NHS absence rates: how can they be reduced?

The government’s solution to the issue of ill health in the NHS is certainly controversial. If it gets its way – and all the signs are that it will, given that it has the backing of NHS trade unions – in the not too distant future, NHS staff who become so ill they are unlikely ever to work again will receive a higher ill-health retirement pension than those who stand a good chance of finding alternative employment.


In October, a two-tier payment system was outlined by NHS Employers – the body that represents NHS trusts on workplace issues – as part of a three-month consultation. It was the centrepiece of a raft of proposals designed to give fresh impetus to the ongoing challenge of what to do about the NHS’s stubbornly high sickness and absence rates.


The plans (see NHS Employers plan, below) include minimum standards for employers on managing sickness absence and more incentives for employers to help staff stay in work. Line managers, too, would be given more clearly defined roles on what steps they should take, including at which point occupational health should be brought into the frame.


Only time will tell whether this latest plan will work. But what isn’t in doubt is that something desperately needs to be done about the sickness absence rates of NHS employees.


Absence rates


According to the latest survey by the NHS Information Centre, covering 2005, sickness absence for the service as a whole stood at 4.5%. But there were wide variations, with ambulance trusts much higher at 6%, and mental health and community trusts not faring much better at 5.3%. At the other end of the scale were strategic health authorities with rates of 2.8% – a huge difference.


A more recent survey published in September this year by Capita Health Service Partners paints, if anything, an even grimmer picture. It found sickness absence across the service as a whole for 2006-07 had actually risen to 5%, compared with 4.6% for 2005-06. What was particularly disappointing was that the increase had come after a number of years when rates had been reportedly falling.


Unqualified nurses and midwives had the highest absence rates (7.4%), followed by healthcare assistants (7.1%) and maintenance and works (5.6%). Absence rates were reported to be generally higher among unqualified staff than their qualified counterparts. The lowest reported rates were for medical and dental staff, at just 1.2%.


There were also regional variations, with average rates ranging from 4.6% to 5.7%, but the researchers cautioned against drawing too many conclusions from this, arguing the differences could be down to the composition of the sample polled as much as variations in the actual absence rate. The cost of sickness absence had also increased from £3.73m per organisation in 2005-06, to £5m in the latest research.


What’s not clear is whether the increase is simply a statistical blip or evidence of something more serious, says David Evans, head of pay and labour market services at Capita.


New developments


The past year has seen the NHS begin one of its biggest ever IT transformation projects, the shift to a single new Electronic Staff Record (ESR) system. This is a rolling project that is replacing about 29 payroll and at least 38 HR systems used in the NHS by the spring of next year. What trusts and OH professionals, as we shall see, are already saying about this, is that it has transformed the way in which absence is recorded and the data subsequently shared.


“There have been suggestions that that may be behind this increase in sickness absence – it may simply be that absence is being recorded better,” Evans suggests. “It may be a blip linked to the start of the ESR, or it may be the start of something bigger.”


It is also clear that the sorts of injuries and illnesses OH practitioners are tackling remain pretty much of a muchness. Musculoskeletal disorders and injuries, stress and psychological illness and general workplace accidents remain the top causes of workplace absence within the NHS, says Sharon Horan, nurse adviser for occupational health at the Royal College of Nursing.


The ‘Health, Work and Wellbeing – Caring for our future’ strategy unveiled by the government in October 2005 has made a difference in terms of focusing minds on the need to tackle workplace ill-health issues. Yet, despite the billions funnelled into the NHS over the past decade, many OH departments are still working furiously hard against a backdrop of continuing resource issues, and deserve recognition for this, she adds.


“I think OH still needs to be much more proactive about health promotion. I am also not sure how much case management goes on because so much time is spent fire-fighting,” she says.


Variations


The biggest difficulty with any debate about NHS absence is the wide variability of absence rates between trusts and the reasons for this, says consultant occupational physician Dr Richard Preece. Some of the best performers on paper report less than 3%, while the worst performers can be as high as 6%. To make things even more complicated, this may just as easily be because the best performers are the worst reporters, and vice-versa.


The most worrying aspect is that, statistically, it is very unlikely that we are seeing over-reporting. So the reality is probably that the 4.5% to 5% cross-service figure is very much the tip of the iceberg. What is more, the statistics do not show all the other costs – for example, the hiring of agency cover, the extra administration costs, extra pressure on covering workers and lowering of morale leading to higher staff turnover.


The incentive for the government in all this is clear enough. Getting even a fraction of the 5% absent at any one time back into the NHS would be the equivalent of giving it a huge injection of cash while at the same time slashing the sick pay bill. Hence all the activity over Health, Work and Wellbeing and the NHS Employers consultation.


OH investment


There is also a good argument to be made that investment in OH is the best route forward in all this. For instance, a report by the government’s watchdog the National Audit Office in 2003 on improving the management of health and safety risks in the NHS found an association between investment in OH and lower absence rates. For every additional £100 invested in the health and wellbeing of the workforce, attendance improved by about 1%.


But, argues Preece, if we’re ever going to bring these stubborn figures down, OH not only needs to raise its game, but to change the game it is playing. Too often, OH departments have been too narrowly focused on safety risks and technical interventions rather than trying to see, and articulate, the bigger picture.


“The preoccupation has been with things like when to immunise. Yet something like one in 20 of the workforce, and one in 10 of ward staff, has not been there on any given day of the week,” he says.


“We need to see absence as not just a health issue for that individual, but as a health issue for everyone whose care that person is involved with,” he adds.


Champion role


What OH needs to do therefore is become a much more vocal champion of the health of the NHS workforce, Preece argues.


“OH should be making a lot of noise about attendance, performance and improving health and wellbeing. Last year, I went to one trust that had an absence rate of more than 6%, walked into the OH department, and they didn’t know. I also know of one trust in Manchester that had a waiting time for counselling of six months – you may as well not bother to spend the money by then,” he says.


The NHS has not been as good as it could be at rehabilitating employees back into work as quickly as possible, concedes Julian Topping, head of workplace health at NHS Employers.


That is, of course, one of the reasons for the consultation. But it is also the reason why NHS Employers launched a print and online advice leaflet in October on healthy workplaces for employers, covering a range of issues such as bullying, discrimination, needlestick injuries and sickness absence.


What’s needed, Topping argues, is more joined-up thinking and working, claiming there is still too much of a ‘them and us’ attitude, particularly between OH and HR.


“It is a question of OH working more closely with its colleagues in HR and line managers,” he says. “It has often been six of one and half a dozen of the other. Once people know someone has gone off sick, they can do something about it. But if no-one tells them, there is not a lot they can do.


“So we need to tighten up information-sharing and work together more to get individuals back into work as quickly as possible,” he adds.


This lack of communication between HR and OH has been an issue, agrees Mary Brassington, head of occupational health services for the Heart of England NHS Foundation Trust and chair of the Association of OH Nurses in the NHS.


“One of the things that has been holding us back is that it is not just an OH problem, it is an organisational problem. There has been no ownership of sickness absence,” says Brassington.


If departments fail to co-operate, then everyone is “dead in the water”, she warns.


Absence focus


Nevertheless, the health, work and wellbeing strategy is enlarging the role and raising the profile of OH within the service and, at a practical level, the introduction of the ESR system is making a difference.


“Until this year, when the ESR system came in, it was not always clear why people were off sick because that information was not collected,” Brassington adds.


A much clearer picture is starting to emerge, she says. At her trust, for instance, healthcare assistants appear to have higher rates of absence so, now, investigations can be carried out to try and gauge why that might be, and what can be done to bring those rates down.


A new HR director at her trust has led to a much greater focus on sickness absence, with the emphasis very much on wellbeing as well as sickness and health. A revised sickness absence policy has also been put in place, she points out.


“There is a much greater emphasis on managers being in charge immediately and making sure they do back-to-work interviews and so on,” she says.


There is much more of a focus, too, on workers being encouraged to take care of their health, plus a recognition that being at work and, where appropriate, keeping people working where possible, can be conducive to good health.


“It is going beyond the normal model of health promotion,” Brassington says. “We are working with HR managers to promulgate a feeling of good health. It is about not just reacting when people have a problem.”


NHS Employers plan


The introduction of a two-tier payment system for ill-health retirement benefit, with those unlikely ever to work again because of ill health receiving greater benefits than those with a reasonable prospect of finding alternative employment.


New minimum standards for employers connected to managing sickness absence to ensure employers do more to support staff who are off sick, including offering options such as a phased return to work, redeployment to another job, and access to services such as physiotherapy and cognitive behavioural therapy.


An overhaul of financial incentives for employers to help staff to stay in work by recharging them the cost of ill-health retirement by their staff (currently borne by the NHS pension scheme).


Ensuring there are clearly defined roles for line managers, making them responsible for recognising health problems at an early stage and taking appropriate steps, including working closely with HR, OH and senior managers.


NHS Plus: help or hindrance?


When it comes to tackling NHS sickness absence, NHS Plus remains a bone of contention for many within the service.


Those against it believe there is still so much to do to improve workplace health and absence rates within the service’s ‘own back yard’ that the role of NHS Plus in providing services commercially to small- to medium enterprises (SMEs) is, at best, a distraction, and at worst, a drain on resources.


Yet the establishment earlier this year by NHS Plus of a Clinical Effectiveness Unit (CEU) may yet be cause for optimism, argues Dr Richard Preece.


The unit has been set up to look at ways to improve the clinical effectiveness of OH services within the service, in particular by the development of clinical management guidelines and through national comparative audits. This has meant in practice a renewed focus on the health needs of NHS workers. “There has been a shift in emphasis,” Preece says.


There has also been a greater recognition that, by tackling NHS absence levels, you indirectly will help SMEs and other businesses bring down their own absence rates, too. After all, if there are fewer people off sick, there is more capacity to treat patients with fewer delays – one of the biggest employer gripes about the NHS.


“If we can get the worst performers on absence up to the best, then we are going to massively increase the number of people at work,” says Preece.


“We need to put the care of our own people at the top of the agenda. If they are at work, everyone is benefiting.”


Yet any suggestion that NHS Plus is a distraction is dismissed out of hand by NHS Employers’ Julian Topping.


There is a lot of work going on at the moment, largely through the CEU, on how NHS OH staff should be splitting their time between the service and NHS Plus, he argues.


Where units are taking work out to SMEs, there is a presumption that this is extra to capacity, and that the work needed internally for NHS employers is being covered. “I am not aware of an area where it is working to the detriment of the NHS,” he stresses.

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