Long term sickness absenceBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7495.802 (Published 07 April 2005) Cite this as: BMJ 2005;330:802
- Max Henderson, clinical research fellow in liaison psychiatry (, )
- Nicholas Glozier, consultant occupational psychiatrist,
- Kevin Holland Elliott, professor of occupational health and health risk management
- Institute of Psychiatry, Department of Psychological Medicine, Weston Education Centre, London SE5 9RJ
- Department of Occupational Health and Safety, King's College Hospital NHS Trust, London SE5 9RS
- Brunel University, Uxbridge, Middlesex UB8 3PH
Is caused by common conditions and needs managing
Sickness absence is a major public health and economic problem. In 2003, 176 million working days were lost; up 10 million on the previous year.1 Each week 1 million people report sick, 3000 of whom will still be away from work at six months.2 Only 20% of people receiving incapacity benefit for more than six months will return to work in the following five years.3 The costs are enormous. Each year, £13bn ($25bn; €19bn) are spent on benefits such as incapacity benefit, and the cost to industry is at least £11bn.4 Long term sickness absence contributes disproportionately to these figures. Although they constitute only a small fraction of absence episodes, longer absences comprise more than a third of total days lost and up to 75% of absence costs.1 2 Longer absences are associated with a reduced probability of eventual return to work and subsequent economic and social deprivation.
The government is increasingly aware of the issue and has made the reduction of work related ill health and disability, and resulting absence, a top priority.5 Recently a major overhaul of the incapacity benefit system was announced, in an attempt to remove some of the financial incentives for remaining incapacitated and some early results of vocational rehabilitation programmes have been filtering through. These are primarily aimed at people who have already been in the benefit system for a long time. Moving the agenda further towards primary prevention, the recent white paper, Choosing Health, included an important, but somewhat overlooked, chapter on work and health proposing several policy programmes.4
What medical conditions are producing such levels of morbidity? It might be expected that only severe illnesses would lead to such marked reduction in function, but in fact most long term absence is due to common conditions that, for whatever reason, fail to improve sufficiently. Until recently the most common causes were musculoskeletal disorders, in particular low back pain. In 1994-5, 194 000 new awards of social security benefits were made for back related incapacities, accounting for more than one in seven such awards.6 However, since then awards for back conditions have dropped by 42%.6
Over the same decade the contribution of psychiatric disorders to sickness absence has increased markedly, and surveys have shown a doubling in the numbers of people reporting stress that was caused or made worse by their work.7 Mental and behavioural disorders now account for more incapacity benefit claims than musculoskeletal disorders.3 This has occurred despite no apparent increase, except for alcohol dependence, in their prevalence.8 In light of this, the Health and Safety Executive has recently produced guidelines on the management of stress at work, based on current understanding of occupational factors such as job strain.9
Several recent government initiatives have been introduced to tackle the low employment rates among people with severe mental illness. These include individual placement support, return to work being included within patient care plans, and a strategy against stigma that is based on the social exclusion unit's recommendations.4 However, it is common mental disorders, such as depression and anxiety, rather than complex psychoses, that contribute most to this rising sickness absence. These are managed almost entirely in primary care, where the focus is on patients with apparently greater clinical needs. Effective evidence based treatments are available for these disorders, including antidepressant medication, problem solving, cognitive behaviour therapy, counselling, and collaborative management.10 Patients tend to prefer psychological therapies,11 but with a limited capacity to provide them the waiting times are commonly long. Novel approaches to delivery, such as computer based cognitive behaviour therapy, are still at an early stage of development. Both employers and patients require a speedier response than is currently delivered, as the longer an individual remains off work, the more difficult a return to work becomes.
Not uncommonly, a position develops where an individual has recovered sufficiently to consider returning to work but perceives that exposure to his employers, colleagues, or other aspects of work will lead to a relapse. General practitioners can have difficulty linking with employers to effect vocational rehabilitation and, as the patient's advocate, may feel uncomfortable recommending returning to work in this situation. Occupational physicians are best equipped to manage these cases, yet the United Kingdom has very poor provision of occupational health (one specialist for every 43 000 workers) compared with the rest of Europe.1 A cluster randomised controlled trial in Holland has shown how early psychological interventions for common mental disorders, delivered through the workplace, can enhance health and reduce absence.12 The intervention consisted of 4-5 sessions of cognitive behaviour therapy to increase activity and coping skills for those off sick for only two weeks. It reduced total sick leave, time taken to return to work, and recurrence at 12 months. If the government is serious about tackling the consequences of common mental disorders then innovative policies, possibly requiring major expansion in occupational health and provision of psychological therapy service in primary care, will be required alongside research into the most effective and cost effective methods of delivering service. This would be a wise investment given the substantial economic and social costs engendered by the current service framework.
Competing interests NG has received speaking and consulting fees from private and public employers who may benefit from a greater return to work of trained employees. KHE is chair of Corporate Health and Performance, a charity established to research the link between health, productivity and performance at work.
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