Sickness absence, or as it can be defined more precisely, absence from work that is attributed

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1 420 * THE MANAGEMENT OF SICKNESS ABSENCE COSTS Correspondene to: Dr S Whitaker, Institute of Oupational Health, University of Birmingham, Birmingham B15 2TT, UK s..whitaker@bham.a.uk Stuart C Whitaker Sikness absene, or as it an be defined more preisely, absene from work that is attributed to sikness by the employee and aepted as suh by the employer, remains high on the agenda for governments in the European Union (EU). Over the last deade most EU governments have implemented legislation that hanges soial seurity payments for the initial period of sikness absene. 1 This has had the evet of transferring the initial ost of sikness absene away from the taxpayer to the employer, who it is thought will have more diret ontrol over absene from work. In some ountries the ost of the initial period of sikness absene has also been transferred bak to the employee by, for example, removing payment for the first day or two of any new period of sikness absene, reduing the level of sikness benefit paid, and in some irumstanes by hanging the employment status of some groups of employees from diret employees to self employed status, where they are responsible for their own sikness absene and other labour osts. In addition many EU governments have introdued programmes aimed at enouraging long term absentees bak into work and making more stringent the medial standards required for early retirement on the grounds of ill health. In Denmark, for example, the government introdued a programme alled soial engagement of ompanies aimed at improving the situation for long term absentees and reduing exlusion from the workplae. In Norway the government and the soial partners agreed a national ampaign to redue absenteeism. 2 In the Netherlands, in 1994, the Duth government passed legislation that requires employers to engage ertified oupational health servies in order to help them manage sikness absene better. w1 w2 In the UK the government has taken additional steps to try to redue absene from work by, for example, setting targets to redue sikness absene in publi setor workers by 30% 3 and by integrating targets for reduing sikness absene by 30% as part of a publi health agenda. w3 OF ABSENCE Whoever pays for the ost of sikness absene, it is well reognised that the osts are enormous. As well as the salary osts for the person who is absent there are the osts of replaement stav or overmanning of the organisation to take aount of a speifi level of absene, osts assoiated with lost produtivity, or redued quality of servies, as well as the management, human resoures, and oupational health time spent dealing with absene that ould be used for other purposes. In order to give some idea of the sale of the problem several examples are given in box 1. Box 1: Cost of sikness absene the sale of the problem In the UK 177 million working days were lost in This has been assessed at over 11 billion (13.2 billion ECU) In Portugal, the two thousand largest enterprises lost 7731 million working days as a result of illness and 1665 million working days due to aidents in 1993 In the Netherlands, the absene rate was 8.3% in 1993, and 14.2% of the workfore were registered as disabled. The ost of providing benefits was NLG35 billion (16.6 billion ECU, 4.1 billion ECU on sikness absene and 12.5 billion ECU on disability benefits) In Germany employers paid up to DM60 billion (30.5 billion ECU) for soial seurity insurane to over osts of absene from work in 1993 In Belgium, with an absene rate of about 7%, BFr93 billion (2.4 billion ECU) was paid on sikness benefits in 1995 and BFr21 billion (0.6 billion ECU) for benefits on aidents and oupational diseases Preventing absenteeism at the workplae European Foundation 2 Oup Environ Med: first published as /oem on 1 June Downloaded from on 23 April 2018 by guest. Proteted by opyright.

2 Eduation Comparing levels of absene Comparing sikness absene rates between ountries, and sometimes between diverent organisations within the same ountry, an be ompliated beause of the use of diverent definitions of absene, variation in the riteria for inlusion and exlusion, and diverenes in the populations being ompared and in the auray of the sikness absene data olleted. For example, within the EU, some ountries exlude groups suh as all publi setor or self employed workers from the national figures. Others inlude those on permanent disability benefits or maternity leave in the sikness absene figures, and at least one an not separate absene due to illness from other reasons for absene. The European Foundation investigated sikness absene within the EU and did not publish a league table of absene rates between ountries beause of the risk of presenting misleading information. At best we an say that we do not have aurate, reliable sikness absene figures that are apable of diret omparison within the EU. 2 Poliy makers and politiians therefore need to be autious in their interpretation of the absene figures that are available both at the national and international level. Even within the same ountry sikness absene an be defined diverently by diverent organisations. In some a month s sikness absene is reorded as four alendar weeks (28 days), while in others it is four working weeks (20 days). Some organisations apture information on partial shift absenes, hospital or dental appointments, while others do not. The denominator used to alulate the absene rate an also vary. Some organisations use ontrated hours and others use established hours (whih inludes ontrated hours for positions that are vaant, but budgeted for), and some make an adjustment for annual leave, largely as a result of whether the information is being olleted for payroll or for manpower planning purposes. The hours lost due to maternity leave are often not reorded as sikness absene in the UK; however, the ontrated hours for those on maternity leave are often still inluded in the denominator and this ould have a signifiant evet when alulating the rate in working populations where there is a high female population. How employees, who still have an employment ontrat but have run out of statutory sik pay, are dealt with in alulating the absene rate an also vary between organisations. The absene rate is often reported based on the average (mean) figure, but in some irumstanes, beause of the binomial distribution of absene data, some use the median figure to report the absene rate. All of the above an be further ompliated by variation in the reliability of the systems used by diverent organisations to apture and reord absene data. Perhaps the most ommon way of determining the rate of absene in the UK is: lost hours over ontrated hours, without any adjustment for annual leave, exluding maternity leave from the numerator and disounting partial shift absenes, hospital appointments, et. The rate is most often reported as an average (mean) rate of absene. The overall rate of absene gives no indiation of the pattern of absene that predominates in an organisation. A large number of frequent, short term absenes or a small number of long term absenes an result in the same figure. The overall rate of absene is too rude a measure to be used on its own to indiate whether interventions to redue absene are working evetively or not. Some have reported the medial reasons for absene in defined populations. w4 6 These studies often use diverent lassifiation systems as there is no one standardised approah to lassifying the reasons for absene that is widely used. The thorny problem that has not been resolved as yet is how to determine what perentage of sikness absene is diretly attributable to onditions that have been aused or made worse by work. Managing attendane Managing attendane at work is always a line management responsibility. Most guidane douments on managing attendane stress the importane of having a robust attendane/absene management poliy that defines learly, for managers and stav, what sikness absene is, when it an be taken, how and when it should be reported and reorded, and what steps should be taken to manage attendane at an individual level. This often starts with having a well maintained individual attendane (or absene) reord that aptures information on the frequeny and duration of spells of absene over a period of time, often one year. The individual reord may also allow periods of absene to be linked to days of the week when sikness absene is taken, or to other events, suh as holidays or weekends in order to identify possible trends in the pattern of absene. However, little attention has been paid to relating patterns of absene to hanging working onditions, types of exposure or organisational events, suh as downsizing, although all of these fators have been linked to inreased absene. The importane of arrying out individual return to work interviews for employees who have been absent is often stressed. It is suggested that the return to work interview signals to the employee that absene is taken seriously in the organisation, and it overs the manager and the employee the opportunity to disuss, in an informal setting, any issues that may be aveting attendane or performane at work. Some organisations set triggers for further ation, suh as automati management review if the employee has been absent for more than three episodes in a 12 month period, or automati referral to the oupational health servie after a speifi number of spells or speifi duration of absene. Referral to oupational health When the manager makes a formal referral for the employee to be seen by the oupational health servie beause of their sikness absene there is often a strong element of ompulsion for the employee to attend. Refusal may lead to negative onsequenes for the employee. However, management and stav may not appreiate fully that an employee annot be ompelled to undergo any form of medial examination or health assessment without first having given their informed onsent for that assessment to take plae. Consent an only be regarded as informed when the individual understands what information is being released, to whom, the purposes for whih it will be used, and the possible onsequenes of that use. Consent must be given freely, under no duress or threat, and applies only for the time and event for whih it is given. w7 Therefore the employee has a legitimate right to refuse a medial examination. However, they should understand that refusal to undergo a medial examination does not prelude further management ation from being taken. Questions that are frequently posed by managers to oupational health professionals on sikness absene referral letters are listed in box 2. *421 Oup Environ Med: first published as /oem on 1 June Downloaded from on 23 April 2018 by guest. Proteted by opyright.

3 Eduation 422 * Box 2: Questions frequently asked by managers to oupational health professionals on referral Can you onfirm that there is an underlying medial ondition ausing the urrent level of absene? Can you estimate the length of time the employee is likely to be absent from work with this ondition? Can you indiate whether, on return to work, the employee is likely to be able to resume his or her normal duties? Are there likely to be any impliations for the health and safety of the employee or others on his or her return to work? Should restrited duties, redeployment or retirement on the grounds of ill health be onsidered at this stage? Does disability disrimination legislation apply in this ase? Verifying the reason for absene It is often the first question in box 2 that auses the most onern. The oupational health professional is being asked to verify the reason for absene and to say whether, in their opinion, the length or pattern of absene, often ertified by the general pratitioner, is justified. If they indiate that, in their opinion, it is not, this alls into question the genuineness of the illness, and the employee s honesty or ommitment to the organisation, and may lead to the manager pursuing disiplinary ation against the employee. Under these irumstanes the employee may feel that their role, during the health assessment, is to onvine the oupational health professional that their absene an be justified on medial grounds. This may lead to employees wanting to present their ase in the best possible light, exaggerating their symptoms and being unwilling to enter into any open disussion on other, stritly non-medial fators, that may nevertheless play a signifiant part in their absene from work. There is onern that plaing the dotor or nurse in the position of having to verify the reason for absene on behalf of the employer so hanges the nature of the dotor patient, nurse patient relationship that this ativity raises serious ethial questions. The International Labour Organisation, a tripartite organisation of the soial partners, has published tehnial and ethial guidane whih states that Oupational health professionals should not be required by the employer to verify the reasons for absene from work. 4 This is largely in order to protet the relationship of trust that is essential for open and honest ommuniation between a patient and health are professional. In Holland general pratitioners have refused to ertify the reason for absene from work sine the beginning of the 20th entury in order to protet the onfidential relationship with their patients. w2 At one point the British Medial Assoiation also pressed for the same position. 5 Sine 1994 Duth oupational physiians, despite fiere protests, have been fored to undertake the task of ertifiation. w2 Reent researh suggests that Duth general pratitioners do not trust oupational physiians who undertake this task on behalf of employers. w8 In Germany it is not only onsidered unethial for the oupational physiian to be asked to verify the reason for absene but also legislation prevents them from doing so. In Spain oupational physiians threatened to take industrial ation if they were to be required to verify the reasons for absene. Yet in the UK this question has beome widely aepted without ausing any further debate on the role of the oupational physiian in verifying the reason for absene or on how this ativity might avet the relationship between oupational health servies and workers. Whether the UK is leading the field in this respet or adopting praties that other health are professionals are unwilling to aept needs further onsideration. The omplex phenomenon of sikness absene Sikness absene is a omplex phenomenon that is influened strongly by fators other than health. The deision to attend or resume work following sikness absene will be related to the real and pereived onditions of work (both physial and psyhosoial), antiipated job demands, management attitudes and behaviours, soial norms in the peer group and ommunity, advie and information from general pratitioners and hospital speialists, as well as eonomi pressures aused through loss of earnings (for the individual) and loss of produtivity (for the organisation). There are also other fators that operate at the individual level, suh as the person s health beliefs, sikness behaviour, motivation to attend, and job satisfation that play a part in this deision making proess. It has been suggested that many workers will attend work with onditions that others will be absent with, 5 and that where there are high rates of absene there are also high rates of presenteeism. w9 If oupational health professionals are to develop interventions that are evetive in helping people to return to work and remain at work, they will need to develop a good understanding of the fators other than disease that influene this behaviour. They will need to find new ways of working with organisations to identify and implement strategies aimed at reduing absene that take aount of these fators. This will require lose ooperation between line managers, human resoures, worker representatives, and oupational health professionals. It is likely that these strategies, whih take aount of the broad range of fators that avet sikness absene, will beome inreasingly important in the future as government poliy will require more long term absentees to be reintegrated bak into the workfore to prevent soial exlusion; fewer people with health problems may be allowed to retire on health grounds, and at the same time there will be inreasing pressure plaed on employers to redue sikness absene still further. New and more dynami approahes to sikness absene may need to be developed. Sikness absene an be viewed from a number of diverent perspetives, and these are listed in box 3. However it is rare that these sometimes onfliting perspetives an be reoniled and all of the diverent fators that avet sikness absene an be onsidered together. The fators that have been linked to inreased rates of absene are shown in box 4. These fators have been investigated by a number of diverent disiplines. Soial sientists have viewed sikness absene as a phenomenon that arises out of a set of written and unwritten rules that operate within the ontext of the labour market in a apitalist soiety. w10 They have onentrated on the influene that sikness absene benefits and soial insurane systems an have on paid absene from work. 6 The impat of severe eonomi deline, 7 industrial downsizing, w11 soioeonomi diverenes, 8 w12 and other fators suh as sex, 9 w13 17 ethni group, w18 and regional variation w10 have been desribed. Psyhologists have investigated individual fators suh as personality, job stress, performane and absenteeism, 10 job satisfation, w19 w20 and the relation between short and long term sikness with soial irumstanes, working onditions, and Oup Environ Med: first published as /oem on 1 June Downloaded from on 23 April 2018 by guest. Proteted by opyright.

4 Eduation Box 3: Different perspetives on sikness absene From the soial perspetive in terms of the rights and benefits that soiety onsiders should be made available to those who are unable to work beause of illness From the eonomi perspetive, inluding the impat that sikness absene has on produtivity and sustainable development at the national and loal level From the perspetive of line managers and human resoures who have to manage individuals and groups of workers within the framework of employment law From the perspetive of health are professionals involved in helping to protet the health of workers From the perspetive of employees and trades unions Box 4: Fators that an affet sikness absene Maro level Organisational level Individual level + limate + thenatureofthe + age industry + epidemis + working onditions + sex + provision of health are + job demands + oupational status servies + soial insurane systems + size of the enterprise + job satisfation + sikness ertifiation + harateristis of the + length of servie praties workfore + taxation + workfore availability + personality + pensionable age + industrial relations + life rises + soial attitudes + supervisory quality + family responsibilities + eonomi limate + personnel poliies + soial support + availability of alternative + labour turnover + leisure ativities employment + unemployment + the provision of oupational health servies + alohol intake + the health status of the individual sex w21 In addition the influene of psyhosoial fators, soial support, marital status, w22 stress, w23 and psyhiatri morbidity w24 30 have been onsidered. From an organisational perspetive fators suh as personal and organisational determinants of pereived absene norms, w31 hanges in the psyhosoial work environment, 14 organisational hange, w32 relationship between job inseurity and work based support, w33 positive peer group interation at work, and satisfation with o-workers w22 have been investigated. Health professionals have investigated the impat on sikness absene of oupational health servies, 17 w34 health promotion w35 38 employee fitness programmes, w39 w40 physiotherapy servies, w41 w42 vaination programmes w43 as well as the evet of work load. 18 Conlusions Sikness absene is likely to remain high on the agenda for government and industry. Oupational health professionals need to have a broad understanding of the fators, other than disease, that avet sikness absene if they are to be able to advise organisations, ommuniate evetively with line managers, and work with individuals. However, the role of the oupational health servie in relation to sikness absene must be defined learly and ommuniated to stav and management if they are to avoid being used simply as a management tool. A positive approah to takling absene, inluding the non-medial, psyhosoial issues that have been shown to have suh an important influene on absene, should be developed further. This will require lose Box 5: Management of sikness absene key points Sikness absene remains high of the agenda for governments in Europe The finanial ost of sikness absene in EU member states remains enormous Most EU member states have implemented legislation that requires employers, and in some irumstanes employees, to bear the initial osts of sikness absene Inreasingly employers are turning to oupational health servies to help them manage attendane better New methods of working with organisations, that reognises that ill health is only one fator to onsider in managing sikness absene, are required Sikness absene is affeted by a large number of different fators: soial insurane systems, benefits payments, and medial ertifiation praties influene attendane at work job seurity, availability of alternative employment, and eonomi limate affet attendane organisational fators suh as size of the enterprise, personnel poliies, and management proedures affet attendane job satisfation, workplae stress, and psyhosoial work environment affet attendane individual fators, suh as personality, soial support, marital status and ill health affet attendane ooperation with human resoures, line management, and workers representatives. The management approah to sikness absene that has largely been adopted in industrialised ountries 19 provides an important framework for managing attendane, but new and innovative approahes to help organisations overome barriers to attendane need to be developed further. The onept that sikness absene an have positive benefits should also be reognised as sikness absene has been onsidered to be too low in some irumstanes. 20 Oupational health professionals are well plaed to promote a positive approah to dealing with sikness absene, both at an organisational and individual level. website extra Additional referenes appear on the Oupational and Environmental Mediine website Referenes 1 Grundemann RWM, Vuuren CV. Preventing absenteeism at the workplae: European researh report. European Foundation for the Improvement of Living and Working Conditions, Offie for Offiial Publiations of the European Communities, Luxembourg, This and the report in referene 2 present the results of a European wide projet to identify and disuss strategies to redue absene. 2 Grundemann RWM, Vuuren CV. Preventing absenteeism at the workplae: a European portfolio of ase studies. European Foundation for the Improvement of Living and Working Conditions, Offie for Offiial Publiations of the European Communities, Luxembourg, Cabinet Offie. Managing attendane in the publi setor: putting best pratie to work. London: Central Offie of Information, This desribes the state of the art in managing attendane from a management perspetive *423 Oup Environ Med: first published as /oem on 1 June Downloaded from on 23 April 2018 by guest. Proteted by opyright.

5 Eduation 424 * 4 International Labour Offie. Tehnial and ethial guidelines for workers health surveillane. Geneva: International Labour Offie, 1998 (Oupational Safety and Health Series No. 72). This artile and the one below provide a useful insight into how sikness absene has been viewed from an oupational health perspetive. 5 Taylor P. Sikness absene: fats and misoneptions. J R Coll Physiians 1974;8: Alexanderson K. Sikness absene: a review of performed studies with fous on levels of exposures and theories utilized. Sand J So Med 1998;26: Kivimaki M, Vahetra J, Thomson L, et al. Psyhosoial fators prediting employee sikness absene during eonomi deline. J Applied Psyhol 1997;82: North F, Syme SL, Feeney A, et al. Explaining soioeonomi differenes in sikness absene: the Whitehall II study. BMJ 1993;306: Messing K, Tissot F, Saurel Cubizolles MJ, et al. Sex as a variable an be surrogate for some working onditions: fators assoiated with sikness absene. J Oup Environ Med 1998;40: Arsenault A, Dolan S. The role of personality, oupation and organization in understanding the relationship between job stress, performane and absenteeism J Oup Psyhol 1983;56: Blank N, Diderihsen F. Short-term and long-term sik leave in Sweden: relationships with soial irumstanes, working onditions and gender. Sand J So Med 1995;23: Niedhammer I, Bugel I, Goldberg M, et al. Psyhosoial fators at work and sikness absene in the Gazel ohort: a prospetive study. Oup Environ Med 1998;55; North FM, Syme SL, Feeney A, et al. Psyhosoial work environment and sikness absene among British ivil servants: the Whitehall II study. Am J Publi Health 1996;86: Vahtera J, Kivimaki M, Pentti J, et al. Effet of hange in the psyhosoial work environment on sikness absene: a seven year follow up of initially healthy employees. J Epidemiol Community Health 2000;54: Rael EG, Stansfeld SA, Shipley M, et al. Sikness absene in the Whitehall II study, London: the role of soial support and material problems. J Epidemiol Community Health 1995;49: Vahtera J, Uutela A, Pentti J. The effet of objetive job demands on registered sikness absene spells; do personal, soial and job-related resoures at as moderators? Work and Stress 1996;10: Hamers P, Kamphius P, VanPoppel J. Relationship between oupational health are and absenteeism. Oupational Mediine 1992;42: Bourbonnais R, Vinet A, Meyer F, et al. Certified sik leave and work load. Br J Oup Med 1992;34: Balombe J, Strange N, Tate G. Wish you were here How UK and Japanese-owned organisations manage attendane. London: The Industrial Soiety, Another state of the art report on how to manage attendane from a management perspetive. 20 Kristensen TS. Sikness absene and work strain among Danish slaughterhouse workers: an analysis of absene from work regarded as oping behaviour. So Si Med 1991;32: QUESTIONS (See answers on page 410) For eah question, indiate whih answers are true and whih are false. (1) In order to ompare sikness absene figures between organisations the following are essential: (a) The same personnel poliies and management proedures for sikness absene (b) The same definition of sikness absene () The same omputerised sikness absene reording system (d) Reliable sikness absene reording systems in the organisations (e) A standardised method of analysis of the sikness absene data in the organisations (f) A standardised oding system for the medial reasons for absene (g) Comparable working populations (2) Monitoring the overall rate of absene over time in an organisation: (a) Indiates if a few people are taking long periods of absene (b) Indiates if most people are taking frequent short term absene () Indiates whether the trend in sikness absene is going up or down (d) Does not indiate whether interventions to redue absene are working or not (e) Indiates ommon underlying reasons for absene (3) Whih of these fators has been linked to inreased sikness absene: (a) Poor working onditions (b) High job demands () Low job satisfation (d) Being male (e) Lak of soial support (f) Smoking (4) The UK government has set targets to redue absene in the publi setor by what per ent? (a) By 10% by the year 2002 (b) By 30% by the year 2003 () By 40% by the year 2005 (d) By 25% by the year 2003 (e) By 25% by the year 2005 Oup Environ Med: first published as /oem on 1 June Downloaded from on 23 April 2018 by guest. Proteted by opyright.