NICE absence guidance to boost occupational health

Employers understandably have a lot on their plates right now, so at first glance, being told they should spend time and effort identifying and training someone to maintain contact with workers on long-term sick leave and doing more to co-ordinate their return to work could be seen as something they need like a hole in the head.

But if anything, argue workplace and health experts, the publication in March of ground-breaking guidance from the National Institute for Health and Clinical Excellence (Nice) is more relevant and important for employers now in a recession, when firms can ill afford to be ‘carrying’ sick workers, than in the good times.

Significant step

For occupational health (OH) practitioners it is another significant step, possibly as significant as Dame Carol Black’s review of the workplace health last year and the government’s response, in bringing the profession more to centre stage in the NHS and the boardroom.

In some respects, argues Cynthia Atwell, chair of the Royal College of Nursing’s Society of Occupational Health Nursing, its specific recommendations are less important (though the fact they have been spelled out to employers in clear, simple English is hugely valuable) than the fact that a body as influential as Nice should have added its weight to the debate about how to manage long-term absence.

“What it is saying is not earth-shattering. There is nothing new, but what is important is that it has been written and hopefully employers will take notice,” she says. “Companies will now be looking at the value of OH and whether they are getting value for money. If OH can prove that what it is doing is value for money, companies will follow that and do it.”

This has been the biggest project Nice has ever undertaken, adds Dr Richard Preece, consultant OH physician and a member of the programme development group that helped to draw up the guidance. “Whether it is good or bad guidance is to an extent less important than the fact that for the first time we have had some definitive national guidance,” he says. “It explicitly recognises the potential role that OH doctors and nurses play in supporting absence management. In recognising, too, that OH will be delivering important clinical pathways, it is putting OH practice in a central role.”

NHS example

Nice’s guidance is mandatory for the NHS, so could well lead to a significant overhaul of how individual departments manage absence and, in turn, their exposure to NHS OH professionals. As professor Mike Kelly, Nice’s Public Health Excellence Centre director, said at the launch, a large NHS trust with 8,000 staff could save about £112,000 a year by implementing it.

However, private providers such as Axa PPP have questioned whether the guidance has given enough consideration to the NHS’s ability to provide the treatment recommended, or indeed whether the guidance’s recommended two- to six-week waiting period before intervention is too relaxed. Nevertheless, for organisations outside the NHS, the guidance could have profound ramifications as a benchmarking tool, predicts Preece.


“Every tribunal is going to look first at whether this guidance is being met by companies when considering cases of dismissal on the grounds of capability. So OH needs to be picking it up, reading it and talking about it with colleagues and HR,” he says. “There will be a process of continual review and it will be revised at least every three years. So this will drive research. It will be living and active well beyond when the Black report has been consigned to the archives.”

An implementation group in Nice will work to promote the guidance to journals and others, says Dr Sian Williams, director of the Occupational Health Clinical Effectiveness Unit at the Royal College of Physicians, and a member of the programme development group. “There has never been such a piece of guidance from such an ­organisation with such a good reputation,” she says.

“This is a gold standard for practice. Most of the recommendations came from the evidence base, of which there may be a small amount, but it is a small amount of high-quality evidence,” she says.

Employers’ organisations such as the Chartered Institute of Personnel and Development (CIPD) will be working with Nice to get the message out to employers, adds CIPD adviser Ben Willmott. “This guidance will help to raise the standard of return-to-work and rehabilitation support that organisations provide individuals who have been off work for long periods of time,” he says. “It provides some good trigger points for management actions and shows the importance of timely return-to-work intervention.”

Similarly, it is likely to be helpful for GPs, particularly against the backdrop of the forthcoming change of the sick note to a ‘fit note’ and the development of Dame Carol Black’s Fit for Work service, suggests Williams. “The fact that it is evidence based and that it is Nice guidance will be helpful to GPs,” she says.

The guidance will be useful for employers of any size, particularly in showing that not all interventions need be costly or complicated, points out Dr Tony Stevens, president of the Society of Occupational Medicine. Simply keeping in touch, after all, need not cost money.

“The fact that Nice is taking an interest in this area and is making this a part of its public health agenda is important,” he says. “Even in a very small organisation if you wish to avoid bogging yourself down in unproductive management activity, this gives you a very useful template.”

And for NHS OH professionals, it could be the start of something special. “This puts NHS OH on a par with all the other parts of the NHS, and that absolutely helps to underpin NHS OH practice,” says Stevens.

What the NICE absence management guidance says

The NICE guidance stresses the need for employers, as part of their absence policies and practices, to liaise with employees who have been on long-term sickness absence or taken recurring short- or long-term sickness absence to help them return to work. Line managers, HR professionals or OH specialists should take on this task.

Employers should identify someone who is suitably trained and impartial to contact the employee and make initial enquiries. This might be an OH physician, a nurse, an HR specialist or a line manager.

Initial enquiries should take place before 12 weeks (and ideally between two to six weeks). There should be a discussion with the employee about:

their reasons for sickness absence, whether they have received appropriate treatment, how likely it is that they will return to work, any perceived (or actual) barriers to returning to work (including the need for workplace adjustments)

their options for returning to work and agreement reached on what, if any, action is required to prepare for this.

If necessary at this point consider whether a detailed assessment is needed to determine what interventions or services are required and to develop a return-to-work plan. This could be achieved through a referral to an OH adviser, a combined interview and assessment, a referral to a GP with OH experience or to another health specialist such as a physiotherapist (or by encouraging the employee to refer themselves).

A combined interview and assessment should involve one or more specialists (for example a physician, nurse or another professional who specialises in OH, health and safety, rehabilitation or ergonomics) and the line manager.

It should evaluate the employee’s health, social and employment situation, anything that is putting them off returning to work and how confident they feel about overcoming these problems, their current or previous experience of rehabilitation, the tasks they carry out at work and their physical ability to perform them, any workplace or work equipment modifications needed.

The return-to-work plan should identify the type and level of interventions and services needed (including any psychological support) and how frequently they should be offered. It could also specify whether a gradual return to the original job is required, a return to some of the duties of the original job, or a move to another job within the organisation, either on a temporary or permanent basis.

When co-ordinating and delivering interventions, it is important to ensure they are appropriate for the employee, that the employee is consulted and agrees to the proposals, that the employer keeps in regular contact with the employee and that everyone involved (such as line managers and OH staff) are effectively liaised with.

Intensive support could be provided by a number of different specialists over several weeks. This should be combined with the care and treatment they are already receiving.

Examples of intensive support may include one or more of the following: cognitive behavioural therapy or education and training on physical and mental coping strategies for work and everyday activities, counselling about issues involved in returning to work, workplace modifications, referral to specialist services or vocational rehabilitation or training.

Examples of light or less intense interventions might include short sessions offering individual, tailored advice on how to manage daily activities at home and at work, encouragement to be physically active, referral to a physiotherapist or psychological services.

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