Case study: a return to work after sickness absence due to mental health

return to work

Managing sickness absence due to mental health is one of the top challenges for HR and occupational health. Felicity Fleming explains how this case study of a successful return to work shows how national policy developments can help.

Sickness absence management in the UK has changed in the last decade in response to a series of national policy developments, with an emphasis on the benefits of an early return to work. The most recent development is the imminent launch of the Fit for Work service. However, employees can sometimes feel under pressure to return to work before they are fully recovered.

The Government’s current approach to the management of sickness absence within the working-age population is predominantly based on the Black (2008) report and the Government’s subsequent response from the Department for Work and Pensions (DWP) (2008).

However, the costs related to sickness absence remain high, and this looks set to continue due to the added challenges of an aging population staying in work longer (DWP, 2013).

Research has identified that after six weeks of sickness absence, an employee is less likely to make an early return to work (NICE, 2009; Waddell et al, 2008). The Government recommends that a referral is made to OH after an absence has reached four weeks (DWP, 2013). Managers should be trained to effectively implement sickness absence policies, and have a comprehensive understanding of their importance in increasing attendance (Palmer et al 2013; Johnson, 2008).

The rationale for the early involvement of OH is based on evidence indicating that prompt diagnosis and intervention increases the likelihood of an early return to work (DWP, 2005; Black, 2008).

HR management teams, acting on the principle of harnessing and maximising the potential of the workforce to optimise performance (Foot and Hook, 2011), have the task of designing policies that are effective in both managing sickness absence, and enabling employees to return to, and remain in, work (Acas, 2014; CIPD, 2014; Palmer et al, 2013). An important consideration for HR in the development of new sickness absence policies is the growing body of research demonstrating that employees who feel valued and motivated have lower rates of sickness absence (Foot and Hook, 2011).

This principle can be seen in the case of an employee who was referred to OH after 20 days of sickness absence, which was reportedly caused by non-work-related stress.

Case study: the management of sickness absence due to mental health

Management of this case began by developing a therapeutic relationship with the employee (Case Management Society UK, 2009), while observing professional regulations (NMC, 2008). Using the biopsychosocial model (Palmer et al, 2013), an initial assessment to determine key facts of the case and the employee’s functional capacity were undertaken. Disclosures by the employee revealed that her stress was due to a complicated combination of factors that included:

  • low self-esteem due to a recent verbal warning;
  • disturbed sleep and panic attacks due to fear of making a further mistake at work;
  • new responsibilities caring for her elderly mother; and
  • a recent bereavement (sister).

The OH adviser was concerned that the employee’s manager was unaware that work-related stress was contributing to her condition. Better outcomes are achieved for employees following sickness absence where managers have good relationships with staff and are fully aware of the causes of absence (Wright, 2014). If, for example, sickness absence is caused by a disability, reasonable adjustments could include the episode of absence being discounted (Gorasia, 2013), thereby avoiding the implementation of unnecessary disciplinary procedures (Acas, 2014).

Recognising that one in six workers in the UK are adversely affected by mental health conditions including stress (The Council for Work and Health 2014), the Health and Safety Executive (HSE) extended the duty of care on employers to encompass risks to employees’ health and wellbeing associated with work-related stress. If this recommendation had been implemented in this employee’s case, her sickness absence could have been prevented, and her referral would have included a work-based risk assessment, stating the measures that had already been put in place to eliminate or minimise the work-based stress.

The absence policy in the workplace made no reference to the GP fit note, and no advice was given to managers about using these certificates to support them in absence management. This placed OH practitioners at a disadvantage, as it does not encourage collaborative working (Thornbory, 2014).

Throughout the management of this case, the OH adviser was never informed of the content of the fit note. Although fit notes were introduced in 2010, a survey in 2012 found that out of 40,000 UK GPs, only 3,500 had been trained in the use of fit notes (Chamberlain, 2012). GPs do not have the relevant knowledge or expertise about an individual’s job activities or the risks involved to be able to make a judgment as to whether an employee was “unfit for work” or “may be fit for some work” (Keyes, 2010). Reasons for sickness absence contained in GP fit notes can be inaccurate, thereby leaving the manager and OH unaware of the impact of work on an employee (Palmer, 2013). The Government has pledged to increase training provisions for GPs regarding fit notes to improve this situation (DWP, 2013).

Recognising that the employee needed to develop relaxation techniques in order to manage her panic attacks, the OH adviser referred her to the organisation’s OH wellbeing adviser, which the individual found beneficial. OH also referred her to the staff-support counselling service, which helped her cope with her bereavement.

A significant barrier to recovery was the employee’s disinclination to take the medication prescribed by her GP. In recognition of the need to respect the decisions and wishes of the client (NMC, 2008), the OH adviser provided gentle advice at this stage, encouraging her to reconsider her decision in view of the effect it was having on her own health and her ability to care for her husband and mother. She subsequently agreed to take the medication prescribed by her GP.

The employee slowly became receptive to OH advice that returning to work could aid her recovery, partly because caring for her mother and husband was making her feel claustrophobic and frustrated. She was encouraged to regain control of her home environment by allocating some responsibility to her adult children. Once these measures were in place, she was then encouraged to consider the benefits of returning to work (Waddell et al, 2008). At this point, she began taking the medication recommended by her GP, which brought about a subsequent improvement in her condition.

The employee disclosed concerns about resuming her employment. She anticipated animosity or diminished respect from some colleagues because her sickness absence was due to a mental health diagnosis. As employees in this situation often experience difficulties returning to work due to feelings of embarrassment (Department of Health, 2012), the OH department planned measures to overcome these barriers, including:

  • OH adviser accompanying her to submit her fit notes to her manager in person;
  • OH accompanying her to visit her workplace to have coffee with colleagues; and
  • encouraging her to meet with colleagues in OH’s absence.

Despite her anxieties about resuming employment, she now wanted to return to work as she was aware that her pay would soon be reduced by 50%. This is a controversial issue for OH. While it is recognised that occupational pay schemes can result in some workers lacking the incentive to return to work while they remain on full pay (CIPD, 2013), financial pressure can cause other employees to resume work too early, resulting in “presenteeism” and further absence (Baker-McClearn et al, 2010). This can create dilemmas for OH in observing the duty to promote health and foster wellbeing (Smedley et al, 2013).

Consideration of reasonable adaptations for her return included the option of requesting flexible working, based on the Employment Rights Act 1996, and Children and Families Act 2013 (amended June 2014), to enable her to care for her husband and mother, as these stressors had been identified as contributing to her sickness absence. As the health of her husband and mother had now improved, this option was not pursued, but she was made aware that it might be available if deemed appropriate in the future.

Recommendations for reasonable adaptations to support her in returning to work were based on adjustments advised for employees with a mental health diagnosis (Department of Health, 2012; Thornbory, 2014), and included:

  • adjusted hours/shifts during her phased return;
  • adjusted duties;
  • working with a “buddy” during her phased return;
  • additional breaks of five-10 minutes as required if feeling stressed or anxious; and
  • work-based stress risk assessment to be completed.

After the employee returned to work, one further appointment was arranged, during her phased return, to check that a return-to-work interview had been conducted, and that agreed recommendations were supporting her effectively. Better outcomes are achieved for employees following sickness absence, where managers have good relationships with staff and are aware of the causes of absence. Supporting the manager with clear and timely advice was therefore important (Wright, 2014).

This case study shows the importance of collaborative working between line managers, HR and OH in the management of sickness absence in the workplace. The role of OH included providing support in the form of: material and psychological assistance to the employee; advice, information and guidance to management; and to help colleagues in HR develop robust policies based on latest evidence about the factors influencing employee attendance.


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