3 Recommendations

Introduction

This is NICE's formal guidance on managing long-term sickness absence and incapacity for work. When writing the recommendations, the Programme Development Group (PDG) (see appendix A) considered the evidence of effectiveness (including cost effectiveness), expert papers, fieldwork data and comments from stakeholders. The PDG also drew on its expertise to help interpret the evidence. Where this has occurred the recommendations are marked as being based on 'inference derived from the evidence' (IDE) in appendix C. Full details are available online.

The evidence statements underpinning the recommendations are listed in appendix C.

The evidence reviews, supporting evidence statements, expert papers and economic analysis are available online.

What the guidance covers

The guidance presents recommendations, based on evidence of effectiveness and cost effectiveness, for interventions that aim to:

  • prevent or reduce the number of employees moving from short-term to long-term sickness absence (including the prevention of recurring short-term sickness absence)

  • help employees on long-term sickness absence return to work

  • reduce the number of employees who take long-term sickness absence on a recurring basis

  • help people receiving incapacity benefit or similar benefits return to employment (paid and unpaid).

What the guidance does not cover

As the focus of this guidance is the management of long-term sickness absence and incapacity for employers and primary care services it has drawn on evidence on return-to-work outcomes. The guidance does not cover prevention of sickness absence before it occurs (primary prevention) or treatment of conditions that cause sickness absence and incapacity. For recommendations on treatment see the following:

  • NICE technology appraisal guidance 51 on computerised cognitive behaviour therapy for depression and anxiety [Replaced by NICE technology appraisal guidance 97]

  • NICE clinical guideline 22 on anxiety [Replaced by NICE clinical guideline 113]

  • NICE clinical guideline 23 on depression [Replaced by NICE clinical guideline 90]

  • NICE clinical guideline 88 on low back pain (2009)

    The guidance does not cover government legislation on employers' legal responsibilities. Both employers and employees may wish to refer to:

  • The Disability Discrimination Act (DDA) 1995/2005 (HM Government 2005a)

  • The Health and Safety at Work etc. Act 1974 (HSWA) and its associated regulations (HM Government 1974)

  • The Employment Rights Act 1996 (HM Government 1996)

  • Data Protection Act 1998 (HM Government 1998).

Two recommendation categories

The recommendations fall into two categories (please note, the way they are numbered does not imply a hierarchy of importance):

  • Recommendations 1–3 cover activities which relate to employees who experience long-term sickness or recurring long- or short-term sickness absence. These aim to encourage a well-managed return to work which will be of mutual benefit to both the employee and their employer.

  • Recommendation 4 relates to activities for those who are unemployed and in receipt of incapacity benefit (or other similar benefits such as employment and support allowance [ESA]).

The diagram illustrates the various stages in the sickness absence pathway and how this relates to the recommendations.

Pathway for managing long-term or recurring short- or long-term sickness absence

Prerequisites underpinning the recommendations

The following prerequisites have been identified from the evidence considered. These underpin and support effective implementation of the recommendations:

  • Primary care trust commissioners (or other commissioners) have ensured:

    • referral mechanisms are available to GPs and any other specialists (such as occupational health physicians and nurses)

    • any interventions or services identified as a result of following recommendations 1 to 4 are commissioned and available.

  • Those responsible for managing certification (such as GPs) have considered the advice given in 'Patients, their employment and their health – how to help your patients stay in work' (Department for Work and Pensions 2008). For example, they should balance the immediate health benefits of prescribing time away from work and the potential long-term disadvantages for the patient.

  • Agreement has been reached with the person experiencing sickness absence or receiving incapacity benefit about what confidential information can be shared with whom and for what purpose.

  • The person experiencing sickness absence or incapacity and the employer are in regular contact and work together to plan and put into practice any agreed activities.

  • The person experiencing sickness absence or incapacity has received the appropriate treatment.

  • The person planning, coordinating or delivering the intervention/s or service/s has the relevant experience, expertise and credibility. For example, they might need training in communications skills. They may need access to supervision and consultation with more skilled professionals. They may also need access to sources of employment and health and safety advice and discrimination law.

  • The proposals outlined in 'Dame Carol Black's review of the health of Britain's working age population. Working for a healthier tomorrow' (Health, Work and Wellbeing Programme 2008) are taken forward.

Factors to consider when planning and delivering the recommended interventions and services

The following factors need to be considered when implementing the recommendations.

Planning

  • The person's age and gender, the condition that led to the sickness absence, their prognosis for returning to work and the type of work they are involved in all needs to be taken into account. These factors may influence their speed of recovery and ability to return to work.

  • The appropriateness of the proposed intervention in relation to the person's specific characteristics, such as their sex/gender, age, race/ethnicity, disability, sexual orientation, religion or belief.

  • Any incentives or financial implications which may encourage or discourage a return to work (for example, whether or not the absence has had any impact on their pay).

  • Local job market, availability of jobs or alternative work or another role within the original workplace.

  • Organisational structure and culture.

  • The multi-faceted nature of long-term sickness absence: that is, sickness absence and incapacity associated with one condition (for example, back pain) may lead to further complications (for example, a stress-related condition).

  • The valuable role that trades union and employee representatives can play in helping employers to develop guidance and policies on the recommended interventions. They may also have a role as advocates for – and supporters of – staff wanting to return to work.

Delivery

  • Activities need to be tailored to the individual's condition, their prognosis for returning to work and any perceived (or actual) barriers to returning to work.

  • A multi-disciplinary or multi-agency approach needs to be adopted. For example, employment specialists could be used or the organisation could work in partnership with Jobcentre Plus staff to help find suitable jobs,

  • The timing, length, frequency and intensity of interventions needs to be determined (early intervention may improve effectiveness).

  • It is important to establish the employee's confidence and trust in the person delivering the intervention (or the confidence and trust of the person in receipt of incapacity benefit). For example, if a member of a statutory service is helping deliver an intervention and has a responsibility to inform state benefit services, this may affect the person's confidence in their impartiality.

  • Organisational sickness absence policies and appropriate health and safety practices should be established and implemented.

  • Evidence suggests that 'actively doing something with people' (for example, physiotherapy) can be more effective than 'advising them to do something' (for example, advising them to undertake regular physical activity) or 'encouraging them to do it for themselves' (for example, providing them with contact details for another organisation).

Who should take action?

For each recommendation a list of 'Who should take action?' is provided. Furthermore, in the 'What action should be taken' sections, various specialists and professionals are suggested as people who may be involved in the delivery of the intervention or service. This is not a definitive list and responsibility often involves a team approach (across the NHS and with external organisations).

Recommendations

Employees on sickness absence

Recommendation 1: initial enquiries

Who is the target population?

Employees experiencing long-term sickness absence or recurring short- or long-term sickness absence, particularly those with musculoskeletal disorders or mental health problems.

Who should take action?

Employers (this may have been devolved to line managers, human resource [HR] professionals or occupational health specialists).

What action should they take?

  • Identify someone who is suitably trained and impartial to undertake initial enquiries with the relevant employees (see above). As an example, they could be an occupational health physician or nurse or a human resource specialist.

  • Within 12 weeks (ideally between 2 and 6 weeks) of a person starting sickness absence (or following recurring episodes of short- or long-term sickness absence) ensure that initial enquiries are undertaken in conjunction with the employee. The aim is to:

    • determine the reason for the sickness and their prognosis for returning to work (that is, how likely it is that they will return to work) and if they have any perceived (or actual) barriers to returning to work (including the need for workplace adjustments)

    • decide on the options for returning to work and jointly agree what, if any, action is required to prepare for this.

  • If action is required consider identifying:

    • whether or not a detailed assessment is needed to determine what interventions and services are required and to develop a return-to-work plan (see recommendation 2)

    • whether or not a case worker/s is needed to coordinate a detailed assessment, deliver any proposed interventions or produce a return-to-work plan.

    • If necessary, appoint a case worker/s (see recommendation 2).

Recommendation 2: detailed assessment

Who is the target population?

Employees experiencing long-term sickness absence or recurring short- or long-term sickness absence, particularly those with musculoskeletal disorders or mental health problems.

Who should take action?

  • Employers (this may be devolved to line managers, HR professionals or occupational health specialists).

  • Case workers (if appointed).

What action should they take?

  • If indicated by the initial enquiries, arrange for a more detailed assessment to be undertaken. The assessment could be coordinated by a suitably trained case worker/s. The case worker does not necessarily need a clinical or occupational health background but should have the skills and training to act as an impartial intermediary. (Note: it may not be an appropriate role for the person's line manager).

  • Arrange for the relevant specialist/s to undertake the assessment (or different components of it) in conjunction with the employee. It could include one or more of the following:

    • referral via an occupational health adviser (or encouragement to self-refer) to a GP with occupational health experience or another appropriate health specialist (such as a physiotherapist). The aim is to diagnose and treat the employee and determine any need for further tests or sick leave

    • use of a screening tool to determine the prognosis for returning to work

    • a combined interview and work assessment by one or more appropriate specialists (such as a physician, nurse or another professional specialising in occupational health, health and safety, rehabilitation or ergonomics). This assessment should also involve the line manager

    • a return-to-work plan.

  • If a combined interview and work assessment is needed it should evaluate:

    • the person's health, social and employment situation, any barriers to returning to work (for example, work relationships) and their perceived confidence and ability to overcome these barriers

    • their current or previous rehabilitation experiences

    • the tasks they carry out at work – and their functional capacity to perform them (dealing with issues such as mobility, strength and fitness)

    • any workplace or work equipment modifications that are needed in line with the Disability Discrimination Act (including ergonomic modifications).

  • If a return-to-work plan is needed it should determine the level, type and frequency of interventions and services needed, including any psychological support (see recommendation 3). A return-to-work plan could also identify if any of the following is required:

    • a gradual return to the original job using staged increases in hours and days worked (for example, starting with shorter hours and/or less days and gradually increasing them)

    • a return to partial duties of the original job or temporary/permanent redeployment to another job.

  • Ensure those assessing which psychological support or interventions to offer are trained in psychological assessment techniques.

Recommendation 3: interventions and services

Who is the target population?

Employees experiencing long-term sickness absence or recurring short- or long-term sickness absence, particularly those with musculoskeletal disorders or mental health problems.

Who should take action?

  • Employers (this may be devolved to line managers, HR professionals or occupational health specialists).

  • Case workers (if appointed).

What action should they take?

  • Coordinate and support the delivery of any planned health, occupational or rehabilitation interventions or services and any return-to-work plan developed following initial enquiries or the detailed assessment. People who have a poor prognosis for returning to work are likely to benefit most from more 'intensive' interventions and services; those with a good prognosis are likely to benefit from 'light' or less intense interventions and services. Liaise with everyone involved (such as line managers and occupational health staff).

  • Where necessary, arrange for a referral to relevant specialists or services. This may include referral via an occupational health adviser (or encouragement to self-refer) to a GP, a specialist physician, nurse or another professional specialising in occupational health, health and safety, rehabilitation or ergonomics. It could also include referral to a physiotherapist.

  • Where necessary, employers should appoint a case worker/s to coordinate referral for, and delivery of any required interventions and services. This includes delivery of the return-to-work plan, if required (including modifications to the workplace or work equipment). The case worker/s does not necessarily need a clinical or occupational health background. However, they should have the skills and training to act as an impartial intermediary and to ensure appropriate referrals are made to specialist services.

  • Ensure employees are consulted and jointly agree all planned health, occupational or rehabilitation interventions or services and the return-to-work plan (including workplace or work equipment modifications).

  • Encourage employees to contact their GP or occupational health service for further advice and support as needed.

  • Consider offering people who have a poor prognosis for returning to work an 'intensive' programme of interventions. For example, offer a programme of multi-disciplinary interventions over several weeks combined with usual care and treatment. Examples may include one or more of the following:

    • cognitive behavioural therapy (CBT) or education and training on physical and mental coping strategies for work and everyday activities (this may be combined with exercise programmes)

    • counselling about a return to work

    • workplace modifications

    • referral to physiotherapy services or vocational rehabilitation (including training).

  • Consider offering more intensive, specialist input when there is recurring long-term sickness absence or repeat episodes of short-term sickness absence.

  • Consider offering 'light' or less intense interventions, along with usual care and treatment, to those with a good prognosis for returning to work. Examples might include short sessions providing one or more of the following, as appropriate: individually tailored advice on how to manage daily activities at home and at work (this could include advice on the benefits of being physically active and on relaxation techniques); encouragement to be physically active; referral to a physiotherapist or psychological services.

  • Ensure psychological interventions and services are evidence-based. Also ensure they are delivered by suitably trained and experienced practitioners. These may be health professionals (such as physicians, nurses or others specialising in occupational health, rehabilitation or ergonomics); social workers; clinical or occupational psychologists; specialist counsellors or therapists.

  • Consider helping people to develop problem solving and coping strategies using evidence-based psychological interventions. The aim is to overcome any barriers they have to returning to work and to support them to return. Examples which have been proven to be effective for certain groups and conditions are listed below:

    • women with musculoskeletal pain: CBT in small groups (involving 5–6 people), with one-to-one telephone follow-up

    • men and women with stress-related conditions: CBT and contact with the employer

    • men and women experiencing low back pain: CBT in small groups (involving 5–6 people) combined with one-to-one sessions of behavioural-graded activity and liaison with the workplace to discuss a return-to-work plan (for guidance on treatment see NICE clinical guideline on patients with chronic [longer than 6 weeks] non-specific low back pain [2009].

    • men and women with psychological or musculoskeletal problems: solution-focused group sessions (using, for example, 'The road ahead course' format)

    • men and women with whiplash injuries: progressive goal attainment programmes combined with physiotherapy or multimodal programmes.

  • Consider providing a multi-disciplinary back management programme to help employees with this condition return to work. It could be delivered by a GP with occupational health experience, a specialist professional (such as a physiotherapist) or a combination of others specialising in occupational health, health and safety, rehabilitation or ergonomics. As an example, a programme could comprise:

    • one intensive session covering attitudes to health, structure and function of the back and posture and the link to symptoms, stress and coping strategies, posture exercises and relaxation training

    • optional sessions to recap on learning and to discuss the experience of putting it into practice.

For guidance on treatment, see NICE clinical guideline on patients with chronic (longer than 6 weeks) non-specific low back pain (2009).

Unemployed people on incapacity benefit

Recommendation 4: returning to work

Who is the target population?

People with health problems who are unemployed and claiming incapacity benefit or ESA.

Who should take action?

  • Department for Work and Pensions.

  • Other bodies or organisations which may commission services for those who are unemployed and claiming incapacity benefit or ESA.

What action should they take?

  • Commission an integrated programme to help claimants enter or return to work (paid or unpaid). The programme should include a combination of interventions such as:

    • an interview with a trained adviser to discuss the help they need to return to work

    • vocational training, including that offered by 'New deal for disabled people' (for example, help producing a curriculum vitae, interview training and help to find a job or a work placement)

    • a condition management component run by local health providers to help people manage their health condition

    • financial measures to motivate them to return to work (such as return-to-work credit)

    • support before and after returning to work: this may include one or more of the following: mentoring, a job coach, occupational health support or financial advice.

  • Evaluate the programme (including any specific components) in line with research recommendation 2 (see section 5 for research recommendations).

The PDG considers that all the recommended measures are cost effective.

For the research recommendations and gaps in research, see section 5 and appendix D respectively.

  • National Institute for Health and Care Excellence (NICE)