Long term sickness absence
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7495.802 (Published 07 April 2005) Cite this as: BMJ 2005;330:802
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Unlike some of my colleagues, I feel that GPs, with their records and
knowledge of these common conditions, are in the best position to make
decisons on absence from work. However the system needs to change to
reflect the greyness of most of these decisions. Thus in some conditions
there are no issues about absence, e.g severe angina. However in many
conditions prompting a review of the fitness to work, the clarity of the
need to refrain can vary from reasonable to dubious/not indicated. These
descriptions would change depending on the how long the patient has been
off already.
Is there some way the GP could indicate that status and that would
allow the employer or the benefits agency to add their opinion and even
make the decision? The GP can give an opinion that it is not clear whether
the patient should refrain and also that working is unlikely to seriously
impair the patients health and then the employer or the benefits agency
could use their knowledge of the job or jobs available to make a decision.
We need a more sophisticated system which retains decisiveness and
speed. We need a system which does not put a bilateral blind amputee in
the same group as a young man with mild chronic depression. That system
also needs to use the GP's skills and knowledge in a way which does not
threaten the GP's therapeutic relationship with the patient.
Competing interests:
None declared
Competing interests: No competing interests
The editorial of Henderson et al (BMJ 2005;330:802-3) identifies the
role of mental health problems within 'Long term sickness absence'. The
increasing relevance of 'stress' and/or 'depression' in the workplace
seems clear. In identifying the need for more Occupational Physicians the
authors did not appear to consider the role of Psychiatry in assessment
and treatment of mental health problems in the workplace. Perhaps this is
because of the lack of training in Occupational Psychiatry (as distinct
from Occupational Medicine and Occupational Psychology) as it does not
exist as a formal specialism.
In the May issue of the Psychiatric Bulletin an invitation will
appear to express an interest in the formation of a Special Interest Group
in Occupational Psychiatry within the Royal College of Psychiatrists. This
group, if formed, would have the opportunity to gather together expertise
to become a force in improving the profile of early identification and
treatment of those with mental health problems in the workplace and
establish a place for Occupational Psychiatry.
Competing interests:
Dr Sharkey is one of the sponsors for a Special Interest Group in Occupational Psychiatry, within the Royal College of psychiatrists
Competing interests: No competing interests
A great deal of sickness absence arises from the worrying trend to
medicalise life. Much absence due to work related stress is in fact
disaffection rather than disease. It manifests itself as unhappiness and
anxiety with the working environment and becomes a withdrawal from work
legitimised as a medical problem through certified absence.
Most healthy people of average fortitude given work which is
interesting, satisfying, properly resourced and professionally managed
will turn up to do it. There is abundant evidence that such work is good
for long term health. The reverse is also true. The common belief held by
bad employers and some politicians that people are naturally workshy is an
urban myth which seems to have aquired longer legs than the Protocols of
Zion.
We need better management rather than better medicine. Good
occuptional physicians should use their influence to encourage good
management within their own organisations, to make sure that stress risks
are systematically and professionally assessed and be at the heart of
rehabilitation in concert with the GP. Good GPs will work with us to get
their patients get back to work.
With an ageing workforce and a difficult and rigorous pensions
climate we had all better knuckle down to the fact that we are going to be
at work for much longer than before. Long term incpacity due to stress
and early retirements, often on tiny pensions, are not sustainable options
for the economy, pension funds the NHS or the future.
We have warehouses full of research and policies all saying the same
things. What we now need is action on behalf of employers who believe
that decency in the workplace makes good health and therefore business
sense matched with action by doctors who believe that work should be part
of their patients solution, not their problem.
Competing interests:
None declared
Competing interests: No competing interests
Sir- Hendersen and colleagues write that sickness absence is a major
public health and economic problem (1). Undoubtedly, it is a major
economic problem, but apparently it does not serve as an appropriate tool
to measure public health.
Norway has some of the highest incidences of sickness absence in the
world, but only 10% of the working stock are responsible for over 80% of
the absence (2). Disorders of various origins that often lead to
disability and unemployment, have largely been neglected in medical
research. The core complaints are often subjective, and cannot be
demonstrated by objective testing.
Apparently reasons for sickness absence have been considered
political problems and have not gained sufficient attention from the
medical and scientific communities. Methodologically rigorous,
longitudinal, and interventional studies are needed to determine
characteristics that are associated with the motivation to work rather
than the ability. Interventions that appear effective in restoring this
interest are needed in most industrialized countries. Such studies need to
be directed toward the 10% that contribute to 80% of the absence, and not
towards the entire working population.
1. Henderson M, Glozier N, Elliott KH. Long term sickness absence BMJ
2005;330:802-803
2. Excersise did not lead to less sickness absence [in norwegian]
http://www.forskning.no/Artikler/2002/oktober/1035182667.9
Competing interests:
None declared
Competing interests: No competing interests
Long term sickness absence
The British Society of Rehabilitation Medicine (BSRM) strongly
supports the thinking behind the comprehensive editorial by Henderson et
al (1). There are, however, a number of practical ways in which such
individuals can be helped back into work which were not included in their
review.
We agree that the role of employers may be a critical factor and
excellent practical advice is given by the Health & Safety Executive
for employers (2). Disability Employment Advisers based at each
JobcentrePlus are also helpful in assisting those with health difficulties
back into work, and have particular expertise in addressing the ‘mismatch’
between the individual’s abilities and the demands of employers (3).
The Primary Care Team can also greatly assist employers by adopting
the following strategies:
1. encouraging the employee to remain in contact with his/her employer and
to be open about their health problem
2. remaining positive about the value of employment to individuals and
their families.
3. pointing out that not working also has major health implications
4. eliciting from patients their perceived barriers to returning to work
and helping them to overcome these (4).
5. producing a realistic “Return to Work Plan” (2). This often entails
encouraging employers to consider a ‘phased return to work’ and adjustment
of the work situation. The latter could include finding less stressful
work initially.
However, the practical difficulties in communication between health
professionals and employers are well recognised (5). Until such times as
all health professionals understand the relationships between health and
employment, both the BSRM (3) and the Royal College of Psychiatrists (6)
‘have called for designated health professionals, ‘Vocational
Rehabilitation Specialists’ with the legal and practical knowledge to
navigate the difficult waters between employment and health (7)’.
We believe that the huge financial and human cost of sickness absence
to the State and to individuals will not be significantly reduced unless
this advice is heeded. Such individuals could either be attached to
primary care teams or to community-based rehabilitation or mental health
teams. Crucially, however, they require expertise in dealing with both
physical and mental health issues as these frequently co-exist in those
with prolonged sickness absence (8).
Reference List
1. Henderson M, Nicholas Glozier, Holland Elliott K. Long term
sickness absence. BMJ 2005; 330: 802-3.
2. Health & Safety Executive. Managing sickness absence and
return to work: an employers' and managers guide. Norwich: HSE Books,
2004.
3. British Society of Rehabilitation Medicine. Vocational
Rehabilitation - the way forward: Report of a Working Party (Chair Frank
AO). London: British Society of Rehabilitation Medicine, 2000.
4. Grove B. Obstacles to solutions. In Holland-Elliott K, ed. What
about the workers?, pp 26-9. London: Royal Society of Medicine Press Ltd,
2004.
5. Sawney P, Challenor J. Poor communication between health
professionals is a barrier to rehabilitation. Occupational Medicine
(Oxford) 2003; 53: 246-8.
6. Royal College of Psychiatrists (CR111). Employment opportunities
and psychiatric disability. A report of the Royal College of Psychiatrists
(Chair Boardman, J.). London: Royal College of Psychiatrists, 2002.
7. Frank AO, Sawney P. Vocational rehabilitation. J R Soc Med 2003;
96: 522-4.
8. British Society of Rehabilitation Medicine. Musculoskeletal
rehabilitation. A report of the British Society of Rehabilitation Medicine
(Chair Neumann V.). London: British Society of Rehabilitation Medicine,
2004.
Competing interests:
Andrew Frank is a medical adviser to Kynixa, a Vocational Rehabilitation Company
Competing interests: No competing interests