Occupational health can play a pivotal leadership role when it comes to supporting an employee struggling with alcohol or substance addiction, as Neelum Sanderson and Professor Anne Harriss show in this case study.
The work of Waddell and Burton (2006(a)) affirms that work is generally good for health. They highlight that an employee who has been absent for six months or more has an 80% chance of being off work for five years or more (Waddell and Burton (2006 (b)).
Occupational health practitioners are frequently involved in strategies to provide managers with support around attendance management, which is a management responsibility.
About the authors
Neelum Sanderson is a specialist occupational health nursing adviser and Professor Anne Harriss is emeritus professor of occupational health
Early interventions are important and organisations with access to occupational health (OH) provision will rely on their guidance in the management of both short- and long-term absence. The aim of OH management referrals is to give impartial advice in the support of both the employee and manager.
This article explores the case management of “Sally” (a pseudonym), a 60-year-old lawyer who for the last 10 years had worked as senior counsel within a small team in the regional office of a multinational law firm.
Sally had had periodic contact with OH following bilateral carpel tunnel decompressions four years previously, with a period of short-term absence requiring a phased return to work (RTW).
Sally had a poor working relationship with her manager, who was based in Singapore and Sally in London had limited contact with her. National Institute for Health and Care Excellence guidelines (2009) stress the importance of actively managing the absence of those employees absent from work with mental ill health. They advise appointing a case worker to coordinate referrals to specialists, case work meetings and be a point of contact for the employee.
Sally had several health issues, including:
- A 30-year history of lower back pain resulting from L4/5 partial disc prolapses, which are managed with twice-weekly Pilates classes, and occasional chiropractor treatment.
- A long-term history of anxiety and depression treated by her GP with fluoxetine (40mg).
- A diagnosis of alcohol dependency syndrome made in 2014, treated by her psychiatrist and attendance at Alcoholics Anonymous meetings. She stated that she had not drunk alcohol since August 2014.
- Two years before the referral to OH, Sally had reported becoming increasingly anxious and tearful, as well as feeling overwhelmed and panicky. She was admitted to a psychiatric facility as an inpatient for 28 days on a voluntary basis.
- Her most recent absence was Sally’s first period of extended absence, and with no indication of a (RTW) date.
There is a wealth of evidence relating to lawyers developing dependancies on alcohol and substances. Leignel et al (2014) refers to instances of drug and alcohol misuse among self-employed lawyers. They found that for 16% of lawyers their alcohol consumption was consistent with alcohol abuse.
Brooke (1997) highlights that many lawyers, even when in the grip of their addiction, still manage to function and continue to practice although, for many, their effectiveness and enthusiasm for work drops.
The case management team
The core team supporting Sally included the regional occupational health manager, occupational health physician and human resources (HR) practitioners. Case management was a collaborative process involving, when required, members of the legal team, employee relations, total remuneration and the regional HR manager, who was also a member of the firm’s pensions board.
Sally’s manager chose not to attend, despite there being a tele-conference option, preferring to let HR deal with the meetings on her behalf.
Handy (1999) advises that a group of between five and seven appears to be the optimum size for a well-functioning team. However, irrespective of the group size, an assertive leader within the rest of the group taking on more of a follower role appears to work well – two assertive leaders do not make for a cohesive group.
In Sally’s case, the regional HR manager took on the leader’s role and the rest of group appeared to have confidence in her, her position and her understanding of the situation and any relevant policies and processes that needed to be followed.
Anstis (2014) discusses the role of the employer or manager when dealing with a long-term sickness absence and mentions the importance of keeping in contact with the employee by phone when they are off. They should also try and meet with the employee before they return to work, perhaps in a mutually convenient place but not necessarily at the workplace, as this could be difficult for the employee. Whilst the employee does not have an automatic right to bring someone else to the meeting, they may find it helpful.
Collaborative approaches to case management promote consideration of both the employee’s health situation and the requirements of the employer. For a case management team to be successful, there should be a clear understanding both of roles and responsibilities and confidential nature of the materials that are to be discussed.
In Sally’s case, the team functioned well, making decisions regarding RTW schedules. However, once more complex decision-making was required, issues began appearing in the team.
A complicating factor, for example, was that initially the legal representative suggested was a colleague of Sally, and a decision was made to request an alternative representative based in the USA.
Absence management policies
A variety of policies were applicable, including:
1) Sickness absence policy. Sally complied with this policy, providing GP and self-certification when required, communicating with her manager and HR when necessary keeping all relevant parties informed and updated regarding any absences.
There were no “trigger points” within the policy to indicate when managers should refer employees to OH. Smedley et al (2013) advises that all employers should have a sickness absence policy which clearly indicates how sickness absence will be managed.
For example, there should be details on how the absence should be recorded and reported, the roles and responsibilities of the employee, manager, occupational health and HR. It should detail how employees may be paid when they are off sick. The role of the manager in terms of absence is key. Their responsibilities include keeping in touch with the employee and holding an informal RTW interview.
Policies generally incorporate “trigger points” for management. For example, if an employee is absent for more than four consecutive weeks they will be referred for an OH opinion. Many organisations use such trigger points for frequent short-term absence too. In this case, there were no trigger points within the organisation’s policy.
2) Occupational health management referral policy. There were concerns, as further clarification was required regarding the reports HR had received from the OH physician (OHP). This required the OHP to undertake an additional telephone consultation.
Sally found these conversations stressful, as this clarification was centred around her role and when she felt she may be able to fulfil all the requirements of her position, in particular full working hours and days. This reinforces the importance of writing a thorough referral in the first instance.
Cooper (2017) provides helpful guidance when reviewing a referral process to ensure all elements have been addressed. Key to this process is the referring manager explaining to the employee the reasons why a referral is being made. The employee should be aware of the information that is being sought and should confirm they understand the process, and their written consent to attend should be obtained.
The referral should include relevant information, including role, length of service, sickness absence data, and any other information to the case. It is important managers appreciate that OH provides guidance but implementing a phased return or suggested adjustments are management decisions.
3) Long-term disability ill-health retirement policy. At the time of implementing this process, guidance from external legal counsel was needed clarifying the definitions of “partial and permanent disability”, as these could have been important in this case.
This policy includes considering the availability of other comparable positions which might be appropriate for Sally should she be deemed unable to perform her post’s requirements.
Since 2001, organisations with five or more employees must offer a stakeholder pension if a suitable occupational or personal scheme is not in place (Palmer et al 2007).
Eligibility for an enhanced pension because of ill health depends on the criteria stipulated by the pension trustees. Criteria vary, but most require some permanency and evidence that the member has gone through a range of treatments.
They usually expect the member to have been engaged with a specialist at some point during their treatment. In addition, there is also an expectation that the employer and employee have explored options for redeployment and any reasonable adjustments.
Many private sector schemes, (and that operated by Sally’s firm was one), operate a two-tier system. The lower tier (partial) is where the employee is unable to fulfil the requirements of their current position and the upper (total) tier is where the employee is unable to do any work at all. Those receiving upper-tier benefit are usually subject to periodic review.
Those with clearly defined life-limiting/progressive conditions, for example cancer or degenerative conditions such as multiple sclerosis, are better understood. However, in Sally’s case the decision on ill-health retirement came down to her mental health and diagnoses of anxiety, stress and depression secondary to alcohol dependency syndrome.
Lahelma et al (2015) explored whether those with “common mental disorders” could be an antecedent to ill-health retirement. The Equality Act (2010) is pertinent here, as a disability is defined as “a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on the ability to do normal daily activities”. Drug and/or alcohol addictions do not fall under the Act, however mental health conditions, perhaps secondary to this, could fulfil this criterion.
Flacks (2012) raises questions as to why alcohol and drug addiction have been excluded when, internationally, an addiction seems to be accepted as a “disability”.
He also mentions that, perhaps, as the term “addiction” does not allow for clear criterion on whether an individual is addicted, this could be an answer. But this exclusion further reinforces the stigma attached to addiction and reinforces the lack of humanity that still exists for many of these sufferers.
Sally was awarded permanent long-term disability as proposed by the OHP and endorsed by the company pensions administrators.
Although the company was satisfied with this, Sally was not. Sally’s psychiatrist had informed the OHP that Sally should only work for three days per week and be restricted to core hours of an eight-hour working day.
The firm’s management was unable to support this request. They could not integrate this within the post requirements and responsibilities of a senior counsel, which included business travel, nor could they support working at these reduced hours until retirement.
Sally was fully conversant with the requirements of the Equality Act (2010) with regards to making reasonable adjustments. The employer had to demonstrate having considered Sally’s request to adjust her working hours and days. It also had to demonstrate sufficient justification for denying this request, otherwise she could make a claim for discrimination should Sally’s symptoms of anxiety and depression fall under the definition of a disability under the Equality Act (2010).
Kloss (2010) discusses this at length, highlighting that altering hours could be a reasonable adjustment along with others, such as allocating some work to someone else.
Lessons learned for occupational health
There was insufficient management involvement and support afforded to Sally. Robertson-Hart (2014) discusses the importance of managers supporting the mental health of their staff, keeping in touch and supporting them during their time off and keeping options open for a successful RTW.
Managers may fear that the employee may see this as harassment. However, from the employee’s perspective, if done sensitively this is not the case. Indeed, lack of contact can leave them feeling that the employer has forgotten about them, making a potential return more difficult.
Consequently, in Sally’s case, when discussions regarding available options were required, it was much more difficult to engage her. Kumar (2016) highlights the importance of managers being aware of issues that may be forming and ensuring there are opportunities to attend any medical appointments where necessary, highlighting that they should ensure they have properly considered workload-avoiding factors that may have led to aggravation of any health issues, such as anxiety.
In Sally’s case, the OH management referral process is now being reviewed following this case. Repeated additional questions being posed by HR heightened Sally’s anxiety and led to a breakdown of trust between HR and the OHP.
The referral form documented a list of questions such as, “is the employee medically fit for work?”, “is a phased RTW recommended?” (Cooper 2017).
These will now be supplemented with an additional section providing opportunities for additional bespoke questions. The regional OH manager was also now planning to present a 15-minute presentation on the OH management referral process at a “supervisor essentials” course for all new managers.
Following this case, a decision was made by the pensions board that, following a response to management being made by the OHP and for cases pending a decision, a multi-disciplinary case conferences would established. This would involve a member of the pensions board and representatives from OH, HR, employee relations and the legal team.
As already highlighted, the firm’s current sickness absence policy does not incorporate any “trigger points” for an OH referral for either long-term or repeated short-term absences. This is left solely down to the manager’s judgement, with some managers more efficient at this than others.
Currently HR and OH are therefore considering the availability of HR software that can track absences more effectively. Smedley et al (2013) stress that the overall responsibility for monitoring and managing absence is integral to the role of effective managers.
It became obvious that Sally’s short-term absence was very high, with Sally frequently, for example, adding an extra day to the weekend or taking Mondays off sick.
This pattern had been evident for years. As her manager was remote and unfamiliar with managing absence, this was left unrecognised. Although the ultimate outcome may have been the same, earlier management recognition might have led to a more positive outcome.
Interestingly, Palmer at al (2007) indicate that employees with alcohol problems have between double- and eight-times higher absence that non-problem drinkers.
Sally retired on the grounds of ill health and her employer was able to fill the position. The long-term outcome for Sally is uncertain; without the structure of work she might lapse, although she would have extra free time available to attend regular counselling and Alcohol Anonymous group meetings. As she becomes used to her life without alcohol, her symptoms of anxiety and depression might dissipate.
Finally, it should be recognised that Sally was dissatisfied with this outcome, as she would have preferred to carry on working. She felt she had been pressured into accepting ill-heath retirement. This, in turn, create a risk of litigation for the employer with regards to discrimination under The Equality Act (2010).
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