People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

This guideline should be read in conjunction with the NICE guideline on workplace health: management practices, the NICE guideline on low back pain and sciatica in over 16s and the NICE guideline on mental wellbeing at work.

This guideline focuses on managing sickness absence among all employees, regardless of whether they have a disability or long-term condition covered by the Equality Act 2010. It should be considered alongside the legal requirements for employers in relation to health and disability, and it is not a substitute for the law or relevant codes of practice.

The recommendations in sections 1.1 and 1.3 to 1.7 are for employers, senior leadership, managers and human resources personnel.

The recommendations in section 1.2 are for those assessing and certifying fitness for work.

The recommendation in section 1.8 is for those responsible for commissioning and delivering advice and support services for people not in work and who are receiving benefits relating to a health condition or disability.

1.1 Workplace culture and policies

1.1.1 Make health and wellbeing a core priority for the top level of management of the organisation. See the section on organisational commitment in NICE's guideline on workplace health: management practices (this section includes making health and wellbeing a core priority, ensuring the commitment of managers, and the importance of policies and of clear communication). [2019]

1.1.2 Foster a caring and supportive culture that encourages a consistent, proactive approach to all employees' health and wellbeing. [2019]

1.1.3 Organisations (for example those with a small number of employees) that do not have formal policies should ensure that clear and accessible procedures for reporting and managing sickness are in place and are explained to all new and existing employees. [2019]

1.1.4 Ensure that all employees know the workplace policies or procedures for notifying and managing sickness absence, and for return to work. Make this part of the induction process for new employees and ensure that they know the sickness absence reporting system is confidential. [2019]

1.1.5 When developing workplace policies for managing sickness absence and return to work, ensure that these are part of a broader, strategically led approach to promoting employees' health and wellbeing (see recommendation 1.1.1). [2019]

1.1.6 Consider using a confidential and accessible employee assistance programme and occupational health provider if the organisation does not already do this. [2019]

1.1.7 Monitor and regularly review the impact of sickness absence policies and procedures to ensure that they are being implemented fairly and consistently across the organisation and that they are fit for purpose. [2019]

1.1.8 Consider collecting non-identifiable data that can enable the sickness absence profile and changing trends to be monitored across the organisation. The data should include information on:

  • the duration and frequency of absence

  • the cause of absence (and whether work related)

  • factors that may be associated with sickness absence such as job role, salary band, department and location of workplace. [2019]

1.1.9 Regularly review the data on trends in sickness absence to identify:

  • areas in which intervention may be needed to support employees' health and wellbeing and

  • policies or procedures that may need to be reviewed or amended. [2019]

To find out why the committee made the recommendations on workplace culture and policies and how they might affect practice, see rationale and impact.

1.2 Assessing and certifying fitness for work

1.2.1 The statement of fitness for work ('fit note') should be completed by the medical practitioner with the most relevant recent knowledge of the person's health, reason for absence and prognosis for return to work. This may be a GP or secondary care specialist. [2019]

1.2.2 Encourage people who are assessed as not fit for work to maintain regular contact with their workplace. [2019]

1.2.3 If the person is likely to be absent from work for more than 4 weeks, consider:

  • referral to health rehabilitation and support services, such as physiotherapy, counselling or occupational therapy

  • signposting them to other possible expert sources of vocational advice and support relevant to their condition. [2019]

1.2.4 Take account of the fact that reasons for sickness absence can be complex. Encourage the person to:

  • reflect on any factors in their work or personal life that may be contributing to their current absence or causing concern about returning to work and

  • identify any additional support they might need. [2019]

1.2.5 Be aware that employers need information on how the employee's health condition or treatment could affect them on their return to work. Use the statement of fitness for work to provide sufficient information in clear, non‑technical language. [2019]

To find out why the committee made the recommendations on assessing and certifying fitness for work and how they might affect practice, see rationale and impact.

1.3 Statement of fitness for work

1.3.1 When a statement of fitness for work ('fit note') is received indicating that someone is not fit for work, start and maintain a confidential record. This record should include:

  • the reason for absence, the anticipated length of absence and any recurrence of absence for the same reason and

  • any comments from the medical practitioner about how the person's condition or treatment affects their capacity for work.

    (Also see the section on keeping in touch with people on sickness absence). [2019]

1.3.2 To support the person who is currently not fit for work and plan for their return to the workplace, consider:

  • taking into account any additional information provided (for example from an allied health professional's health and work report) about how their condition may affect their ability to do their role

  • seeking information and advice on what support they might need, such as from an occupational health service or from other possible expert sources of vocational advice and support relevant to their condition (this may include online resources, or telephone advice from external bodies)

  • discussing with them what adjustments or other support might be needed if any ongoing health needs are anticipated for when they return to work; if adjustments need approval, discuss these with decision makers to gain sign-off. [2019]

1.3.3 When a statement of fitness for work indicates that a person may be fit for work, contact them as soon as possible:

  • Discuss what adjustments (such as flexible working, phased return, reduced hours, changes to workstations or duties) might help them return to work. Use any recommendations in the statement of fitness for work as a starting point.

  • Involve the employee and line managers in these discussions initially, and occupational health services if needed.

  • Human resources, trade unions or occupational health services (if not already participating) may also be involved, especially if the circumstances or adjustments are more complex. [2019]

1.3.4 If adjustments suggested by a medical practitioner in the statement of fitness for work or requested by the employee cannot be made, explain the reasons clearly in writing to the employee. With their informed consent, send a copy to the certifying medical practitioner. [2019]

1.3.5 If a person may be fit to return to work with adjustments but those adjustments cannot be made, the person should continue to be treated as 'not fit for work', in line with the Department for Work and Pensions' guidance for employers. In such cases:

  • Advise the person that they should return to work only when they have sufficiently recovered and are able to perform their regular duties.

  • Discuss and jointly agree a plan for keeping in touch during their extended absence. Discuss any actions that may support them in making a full recovery and returning to their regular duties, and agree to regularly review these (see the section on early intervention). [2019]

To find out why the committee made the recommendations on statement of fitness for work and how they might affect practice, see rationale and impact.

1.4 Making workplace adjustments

1.4.1 When any work adjustments have been agreed with a person returning from sickness absence:

  • Arrange additional risk assessments if needed. Guidance on these is available on the Health and Safety Executive website.

  • Discuss with the returning person whether colleagues could be informed about the adjustments to help them understand the need for them. Seek the person's informed consent and, if it is given, explain the reasons why the adjustments are being made. Discuss with colleagues any concerns that they may have about the impact of adjustments. [2019]

1.4.2 Record any workplace adjustments agreed with the employee, including a timeframe for their implementation and how long they are expected to last, in a written return-to-work plan for the employee and their line manager. [2019]

1.4.3 Monitor any workplace adjustments that have been put in place to see if they are meeting the needs of both the employee and employer. Review this regularly, within a timeframe agreed by the employee and line manager in the written return-to-work plan.

  • Encourage the employee to raise any issues related to the workplace adjustments and discuss who to raise them with. This may be an independent, impartial person. If necessary, think about making changes to the return-to-work plan.

  • Ensure that the employee is aware of other interventions that may be available to support them in their workplace (see the section on early intervention). [2019]

To find out why the committee made the recommendations on making workplace adjustments and how they might affect practice, see rationale and impact.

1.5 Keeping in touch with people on sickness absence

1.5.1 Ensure that the organisation regularly keeps in touch with people who are 'not fit for work' during periods of sickness absence, including people with a chronic health condition or a progressive illness or disability covered by the Equality Act 2010. [2019]

1.5.2 Make contact as early as possible, and within 4 weeks of them starting sickness absence, depending on the circumstances. [2019]

1.5.3 When contacting the employee:

  • Be sensitive to their individual needs and circumstances.

  • Be aware that communication style and content could affect their wellbeing and decision to return to work.

  • Ensure that they are aware that the purpose of keeping in touch is to provide support and help them return to the workplace when they feel ready.

  • If an early referral to support services (for example physiotherapy, counselling or occupational therapy) is available through the organisation's occupational health provider, discuss if this may be helpful.

  • Discuss how they would like to be contacted in future, how frequently and by whom. If the line manager is not the most appropriate person to keep in touch, offer alternatives.

  • Provide reassurance that anything they share about their health will be kept confidential, unless there are serious concerns for their or others' wellbeing. [2019]

1.5.4 Ensure that members of staff responsible for keeping in touch with people on sickness absence:

  • are aware of the need for sensitivity and discretion at all times

  • understand the organisation's policies or procedures on managing sickness absence and returning to work

  • are competent in relevant communication skills and are signposted to and encouraged to use online or other resources and advice to improve these skills. [2019]

To find out why the committee made the recommendations on keeping in touch with people on sickness absence and how they might affect practice or services, see rationale and impact.

1.6 Early intervention

1.6.1 In organisations that offer access to early interventions (such as rehabilitation, counselling or an employee assistance programme) ensure that all employees are aware of their availability, remit and confidentiality. [2019]

1.6.2 Assure employees that all contact with the employee assistance programme is confidential. [2019]

1.6.3 For employees whose sickness absence is expected to continue beyond 4 weeks, in organisations with access to an occupational health provider:

  • discuss the possibility of a referral to occupational health for an assessment of fitness for work or

  • discuss the suitability for early referral to support services; if referral is appropriate, ensure that this takes place as early as possible. [2019]

1.6.4 If occupational health services or an employee assistance programme are not available, encourage employees whose sickness absence is expected to continue beyond 4 weeks to discuss with their GP or secondary care specialist any options for referral to support services such as physiotherapy, counselling or occupational therapy. [2019]

To find out why the committee made the recommendations on early intervention and how they might affect practice, see rationale and impact.

1.7 Sustainable return to work and reducing recurrence of absence

Sustainable return to work for people with a musculoskeletal condition

1.7.1 For people who have been absent for 4 or more weeks because of a musculoskeletal condition, consider interventions to help them return to work. For example:

  • A programme of graded activity delivered by someone with appropriate training (for example, a physical or occupational therapist).

  • Problem-solving therapy.

  • A worksite assessment by a suitably qualified professional to review and discuss with the employee, together with a representative of the employer, the suitability of work tasks or any adjustments that could be made.

  • A meeting between the employee and their line manager, facilitated by an impartial person, to agree the key barriers to returning to work and what modifications could be made to the work environment to overcome these. [2019]

Reducing recurrence of absence for people with a common mental health condition

1.7.2 For people who resume work after an absence of 4 or more weeks for a common mental health condition, consider a 3‑month structured support intervention to reduce the likelihood of a recurrence of absence. Involve the line manager in this process, which could be led by an impartial person. The intervention may include:

  • Meeting the person to identify any issues encountered since their return to work, and exploring possible solutions and support needs.

  • Developing an action plan to implement, which is agreed with the person's line manager.

  • Regular follow-up meetings with the person and their line manager to evaluate progress. [2019]

To find out why the committee made the recommendations on achieving a sustainable return to work and how they might affect practice, see rationale and impact.

1.8 People with a health condition or disability who are not currently employed

1.8.1 Commission an integrated programme to help people receiving benefits who have a health condition or disability to 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 (for example help producing a CV, 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

  • support before and after returning to work that may include 1 or more of the following: mentoring, a job coach, occupational health support or financial advice. [2009]

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary or, for public health and social care terms, the Think Local, Act Personal Care and Support Jargon Buster.

Common mental health condition

Common mental health conditions include conditions such as depression, generalised anxiety disorder, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder and social anxiety disorder.

Condition management

Programmes delivered by healthcare professionals that do not treat the underlying condition, but that focus on improving the likelihood of people being able to return to, or stay in, work. These programmes may aim to improve a person's understanding of their condition, increase their confidence and improve their ability to function in the workplace, through for example, pain or stress management and building self‑esteem and confidence.

Employee assistance programme

An employer-funded programme offering confidential services such as counselling and advice on a range of work and personal issues. Although the employer may receive an indication of numbers of employees taking up the service, no personal information is shared with the employer that would enable them to identify which employees access the service or their reason for doing so.

Employment and support allowance

Employment and support allowance (ESA) is a 2‑tier system of benefits that will be replaced by the introduction of Universal Credit. All claimants who are out of work because of ill health or a disability are entitled to claim ESA (paid at the same rates as job seeker's allowance). Those deemed capable of work at some time in the future (by a medically administered 'work capability' test) are placed in a work‑related activity group. Those deemed not capable of work because of the severity of their physical or mental condition are placed in a support group with no conditions (and until April 2017 received a higher support allowance).

Graded activity

Graded activity aims to increase a person's activity levels gradually using a behavioural approach. Typically, people with musculoskeletal conditions attend individually focused training sessions with a gradually increasing exercise programme.

Long-term sickness absence

Long-term sickness absence is sometimes defined as an absence lasting more than 2 weeks, but for this guideline it is defined as 4 or more weeks (as per the scope of this guideline and previous NICE guidance). Recurring long-term sickness absence has been defined as more than 1 episode of long-term sickness absence, with each episode lasting more than 4 weeks.

Micro-, small- and medium-sized organisations

Organisations employing fewer than 250 people. Micro-sized organisations employ between 0 and 9 people, small organisations employ between 0 and 49 people and medium-sized organisations employ between 50 and 249 people.


Inappropriately continuing to go to work despite health problems. It also describes someone's attendance at work without performing all of their usual tasks (regardless of the reason). When employees feel the need to attend work although they are not functioning fully, it can result in losses in productivity. Presenteeism can also make health problems worse.

Problem-solving therapy

Therapy that involves learning or reactivating problem-solving skills.

Short-term sickness absence

For this guideline it is defined as an absence lasting up to (but less than) 4 weeks. Recurring short-term sickness absence is defined as more than 1 episode of short-term sickness absence, each lasting less than 4 weeks.


Wellbeing is the subjective state of being healthy, happy, contented, comfortable and satisfied with one's quality of life.

Vocational rehabilitation

Helps those who are ill, injured or who have a disability to access, maintain or return to employment or another useful occupation. It may involve liaison between healthcare and rehabilitation practitioners; management, human resources and other in‑house or external facilitators. It may result in transitional working arrangements, training, social support and modifications to tasks.

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)