COSTS OF ABSENCE

Whoever pays for the cost of sickness absence, it is well recognised that the costs are enormous. As well as the salary costs for the person who is absent there are the costs of replacement staff or overmanning of the organisation to take account of a specific level of absence, costs associated with lost productivity, or reduced quality of services, as well as the management, human resources, and occupational health time spent dealing with absence that could be used for other purposes. In order to give some idea of the scale of the problem several examples are given in box 1.

Comparing levels of absence

Comparing sickness absence rates between countries, and sometimes between different organisations within the same country, can be complicated because of the use of different definitions of absence, variation in the criteria for inclusion and exclusion, and differences in the populations being compared and in the accuracy of the sickness absence data collected. For example, within the EU, some countries exclude groups such as all public sector or self employed workers from the national figures. Others include those on permanent disability benefits or maternity leave in the sickness absence figures, and at least one can not separate absence due to illness from other reasons for absence. The European Foundation investigated sickness absence within the EU and did not publish a league table of absence rates between countries because of the risk of presenting misleading information. At best we can say that we do not have accurate, reliable sickness absence figures that are capable of direct comparison within the EU.2 Policy makers and politicians therefore need to be cautious in their interpretation of the absence figures that are available both at the national and international level.

Even within the same country sickness absence can be defined differently by different organisations. In some a month's sickness absence is recorded as four calendar weeks (28 days), while in others it is four working weeks (20 days). Some organisations capture information on partial shift absences, hospital or dental appointments, while others do not. The denominator used to calculate the absence rate can also vary. Some organisations use contracted hours and others use established hours (which includes contracted hours for positions that are vacant, but budgeted for), and some make an adjustment for annual leave, largely as a result of whether the information is being collected for payroll or for manpower planning purposes. The hours lost due to maternity leave are often not recorded as sickness absence in the UK; however, the contracted hours for those on maternity leave are often still included in the denominator and this could have a significant effect when calculating the rate in working populations where there is a high female population. How employees, who still have an employment contract but have run out of statutory sick pay, are dealt with in calculating the absence rate can also vary between organisations.

The absence rate is often reported based on the average (mean) figure, but in some circumstances, because of the binomial distribution of absence data, some use the median figure to report the absence rate. All of the above can be further complicated by variation in the reliability of the systems used by different organisations to capture and record absence data.

Perhaps the most common way of determining the rate of absence in the UK is: lost hours over contracted hours, without any adjustment for annual leave, excluding maternity leave from the numerator and discounting partial shift absences, hospital appointments, etc. The rate is most often reported as an average (mean) rate of absence.

The overall rate of absence gives no indication of the pattern of absence that predominates in an organisation. A large number of frequent, short term absences or a small number of long term absences can result in the same figure. The overall rate of absence is too crude a measure to be used on its own to indicate whether interventions to reduce absence are working effectively or not.

Some have reported the medical reasons for absence in defined populations.^w4–6 These studies often use different classification systems as there is no one standardised approach to classifying the reasons for absence that is widely used. The thorny problem that has not been resolved as yet is how to determine what percentage of sickness absence is directly attributable to conditions that have been caused or made worse by work.

Managing attendance

Managing attendance at work is always a line management responsibility. Most guidance documents on managing attendance stress the importance of having a robust attendance/absence management policy that defines clearly, for managers and staff, what sickness absence is, when it can be taken, how and when it should be reported and recorded, and what steps should be taken to manage attendance at an individual level. This often starts with having a well maintained individual attendance (or absence) record that captures information on the frequency and duration of spells of absence over a period of time, often one year. The individual record may also allow periods of absence to be linked to days of the week when sickness absence is taken, or to other events, such as holidays or weekends in order to identify possible trends in the pattern of absence. However, little attention has been paid to relating patterns of absence to changing working conditions, types of exposure or organisational events, such as downsizing, although all of these factors have been linked to increased absence.

The importance of carrying 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 absence is taken seriously in the organisation, and it offers the manager and the employee the opportunity to discuss, in an informal setting, any issues that may be affecting attendance or performance at work. Some organisations set triggers for further action, such as automatic management review if the employee has been absent for more than three episodes in a 12 month period, or automatic referral to the occupational health service after a specific number of spells or specific duration of absence.

Referral to occupational health

When the manager makes a formal referral for the employee to be seen by the occupational health service because of their sickness absence there is often a strong element of compulsion for the employee to attend. Refusal may lead to negative consequences for the employee. However, management and staff may not appreciate fully that an employee cannot be compelled to undergo any form of medical examination or health assessment without first having given their informed consent for that assessment to take place. Consent can only be regarded as informed when the individual understands what information is being released, to whom, the purposes for which it will be used, and the possible consequences of that use. Consent must be given freely, under no duress or threat, and applies only for the time and event for which it is given.^w7 Therefore the employee has a legitimate right to refuse a medical examination. However, they should understand that refusal to undergo a medical examination does not preclude further management action from being taken.

Questions that are frequently posed by managers to occupational health professionals on sickness absence referral letters are listed in box 2.

Verifying the reason for absence

It is often the first question in box 2 that causes the most concern. The occupational health professional is being asked to verify the reason for absence and to say whether, in their opinion, the length or pattern of absence, often certified by the general practitioner, is justified. If they indicate that, in their opinion, it is not, this calls into question the genuineness of the illness, and the employee's honesty or commitment to the organisation, and may lead to the manager pursuing disciplinary action against the employee. Under these circumstances the employee may feel that their role, during the health assessment, is to convince the occupational health professional that their absence can be justified on medical grounds. This may lead to employees wanting to present their case in the best possible light, exaggerating their symptoms and being unwilling to enter into any open discussion on other, strictly non-medical factors, that may nevertheless play a significant part in their absence from work.

There is concern that placing the doctor or nurse in the position of having to verify the reason for absence on behalf of the employer so changes the nature of the doctor–patient, nurse–patient relationship that this activity raises serious ethical questions. The International Labour Organisation, a tripartite organisation of the social partners, has published technical and ethical guidance which states that “Occupational health professionals should not be required by the employer to verify the reasons for absence from work”.4This is largely in order to protect the relationship of trust that is essential for open and honest communication between a patient and health care professional.

In Holland general practitioners have refused to certify the reason for absence from work since the beginning of the 20th century in order to protect the confidential relationship with their patients'.^w2 At one point the British Medical Association also pressed for the same position.5 Since 1994 Dutch occupational physicians, despite fierce protests, have been forced to undertake the task of certification.^w2 Recent research suggests that Dutch general practitioners do not trust occupational physicians who undertake this task on behalf of employers.^w8 In Germany it is not only considered unethical for the occupational physician to be asked to verify the reason for absence but also legislation prevents them from doing so. In Spain occupational physicians threatened to take industrial action if they were to be required to verify the reasons for absence. Yet in the UK this question has become widely accepted without causing any further debate on the role of the occupational physician in verifying the reason for absence or on how this activity might affect the relationship between occupational health services and workers. Whether the UK is leading the field in this respect or adopting practices that other health care professionals are unwilling to accept needs further consideration.

The complex phenomenon of sickness absence

Sickness absence is a complex phenomenon that is influenced strongly by factors other than health. The decision to attend or resume work following sickness absence will be related to the real and perceived conditions of work (both physical and psychosocial), anticipated job demands, management attitudes and behaviours, social norms in the peer group and community, advice and information from general practitioners and hospital specialists, as well as economic pressures caused through loss of earnings (for the individual) and loss of productivity (for the organisation). There are also other factors that operate at the individual level, such as the person's health beliefs, sickness behaviour, motivation to attend, and job satisfaction that play a part in this decision making process. It has been suggested that many workers will attend work with conditions that others will be absent with,5 and that where there are high rates of absence there are also high rates of “presenteeism”.^w9

If occupational health professionals are to develop interventions that are effective in helping people to return to work and remain at work, they will need to develop a good understanding of the factors other than disease that influence this behaviour. They will need to find new ways of working with organisations to identify and implement strategies aimed at reducing absence that take account of these factors. This will require close cooperation between line managers, human resources, worker representatives, and occupational health professionals.

It is likely that these strategies, which take account of the broad range of factors that affect sickness absence, will become increasingly important in the future as government policy will require more long term absentees to be reintegrated back into the workforce to prevent social exclusion; fewer people with health problems may be allowed to retire on health grounds, and at the same time there will be increasing pressure placed on employers to reduce sickness absence still further. New and more dynamic approaches to sickness absence may need to be developed.

Sickness absence can be viewed from a number of different perspectives, and these are listed in box 3. However it is rare that these sometimes conflicting perspectives can be reconciled and all of the different factors that affect sickness absence can be considered together. The factors that have been linked to increased rates of absence are shown in box 4.

These factors have been investigated by a number of different disciplines. Social scientists have viewed sickness absence as a phenomenon that arises out of a set of written and unwritten rules that operate within the context of the labour market in a capitalist society.^w10 They have concentrated on the influence that sickness absence benefits and social insurance systems can have on paid absence from work.6 The impact of severe economic decline,7 industrial downsizing,^w11socioeconomic differences,8 ^w12 and other factors such as sex,9 ^w13–17 ethnic group,^w18 and regional variation^w10 have been described.

Psychologists have investigated individual factors such as personality, job stress, performance and absenteeism,10job satisfaction,^{w19 w20} and the relation between short and long term sickness with social circumstances, working conditions, and sex.11 In addition the influence of psychosocial factors,12-14 ^w21 social support,15 16 marital status,^w22stress,^w23 and psychiatric morbidity ^w24–30have been considered.

From an organisational perspective factors such as personal and organisational determinants of perceived absence norms,^w31changes in the psychosocial work environment,14organisational change,^w32 relationship between job insecurity and work based support,^w33 positive peer group interaction at work, and satisfaction with co-workers^w22have been investigated.

Health professionals have investigated the impact on sickness absence of occupational health services,17 ^w34 health promotion^w35–38 employee fitness programmes,^w39 w40 physiotherapy services,^{w41 w42} vaccination programmes^w43 as well as the effect of work load.18

Conclusions

Sickness absence is likely to remain high on the agenda for government and industry. Occupational health professionals need to have a broad understanding of the factors, other than disease, that affect sickness absence if they are to be able to advise organisations, communicate effectively with line managers, and work with individuals. However, the role of the occupational health service in relation to sickness absence must be defined clearly and communicated to staff and management if they are to avoid being used simply as a management tool. A positive approach to tackling absence, including the non-medical, psychosocial issues that have been shown to have such an important influence on absence, should be developed further. This will require close cooperation with human resources, line management, and workers representatives. The management approach to sickness absence that has largely been adopted in industrialised countries19provides an important framework for managing attendance, but new and innovative approaches to help organisations overcome barriers to attendance need to be developed further. The concept that sickness absence can have positive benefits should also be recognised as sickness absence has been considered to be too low in some circumstances.20 Occupational health professionals are well placed to promote a positive approach to dealing with sickness absence, both at an organisational and individual level.