Dealing with long-term absence caused by a medical diagnosis can be difficult. Dr Lucy Wright clears up some of the confusion.
Managers often find sickness absence difficult to manage (CIPD, 2006). Where the illness is the only barrier to the employee returning to work, however, managers do not find it as tricky, as there is often an understanding of treatment times and outcome expectations that allows them to plan their management strategy.
Although most absences are attributed to the actual illness, and that is a significant component, other issues may occur that can complicate recovery and return to work. In absences, psychological or social issues are often the most significant barriers when considering a return to work, and the primarily medical model often leads to a delay in addressing these barriers.
The biopsychosocial approach to illness (Engel, 1977) identifies not only the biological barriers to working – for example, impairments of the body structure and functions – but also the psychological limitations and social barriers. These include personal beliefs and perceptions of the disease or affliction, as well as coping strategies and the social and cultural expectations of the sick person’s role. In the workplace, these non-biological issues may cause significant confusion for the manager as they do not understand why a person who has a medical condition that appears to be relatively stable and well controlled does not return to work.
Culture plays its part
Management culture and company policy may contribute to absence, but this is not always recognised within organisations.
The most important thing a manager can do to aid return to work is to keep in touch with the absent staff member (Acas, 2010; CIPD, 2013). This is simple to do, but often does not occur. Managers will frequently avoid contact with absent employees because they feel that they might be accused of bullying and harassment.
They also often report that there is no need to keep in touch, because they know that the staff member is genuinely ill and will return to work as soon as they can.
This belief that contact is only needed in cases where the absence is not for a genuine medical reason is erroneous, and can actually precipitate the very reaction they are trying avoid – namely, that the calls are seen as harassment if the company norm is not to keep in contact with everyone.
Isolation from the working environment is known to grow with the length of absence and becomes a significant barrier to return to work.
Other organisational issues may also have a significant effect on return to work. Some organisations do not support graded return-to-work programmes. There are a few roles that require an absolute level of fitness to be achieved, but many jobs can be done on a semi-restricted basis while the individual builds up stamina, recovers or awaits a therapeutic intervention.
If organisations do not allow this, then the period of absence is prolonged, with the associated risks of isolation and alienation from the workplace occurring.
Sick-pay provisions may also encourage or discourage absence, and it is important that an organisation monitors and analyses its absence recording systems in order to pick up any perverse behaviours being driven by the sick-pay schemes. For example, it is not uncommon to see spikes of return to work when an absent employee moves to half pay or no pay.
Some schemes do not pay for self-certificated leave, but will pay after one week regardless, and the payment can include the period of self-certification. This can lead to absence being extended in order to get the payment for the earlier period.
Absence policies that allow more favourable treatment for certain types of absence – for example, work-related injury – are also known to lead to significant amounts of management and individual time being taken up trying to prove or disprove that the injury or illness is work related.
Managers’ uncertainty about what they are allowed to discuss and question employees about also hinders clarification of the barriers preventing a return to work.
This is particularly so when managers have not received adequate training in managing absence. They are not happy asking how the employee manages their condition at home as it may be seen as an intrusive question, but if they do ask they are able to gain some insight as to how the workplace can be adjusted to facilitate the employee’s return to work.
Managers may also find that they lack the confidence to challenge the information the employee has given them, especially when it does not seem to fit the limitations reported – for example, the employee may report that they are unable to sit for prolonged periods, but then they take a four-hour flight to go on holiday.
In this type of situation, it is important to explore what the employee is doing to manage their condition so that the coping behaviour can be replicated in the workplace environment. Waiting times for treatment and the degree of understanding the treating healthcare professionals have about the individual’s work and working environment can also have an impact on absence.
Where patients are encouraged to return to normal activity and work is regarded as part of their rehabilitation, then return to work is often easier and quicker. The Royal College of Surgeons has published guidance on expected return-to-work times after operations, which may be helpful.
Back pain and cardiac rehabilitation programmes now usually contain an expectation of return to normal function, including a return to work.
There are still significant issues around rehabilitation and support in returning to work – both within the healthcare system and within workplaces – for those with severe mental health problems and those who have had an incident causing brain damage, for example, a stroke or a head injury (Loughborough University, 2009).
Culturally, there remains a belief that work is bad for you and consequently there is an expectation that absence from work is good for you. Evidence points to this not being the case in most organisations. If this culture is still operating in your workplace, it needs to be explored and challenged.
Managers will often blame the GP-signed “sick note” for encouraging absence, not recognising that the GP has no knowledge of the working environment except for the information given to them by their patient (Waddell and Burton, 2006; Black and Frost, 2011).
Any limitation of advice given in a fit note in relation to a return to work may well be a response to the patient’s own view of the conditions pertaining to their place of work.
Understand the procedure
In order to manage absence effectively, it is important that managers are confident in their role and in the absence management process, and that they understand what they should be doing – an area where many managers lack confidence.
The role of the manager is to know their employees and maintain a good working relationship with them, as it is ultimately this relationship that will support a return to work. They should monitor performance and manage the associated issues, including absence.
It is very important that the manager does not move into the role of counsellor or therapist at any point during an employee’s absence, but they should maintain contact during the period of absence in order to facilitate a successful return to work. Managers who handle the attendance consistently and according to their policy lessen the risk of accusations of bullying and harassment and also provide a framework for new managers.
Following procedure also provides a predictable framework for the employee to understand what is happening to them in relation to their work. This can be especially useful in dealing with cases involving mental health issues or substance misuse.
Managers can only make decisions based on any information and advice they have, medical or otherwise, together with any other available evidence and the needs of the business. This can cause difficulties if the employee refuses to discuss the underlying causes or issues in relation to the absence.
However, working to the organisational policy will help managers in these circumstances.
Managers need support to understand that conversations with employees about health issues do not have to be difficult, provided they follow these guidelines:
- The role of the manager is to manage performance and attendance, so the conversation should be framed around that and not around illness.
- Work is good for people and remaining at home when this is avoidable is not good for anyone.
- The conversation should be held in an adult-to-adult manner and with respect on both sides. It is the employee’s job to manage their illness, and this is not something the manager should start to take ownership of.
- The individuals can be asked what are they doing to get better – for example, are they seeing healthcare workers and accessing the recommended treatments?
- Employees can be asked what they are doing at home to cope. The manager should then consider if these strategies can be replicated in the workplace.
- There should be a discussion about any issues apart from the illness that are preventing the employee from returning to work. There are often other factors involved – for example, difficulties with transport and working hours.
- If the manager has evidence of inconsistent behaviour, then they should discuss that – for example, if the employee is working for another employer during their absence – but this should only be done with evidence.
Moving consideration of absence from the medical model to the biopsychosocial model and demedicalising the managers’ thoughts and actions around attendance can achieve results.
At Atos Healthcare, a programme was developed involving manager education from the senior levels throughout the organisation. Data analysis of the organisation’s absence statistics showed areas to target.
Masterclasses on common health issues in the organisation were held for HR advisers and managers. At every meeting with the OH provider, the manager was supported in demedicalising the issues (where appropriate).
Feedback from managers throughout the organisation has been very positive, and over the six-year programme the following tangible results have been obtained:
- absence has decreased by 3.8 days per employee;
- a savings of £26 million was achieved; and
- the increase in staff attending work was equivalent to 1,500 full-time staff.
Demedicalising how managers think about and deal with sickness absence in an organisation enables them to control absence more effectively, providing tangible organisational benefits.
Acas (2010). Managing attendance and employee turnover.
Dame Carol Black (2008). “Working for a healthier tomorrow”. London;TSO.
Black C, Frost D (2011). Health at work – an independent review of sickness absence.
Engel GL (1977). “The need for a new medical model: a challenge for biomedicine”. Science; vol.196, pp.129–136.
CIPD (2013). “Absence management: annual survey report 2013”.
Royal College of Surgeons. “Get well soon – helping you make a speedy return to work after your surgery”. Available at: www.rcseng.ac.uk/patients/get-well-soon
Loughborough University and Mental Health Foundation (2009). Returning to work: The role of depression.
Waddell G, Burton AK (2006). “Is work good for your health and wellbeing?”. London;TSO.