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Managing long-term sickness and incapacity for work

About

What is covered

This pathway covers interventions that aim to:
  • prevent or reduce the number of employees moving from short- to long-term sickness absence (including the prevention of recurring short or long-term sickness absence)
  • help employees on long-term sickness absence return to work
  • reduce the number of employees who take long-term sickness absence on a recurring basis
  • help people receiving Employment and support allowance (ESA) or similar benefits return to employment (paid and unpaid).
In particular, it aims to benefit people with musculoskeletal disorders or mental health problems.
The recommendations are for employers and NHS (particularly primary care services and occupational health) professionals. This includes those working in local authorities and in the community, voluntary and private sectors. It will also be of interest to workplace representatives and trades unions.

Updates

Updates to this pathway

23 June 2015 Link to NICE pathway on workplace health: policy and management practices added.

Prerequisites underpinning the recommendations

The following prerequisites have been identified from the evidence considered. These underpin and support effective implementation of the recommendations:
  • Primary care trust commissioners (or other commissioners) have ensured:
    • referral mechanisms are available to GPs and any other specialists (such as occupational health physicians and nurses)
    • any interventions or services identified as a result of following the recommendations are commissioned and available.
  • Those responsible for managing certification (such as GPs) have considered the advice given in 'Patients, their employment and their health – how to help your patients stay in work' (Department for Work and Pensions 2008). For example, they should balance the immediate health benefits of prescribing time away from work and the potential long-term disadvantages for the patient.
  • Agreement has been reached with the person experiencing sickness absence or receiving benefits about what confidential information can be shared with whom and for what purpose.
  • The person experiencing sickness absence or incapacity and the employer are in regular contact and work together to plan and put into practice any agreed activities.
  • The person experiencing sickness absence or incapacity has received the appropriate treatment.
  • The person planning, coordinating or delivering the intervention/s or service/s has the relevant experience, expertise and credibility. For example, they might need training in communications skills. They may need access to supervision and consultation with more skilled professionals. They may also need access to sources of employment and health and safety advice and discrimination law.
  • The proposals outlined in 'Dame Carol Black's review of the health of Britain's working age population. Working for a healthier tomorrow' (Health, Work and Wellbeing Programme 2008) are taken forward.

Who should take action?

Various specialists and professionals are suggested as people who may be involved in the delivery of each intervention or service. This is not a definitive list and responsibility often involves a team approach (across the NHS and with external organisations).

Long-term sickness absence

Long-term sickness absence has been defined in the literature as an absence lasting more than 2 weeks. For the purposes of this pathway, it is defined as 4 or more weeks. This is half-way between the usual minimum of 2 weeks in the literature, and the 6-week period after which the chance of an early return to work starts to diminish. In addition, 4 weeks is commonly used as a cut-off in the international literature. Recurring long-term sickness absence has been defined as more than 1 episode of long-term sickness absence, with each episode lasting more than 4 weeks.

Short-term sickness absence

Short-term sickness absence has been defined in the literature in days or weeks. For the purposes of this pathway, it is defined as an absence lasting up to (but less than) 4 weeks. Recurring short-term sickness absence has been defined as more than one episode of short-term sickness absence, each lasting less than 4 weeks.

Stress

There is no simple definition of stress, but there is consensus that it is caused by a person's appraisal of a situation and how their mind and body prepares to respond. Stress is a natural but sometimes distressing reaction leading to a psychological and physiological tension which is referred to as the 'flight or fight' response. It may be positive (for example, as part of preparation for a sporting event or in response to an exciting work challenge). It may also be negative (for example, it may be a response to bereavement or to excessive pressure).
It leads to an increase in heart rate and blood pressure and may result in frequent, intrusive thoughts and accompanying feelings of fear or excitement. Stress may occur in response to a single event experienced over a short period of time (for example, unexpected increases in workload). Alternatively, it may occur in response to multiple events over long periods of time (for example, in response to protracted periods of treatment for an illness). In the majority of cases (and with appropriate intervention) people will adapt and cope. However, there are some occasions when this does not occur.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on managing long-term sickness and incapacity for work in an interactive flowchart

What is covered

This pathway covers interventions that aim to:
  • prevent or reduce the number of employees moving from short- to long-term sickness absence (including the prevention of recurring short or long-term sickness absence)
  • help employees on long-term sickness absence return to work
  • reduce the number of employees who take long-term sickness absence on a recurring basis
  • help people receiving Employment and support allowance (ESA) or similar benefits return to employment (paid and unpaid).
In particular, it aims to benefit people with musculoskeletal disorders or mental health problems.
The recommendations are for employers and NHS (particularly primary care services and occupational health) professionals. This includes those working in local authorities and in the community, voluntary and private sectors. It will also be of interest to workplace representatives and trades unions.

Updates

Updates to this pathway

23 June 2015 Link to NICE pathway on workplace health: policy and management practices added.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Pathway information

Prerequisites underpinning the recommendations

The following prerequisites have been identified from the evidence considered. These underpin and support effective implementation of the recommendations:
  • Primary care trust commissioners (or other commissioners) have ensured:
    • referral mechanisms are available to GPs and any other specialists (such as occupational health physicians and nurses)
    • any interventions or services identified as a result of following the recommendations are commissioned and available.
  • Those responsible for managing certification (such as GPs) have considered the advice given in 'Patients, their employment and their health – how to help your patients stay in work' (Department for Work and Pensions 2008). For example, they should balance the immediate health benefits of prescribing time away from work and the potential long-term disadvantages for the patient.
  • Agreement has been reached with the person experiencing sickness absence or receiving benefits about what confidential information can be shared with whom and for what purpose.
  • The person experiencing sickness absence or incapacity and the employer are in regular contact and work together to plan and put into practice any agreed activities.
  • The person experiencing sickness absence or incapacity has received the appropriate treatment.
  • The person planning, coordinating or delivering the intervention/s or service/s has the relevant experience, expertise and credibility. For example, they might need training in communications skills. They may need access to supervision and consultation with more skilled professionals. They may also need access to sources of employment and health and safety advice and discrimination law.
  • The proposals outlined in 'Dame Carol Black's review of the health of Britain's working age population. Working for a healthier tomorrow' (Health, Work and Wellbeing Programme 2008) are taken forward.

Who should take action?

Various specialists and professionals are suggested as people who may be involved in the delivery of each intervention or service. This is not a definitive list and responsibility often involves a team approach (across the NHS and with external organisations).

Long-term sickness absence

Long-term sickness absence has been defined in the literature as an absence lasting more than 2 weeks. For the purposes of this pathway, it is defined as 4 or more weeks. This is half-way between the usual minimum of 2 weeks in the literature, and the 6-week period after which the chance of an early return to work starts to diminish. In addition, 4 weeks is commonly used as a cut-off in the international literature. Recurring long-term sickness absence has been defined as more than 1 episode of long-term sickness absence, with each episode lasting more than 4 weeks.

Short-term sickness absence

Short-term sickness absence has been defined in the literature in days or weeks. For the purposes of this pathway, it is defined as an absence lasting up to (but less than) 4 weeks. Recurring short-term sickness absence has been defined as more than one episode of short-term sickness absence, each lasting less than 4 weeks.

Stress

There is no simple definition of stress, but there is consensus that it is caused by a person's appraisal of a situation and how their mind and body prepares to respond. Stress is a natural but sometimes distressing reaction leading to a psychological and physiological tension which is referred to as the 'flight or fight' response. It may be positive (for example, as part of preparation for a sporting event or in response to an exciting work challenge). It may also be negative (for example, it may be a response to bereavement or to excessive pressure).
It leads to an increase in heart rate and blood pressure and may result in frequent, intrusive thoughts and accompanying feelings of fear or excitement. Stress may occur in response to a single event experienced over a short period of time (for example, unexpected increases in workload). Alternatively, it may occur in response to multiple events over long periods of time (for example, in response to protracted periods of treatment for an illness). In the majority of cases (and with appropriate intervention) people will adapt and cope. However, there are some occasions when this does not occur.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

a behavioural intervention that aims to increase a person's activity levels gradually. Typically, people with back problems attend 15 1-hour sessions covering activities that are relevant to them. A further 3 sessions are dedicated to back education and lifting instructions delivered by an occupational therapist
cognitive behavioural therapy (CBT) is a psychological treatment where people work with a therapist to look at how their problems, thoughts, feelings and behaviour fit together. CBT can help people to challenge negative thoughts and change any behaviour that causes problems. It may be delivered in one-to-one or group sessions
non-treatment programmes designed to help people better manage their health condition with a view to returning to work
the overall aim of counselling is to provide an opportunity for the client to work towards a more satisfying and resourceful life. Counselling involves a relationship between a trained counsellor and an individual. The objectives will vary according to the client's needs. They may include addressing and resolving specific problems, making decisions, coping with crisis, developing personal insight and knowledge, working through feelings of inner conflict or improving relationships. A distinction needs to be made between counselling and counselling skills. Many health service and other professionals routinely and appropriately use counselling and basic human relationship skills as part of their work. This is distinct, however, from more formal counselling which involves a clearly defined professional relationship
this may be devolved to line managers, human resource professionals or occupational health specialists
employment and support allowance (ESA) is a two-tier system of benefits. All claimants who are out of work due to ill health or a disability are entitled to the ESA basic benefit (paid at the same rates as unemployment benefit – job seeker's allowance). Those judged (via a medically administered 'work capability' test) unable to work, or with limited capacity to work due to the severity of their physical or mental condition, receive a higher support allowance, with no conditionality. Those who are deemed 'sick but able to work' only receive additional employment support if they participate in employability initiatives such as Pathways to Work
this generic term is used in this pathway to describe an intervention, programme, strategy or policy. It involves a single action (or set of actions) to alter the outcome of a situation. For example, in the case of long-term sickness absence from work, it could involve implementing an organisation's sickness absence policy to help someone to return to work
jobcentre Plus is a government agency that helps people of working age move from welfare benefits into work and helps employers to fill their vacancies. Jobcentre Plus is part of the Department for Work and Pensions. It plays a major role in supporting the Department's aim to 'promote opportunity and independence for all through modern, customer-focused services'
programmes to manage back pain with input from different professionals. It covers relaxation training, exercises to reduce cervical and lumbar lordosis (curvature of the spine) and psychological support to reduce anxiety. It also includes eye fixation exercises and manual treatment of the cervical spine, using techniques such as massage and mobilisation
standardised psychosocial rehabilitation programmes that aim for a gradual increase in daily, goal-directed activity by overcoming any psychological obstacles to such activity. The main components are education and reassurance
the action of restoring someone to a previous condition, status or some degree of normal life
this involves helping those who are ill, injured or who have a disability to access, maintain or return to employment or another useful occupation. It may involve liaison between occupational health, management, human resources and other in-house or external facilitators. It may result in transitional working arrangements, training, social support and modifications to the usual tasks

Paths in this pathway

Pathway created: January 2014 Last updated: December 2016

© NICE 2017

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