Managing common health problems at work

The role of GPs and managers in rehabilitation was an issue debated at a recent conference on managing mental health at work. Sarah Silcox reports.

GP sickness certificates should be used as a treatment intervention in a similar way as a prescription, and not merely as a piece of administration, according to Dr Bob Grove, head of the employment programme at the Sainsbury Centre for Mental Health.

Chairing a LexisNexis IRS conference on tackling mental health at work, Dr Grove, who is advising the Department for Work and Pensions on the reform of incapacity benefits (IB), said that most GPs do not have a good grasp of the implications of issuing sickness certificates to employees, and particularly the impact successive certification has on an employee's chances of returning to work. However, he was optimistic that this will change in future, adding that GPs in the IB reform pilot areas were already starting to work constructively with advisers in job centres to help people back into work.

Mental ill health among workers costs employers £3.9 billion a year, and a company with 1,000 employees can expect between 200 and 300 of them to suffer from depression each year, as well as one suicide per decade in the workforce, Dr Grove told the audience of HR and occupational health professionals.

But does this mean there is an epidemic of mental illness? The evidence is equivocal, but most agree that there has been a steady rise in the level of reported mental ill health and stress since the 1990s - mental ill health is now the most frequently cited reason for claiming incapacity benefits, Dr Grove reported. However, the health service is not treating more cases of mental ill health, so "something is going on here". He suggested people are more willing to identify themselves as suffering from mental ill health and to give it as a reason for being off work.

There are barriers stopping people with mental health problems from returning to work, including the absence of work-focused discussions and help from mental health professionals. Dr Grove reported that 40% of those admitted to hospital with mental ill health for the first time have a job, but seldom receive advice on how and when to start working again; the result is that 80% do not return to work after hospital treatment. Employees also lose touch with the workplace easily and discover that managers and colleagues have different attitudes towards those off sick with mental health problems, compared with their attitudes and behaviours towards those absent for other reasons.

If they do return to work, people with mental health problems often find that nothing has changed, and that the circumstances that may have contributed to their absence remain. For example, workloads have not been cleared or employees are required to report to the same manager with whom they have a poor working relationship. Research suggests that one of the best indicators of a successful return to work in mental health cases is a manager's belief in, and encouragement of, the employee, Dr Grove added.

Employers can help to remove these barriers by maintaining early and regular contact with absent employees, and by helping line managers to do their jobs, perhaps by writing "scripts" for them to use when contacting people at home. Managers also need to carefully plan the return to work with the employee and clinicians, including planning for reasonable adjustments and developing a strategy on how to encourage employees to disclose mental health problems in the first place.

Case management is helpful, although Dr Grove accepted that there is no consensus on who should perform the role. Access to short, focused therapy, including cognitive behavioural therapy, should be provided, and organisations should consider introducing a mental health policy. The advantages of a policy are that it demonstrates a high level of commitment to prevention, retention and support for employees with mental health problems and clarifies the responsibilities of the different players in an emotionally charged area of people management. A policy can also contain a strategy on disclosure - for example, by setting out who employees should talk to, what they need to say and what to expect from managers.

St George's Mental Health Trust in south London decided it needed to adopt good practice as an employer if it expects others to employ its patients, so it introduced a mental health policy. This changed perceptions of mental ill health in the workforce, with the result that the proportion of employees acknowledging their use of mental health services rose from one in nine in 1997 to one in four in 2004. This was not because the trust employs more people with mental health problems, but because staff feel more comfortable about disclosing problems, according to Dr Grove. A supported employment programme has been introduced, covering 50 employees with a history of severe mental ill health working throughout the trust, including cleaners and clinicians. Sickness absence among this group is two percentage points lower than in the rest of the workforce, which is "hugely significant in financial and other terms", Dr Grove adds.

De-medicalising rehabilitation

Financial services firm HBOS has developed a non-medical model for absence management, and has recently developed a system of "absence champions" - HR professionals who spend around half of their time advising line managers on absence issues. Mary McFadzean, the HBOS organisational health manager, believes managers should be at the heart of managing employees with mental health problems, as they know their teams best, including their ability to cope with pressure, and their skills at work. Line managers are also in a prime position to take a lead in rehabilitation - a process that can involve up to 27 people in one person's case.

However, line managers fear getting involved in cases of mental health-related absence and need to be equipped to take back control in this area, McFadzean suggested. Managers need to understand the underlying causes of absence, that is, that much of it is not strictly medically related, but connected to social and work factors. HBOS encourages this by raising managers' capability and confidence, using training and guidance from the new absence champions. As a result, long-term absence cases are handled in-house as far as possible, and individuals referred to health professionals receive rehabilitation-centred therapy.

The absence policy at HBOS uses the underlying causes of absence as the focus for rehabilitation. According to McFadzean, the de-medicalisation of absence has given HR and line managers the confidence to take action and work with GPs in support of employees' rehabilitation. Line managers are properly trained in a way that focuses on the return to work and, in particular, the need to consider reasonable adjustments, regardless of the cause of absence.

Absence champions encourage managers to take ownership of the cases and to begin considering reasonable adjustments at an early stage. The absence champions are already reporting that making early adjustments and listening to employees' concerns helps avoid absence in the first place, and that most employees are grateful that the underlying cause of their absence is being taken seriously.

HBOS considers using private health support in cases of mental health-related absence of more than 20 days. Certain criteria have to be met for a referral to private health treatment - the employee has to try the employee assistance programme first, have no date for a return to work, and most importantly, be motivated to return. "Why spend £14,000 on The Priory if the person does not want to return?" McFadzean asked the conference. If private treatment is used in cases of mental health-related absence, there is end-to-end case management, which feeds back to the absence champions and management information is collected on the effectiveness of the intervention. Line managers are closely involved in this case management approach and use information from HR and the absence champions to plan reviews and ultimately help employees return to work, or make a decision on dismissal if no return is likely.

Risk assessing for stress

Somerset County Council - the employer in one of the most high-profile work stress legal cases to date, that of Barber v Somerset County Council¹ - has had three chief executives and two complete reorganisations in the past four years, presenting significant challenges to the health and wellbeing of the 17,500 staff, according to Brian Oldham, the manager responsible for taking forward the council's work on stress and wellbeing. Speaking at the conference, Oldham outlined how the council has responded to these challenges by adopting comprehensive proactive, reactive and operational risk assessment for work stress.

The council used external consultants to conduct an audit in June 2001 - called the Quality of Working Life Survey - and has used the results of this to develop action plans in the four main directorates. The survey revealed particular stress "hotspots" (for example, among senior social workers and in education) and primary interventions, including job redesign and staffing.

A corporate-level action plan focuses on information and training for all managers and staff, and has also led to changes in the counselling service for employees. The previous EAP provider did not produce management information, so has been replaced with a far tighter contract providing quarterly and annual reports that help gauge progress against the corporate action plan, Oldham added.

The stress audit also led to changes in the external occupational health contract, which used to be with the local NHS trust. However, the council felt that this service was "too remote", so has developed a new nurse-led service, with occupational health nurses working "in and amongst our staff", according to Oldham. Policy developments in absence management, home working, work-life balance and equality and diversity have also resulted from the proactive risk assessment, or audit, exercise.

Absence at Somerset County Council has fallen from 10.75 days in 2001/02 to a provisional eight days in 2004/05. In total, £390,000 was spent on the proactive risk assessment audit in 2001 and the follow-up interventions in the following two years, giving a net saving in the cost of absence of £1.13 million, according to an independent review in August 2004.

Many of the stress solutions arising from the audit were implemented using existing resources and for relatively small sums of money, according to the consultants involved in the exercise. Challenges remain, however, and Somerset County Council plans to review its 2001 risk assessment exercise by resurveying the workforce. It also hopes to evaluate the effectiveness of its training on reactive risk assessment, and to develop preventative, proactive health promotion initiatives.

1. House of Lords (2004).See OHR 109, pp.2-6.