Workplace health: long-term sickness absence and capability to work

Why the committee made the recommendations

Evidence from the UK showed that workplace policies on sickness absence and return to work may help to reduce uncertainty around the process of enabling return to work for employees and employers, but only if they are properly implemented. The committee agreed that it is important for all sizes of organisation to clearly communicate policies and procedures to staff.

However, smaller organisations may not have formal policies in place. The committee agreed that in these situations it is important that all employees are aware of the procedures for reporting and managing sickness. Regularly reviewing these policies and procedures would be good practice to ensure that they are appropriately applied and fit for purpose.

The committee discussed testimony from experts in occupational health and in employment research. The expert in occupational health was asked how the occupational health service in their NHS trust had contributed to achieving and maintaining a relatively low sickness absence rate and the barriers and facilitators to doing so. The expert in employment research was asked about common and more innovative measures used by organisations to reduce sickness absence rates.

The testimony provided by the experts identified that a commitment to employee health and wellbeing, proactively and strategically led from the top levels of management, should underpin sickness absence and return-to-work policies. The committee discussed the importance of these policies being part of a wider culture that values and promotes employee health and wellbeing.

The committee discussed that inappropriately applied return-to-work policies can result in presenteeism or longer absences from work. They highlighted the importance of ensuring that everyone is treated fairly. For this reason, they thought it important to regularly review how policies are implemented across the organisation, to ensure that those who are off work or planning a return to work are treated consistently.

The focus of this guideline is on managing sickness absence among all employees, regardless of whether they have a disability or long-term condition covered by the Equality Act 2010. Although the committee were aware that organisations should also have policies and procedures in place for managing disability leave, this area is not included within the scope of this guideline. The committee noted that there are legislative requirements about health and disability for employers and that the recommendations in this guideline should be considered alongside those requirements.

There is a small amount of low-quality evidence that employers providing early access to interventions, for example through an occupational health provider or employee assistance programme, can benefit both employees and employers. There is also some similarly limited evidence that accessing interventions early may help to reduce sickness absence rates and promote a more sustainable return to work.

Testimony from an expert in occupational health supported the evidence that was found on providing early access to interventions, when appropriate. Furthermore, the committee noted that guidance for employers on commissioning an occupational health service is available from the Society of Occupational Medicine. The committee discussed the limitations in the evidence and, in particular they noted that micro-, small- and medium-sized organisations are not represented in the evidence and may not have access to such services.

The committee also heard from experts, particularly the expert in occupational health, that organisations that are considered to be examples of good practice collect detailed data on trends in sickness absence according to factors such as job type and location. This detailed non-identifiable data can help the organisation target specific interventions and resources where they are most needed. It may also help to highlight any inequalities and identify policies or procedures that may need to be reviewed or amended.

The evidence seen by the committee focused almost entirely on supporting people to return to work after a period of long-term sickness absence (4 or more weeks). No evidence was found on preventing recurrent short-term sickness absence (of less than 4 weeks per episode) or on preventing people moving from short-term to long-term sickness absence.

Despite the lack of direct evidence the committee agreed that, in practice, interventions that were effective in supporting people to return to work after long-term sickness absence may also help to prevent recurrent short-term absences and to prevent people moving from short to long-term sickness absence. This is because they may have to overcome similar barriers and need similar support when returning to work. The recommendations therefore do not distinguish between supporting people returning from long-term or recurrent short-term sickness absences.

Because no evidence was found on preventing recurrent short-term sickness absence, the committee recommended research in this area (see research recommendation 2). They also agreed that research is needed on supporting people to return to work after long-term sickness absence in a UK context (see research recommendation 1). Most of the evidence they considered was not from the UK, but from countries with different systems for managing sickness absence. The committee therefore agreed there was a need for more evidence that was directly applicable to the UK population. The committee considered that alongside data on supporting return to work it would be helpful if studies collected data on the impact of absenteeism and presenteeism.

Although there was no evidence on preventing the move from short-term to long-term sickness absence, the committee did not make a research recommendation in this area. This is because of the potential difficulties of identifying people with short-term sickness absence that may become long-term sickness and the feasibility of recruiting them to take part in research trials before they cross the 4‑week threshold into long-term sickness absence.

How the recommendations might affect practice

The recommendations reflect good practice. Larger organisations are more likely to already have formal policies and procedures, but they may need to develop procedures for regularly reviewing them and how they have been implemented.

The resource implications are likely to be greater for micro-, small- and medium-sized organisations that don't have formal policies or provide access to occupational health or employee assistance programme services. Larger organisations are more likely to have these in place, but the committee heard from an expert in employment research that this may not always be the case.

The committee noted from their experience that it would be good practice for smaller organisations that do not currently have access to such services to explore where additional services (such as occupational health) may be available to provide support. This would be part of a proactive approach to promoting employee health and wellbeing. If recommendations are widely implemented, it may result in a larger number of employers having appropriate policies and procedures in place and may help to encourage the spread of good practice. Implementing the recommendations may need resource input initially, but over time may result in a reduction in the costs of sickness absence and improved productivity.

Return to recommendations

Why the committee made the recommendations

There was evidence from a small number of UK studies that showed there can be challenges for GPs in completing fit notes. GPs may feel that they do not have the occupational health experience or the knowledge of the workplace needed to make suggestions about workplace adjustments.

The committee discussed that other medical practitioners were also likely to experience the same challenges and agreed that the best person to complete the fit note is the medical practitioner with the most relevant recent knowledge of the person's situation. In many cases this will be a GP, but it could also be a person's specialist in secondary care. The specialist may be able to provide more information than the GP on the anticipated effects of treatment, timeframes for rehabilitation and adjustments for when the person returns to work. September 2022: we changed the recommendation on who can complete a fit note in line with new legislation, to include registered nurses, occupational therapists, pharmacists and physiotherapists.

There was evidence from a small number of UK studies that showed it is important to avoid people becoming disconnected from work during their absence. Keeping in touch regularly with the workplace is important for building the person's confidence to return, monitoring their recovery and maintaining a focus on the goal of returning to work.

This evidence suggested and the committee agreed that the GP may be particularly well placed to refer people on long-term sickness absence to rehabilitation and support services, especially if these are not offered by the employer as part of occupational health provision. They noted that specialists may also refer people under their care to some rehabilitation services. They also noted that it may be helpful to signpost people to other possible expert sources of vocational advice and support relevant to their condition. This may include advice and support from the voluntary sector.

The committee did not specifically recommend keeping in touch regularly with the GP because this may have a resource impact that had not been assessed.

The committee noted that reasons for sickness absence can be complex and agreed that GPs primarily view their role as a patient advocate. GPs are therefore well placed to explore whether sickness absence is exacerbated by aspects of the person's job, home life (such as caring responsibilities) or workplace relationships that the person feels unable to discuss with their employer (such as poor relationships with line managers).

If the practitioner anticipates that the absence is likely to be long term (4 or more weeks), they could consider referral to rehabilitation and support services.

There is evidence from a small number of UK studies suggesting that patients believe the advice on fit notes can empower them in negotiating changes at work. But there is also evidence that employers can find fit notes unsatisfactory. In particular, employers have reported that fit notes may not give enough useful information on how the person's health condition may affect their ability to do their job. This can make employers wary of any risks associated with someone returning to work if they are not fully recovered.

The committee therefore agreed that it is important to encourage practitioners to state clearly how the person's health condition or treatment might affect them in their workplace, so that appropriate support and adjustments can be considered. However, this type of detail on the fit note needed to be added only with the person's agreement. The committee also discussed that unless the practitioner has specific knowledge about a person's workplace or role, it may be difficult for them to understand the implications of someone's condition on their ability to do their job.

How the recommendations might affect practice

If specialists certify sickness absence to employers, rather than referring them to their GP, this would free up GP appointment time and may provide more useful information for employers. However, there may then be an impact on specialists' time.

The committee agreed that it is part of the GP's role to refer people on sickness absence to rehabilitation and support services and so this should not incur an additional cost. However, there may be an additional impact on support services, such as physiotherapy and counselling.

Return to recommendations

Why the committee made the recommendations

Some UK studies showed that employers think fit notes can provide useful information to support managers in communicating with people who are absent. They can help managers understand the employee's health condition and what support they might need when they return to work. This can enable them to plan for suitable adjustments to ensure a safe and sustainable return to work.

The committee agreed that it would be good practice to start a confidential record for every absence for which a fit note is received, not just when it is anticipated that the person will be taking a long-term sickness absence. This is because it may not be immediately clear when an absence may become long term, because there may be subsequent fit notes received for the same episode of absence. In addition, keeping such records may also help to identify recurrent sickness absence.

The committee agreed it is good practice to be proactive and plan ahead how to support someone once they are ready to return to the workplace. Although there was no evidence identified on planning ahead, the committee made a recommendation encouraging employers to do so, based on good practice.

The committee were aware that there are various potential sources of expert advice available to help managers understand the effects of health conditions or treatments. These can be particularly useful if the employing organisation does not have its own occupational health adviser. This may include online information and resources that give vocational advice and specific advice relevant to the employee's particular condition.

Although the committee had not reviewed these resources and they were conscious they may change over time, they noted that information from organisations, such as Public Health England, and some voluntary sector organisations may be helpful.

The committee noted that it is important to discuss adjustments that may be helpful with the returning employee. In many cases this discussion may involve only the employee and their line manager, and if necessary, occupational health. The evidence suggests that being able to have such a conversation may depend on a good relationship between line manager and employee.

The committee heard evidence from experts in occupational health and from a mental health support service, which showed that if relationships are difficult, or adjustments are more complex, it can be helpful to involve an impartial party to help reach an agreement.

The committee noted that recommendations for adjustments that a practitioner makes on a 'may be fit for work' note are advisory. Evidence shows that employers may have concerns about employee expectations and the possibility of conflict, if adjustments can't be accommodated. Also, the evidence suggested and the committee discussed that some GPs and patients have reported feeling undermined when their suggestions to employers are not acted on.

The committee agreed that guidance on what employers should do, if adjustments cannot be agreed, would minimise conflict. They recommended that the person should be treated as 'not fit for work' and noted the importance of maintaining contact with them. They also noted that when suggested adjustments can't be made it would be helpful to provide GPs, with the employee's informed consent, with feedback, so that they are aware of the person's continuing absence and are better informed about their particular workplace context.

The committee's recommendations on making adjustments to support people to return to work focus on all employees. But they noted that if someone has a chronic or progressive illness or disability covered by the Equality Act 2010, the employer has a legal obligation to make reasonable adjustments in the workplace.

This legal obligation applies to all employees with an illness or disability covered by the Act, not just those returning from sickness absence. But the committee noted that particular consideration may need to be given to adjustments when an employee with a disability or condition covered by the Act is returning from sickness leave, to provide them with the best possible support.

How the recommendations might affect practice

Larger organisations are more likely to already have formal policies and procedures in place for making return-to-work plans.

Resource implications are likely to be greater for micro-, small- and medium-sized organisations, which may not have capacity to plan ahead for someone returning to work, or the capacity or resources to make adjustments to the workplace or duties. The committee noted that if an employee has a disability or a long-term condition that makes it difficult for them to do their job, organisations may find it helpful to explore whether they are eligible for funding to support making adaptations to the workplace.

Providing feedback to practitioners when adjustments they have recommended cannot be accommodated would be good practice. However, the committee were aware that a mechanism for providing this feedback would need to be developed and maintained and that for some organisations, particularly micro-, small- and medium- sized organisations, this may not be sustainable.

Implementing the recommendations may need resource input initially, but over time it may result in a reduction in the costs of sickness absence and improved productivity. If the resource input makes returning to work part of a proactive approach to supporting employee health and wellbeing, this investment may help to reduce the costs of sickness absences in the longer term.

Return to recommendations

Why the committee made the recommendations

The committee were aware that it is a legal requirement for employers to carry out risk assessments to ensure a healthy and safe environment in the workplace and that guidance on these is available from the Health and Safety Executive (see Regulation 3 of the Health and Safety Executive's Management of Health and Safety at Work Regulations 1999). They discussed and agreed from their experience and expertise that it is good management practice to undertake an additional risk assessment for a person returning from sick leave and before making workplace adjustments.

There is a small amount of low-quality UK evidence to suggest that some colleagues may resent adjustments being made to the returning person's role or workload. However, other similarly limited evidence noted that other staff members can be understanding about workplace and role adjustments and help with supporting their colleagues' return to work.

The committee noted that to maintain relationships and productivity in the wider team it may be helpful to explain the reasons for the adjustments and give colleagues the opportunity to raise any concerns. It is important that this is only done after discussion with the returning person and with their informed consent.

The committee agreed that it is important to keep a written record of the adjustments that have been agreed in a written return-to-work plan. This should be based on the individual employee's needs and their role in the organisation and as such there will need to be some flexibility in terms of what the plan covers. The committee agreed it is important to regularly review the return-to-work plans to ensure that they continue to meet the person's needs as their recovery progresses and to amend them if necessary. It can also be helpful, when reviewing how the adjustments are working, to remind the person of any other interventions the employer may provide, if these are available.

How the recommendations might affect practice

Larger organisations are more likely to already have formal policies and procedures in place for making return-to-work adjustments. They may need to develop additional procedures and provide resources or training for risk assessment of return-to-work plans, developing written return-to-work plans and monitoring how well workplace adjustments are working.

Resource implications are likely to be greater for micro-, small- and medium-sized organisations, which may not have capacity to make adjustments.

The committee noted that the capacity of organisations to provide risk assessment training may need to be considered.

Implementing the recommendations may need resource input initially, but over time may result in a reduction in the costs of sickness absence and improved productivity.

Return to recommendations

Why the committee made the recommendations

Evidence from UK studies shows that keeping in touch with people who are on extended periods of sick leave can help them feel supported, valued and more confident about returning to work. The committee agreed that a positive commitment to keeping in touch should form part of the organisation's sickness absence and return-to-work policies.

The committee discussed that managers may have concerns about contacting and keeping in touch with those who are off work, and that employees may feel that this is putting additional pressure on them to return to work. Evidence from UK studies supported this discussion.

The committee also noted that if people are absent for reasons that relate to an illness or disability that is covered by the Equality Act 2010, managers may feel additional concern about the appropriateness of contacting them. These concerns may lead to those who have an illness or disability covered by the Act being disadvantaged compared with others if their employers do not contact them for fear it may be inappropriate to do so. The committee agreed that policies on keeping in touch should be followed with everyone who takes sickness absence.

The timing of initial contact should take into account the personal circumstances of the employee and their reason for, and anticipated length of, absence. In addition to making the employee feel supported, the aim is to help prevent a short-term absence becoming a long-term absence.

For this reason, the committee recommended getting in touch with the employee as soon as possible and within 4 weeks. However, they were mindful of the need to keep this flexible, particularly when sickness absences may be planned or when recovery will clearly take longer than 4 weeks. For example, for recovery from surgery or cancer treatments.

The committee discussed the limitations in the evidence, but noted that it has shown that relationships with managers are an important factor in people's decisions about returning to work. The committee noted that this may be particularly pertinent when there is a mental health component to the absence. It is therefore important to establish from the employee's perspective whether the line manager is the best person to keep in touch with them.

The committee noted that it is important to reassure people that anything they share about their health will remain confidential. However, they acknowledged that in circumstances when there are serious concerns for the wellbeing of the employee or others, information may have to be disclosed in order to meet an employers' duty of care, or to meet professional or legal obligations.

The evidence suggested, and the committee agreed, that the communication style of the person with responsibility for keeping in touch with the employee and the content of the communication can affect the employee's wellbeing and decisions about returning to work.

For this reason, the committee recommended that organisations should provide those with keeping in touch responsibilities access to communication skills training and encourage them to access online resources and advice to ensure that they are competent and confident in this area. Resources to help employers with this include the NHS Employers website, and Public Health England's website.

How the recommendations might affect practice

Micro-, small- and medium-sized organisations may find it more difficult to offer alternatives to the line manager as a contact person for people on sickness absence. They may be less likely to have formal procedures or policies on keeping in touch with people on sickness absence.

Resource implications are likely to be minimal and focus mainly on communication skills training. Formal training may be more likely to be offered by larger organisations, but there are useful online resources and advice that can be used by and adapted for smaller organisations.

Implementing the recommendations may need resource input initially, but over time may result in a reduction in the costs of sickness absence and improved productivity.

Return to recommendations

Why the committee made the recommendations

There was a small amount of low-quality evidence from UK studies that providing free-to-access employee assistance programmes and occupational health services is regarded as good employer practice. It is valued by employees as an indication that the organisation cares about the health and wellbeing of the workforce.

However, the evidence suggested that employees are not always aware that these services are available or what their remit is. This possible lack of awareness was discussed by the committee and also identified by the expert testimony from the occupational health expert. Particular reference was made to employee assistance programmes, for which there may be a misperception that programmes focus only on mental health and there can be stigma associated with this. In reality, they can also offer practical advice on other issues such as debt counselling.

The committee further discussed that employees may have concerns about the confidentiality of employee assistance programmes. Within this discussion the committee noted that the services provided by these programmes are confidential. They also recognised the importance of employees having information on how to access the programmes independently and without needing to ask their employer.

The committee discussed evidence and expert testimony from the occupational health expert that early access to interventions offered by occupational health providers are regarded positively by employers and employees, and may help to reduce sickness absence rates and support sustainable return to work. These can include fast-tracked access to physiotherapy or counselling sessions.

Although it was unclear whether the interventions included in the economic model were provided at an early stage, the model suggested that providing specific interventions was cost saving. The committee noted that it is important that the potential benefits and decision to refer to occupational health are discussed and agreed between the employee and their manager to avoid it being perceived as a punitive response to absence.

The committee were aware that services such as these tend to be offered by larger employers and that people working in micro-, small- and medium-sized organisations may not have access to them. They were aware from the government policy paper on 'Improving lives – the future of work health and disability' that around 43% of employees in the UK are employed by small- or medium-sized organisations.

The committee agreed that research is needed to determine effective and cost effective ways to support people to return to work after sickness absence, in UK workplaces of all sizes, including micro-, small- and medium-sized organisations (see research recommendation 1). In addition, they agreed there is a need for research on the challenges and potential solutions for UK employers and employees in managing sickness absence and return to work in smaller organisations where access to additional services may not be readily available (see research recommendation 5).

How the recommendations might affect practice

Larger organisations are more likely to already fund services providing early intervention opportunities, whereas micro-, small- and medium-sized organisations may not be in a position to fund external occupational health provision or provide employee assistance programmes.

Implementing the recommendations may need resource input initially, but over time may result in a reduction in the costs of sickness absence and improved productivity. For example, providing 'fast track' or early access to interventions may incur an additional cost. However, this may be included as part of an occupational health service that an organisation provides, as part of a proactive approach to supporting employee health and wellbeing, and this investment may help to reduce the costs of sickness absences in the longer term.

Return to recommendations

Why the committee made the recommendations

The committee discussed that musculoskeletal conditions and common mental health conditions are the most frequent causes of long-term sickness absence among employees. Evidence from a small number of non-UK studies in people with musculoskeletal conditions suggested that interventions to strengthen a person's physical and mental health, and to focus on reducing potential barriers in the workplace, may increase return-to-work rates.

Although the committee noted the limitations in the evidence, they agreed that for employers with occupational health access, it would be useful to have the option of arranging a therapeutic programme of graded activity or problem solving for employees who are absent for 4 or more weeks because of musculoskeletal conditions. Although the economic analysis focused only on changes in absenteeism, because of a lack of data on other outcomes, such as productivity, staff turnover and wellbeing, the committee noted that these types of interventions could be cost saving.

The committee discussed evidence which showed that the time people take to return to work after absence because of a musculoskeletal condition may be reduced if flexible adjustments are agreed between employee and employer, as part of a planned return-to-work process.

The committee heard from an occupational health expert and an expert from a mental health support service that it can be helpful for an impartial person (who may or may not be part of the organisation) to facilitate discussions between the employee and employer, to help agree adjustments that are acceptable to both. The committee noted that there may be a number of people who could fill this role, examples include people from occupational health services, occupational therapists and vocational rehabilitation consultants.

A study of people who had returned to work after absence related to mental health conditions showed a supportive monitoring and problem-solving intervention delivered over 3 months to be associated with a reduced risk of recurrent absence. Although the economic analysis only considered the impact on absenteeism, this intervention was estimated to be cost saving.

Although the evidence was limited, in that it was based on 1 low-quality study, the committee also heard from an expert who supports people with mental health conditions that have resulted in them being absent from work or struggling to remain in work. Their testimony described the use of individual support plans and supportive monitoring. Based on this evidence and their expertise, the committee noted that such interventions are considered to be good practice for people with long-term absence due to common mental health conditions.

The committee noted that although there are substantial limitations in the evidence on supporting people to return to work after absence due to musculoskeletal or mental health conditions, particularly the lack of UK-based studies, it is important to not discourage what is considered to be good practice.

The committee agreed that interventions for those with common mental health conditions should be a research priority. This group may experience recurrent and long-term sickness and there is a lack of evidence on supporting their return to work. The committee recognised that reasons why a person may take sickness absence may be complex. They therefore agreed that research studies should aim to capture the context of the sickness absence and the preferences of participants in supporting them to return to work, alongside data on whether they have been able to return to work (see research recommendation 3 and research recommendation 4).

How the recommendations might affect practice

The recommendations made in this area reflect good practice but some may currently be more accessible to people working in larger organisations. For example, organisations may buy in occupational health services that provide access to physiotherapy, counselling or ergonomic assessment of worksites.

Not all organisations have access to such services, particularly micro-, small- and medium-sized organisations. But they may be able to access them with minimal resource implications, for example by being part of a local or sector association that subscribes to these services.

There may be resource implications if everyone returning to work after absences of 4 or more weeks because of a common mental health condition is offered a 3‑month programme of structured support.

Economic modelling indicated that such an approach could be cost saving. The committee considered that these interventions could offer value for money and in the long run could reduce their costs. In the model these were achieved through savings associated with reduced absenteeism. The committee were mindful of other potential benefits not captured in the model, such as increased productivity as a result of early or sustained return to work and reductions in the costs associated with staff turnover.

Implementing the recommendations may need resource input initially, but over time may result in a reduction in the costs of sickness absence and improved productivity.

Return to recommendations