness (Acas, 2014). Several pieces of legislation and reports provide guidance to employers, HR and OH departments in this area, including the Equality Act and the Black report. It must be ensured that OH professionals adhere to the legislation and relevant policies, particularly in cases involving complex health conditions and disabilities. The OH practitioner can advise line managers and HR on adjustments or interventions to reduce absence in such cases.
Catherine Carr is an occupational health nurse, quality and planning, at Nottingham Occupational Health.
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