How occupational health can attend to absence

Managing people back to work is very much on the agenda with the proposed government reforms of incapacity benefit and a new workplace health strategy. But there are threats, as well as opportunities, for occupational health practitioners in taking on more responsibility for absence management. The key seems to lie in deciding to what extent OH practitioners’ clinical skills qualify them to manage a problem which is often a consequence of managerial and organisational issues outside the traditional OH remit.

One thing that isn’t in doubt is the scale of the problem for employers. The latest survey from the Chartered Institute of Personnel and Development (CIPD) shows that absence costs an average of £601 per employee, with minor illness, musculoskeletal disorders (MSDs), stress and recurring medical conditions being the most common reasons for staff missing work.

OH practitioners cannot afford to ignore an issue that is such a high priority for employers, but they must ensure that their involvement in absence management is making the best use of their specialist skills. If OH gets involved in the low-skill aspects of absence management, policing it could have an adverse impact on overall OH service delivery. However, there are big opportunities for OH in case management and rehabilitation where the range of OH skills make practitioners ideally suited, and offer them an opportunity to boost their influence with line managers and HR.

Area of focus

Royal College of Nursing (RCN) advisers are clear that OH practitioners should focus on long-term absence and incapacity rather than policing short-term absence. Carol Bannister, RCN adviser on occupational health, believes that OH advisers should use their practical skills to advise managers on reasonable adjustments and work practices. OH nurses also have a role in case management – not an area where most practitioners traditionally have acquired experience or competence.

“Long-term sick leave and case management are both important roles for OH nurses,” she says. “Assessing fitness to work for people who have been absent due to incapacity or long-term sickness, and looking at reasonable adjustments and changes to work patterns is the context in which OH practitioners need to be based.

“But people taking odd days off all the time is not an OH issue; this is a management issue. There are clearly issues concerning motivation and relationships at work when this happens.”

Role of OH

Sharon Horan, occupational health consultant and Professional Nursing Development adviser, occupational health, at the RCN has concerns about OH practitioners focusing too much on absence management, particularly short-term absence, which is the major problem for employers. The increase in rapid follow-up for absence, sometimes call-centre based, is not an appropriate use of the time of a qualified OH practitioner, she says.

“Absence management is a good thing, and is in keeping with government strategy,” Horan says. “But a balance is needed. We are not there to police the system. Policies and procedures should be followed, and we are not going to knock on people’s doors on day one of their sick leave.”

In line with government priorities, OH needs to focus on MSDs, psychological illness and accidents, says Horan. Keeping track of staff with these conditions and following up each case should be a priority, but practitioners should beware of absence management becoming their exclusive focus.

“The threat of deskilling comes if absence management is all you do,” she warns. “The focus should be on working life. If you are doing nothing but absence management all day long, that will call into question your ability to do anything else. There are very few people who want to do just that – the OH role is so multi-faceted.”

Some practitioners see the OH role in absence management extending beyond rehabilitation to consulting with HR and line managers about non-clinical issues, and see this as a way to raise the profile and influence of OH within organisations. Mary MacFadzean, organisational health manager with Halifax Retail HR, believes that OH practitioners can play an important part in helping managers understand the organisational causes of absence.

“Absence management is an opportunity on the education side, and OH needs to educate HR professionals,” says MacFadzean. “OH doesn’t need to manage the whole process. It’s about getting the right people in the right places. And HR has the same objectives as OH in terms of workplace health.

“But it’s important to understand the causes of absence. There is more to this than referring someone to the OH nurse.”

Dr Mark Simpson, director of health insurer AXA-PPP, agrees that there is an opportunity for OH practitioners in demonstrating that absence is a symptom of organisational distress.

“If the causes of absence are understood, it could push the role of OH higher up the corporate agenda,” says Simpson. “If absence has a higher profile, then OH should have a higher profile too.”

Given the wide range of ways that OH services are set up, it would benefit the profession if good standards of practice in absence management were more widely spread among employers. But as a result of this lack of standards, many OH practitioners may lack the skills and experience to manage absence effectively.

“Some people see us as the end of the line, others will refer staff to us immediately so that we can refer them for physiotherapy or counselling,” says Simpson. “Some organisations think that if someone is ill, they will refer them to OH, and OH will sort that person out until they are fit enough to come back to work. And different skills are asked for in each case.”

Simpson calls for OH practitioners to use the full range of their knowledge to take a more leading role in managing absence within organisations, including policy development and planning.

“OH should be involved in policy development – absence management policy, drug and alcohol policies and so on,” he says. “OH staff should take the opportunity to look at the organisation to see what is causing absence, and get into organisational planning.

Mike Walters, director of specialist HR company Whitmuir HR and author of Personnel Today’s One-Stop Guide to Absence Management, suggests that OH practitioners offer a consultancy service to HR. “Other functions do need OH expertise,” he says. “You can give HR and line managers a whole range of ways to address the issue of absence management, but there will always be borderline cases where a clinical background is essential.”

However, the current evidence is that most OH professionals simply do not have the necessary skills to play more of a leading role in absence management, and that many do not regard it as a priority. An RCN survey published in December last year found that only 34% of OH nurses had a lead role in attendance management, and only 28% rated their competence as excellent in this area. Attendance management was also considered a lower priority than several other areas, including ‘confidential counselling’.


Help is at hand for OH professionals in the form of training specifically geared towards absence management, for example, in developing case management skills.

Following the launch of the government’s welfare Green Paper A New Deal for Welfare: Empowering people to work, in February this year, the RCN is in discussion with the Department for Work and Pensions (DWP) about training for nurses and other health professionals in case management practice. The DWP is looking at setting up an online training module with the RCN, which will promote good practice in this context.

Bannister hopes that the new training module will help OH nurse practitioners to take an active part in enabling the government’s strategy of improving GP services to get incapacitated staff back to work.

“It’s about skilling people to work in a more effective way – training is the key,” she says. “OH staff are experts in the needs of the workplace and the employee. Working with community nurses and GPs, they can help facilitate a smooth transition from sickness to work.”

Skilful application

Cynthia Atwell, occupational health consultant and senior visiting teaching fellow at the University of Warwick, runs courses on managing absence. Atwell believes OH nurses need to learn how to exploit their skills to identify whether a problem needs a clinical referral or can be dealt with as a managerial and organisational issue. OH practitioners who know employees and the workplace are in a better position to make such assessments than GPs who do not.

“The training focuses on two main issues: MSDs and stress or mental health,” she says. “We have tools which help people assess whether an employee’s depression means they need referral, for instance, or if they have anxiety, which their line manager can do something to help with.”

Absence levels could be cut if more OH professionals were able to use their skills in this way, she believes. “They already have these skills – it’s just a question of knowing how to use them. It’s about putting it into context. Companies still say ‘Someone is off sick, they have a doctor’s note, so you can’t do anything about it’. But the GP won’t know what their job is.”

Like Bannister, Atwell sees a strong OH role in getting employees signed off sick back into work, and ensuring that it’s not work that will worsen their condition. She believes that employers worry unnecessarily about their liability if they bring staff who are signed off sick into the workplace.

Keeping them at home isn’t the answer; what they need to do, is put proper rehabilitation programmes in place.

“Once people are off sick for any length of time, they think ‘I can’t’, [go back to work]” she says. “Anyone who is off sick for more than six months only has a 50% chance of returning to work at all. Return-to-work assessments are very, very important. And you need the support of managers and the support of employers.

“OH nurses have competencies that enable them to look at this holistically, and they could develop rehabilitation programmes which would keep people in work.”

Top 10 tips for managing absence

Locate your organisation’s absence hot spots and problem areas

Be clear about the OH role – occupational health staff are experts who can offer HR a consultancy service about illness and rehabilitation

Staff who throw frequent ‘sickies’ (absences of one or two days) should be dealt with by HR or line managers rather than OH

Get the balance right – OH practitioners risk deskilling if managing absence becomes too big a role

Raise awareness about why absence happens – an organisation with high absence rates isn’t healthy

Consider lobbying for influence within your organisation, and getting involved in policy decisions

Get the right training

Be focused on government priorities for improving workplace health: musculoskeletal disorders, psychological illness and accidents. Having an impact here will prove your value to the organisation

Consider taking responsibility for case management and rehabilitation programmes

Be positive about your skills – OH staff are uniquely placed to tackle absence. You have the skills – learn how to use them in this context.

What works and what doesn’t?

Green light

  • Linking attendance to performance
  • In 2004, car manufacturer Jaguar brought in a holistic policy which builds attendance into work appraisals and performance targets. Its Halewood plant has a target of getting absence down to less than 3%, and this is filtered down into personal objectives. Line managers carry out return-to-work interviews within 24 hours. Staff who are off sick for the same reason twice or more in 12 months are referred to the company doctor, who checks for signs of a chronic underlying illness, and employees are referred to OH at the first sign of stress. A range of support is available, including flexible working, practical advice, counselling and time off to sort out domestic problems. Staff with consistent attendance earn an additional 30 per week. Absence rates have fallen from 3.24% to 2.76%.

    Strategic outsourcing
  • Employee absence at home-building firm Taylor Woodrow has been cut to less than half the construction industry average in the past three years. The OH service – supplied by BUPA Wellness – provides 4,500 staff with access to advice on work-related and personal issues. The four-strong OH team carries out fitness-to-work examinations and pre-employment assessments. Since the new programme was launched in 2003, the average number of sick days per employee has fallen from 3.2 to 2.8 per year. This compares to an average of 6.6 days across the construction industry. The team works with the safety department to safeguard staff, and carries out annual health checks.
  • Additional support
    Royal Mail’s prize draws for good attendance hit the headlines, but the company has done much more than this to tackle absence. Staff on sick leave have more support, the company’s absence management scheme is managed by a strategic steering group, and it works to a 13-point managing absence standard. The central role of line managers has been stressed – they carry out return-to-work interviews, maintain contact with staff if they are off sick, and ensure that team members have access to OH. Around 13,000 line managers across Royal Mail were given training to use the standards. And the company has also renegotiated its contract with its OH provider. Employees are now referred to OH after 14 days instead of 21, and those suffering from stress or musculoskeletal disorders are referred on their first day of absence. The new policy boosted attendance by 11% from 2004-05.

Red light

Trialled in the US, ‘personal time off schemes’, or PTOs, are designed to put an end to ‘duvet days’, where staff simply take extra time off as sick leave. Staff subsequently tend to regard their PTO day as legitimate sick leave, so they can hang on to their full holiday entitlement.

  • Punishments
    Staff at West Yorkshire Probation Board were initially ‘cautioned’ if they had nine days off in one go, or took three separate periods of sick leave in 12 months. Two cautions were the first step to dismissal. The cautions are now known as ‘improvement notices’, because of the negative connotations associated with police cautions.

    An absence management survey carried out by the Chartered Institute of Personnel and Development last year, found that 10% of the respondents do not have a written absence policy at all. “We might talk to two people in the same organisation, and one will complain their line manager was hounding them from day one of their sick leave, while the other says they have heard nothing from the company for weeks,” says Dr Mark Simpson, head of OH at AXA-PPP. “Inconsistency is a no-no.”

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