Line managers and occupational health

The revised medical statement of fitness for work, or fit note, is an opportunity for occupational health professionals (OHPs) to consider afresh the difficult role that line managers play in managing workplace attendance.

Dame Carol Black’s review of the health of Britain’s working age population in 20081 considered the role of line managers in ­return-to-work and although much attention will be focused on the role of GPs in this process, it is likely the line manager will be at the heart of the interface between the employee and the organisation.2 One important question that will need to be addressed is how OHPs are going to support them.

The support of senior management is vital to promote health and wellbeing by acknowledging that good health is good business. However, as the Black report stresses, line managers need support to understand that the health and wellbeing of employees is their responsibility. Who better to support them in this vital role than the OH team?

Manager behaviour

It is now well documented that manager behaviour influences employee wellbeing, and the latest report by the Chartered Institute of Personnel and Development (CIPD)3 stresses, as in previous years, that line managers are central to the effective implementation of absence management policies. The CIPD noted that the average level of employee absence has fallen from eight days to 7.4 days per employee overall since the previous year, although it is too soon to assume that this is a long-term trend, particularly as the economic downturn in the UK may be influencing employees to take less time off sick than previously.

In December 2007 the Sainsbury Centre for Mental Health4 suggested that presenteeism, where employees go to work even when they are ill, accounts for 1.5 times as much working time lost as absenteeism and costs more to employers because it is more common among higher-paid staff.

Although this report focused on mental health, other evidence suggests presenteeism might affect other areas of health concern, notably the timing of disclosure of chronic illness.5 The research, by Munir and Haslam, questions whether current sickness absence management strategies encourage attendance or ‘risk-taking’ presenteeism in employees with chronic illness.

Action points

In the National Institute for Clinical Excellence (Nice) guidelines for promoting mental wellbeing,6 Recommendation4 covers the role of line managers in some detail, with a list of action points including ensuring that managers are both able to identify and respond sensitively to employees’ concerns and to understand when it might be advisable to refer an employee to OH services. Irvine7 reports that the lack of response and engagement in discussion of employees’ mental health problems could be linked to low levels of knowledge and understanding among some line managers and occupational health staff.

Threatening or supportive?

Another problem is that employees may perceive OH services as threatening when line managers fail to present OH as supportive. Irving describes a situation where some people perceived their line manager’s response as an over reaction or as discriminatory when, for example, an employee was “sent” to occupational health on disclosure of recurring experiences of depression to the line manager when offered promotion at work. The employee responded by deciding not to mention mental health problems to future line managers. How common an occurrence might that be in practice?

The Nice guidelines also refer to research by Investors in People, the Health and Safety Executive and the CIPD in progress since 2005, which has produced updated guidance for line managers.8,9 However, even when managers are committed to positive interventions, some of the barriers to progress are identified in the study as being:

  • Job related – workload and tight deadlines, conflicting priorities
  • Organisational barriers – bureaucracy, senior management attitudes
  • Team capabilities – attitudes of team members, or problem behaviours
  • Personal circumstances – lack of confidence, external pressures.

Effective support

Cunningham et al found that line managers face difficulties in complying with policy expectations to provide sympathetic and effective support as a result of tensions between this and other aspects of their work roles. In practice support falls short of employee needs and what is envisaged by policy makers.10 This is reminiscent of the “Myth of the Hero-Innovator”11 identified in 1975 research by Georgiades and Phillimore – someone who attends a training course and returns to their organisation as a knight in shining armour with the belief that he will return to the organisational fortress and institute changes both in himself and others at a stroke.

Evidence suggests the contrary, and in the study already mentioned8 it was found that three months after attending the line manager’s workshop only one-third of attendees had got support from their managers and about 25% from their team and colleagues to put any new ideas into practice. One of the key strategies for promoting positive behaviour in managing attendance within any organisation is to have a senior manager as a champion for initiatives. The recent Boorman Final Report12 into health and wellbeing of NHS staff recommended that all NHS leaders and managers be developed and equipped to recognise the link between staff health and wellbeing and organisational performance.

Board-level champion

It is also seen as essential that health and well-being has a clearly identified board-level champion and support from the senior management team. This concept is also developed in,8 but Boorman goes further in suggesting that employee commitment to stress-related absence initiatives depended on who the message came from. Stakeholders agreed that when presented as a joint activity, for example by HR, health and safety and OH, success was more likely. This highlights the importance of working collaboratively within organisations. Developing skills in partnership and using opportunities to lead and influence change are essential components of specialist community public health practice, and should be encouraged.


Within the Boorman report it is clear that there are implications for the role of OH provision within any health and wellbeing strategy. We have yet to see whether these suggestions become reality and are adequately resourced. Boorman says OH services can be seen by employees as a management tool and need to be rebranded with a more positive wellbeing focus.

The priorities of OH teams should be reviewed to improve service image and delivery. So how can OHPs support the line manager?

  • Ensure there is access and influence at senior management level
  • Be proactive in attendance management policy development
  • Work in collaboration to give managers access to effective training and guidance
  • Use data effectively to carry out risk assessments and identify problems to facilitate early intervention
  • Have a structured approach to health and wellbeing within the organisation that is reviewed against progress and national priorities
  • Practice according to best available evidence that includes maintaining standards and CPD.

Key questions

One key question to address in any attendance or wellbeing strategy is: “Are workplace conditions and processes in place that either bind employees closer to their employer or push them further away?”12 A healthy and productive workforce can be achieved if an employer focuses on: organisational rather than individual drivers of absence; prevention of the common causes of absence through the reduction of incidence; linking wellbeing strategies to the business case; and using technology effectively.

It is important to recognise many line managers are under considerable pressure and that many need support and encouragement to deal with the people management demands they face.

All OH practitioners need to develop leadership roles and embrace opportunities to influence service change and development to meet business needs on a strategic level. OH needs to base its activities on the best evidence available to meet the needs of the existing workforce and those returning to or entering work.

The Black review1 pointed out both the challenge and opportunity for occupational health to unite all those involved in improving or restoring the health of working age people as a once-in-a-generation chance to build on the successes of the past and make a real difference in the future. It is hoped that by supporting line managers, OH will achieve just that.

Elizabeth Griffiths is an OHN lecturer at the School of Health Sciences and Social Care at Brunel University


1 Black C (2008) Working for a healthier tomorrow. London, TSO.

2 Health, Work and Well-being Directorate (2010) Reforming the Medical Statement.

3 Chartered Institute of Personnel and Development (2009) Absence Management Annual Survey report. July 2009.

4 The Sainsbury Centre for Mental Health (2007) Policy Paper 8 Mental Health at work: Developing the business case.

5 Munir F, Yarker J, Haslam C (2008) sickness absence management: encouraging attendance or “risk taking” presenteeism in employees with chronic illness. Disability & Rehabilitation; Vol. 30, No. 19, p1461-1472.

6 National Institute for Health and Clinical Excellence (2009) Promoting mental wellbeing through productive and healthy working conditions: guidance for employers.

7 Irvine A (2008) Managing mental health and employment Research report No 537.

8 IIP, HSE, CIPD (2009) Preventing stress – Promoting positive manager behaviour.

9 CIPD (2009) Line management behaviour and stress at work, Updated guidance for line managers.

10 Cunningham I, James P, Dibben P (2004) Bridging the Gap between Rhetoric and Reality: Line Managers and the Protection of Job Security for Ill Workers in the Modern Workplace. British Journal of Management, Vol. 15, p273-290.

11 Georgiades N. J., Phillimore L. 1975. The Myth of the Hero-Innovator and Alternative Strategies for Organizational Change. In: Kiernan CC. And F. P. Woodford (eds). Behaviour Modification with the Severely Retarded. London: Associated Scientific Publishers.

12 DH (2009) NHS Health and Well-being Final Report November 2009.

13 Anderson E (2004) What’s Absent in absence Management? Employee Benefits Journal March 2004 25-30.

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