Presenteeism: prevention is better than cure

There is increasing recognition in the workplace that occupational health’s (OH) role is much wider than just absence and attendance management. While these remain core parts of OH’s function, enlightened employers are shifting the debate towards an emphasis on health and wellbeing – so the links between health and productivity and addressing the health needs of those at work as well as those absent.

In this context, therefore, The Work Foundation’s report on the need for employers to address sickness presenteeism as well as sickness absence in the workplace (OH News, May) is unlikely to generate many surprises in the profession. The report, published in conjunction with health provider AXA PPP (it polled 510 AXA PPP employees) argued that the cost of working when ill – sickness presence or presenteeism – could match or account for one and a half times more working time lost than the estimated £13bn annual cost of sickness absence.

Full potential

In other words, as well as focusing on empty seats at work, employers need to tackle the issue of seats with people on them but who are not working to their full potential or productivity because of illness, work-related stress or other health-related reasons, it suggested.

It also argued that sickness presence was a more prevalent malaise than sickness absence and, if allowed to fester, could lead to higher levels of sickness absence, as well as being a drain on productivity and competitiveness – both key issues for employers as we come out of the recession and the economy begins to recover (see box below).

Nevertheless, while there may be an element of preaching to the converted when it comes to an occupational health audience, it is clear that presenteeism is an issue increasingly coming on to the corporate radar. In September last year, for example, a report by healthcare provider SimplyHealth argued that fears over job security and redundancy during the recession had led to a sharp rise in sickness presenteeism, with two out of five workers admitting not having taken a day off sick in the previous year.

Working while ill

In March, the TUC argued that about a fifth of public-sector employees had worked when ill during the previous month, while more than two-fifths had done so over the previous year, as well as more than a third of private-sector employees. In November 2009, Manchester-based business psychologists Robertson Cooper estimated in a poll of more than 39,000 workers that a quarter struggled into work while ill simply to show their bosses they were present.

“The biggest thing for occupational health is to highlight that this problem exists,” stresses James Glover, sales and marketing director at SimplyHealth. “A lot of employers are tempted to just put their heads in the sand and think, if someone is coming into work and doing the hours, then everything is OK. Sick presence is not going to appear on any KPIs.”

Robertson Cooper managing director Ivan Robertson agrees. “If someone is working at 80% capacity, then for some employers that is 80% better than them not being there at all. We do not have good models about this and what we should be doing about it,” he adds.

Judgement call

Another challenge, argues Dr Sayeed Khan, chief medical adviser at the manufacturers’ organisation EEF, is how ill is ill when we are talking about sickness presence? “Is it just a bit of hay fever or are they having chest pains and about to have a heart attack? So you have to make a judgement call about how ill is ill and what we consider is reasonable. Hay fever, generally, is probably not a reason to be off. Conversely, if someone is having chest pains or angina then that clearly needs to be treated,” he explains.

“Then there is the issue of what work the employee does. Is he/she the only person doing that job in the workplace and would have a huge pile of work to come back? In that scenario, struggling into work if you are not too ill can seem like the lesser of the two evils,” he adds.

To complicate matters, there are many other forms of presenteeism that employers should be tackling, many of them outside the health remit of OH, he suggests. “You can get unmotivated presenteeism or simply incompetent presenteeism, for example. So it needs to be broadened out and dealt with as a wider performance issue.”

There is a strong argument for employers to be taking a more innovative approach to health and wellbeing and not getting so overly focused on absence and attendance, argues AXA PPP Healthcare employee engagement manager Ian Clabby. “Lots of organisations track absence and monitor trends, but how many organisations map health? Absence management is clearly a key issue, but it ought perhaps to be a sub-set of the whole well-being agenda rather than the other way around,” he suggests.

Sickness presence in the workplace: the facts

Key findings:

  • Sickness presence is significantly related to performance, associated with lower line manager supervision and assessment, reduced psychological wellbeing and increased levels of sickness absence
  • It is more prevalent than sickness absence, with 45% of employees reporting one or more days of sickness presence against 18% reporting sickness absence over the same period
  • Personal financial difficulties, work-related stress, perceived workplace pressure (from senior managers, line managers and colleagues) to attend work when unwell were found to be key contributing factors
  • As well as reporting a higher number of days’ sickness presence, employees who perceived pressure from managers and colleagues to work when unwell were also more likely to report their performance was adversely affected by working when unwell
  • Employees who were unable to adjust their work around their health problem were more likely to report that their performance was adversely affected by working unwell, while employees who had financial worries had a significantly higher number of sickness presence days
  • Sickness presence can act for employers as a useful bellwether of an employee’s health and wellbeing in general
  • Employers that focus solely on sickness absence may be at risk of underestimating employee ill health and missing important warning signs

Key recommendations:

  • Organisations should look at how they are applying absence management policies and how, or whether, they are properly understood by managers at all levels
  • The capability of line managers to deal with work-related stress, including any managerial and organisational causes of reduced psychological wellbeing and stress, should be prioritised
  • Organisations should embrace the fit note as a constructive opportunity to review how managers and their teams are working together to adjust work for employees and accommodate any health problems
  • Employers should consider whether it makes sense to offer workplace-based financial support for employees
  • HR should assess the need for ongoing monitoring and evaluation of employee health and wellbeing and to evaluate the effectiveness of any targeted interventions

Source: Why do employees come to work ill? An investigation into sickness presence in the workplace. The Work Foundation



“Education is going to be the key. A lot of presenteeism can be characterised around psychological rather than physical ill health. If you are stressed or anxious and still trying to perform you are not going to be able to concentrate as well for the hours you are there. It is about helping managers to be receptive to these issues and how to detect early-stage mental ill health. There may also be an argument for putting in place additional facilities to help employees deal with, say, financial issues,” Clabby adds.

OH can make a difference (once it is on the radar as an issue, that is) simply in helping to educate HR, senior managers and front-line managers to be more aware of it. It is about ensuring management and managers take more responsibility for employee health and wellbeing and making the business case to the board to consider investing in tools or support services (perhaps such as Employee Assistance Programmes, helplines or financial advice portals) that will be able to help employees, agrees SimplyHealth’s Glover.

Another key role for OH is likely to be its expertise in case management. A case management approach can be valuable when it comes to managing return-to-work employees, but it could also, with the right models and protocols in place, play its part in helping to manage presenteeism, suggests Robertson Cooper’s Robertson.

“Every individual case can be managed effectively, from the GP, line manager and occupational health,” he argues.


Early-stage, case-managed interventions could make a difference, agrees Glover. Too often, managers do not have the right tools, information or knowledge to make these decisions or know who or when to refer on – and so this is one area where more proactive use of OH could make a difference.

Another issue, and one that feeds into this debate about earlier intervention, is whether the new fit note, the raison d’etre of which is to encourage people to carry on working, often with adjustments or temporarily in another capacity, when they are not 100% fit, will be a help or a hindrance in terms of dealing with presenteeism.

The EEF’s Khan, for one, argues the fit note may help because it will generate a more formalised, structured debate between GPs, employers and (if they have access to them) an occupational health department, about exactly what it is “sick present” workers can and cannot do, particularly when they are manual workers.


“For occupational health, this is further support for a case management approach, which OH can be leading. The fit note will potentially mean that OH services will, much earlier in the process, be having to start adjudicating on whether people are fit to do such and such at work and make sure the sicknote does not just disappear into payroll. Whether it is HR or OH, someone needs to be seeing the fit note and assessing it,” Khan suggests.

Similarly, AXA’s Clabby argues the fit note will lead to more of a focus on adjustments and how they should be made, and hopefully generate a better, and earlier, debate about when, where and how to intervene to keep an employee at work and functioning properly, as well as getting people back from sick leave.

“The fit note is about getting the right balance. It is potentially a good thing. It will require people to be more inventive and creative when considering return-to-work opportunities. But you don’t want to create a climate where people are returning to work when they shouldn’t be,” he says.

What employers need to be doing, advises the Work Foundation’s Ashby, is exploring the reasons behind sickness presence, particularly any work-related triggers that could lead to sickness presence becoming more prevalent. And what a lot of this debate led back to was the whole issue of “good work”, or how well-designed jobs where there was flexibility, good management and workers felt more in control, could help to improve motivation, job satisfaction and productivity.


“It is about ensuring people – employees and line managers – are aware of the options. It is important that occupational health, line managers and employees work together to see what they could be doing. The fit note could be helpful because it provides a context within which to think about these options,” Ashby asserts.

The report, for example, recommends that, where it is found employees have little control over their work or their working environment, that more dialogue between line managers, employees and occupational health is introduced. This could be a conversation focused on different types of work an employee could carry out when they are unwell but willing to work – one of the key ways in which the fit note is expected to assist managers in managing workers who are unwell.

Working environment

Ultimately, whoever is leading the process – whether it is HR, OH or management more generally – it is imperative that businesses recognise they have a responsibility to ensure they understand how to create the best, more productive working environment for employees, argues Alex Gourlay, chairman of Business Action on Health and chief executive of the health and beauty division at Alliance Boots.

Too often in this context, health and wellbeing initiatives will focus on things such as healthy eating, physical activity or health promotions. While laudable and often popular in workplaces, there is an argument for employers to be thinking more widely about this issue and looking closely at the relationship between health, presence and performance.

“People who are fully present will be physically and mentally more productive. Employers need to be prepared to listen and develop their line managers to understand their responsibilities,” he argues. “The cost of absenteeism is a relatively easy cost for the business to focus on. But there is a bigger prize underneath,” Gourlay adds.

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