Pressure to work through periods of short term sickness

We were very pleased to see the important, but often neglected issue
of the health of health professionals and the effect that this may have on
their work discussed in a recent editorial (1). However, we were
surprised that Professor Dew took such a uni-dimensional view of
presenteeism, describing it in such a way as to imply that it is always
wrong for an individual to be at work while they have symptoms which may
impact their occupational performance. Presenteeism is difficult to
define and is more complex than this would suggest. He cites a study
where the researchers measured presenteeism by asking healthcare workers
to retrospectively self-report if they had been present at work when they
perceived that they should have taken sick leave. This is a highly
subjective assessment. Not only do attitudes to health and illness vary
between individuals and workplaces, but it is part of the self-image of
some workers, for example doctors, that they have to be very ill to avoid
work.

Whilst few would disagree that individuals who are too ill to work
should not be pressurised to do so, there is overwhelming evidence that
individuals with medical problems that prevent them from working at full
capacity can benefit from adapted duties (2). It is well recognised that
the longer an individual is absent from work due to illness, the greater
the likelihood of them developing psychological barriers to return to work
(3). This in turn leads to an increased risk of long-term disability and
loss of employment.

In England, the Government has recognised the importance of
maintaining individuals with medical disorders in the workplace by
replacing the 'sick note' with the ' fit note'. The aim of the fit note
is to shift the focus of advice from what people with medical problems
can't do to what they can do, thereby facilitating their retention in the
workplace (4). Employers generally would prefer to pay for an employee to
be at work, albeit at reduced capacity, for a few weeks than to pay them
full pay to be at home. In addition many employers recognise that making
temporary adaptations to job requirements to facilitate the retention of
an employee with a medical condition, often results in the employee
returning to their full productivity at an earlier stage than if they had
stayed off work on sick leave.

Individuals whose illness may pose a health or safety risk to others
in the workplace, including members of the public, should clearly remain
away from the workplace until safe to return. Additionally, individuals
who consistently under-perform at work due to a medical condition should
be referred for occupational health advice. But presenteeism is complex;
it has many positive aspects and is not just a negative phenomenon as
implied by Professor Dew.

1) Dew K. Pressure to work through periods of short term sickness.
BMJ 2011; 341:d3446

2) Waddell G, Burton K and Kendall N, Vocational Rehabilitation: what
works, for whom and when? The Stationary Office, 2008

3) Waddell G, Aylward Mansel. Models of sickness and disability
applied to common health problems. : The Royal Society of Medicine; 2010

4) Verbeek J, Madan I. From sick notes to fit notes. BMJ 2009;
339:b3114

Dear Sir,

Presenteeism present in Manchester - you bet your BIPPY!

Readers of the BMJ and of the dumb-cluck things our employers do
nowadays will be unsurprised to learn that presenteeism is part of the
employment policy of Central Manchester Foundation trust

Yes readers, pressure to turn up to work in Hospital when you're ill!

In 2010, the trust as employer informed the work force medical and
ancillary that they were inserting new terms into our contracts and that
would be The Behavioural Incremental Pay Policy. The new terms would mean
anyone who had eighteen days off in a rolling year or four periods of
illness would not receive their contracted pay increment. This was done
without agreement as the Trust said agreement was not necessary. Other
trusts are excitedly watching this introduction and how well it works, we
are told!

Those that turn up to work ill and obviously
unable to function - perhaps because they are pyrexial or obviously
infected in other ways are encouraged to self-certify they are unable to
work (rather than be sent home by their employer). Given that the worker
has self-certified himself, their line manager can then enter their names
into the list of those to be paid less. They do this in a very very
concerned way. We are certain the list is enlarged with great regret, but
bonuses, we all know, depend on circumstances such as these.

Administration was unable to say how much money these manoeuvres had
saved the trust to date although the low morale and demotivation that this
causes can and has been measured.

Yours sincerely

Oliver R Dearlove M.A., M.B., BChir., F.R.C.A.

Late Chairman of Royal Manchester Children's Hospital medical staff
committee

Conflict of Interest; These views DO reflect his employers views
although obviously not of any sane person. No other declaration of
conflict other than treated ca rectum.