Vocational rehabilitation: an end to the sick-note culture?
Chris Dyer reviews the government's proposals for helping sick and injured workers back into employment.
Over the past two decades, the number of people on Incapacity Benefit has trebled to around 2.7 million, which is approximately 7.6% of the working age population. Around 40 million working days were lost due to work-related illness or injury in 2001/02, and it is estimated that in any one day about 2% to 3% of the working age population is on sick leave. The CBI estimates that one-third of all working days lost due to sickness is accounted for by long-term absence (20 days or more) at an annual cost of £3.8 billion. Furthermore, 20% of employees who are off sick for six weeks never return to their job and eventually leave paid employment altogether.
Absence management should therefore be an important issue for businesses. The government has recognised this with new initiatives centred around vocational rehabilitation; the HSE has also recently issued guidance on absence management. Addressing a Royal Society of Medicine conference on rehabilitation in October, Alan Johnson, the Secretary of State at the Department for Work and Pensions (DWP), stressed that simply signing people off as long-term sick is not always the best way to deal with their health problems. Asking for their help in ending the "sick-note culture", Johnson said: "While we must provide security for those who cannot work, doctors agree increasingly that, for people who are able to work again, a job can itself be an important step on the road to recovery and rehabilitation."
Pathways to work
Johnson referred to early evidence from the government's "Pathways to work" initiative (see box 1 ), which is intended to help people on Incapacity Benefit to get back to work (HSB 315) and to a forthcoming White Paper on public health, which will recognise the beneficial role that some work can have in helping people recover from illness or disease. The White Paper will emphasise the damaging effects of being out of work and urge the NHS to see return to work as the norm.
"Our early evidence shows that given the right support most people claiming Incapacity Benefit can be helped back to work," Johnson said. "We are already starting to see very encouraging evidence that more people are leaving benefit in 'Pathways to work' pilot areas compared to the rest of the country. The number of people on Incapacity Benefit getting jobs nationally has risen and in Pathways areas the success rate is double the national average."
The latest figures on Incapacity Benefit show a small fall for only the second time since records began. The government says it is committed to ensuring that individuals with health conditions or impairment are enabled to fulfil their employment potential; an important contribution to realising this commitment will be the development of a strategy for vocational rehabilitation (VR).
Vocational rehabilitation framework
In its second report reviewing Employers' Liability Compulsory Insurance (ELCI), published in December 2003 (HSB 325), the government made a commitment to producing a framework for VR. Government ambitions for VR are that it should enable more people who have a health condition, impairment or injury to access, to remain in, or to return to, work for the benefit of all concerned - not least the individuals themselves and their employers. The government has decided that initial efforts flowing from the VR framework should focus on helping people in employment to remain in work, or return to work, for example individuals in work who have been sick or injured and who are looking for an early return to work within weeks or months. This work has only just started; government initiatives to help people not in employment, such as 'Pathways to work' with its elements of VR, are better developed (see box 2 ).
In May 2004, the DWP published a discussion paper as a prelude to the VR framework and distributed it to 8,000 stakeholders with an interest in VR. In their responses, and in face-to-face discussions with the DWP, many stakeholders highlighted that more needs to be done on VR.
The government says this is a significant task, hampered by the inconclusive evidence of the effectiveness of VR. In the VR framework document, which has now been published1, the government says that it is not yet in a position to produce a new approach for VR because of the shortcomings of the VR evidence base. Work is under way to improve this, and evaluation of the Pathways pilots will make a contribution. The DWP has also commissioned research to fill part of the evidence gap.
Good rehabilitation practice
Part of the DWP research sought to find a consensus as to what constituted good practice in current VR. In-depth interviews were held with employers, insurers, occupational health and safety providers in the private sector, and vocational and general rehabilitation providers in the private sector.
The report on the research2 shows that ideas about what exactly VR is varied among providers, insurers and those employers who had heard of it. Some took a narrow view and saw it as rehabilitation to a new "vocation" (employment) after sickness or injury. Others took a broad view of VR to encompass workplace initiatives that were designed to prevent injury or illness, as well as those designed to manage and reduce absence from work. For the purposes of the study, the researchers decided to adopt a broad, all-encompassing definition of VR: "whatever it takes to get people back into work".
The research covered all sizes of employers; from large multinationals, with their own human resources (HR) and occupational health departments, to micro-employers, where responsibilities are devolved to the owner/director. Awareness and understanding of VR and similar initiatives varied enormously. Many larger employers and some small and medium-sized enterprises (SMEs) had instituted some kind of absence management system to reduce the incidence of sick leave. Some - mainly larger - companies were using VR in one form or another as part of this absence management process. In many of these companies, sickness pay packages are relatively generous and it is not surprising that they are keen to minimise or, at least, not to encourage employees taking overlong sickness absence. This desire to reduce sickness absence is reinforced when the difficulty and cost of replacing staff is taken into consideration.
Smaller and micro-employers without a formal HR function know little or nothing about VR and have little experience or understanding of how to manage long-term sickness absence. Protracted sickness absence is a rare or infrequent occurrence in this group, but when small or micro-employers are confronted by long-term sickness or injuries, it can be a major problem. One person off sick in a small company leaves a large gap that has to be filled, and their absence has a significant knock-on effect for other staff.
The active ingredients
The research found that a good VR approach involves:
being proactive;
early intervention after injury or illness;
making the patient central to the process;
undertaking relevant interventions;
not making an artificial distinction between medical rehabilitation (treatment of the injury or illness) and VR (initiatives to enable a return to work);
adopting a holistic approach to the rehabilitation plan;
being realistic;
case management; and
knowing when to draw the line.
Being proactive
A proactive approach involves preventing illness and injury in the workplace by identifying possible trouble spots, changing or adapting the workplace environment to head off the risk of injury or illness, and offering or providing access to early treatment, for example physiotherapy or chiropractic treatment, before the employee goes off sick. Employers felt it was better to prevent a problem occurring rather than allowing it to happen and then having to deal with it.
This approach has cost benefits as employees who are not working are non-productive. It is better for staff morale and reduces potential stress among those employees who would otherwise have to cover for absent colleagues.
Early intervention
Early intervention after injury or illness consists of assessing what is needed as soon as possible to get the employee back to work. Relevant interventions provide early help and stop the employees' "working" mindset being replaced by an illness-orientated mentality, in which they start to believe they are no longer able to work.
Patient-centred process
Making patients central to the process involves convincing them that getting back to work sooner is in their own interest. The VR provider and the individual need to look at goals and personal and circumstantial barriers to getting back to work. The process might also involve liaising with the employer to plan a phased return to work or agree modifications to the workplace to enable an earlier return to work.
Relevant interventions
Providing relevant interventions requires identification of what is needed to help the individual get back to work, and the drawing up of a rehabilitation plan, taking into account the individual's circumstances and likely functionality. There is a strong sense among VR providers that it is important to focus on the individual's present and potential abilities, rather than on what they can no longer do. This helps in devising a feasible rehabilitation plan, and in keeping the employee's mind focused on returning to work. In some instances, an intervention could be quite basic, such as offering a phased return to work, lighter duties, or making minor modifications to the workplace.
Repair and restoration
There is agreement that good VR involves not making a distinction between medical rehabilitation (repair) and VR (restoration and integration). There is some feeling that this distinction is artificial and that the two processes have a common aim and are complementary. Some providers observe that mental health problems very often develop alongside long-term illness or injury, and that these have to be addressed before people feel willing or able to return to work.
Holistic approach
It is important to adopt a holistic approach to the rehabilitation plan. This involves not just looking at the individual's symptoms but also taking into account factors such as:
the individual's personality and goals;
the period off sick;
the influence of family and friends;
what support systems exist or could be created;
other influences, such as lawyers, doctors and insurers;
the individual's functionality; and
the individual's financial situation.
Being realistic
A realistic approach involves:
drawing up a costed rehabilitation plan and, in so far as is possible, sticking to both the plan and the costing;
deciding what needs to be done to help individuals get back to work rather than trying to make their world a better place; and
working towards getting the individuals a job they can do, and not necessarily the job they were in before the illness or injury, or the job of their dreams.
Case management
Case management is particularly important, especially in cases of more acute injury and illness, in bringing the elements of good VR together. The patient is likely to have complex problems and to need help on many different fronts; these could include housing modifications, transport, prosthetics and financial and emotional counselling. Most insurers and VR providers agree that case managers have a crucial role in identifying appropriate and effective help, liaising with the various agencies and facilitating interventions from the relevant parties. Inevitably, there are disagreements about what kind of case management works best, how hands-on it should be and whether it should be face-to-face.
Drawing a line
Finally, VR providers and case managers have to know when to draw the line. In some instances it was acknowledged that, however much was done in the way of rehabilitation, the individual was never going to be able to return to any form of employment. In such situations, the case manager needs to recognise that, in the interests of all parties, the process should be discontinued.
Barriers to successful VR
Barriers to successful VR arise from five main sources:
employers;
the system;
problems related to the supply of VR services;
the legal and claims processes; and
claimants.
Employers as barriers
Employers, especially those without access to occupational health and HR facilities (mainly smaller employers), are often ill-informed about ways of handling long-term sickness or serious injury, and are inclined to accept a GP's prognosis and/or sick note. Such employers are concerned about appearing not to be harassing their sick employees back to work or breaching employment law. Often they are paying Statutory Sick Pay (SSP) fairly soon after the employee goes off sick and are thus under less financial pressure than if they were having to pay a full salary. Consequently, they are not motivated to resolve the situation.
There are claims that some large employers are slow to inform occupational health departments and insurers about staff who are off sick with illnesses that may be work-related. This delays effective intervention.
Some larger employers identify line managers as a barrier to VR. They may be reluctant, unwilling, too busy or just not very good at reaching out to those off sick. Sometimes the line manager will be part of the reason why the employee is off sick. There are also indications that line managers and work colleagues can resist phased return-to-work programmes because they disrupt the routine of the workplace.
There are claims that work colleagues and other staff resent the preferential treatment given to the long-term sick returning to work. They see special consideration being given to the needs of those returning to work as "rewarding absence" and this sometimes leads to complaints about not being given similar facilities and arrangements or treatment.
Company culture can get in the way of companies adopting VR processes. Some employers are not disposed to get involved with VR initiatives. As far as they are concerned, employees are either fit for work and at work, or they are not. In other companies, the circumstances of work can operate against VR. For example, employers argue that they cannot afford to have semi-fit workers on a building site, and there is little scope for alternative jobs or workplace modifications.
The system as barrier
Some providers, employers and insurers suggest that GPs are one of the barriers to successful VR: GPs unwittingly exacerbate the problem by repeatedly signing people off sick without exploring the nature of the problem. There is also a view that GPs do not necessarily understand, or appreciate, the correlation between the nature of a patient's job and his or her actual fitness to work.
Furthermore, some respondents argue that the willingness of GPs to provide sick notes encourages a sickness culture. Many people who are off work with stress or depression will not be fit for work until they return to work; indeed, the sick note is making them ill. Employers add that some GPs are unhelpful, slow to respond to enquiries, and want payment before they provide information.
Despite general praise for NHS emergency treatment and specialist centres, such as cardio-rehabilitation and spinal units, the respondents acknowledged that the NHS was often stretched when providing treatment for non-acute cases. It was also widely noted that there was a gap in continuity of care after discharge from hospital. Typically, there were long delays before patients could access additional recuperative treatment such as physiotherapy.
The benefit system can be another potential barrier to successful take-up of VR. Incapacity Benefit and associated benefits can provide a secure, safe source of income, especially for those with lower earning potential. Some claimants become acclimatised to the world of benefits and the idea of returning to the world of work, especially to a different employer or different occupation, is too challenging. The idea of leaving the benefits system for employment can seem like a risky option, especially if they are disabled or have been out of work for a long time. There are some indications that the benefit system and its complexities discourage phased return to work or working part time. Sick or injured persons can find their benefits are at risk if they work too many hours.
The tax system's treatment of "benefits in kind" can be a barrier. Some employers are prepared to offer "perks", such as private medical insurance or physiotherapy, that should contribute towards a reduction in work absence or facilitate an early return to work. Their employees, however, can attract a benefits-in-kind tax liability if they take up these offers. Significantly, some employers are taking it on themselves to pay their employees' tax liability because they think that the benefits of earlier medical treatment outweigh the cost. Employers noted that some employees refused the offer of private medical insurance because they were unwilling to pick up the additional tax burden. Insurance premium tax imposed on employers for providing private medical insurance is a further cost to employers.
Three final barriers
Supply problems. There is a general impression of a rapid growth of providers keen to sell their services. But there are also claims of a shortage of properly qualified and trained staff in areas such as occupational health, physiotherapy and cognitive behavioural therapy with experience of work-related issues. The lack of recognised or established accreditation for VR providers and of a directory of suppliers and providers of VR is a problem.
Legal and claims processes. Insurers, employers and some providers say there is a growing perception of a claims culture that encourages people to make claims in order to get money. There were reports that solicitors (often offering a "no win, no fee" service) were encouraging clients to think in terms of a large financial settlement rather than restoration through VR and a reduced settlement. The adversarial system of handling insurance claims can hinder early intervention and assistance for the claimant.
Claimants. Stakeholders interviewed for the research thought that, for some claimants, the accident or illness provided an opportunity to give up working. For others, the idea of returning to work was too challenging. Sometimes, the ill person's family becomes dependent on them to provide domestic support, for example by looking after the children. Lack of motivation to return to work could be reinforced by the security of Incapacity Benefit and other benefits (see above ). Even those who, in theory, want to return to work can be put off if their GP advises a lengthy period of rest.
Reasons to be wary
At present, initiators of VR are usually insurance companies (although only in a limited number of cases) and larger, more progressive employers or occupational health departments. There are indications that VR is not used unless someone suggests or requests it. The researchers suspect only a rudimentary awareness among many GPs and most employers of VR and what it can do, and the situation is even more limited among the general public.
But while some insurers are enthusiastic proponents of VR, others are rather more cautious in their willingness to advocate and use VR. This wariness reflects a combination of factors:
the insurer may not know about the claimants and their circumstances, such as in third party injury cases;
the likely value of the claim may not justify a perceived substantial VR expenditure, for example where an older claimant with severe injuries is employed in manual work;
claims managers are not always best able to identify cases where VR might be suitable or appropriate;
the insurer was only partially liable for the accident or injury;
there is a suspicion of fraud on the part of the claimant (in a minority of claims); and
solicitors do not agree to the insurer or its representative visiting the claimant to discuss the idea of VR (this is a claim made by some insurers).
There also seem to be some doubts within the insurance industry about the efficacy and financial benefits of VR, particularly the lack of hard data on which to base a judgment.
There is some anecdotal evidence to suggest that some sick and injured people might refuse to agree to take part in VR because they:
are suspicious of the insurance company's motives;
are fearful or reluctant or not interested in returning to work; and
prefer the security of the benefit system or were caught in the benefit trap.
New guidance and tools
The government now plans to develop the VR framework by:
setting up a VR steering group to help stakeholders assist in the development of any new approach to VR, and to help manage the delivery of the framework;
setting up a research working group to identify, and agree action to deliver, research priorities; and
asking the VR steering group to consider how best to increase standards and determine the case for the accreditation of VR providers.
Government departments are also involved in developing new guidance and tools to help meet stakeholders' immediate needs, including:
the HSE's October publication of a best practice approach to managing sickness absence and return-to-work (see boxes 3 and 4 );
the DWP will launch the second module of an online distance learning package for GPs to cover health and work issues; and
the HSE has commissioned the Institute of Occupational Medicine to develop a sickness absence recording tool to help SMEs identify interventions that will avert long-term sickness absence.
As the steering group develops a new strategy for VR, it will consider other stakeholder concerns, including:
how better to link all rehabilitation support;
future delivery mechanisms and generating capacity;
consideration of ELCI issues related to VR;
the future role of the Industrial Injury Scheme (IIS);
mechanisms to deliver early VR;
steps to avoid a two-tier rehabilitation system, which could exclude those without liability cover from access to effective VR support;
income tax issues related to VR; and
the need for a flexible strategy to meet the needs of an ever-changing world.
The government is also commissioning work to examine the costs and benefits to employers of employing people with health conditions or impairments that will support the development of a business case for VR.
The government does not see the current inconclusive evidence base as a reason to delay consideration of how to move forward on VR and, in particular, consideration of how to address stakeholders' VR needs. The intention of the framework document is to provide the UK with a solid platform on which to build a new common approach aimed at achieving a cultural change in rehabilitation.
Commenting on the launch of the HSE's guidance on managing sickness absence and return to work as part of the VR framework, Jane Kennedy, Minister of State for Work, said: "For too many people, long-term sickness absence leads to the spectre of unnecessary job loss, continued ill health and social exclusion. A culture exists where long-term sickness absence is accepted as a fact of life. We need to change this culture."
Chris Dyer is a freelance journalist and editor of HSB.
1 "Building capacity for work: a UK framework for vocational rehabilitation", ELCI3, DWP, www.dwp.gov.uk/publications/vrframework, free.
2 "Developing a framework for vocational rehabilitation", Andrew Irving Associates, DWP report 224, www.dwp.gov.uk/asd/asd5/index.asp, free.
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The 'Pathways to work' pilot includes: support from a skilled personal adviser with monthly contact in the first eight months of the claim (when people can be most readily helped back to work);
new NHS rehabilitation support so that patients can learn to manage and cope with their health condition (for example back pain, angina and mental illness), and so that they can get back to work;
strong local partnerships with the New Deal for Disabled People, including voluntary and private sector employment advisers;
£40 a week return-to-work credit once the patient gets a job, so that it pays to get back to work; and
work with local GPs and employers to ensure people on Incapacity Benefit are not discouraged from working again.
The Pathways pilots have targeted new Incapacity Benefit claimants and existing claimants who volunteer to take part. From early 2005, the approach will extend to those who have been on Incapacity Benefit for over a year. Early indications suggest that more people in the pilot areas have moved off Incapacity Benefit to return to the labour market than in the rest of the country. In the pilot areas, six times as many people claiming Incapacity Benefit have taken up support from the New Deal or other rehabilitation programmes. Furthermore, the government claims that the Pathways pilot is proving so successful that people on Incapacity Benefit in the pilot areas who do not qualify for the pilot are volunteering to participate. There are seven pilots - the first wave was launched in October 2003 in Renfrewshire, Derby and Bridgend. A further four pilots started in April 2004 in Essex, Gateshead and South Tyneside, Somerset and East Lancashire. |
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Box 2: Vocational rehabilitation initiatives The HSC's new strategy, A strategy for workplace health and safety in Great Britain to 2010, includes a commitment for the HSE to work with the Department for Work and Pensions (DWP) and others to strengthen the role of health and safety in getting people back to work through greater emphasis on rehabilitation (see "All dressed up", but where will the HSC's strategy go?). The work that the HSC/E are doing on managing sickness absence and return to work, and on occupational health, safety and rehabilitation support pilot schemes, are important contributions in the development of a VR framework.
The "Job retention and rehabilitation pilot" is a joint initiative between the DWP and the Department of Health, with support from the HSE and the Scottish and Welsh administrations. The pilot tests the impact of a person-centred approach to the delivery of services that boost individual access to healthcare services, occupational- and workplace-focused help, and combined healthcare and workplace help. The pilot is open to employed and self-employed volunteers who have been off work for between six and 26 weeks. The two-year pilot began in April 2003; final reports will be available in late 2005.
Choosing heath - the Department of Health consultation on public health1. The aim of this consultation was to come up with practical strategies that will help encourage people to make healthy lifestyle choices. The document contains a chapter on work and health that is relevant to VR (see HSE misses worker participation chance). Following consultation, the government recently published a White Paper on action to improve public health (see Workplace smoking to end in 2008).
NHS Plus is a network of more than 100 occupational health departments in the NHS that provide, on a commercial basis, support to non-NHS employers, particularly small and medium-sized organisations. In addition, NHS Plus has a website with guidance to employers and employees about how to deal with common occupational health problems2. It is also funding and coordinating the production of evidence-based guidelines to secure improvements in the quality and delivery of occupational health care.
The Better Regulation Task Force report, Better routes to redress3, looked at insurance liability issues (HSB 326). It recommended that the Chief Medical Officer lead a cross-department group to assess the economic benefits of greater NHS-provided rehabilitation, and that the DWP should lead a group, including insurers, lawyers, the HSE and the NHS, to develop mechanisms for earlier access to rehabilitation.
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Box 3: HSE advice to employers The HSE's new guidance offers a practical approach to managing sickness absence and getting people back to work quickly. The guidance is aimed at employers and managers across UK business.1 The HSE believes that there are considerable benefits for employers from working in partnership with employees and their trade union and other representatives to help sick workers return to work. These include: keeping valued staff and avoiding unnecessary recruitment and training costs;
keeping the business productive and, where the sick employee has built up a loyal client base, keeping this as a source of income;
reducing unnecessary overheads, for example saving on lost wages and sick pay costs;
helping to meet the employer's legal duties and avoiding discrimination against disabled workers; and
maintaining and improving workplace relations by working in partnership with employees and their representatives.
Employers should record and monitor all sickness absence. It is important to know the cause of sickness, in case it is work-related. If it is, organisational measures - ie modified work, including reasonable adjustments - can be put in place that will help those who are sick or want to return to work. The HSE offers the following advice according to the length of absence: Less than three days of sickness absence Employees should be asked why they are absent from work.
When the employee returns to work, he or she should be welcomed back and there should be an informal discussion about the absence.
Between four and 14 days of sickness absence The employer should keep in touch with the employee.
When the employee returns, the employer should conduct a return-to-work interview. In many cases this will be a simple welcome back but the employer may need to discuss actions to help the employee's performance at work or underlying issues if short-term absence is frequent.
Between 15 and 28 days of sickness absence The employer should keep in touch regularly with the employee and identify the barriers that prevent returning to work (many of these will not need a medical solution).
The employer may need to consider expert advice from, for example, doctors, occupational health departments and rehabilitation providers.
The employer should welcome the employee back and conduct a return-to-work interview.
If it seems that the employee is not likely to return to work soon, the employer should talk to the employee about the need to consider a return-to-work plan.
After 28 days of sickness absence The employer should continue to keep in touch regularly with the employee about the absence.
The employer should put together a plan of action and reasonable adjustments to help the employee return to work, including seeking expert advice if necessary, and agree these with the employee and others involved.
The employer should welcome the employee back and implement the plan.
The employer should review the employee's progress after the return to work until full duties are resumed.
Despite everybody's best efforts, it is not always possible to return a sick employee to full or even partial employment. It is important not to jump to conclusions before alternative solutions have been explored, and the employer may need to consider seeking expert advice before making any decisions. 1 "Managing sickness absence and
return to work: an employers' and managers' guide", HSG249, HSE Books,
ISBN 0 7176 2882 5, £9.95, and "Managing sickness absence and return to
work in small businesses", INDG399, HSE Books or www.hse.gov.uk/sicknessabsence/resources.htm,
free. Advice and help is also available at www.hse.gov.uk/sicknessabsence. |
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Box 4: HSE advice to employees The HSE believes that avoiding long-term sickness absence is good for individuals and that work can be an important part of the recovery process. It has produced guidance for employees on managing their own sickness absence1. Employees should tell their doctor about their job and ask about: going back to work;
any work tasks that need adjusting on a temporary or permanent basis to allow the employee to return; and
any side effects of treatment or medication that could affect the employee's work.
Employees could ask their employer to write to their doctor about their job and adjustments needed to help them return. The doctor will not discuss their health without their consent. Staying in touch with the employer will help the employer and employee to plan the employee's return to work. Employees should talk to their employer about what it might be able to do to help. Actions the employer can take include: taking advice from the employee, his or her manager or supervisor and trade union or other representatives;
using this advice to put together a return-to-work plan setting out any adjustments to the employee's job or changes to health and safety control measures before the employee returns; and
making sure everyone agrees the plan.
Examples of adjustments that employers may be able to make include: starting the employee back on shorter hours, then increasing them within an agreed timescale;
adapting or changing the equipment the employee uses at work to make it safe and comfortable;
starting the employee with a reduced workload or work at a slower pace and then building it up to normal; and
adapting the employee's job by replacing or reallocating tasks on a temporary or renewable basis.
Employees need to make sure they understand the effect of such adjustments on their pay. The employer needs to decide whether existing health and safety control measures will protect the employee's health and safety after he or she returns to work. If changes are needed, the employer has a duty to consult the employee's trade union safety representatives or representatives of employee safety about the effects of the changes on the health and safety of the employee and his or her colleagues. The employer cannot discuss the employee's personal or health details without consent. Sometimes, the employee or employer may need professional or specialist advice. A disabled employee can apply to the nearest Jobcentre Plus for help. A disability employment adviser will see whether the Access to Work Scheme can help the employee and the employer. If the employee has been off work for a long time, an informal visit during lunchtime or coffee breaks can help "catch up".
The employer or manager will want to welcome the employee back and check how he or she is feeling. Employees should use this opportunity to discuss the return-to-work plan and any problems they have.
Employees should help their employer or manager to look at their progress and to make any changes needed to their return-to-work plan.
1 "Off sick and worried about your job?" INDG397, HSE Books, or www.hse.gov.uk/sicknessabsence/resources.htm, free. Advice and help is also available at http://www.hse.gov.uk/sicknessabsence. |
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Case Study 1: Small Voluntary Organisation Included within the DWP's Building capacity for work: a UK framework for vocational rehabilitation is a series of VR approaches and interventions that stakeholders have implemented and found useful. Health@Work in Liverpool offers free independent occupational health advice to patients in GP surgeries; individuals can self-refer or be referred by clinical staff. Health@Work also offers employers occupational health and safety advice and targets SMEs, some of which are referred by the HSE and local authorities as companies at risk of prosecution. Example A GP referred a project manager employed by a small voluntary organisation to an occupational health adviser. The adviser provided information to the individual on employment rights and health and safety and discussed general work-related issues. The adviser also referred the individual to the adviser for small- and medium-sized businesses who carried out a health and safety audit for the organisation. The result of this intervention was that both employer and employee benefited from advice that enabled the organisation to implement policies and changes to the working environment, which ultimately resulted in the employee returning to work. Source: DWP. |
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Case study 2: Exercise referral scheme The occupational health service of Trafford Healthcare NHS Trust is piloting an exercise referral scheme in partnership with a local authority leisure centre. Leisure services staff have received specialist training to enable them to understand a range of medical conditions, the effects of medication and the psychology of exercise and illness. This enables them to design customised activity programmes that meet the individuals' needs while avoiding any harm related to their health condition. Example 1 A, a 45-year-old trained senior nurse, worked full time in a busy acute medical unit. She was married with a three-year-old child and had to balance conflicting demands in her life. She had suffered from asthma for five years. Although A was prescribed inhalers, her condition was poorly controlled and she was also suffering from recurrent chest infections, necessitating a number of short courses of systemic steroid medication and antibiotics. A was referred to the exercise referral scheme in order to assist her with improved asthma control and to minimise the likelihood of her having to take time off work. Prior to this, her activity level involved walking 20 minutes per day. Self-assessment of her physical wellbeing at referral was five (on a scale of one to 10, with 10 being extremely well); and self-assessment of her psychological wellbeing at referral was also five. At the six-week review, A had significantly increased her activity level. Self-assessment of both physical and psychological wellbeing was eight, and she reported a considerable improvement in her ability to cope with the physical demands of her job in addition to feeling more energised. At 12 weeks, A had been suffering from a long-term chest infection that had curtailed her activity, with some reduction in her self-assessed health status, but she planned to return to exercising as it made a great difference in her ability to do her work. She also planned to look seriously at her work in relation to her health and wanted to apply for some flexible working to help with childcare and to support her in maintaining her activity and health. Her long-term health status will be assessed at a further review. Example 2 B was 60 years old and worked part-time as a support services assistant, with responsibility for domestic work on a hospital ward. He was referred to the exercise referral scheme following a heart attack some months previously. At referral, he was anxious about undertaking activities and exercise, despite having attended a cardiac rehabilitation programme. At referral, B assessed his motivation to exercise as six and his confidence that he would exercise at five. He responded well to the induction and tailored activity programme, gaining confidence in his ability to increase his activity level in preparation for his return to work. At the six-week review, his motivation to exercise had increased to eight, and his confidence to sustain his new activity programme increased to seven. B said that the programme increased his confidence that he could go back to work on a phased return-to-work programme. He is now planning to join the leisure centre to maintain his health and activity level. Source: DWP. |
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Case Study 3: public transport operator The organisation is a large, mainly public sector employer with its own internal occupational health department. The department's services include medical advice, physiotherapy, a specialist counselling and trauma unit, and drug and alcohol advice and treatment. It also runs a programme designed to help and encourage those off sick or injured to return to work if possible. The department's role includes assessing the fitness of the staff to do their work and advising managers on the medical aspects of people who are off sick and how quickly they can return to work. In order to reduce levels of sickness absence, the organisation is using the case management approach to allocate the kind of help and treatment that might be suitable to help individuals back into work. These initiatives are designed to be holistic and include: physiotherapy;
cognitive behavioural therapy;
counselling sessions;
stress reduction;
adjusted working hours;
agreed return-to-work programmes; and
modifications to the workplace and the duties undertaken.
A system has been set up whereby after 28 days off sick, all cases are reviewed by the line manager, HR and occupational therapists to agree an approach to help employees back to work. Examples L, a station assistant, was suffering from multifunctional visual impairment that would normally compel him to take early retirement or give up working. To enable him to continue working, the ticket office was adapted to suit the needs of someone with significant visual impairment. Usually station assistants working on platforms and ticket offices would be required to meet quite stringent vision requirements. Making an exception to allow this particular employee to work in one place represented a significant modification of established procedures. M, an operational trainer, was suffering from the effects of chronic heart disease. In order to allow her to continue working, she was allowed to work three days a week at the training centre and two days a week from home. Working at home meant that she did not have to undertake the journey to work and she could spread her work throughout the day and take rest periods as needed, allowing her to complete her work over a longer period. Arrangements were also made to minimise her journey when she did come into work. The job is now arranged so that M does not need to take much exercise, and because she has to walk slowly and stop regularly to take her breath, sufficient time is allowed for her to walk from one location to another. The job has also been adapted from continually delivering training to marking papers and developing courses. |
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Case Study 4: Return to Work PerkinElmer, a Wales-based company manufacturing and distributing instruments for the life and analytical sciences industries, controls absence through return-to-work interviews and offers a rehabilitation programme for employees who have been absent for an extended period. When employees are absent from work, for no matter how short a period, they have a return-to-work interview with their line manager. The absenteeism is recorded in a database, where the accrual of points triggers three interviews with: the line manager; the line manager and the HR leader; and finally the operations director and her leader. These interviews form part of a tightly controlled absenteeism programme. When an employee is absent from work for a long period due to sickness, a rehabilitation programme is arranged where the employee is introduced back into the workplace gradually. Employees start with a couple of hours each day, until they are ready to work more hours. There is no pressure on them to return to work full time. The company also looks at their work area to see if there are any alterations that could ease the return to work. Example An employee had a heart attack and was off work for six months. His doctor said that he was fit to return to work, but the employee was anxious about going back to work full time. He was encouraged to start work at 10am and finish at lunchtime, then, over six weeks, he gradually introduced more hours until he was ready to work full time. Source: DWP. |
