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Managing long-term sickness absence and capability to work

About

What is covered

This NICE Pathway covers how to help people return to work after long-term sickness absence, reduce recurring sickness absence, and help prevent people moving from short-term to long-term sickness absence.

Updates

Updates to this NICE Pathway

3 September 2021 Workplace health: long-term sickness absence and capability to work (NICE quality standard 202) added.
19 November 2019 Updated on publication of workplace health: long-term sickness absence and capability to work (NICE guideline NG146).

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

Short Text

Everything NICE has said on managing long-term sickness absence and capability to work in an interactive flowchart

What is covered

This NICE Pathway covers how to help people return to work after long-term sickness absence, reduce recurring sickness absence, and help prevent people moving from short-term to long-term sickness absence.

Updates

Updates to this NICE Pathway

3 September 2021 Workplace health: long-term sickness absence and capability to work (NICE quality standard 202) added.
19 November 2019 Updated on publication of workplace health: long-term sickness absence and capability to work (NICE guideline NG146).

Sources

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

Quality standards

Workplace health: long-term sickness absence and capability to work

These quality statements are taken from the workplace health: long-term sickness absence and capability to work quality standard. The quality standard defines best practice for managing long-term sickness absence and capability to work and should be read in full.

Quality statements

Workplace culture and policies

This quality statement is taken from the workplace health: long-term sickness absence and capability to work quality standard. The quality standard defines best practice for managing long-term sickness absence and capability to work and should be read in full.

Quality statement

Employees work in organisations that develop policies for managing sickness absence and return to work as part of a broader, strategically led approach to promoting employees’ health and wellbeing.

Rationale

Workplace policies on sickness absence and return to work that are part of a proactively and strategically led commitment to employee health and wellbeing can help to prevent long-term sickness absence. These policies can help to reduce uncertainty about the sickness absence process and help employees return to work. Sickness absence and return-to-work policies should be flexible enough to support employees in different situations, depending on their individual circumstances and needs. Some organisations may not have formal policies in place, but they should still ensure that clear and accessible procedures are developed. Policies or procedures on sickness absence and return to work should be explained to all existing and new employees.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of a strategically led approach to employee health and wellbeing.
Data source: Local data collection, for example an employee health and wellbeing strategy with metrics and details of the progress made.
b) Evidence that policies for managing sickness absence and return to work are part of a strategically led approach to employee health and wellbeing.
Data source: Local data collection, for example policy reviews.
Outcome
a) Rates of long-term sickness absence.
Data source: Local data collection, for example HR management systems.
b) Rates of recurrent short-term sickness absence.
Data source: Local data collection, for example HR management systems.
c) Employee satisfaction with organisational implementation of policies for managing sickness absence and return to work.
Data source: Local data collection, for example staff surveys.

What the quality statement means for different audiences

Organisations (senior management teams) ensure that they have sickness absence and return-to-work policies in place, and that these policies are part of a proactive, strategic approach to promoting employee health and wellbeing. They ensure that the culture in their workplace is caring and supportive, and that the policies work for all employees. Organisations that do not have formal policies have clear and accessible procedures. They ensure that policies or procedures on sickness absence and return to work are explained to all existing and new employees.
Line managers ensure that they understand and apply sickness absence and return-to-work policies in a way that reflects a wider organisational culture that values and promotes employee health and wellbeing. They consider and accommodate the individual needs of employees when applying the policies. Line managers in organisations that do not have formal policies have a good understanding of available alternatives and apply clear and accessible procedures.
Employees are familiar with sickness absence management policies or procedures in their workplace. They are supported by their line managers in line with those policies or procedures in a way that meets their individual needs and situation. They experience this as part of a caring and supportive organisational culture that values and promotes employee health and wellbeing.

Source guidance

Definitions of terms used in this quality statement

Long-term sickness absence
An absence lasting 4 or more weeks. Recurring long-term sickness absence is defined as more than 1 episode of long-term sickness absence, with each episode lasting more than 4 weeks. [NICE’s guideline on workplace health: long-term sickness absence and capability to work]
Short-term sickness absence
An absence lasting up to (but less than) 4 weeks. Recurring short-term sickness absence is defined as more than 1 episode of short-term sickness absence, each lasting less than 4 weeks. [NICE’s guideline on workplace health: long-term sickness absence and capability to work]
Wellbeing
Wellbeing is the subjective state of being healthy, happy, contented, comfortable and satisfied with one's quality of life. [NICE’s guideline on workplace health: long-term sickness absence and capability to work]

Equality and diversity considerations

Employees should be provided with policies that they can easily read and understand themselves, or with support. Policies should be in a format that suits their needs and preferences. They should be accessible to people who do not speak or read English, and they should be culturally and age appropriate. Policies should consider the needs of employees as individuals, including requirements under the Equality Act 2010.

Support during sickness absence

This quality statement is taken from the workplace health: long-term sickness absence and capability to work quality standard. The quality standard defines best practice for managing long-term sickness absence and capability to work and should be read in full.

Quality statement

Employees who are assessed as ‘not fit for work’ are contacted by their employer as soon as possible to provide support and discuss arrangements for keeping in touch during sickness absence.

Rationale

Making contact with employees who are assessed as ‘not fit for work’ in their statement of fitness to work (‘fit note’) and offering support and reassurance can help people return to work, and prevent a short-term absence becoming a long-term absence. The first contact should happen as soon as appropriate after the employee’s 7 day self-certification period, and within 4 weeks of the start of the sickness absence. After considering the personal circumstances of the employee, their reason for and anticipated length of absence, as well as their communication needs and preferences, the first contact can be used to make it clear to the employee that the purpose of keeping in touch is to provide support, and help them return to the workplace when they feel ready. The person making contact can discuss with the employee how they would like to be contacted in the future, how frequently, and by whom. This will help to provide a supportive link between the employee and their workplace.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of policies or procedures to ensure that employees who are assessed as ‘not fit for work’ in their ‘fit note’ during periods of sickness absence are contacted by their employer as soon as possible during their sickness absence, and within 4 weeks of the start of the sickness absence.
Data source: Local data collection, for example review of organisation sickness absence and return-to-work policies, and HR management systems.
Process
a) Proportion of employees assessed as ‘not fit for work’ in their ‘fit note’ during periods of sickness absence who are contacted by their employer.
Numerator – the number in the denominator who are contacted by their employer.
Denominator – the number of employees who are assessed as ‘not fit for work’ in their ‘fit note’.
Data source: Local data collection, for example employee HR records.
b) Proportion of employees assessed as ‘not fit for work’ in their ‘fit note’ who were contacted by their employer within 4 weeks of the start of their sickness absence.
Numerator – the number in the denominator who were contacted by their employer within 4 weeks of the start of their sickness absence.
Denominator – the number of employees assessed as ‘not fit for work’ in their ‘fit note’ during periods of sickness absence.
Data source: Local data collection, for example employee HR records.
Outcome
a) Rates of long-term sickness absence.
Data source: Local data collection, for example HR management systems.
b) Employee satisfaction with the support from their employer during their sickness absence.
Data source: Local data collection, for example employee surveys.

What the quality statement means for different audiences

Organisations (senior management teams, including the chief executive, and departmental managers) ensure that systems are in place to consider the earliest appropriate opportunity to contact employees who are assessed as ‘not fit for work’ in their ‘fit note’ during periods of sickness absence. They have systems in place to ensure that this happens within 4 weeks of the start of the sickness absence, that a meaningful and supportive discussion takes place, and that the employee is contacted by the most suitable person, which may not be their line manager.
The person making contact ensures that they contact the employee who is assessed as ‘not fit for work’ in their ‘fit note’ during periods of sickness absence, at the earliest appropriate opportunity, and within 4 weeks of the start of the sickness absence. They consider the individual circumstances and communication needs and preferences of the employee before making contact. They ensure that a meaningful discussion with the employee takes place that is supportive and does not pressure them about returning to work.
Employees who are advised that they are ‘not fit for work’ by a GP or hospital doctor are contacted by their employer as soon as it is appropriate for them, and within 4 weeks of the start of the sickness absence. They are contacted in a way that suits their communication needs and preferences and the personal circumstances of their absence. They feel supported and valued by this contact and are offered help to return to work when they are ready, without pressure from their employer. They understand that anything shared about their health will be confidential (unless there is serious concern for their or others’ wellbeing). They have the opportunity to discuss how they would like to be contacted in the future, how frequently, and by whom, including alternative options to their line manager if this contact is not appropriate.

Source guidance

Definitions of terms used in this quality statement

Evidence of sickness absence
Employees can be asked to produce evidence of their reason for sickness absence if they are ill for more than 7 days in a row. Employers have flexibility over what evidence they accept. If the employee has been assessed by their GP or doctor, they may have been provided with a statement of fitness for work (‘fit note’) advising whether they are ‘not fit for work’ or ‘may be fit for work’.
Short-term sickness absence
An absence lasting up to (but less than) 4 weeks. Recurring short-term sickness absence is defined as more than 1 episode of short-term sickness absence, each lasting less than 4 weeks. [NICE’s guideline on workplace health: long-term sickness absence and capability to work]
Long-term sickness absence
An absence lasting 4 or more weeks. 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. [NICE’s guideline on workplace health: long-term sickness absence and capability to work]

Statement of fitness for work (‘fit note’)

This quality statement is taken from the workplace health: long-term sickness absence and capability to work quality standard. The quality standard defines best practice for managing long-term sickness absence and capability to work and should be read in full.

Quality statement

Employees have information in their statement of fitness for work about how their reason for sickness absence or their treatment might affect them on their return to work.

Rationale

Employers have an important role in helping their employees return to and stay in work after a period of sickness absence. To provide personalised and appropriate support the employers need information that can help them understand the reasons for the absence and what kind of support the employee may need. Healthcare professionals can use the ‘may be fit for work’ option in the ‘fit note’ when appropriate to include advice for adjustments that may support the employee’s return to work, including a phased return to work, altered working hours, amended duties, and workplace adaptations. The fit note also allows them to make additional comments and add detail that can help the employer to support the employee to return to work. This information should be provided in clear, non-technical language for employees and employers to use.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence that statements of fitness for work include information on how an employee’s reason for sickness absence or their treatment might affect them at work.
Data source: Local data collection, for example local audit of statements of fitness for work issued.
Process
Proportion of statements of fitness for work making use of the ‘may be fit for work’ option that include ‘may be fit for work’ advice.
Numerator – the number in the denominator that include ‘may be fit for work’ advice.
Denominator – the number of statements of fitness for work making use of the ‘may be fit for work’ option.
Data source: NHS Digital’s fit notes issued by GP practices covers information on the proportion of fit notes making use of ‘may be fit for work’ broken down by the advice selected.
Outcome
a) Employee satisfaction with adjustments and support on their return to work.
Data source: Local data collection, for example employee surveys.
b) Rates of recurrent sickness absence.
Data source: Local data collection, for example HR management systems.

What the quality statement means for different audiences

Organisations (senior management teams, including the chief executive, and departmental managers) ensure that systems are in place for acknowledging and making appropriate use of the information in an employee’s statement of fitness for work. They ensure that systems are in place to help employers understand the employee’s reason for sickness absence and what support they might need when they return to work.
Healthcare professionals (GPs and hospital doctors) consider what information about a person’s condition or treatment might affect their return to work and include this in the relevant sections of their statement of fitness for work. They include information that will help employers understand the reason for sickness absence and what adjustments may be needed to help the employee return to and stay in work when appropriate.
Line managers ensure that any information included in an employee’s statement of fitness for work is recorded and used appropriately, in line with systems in place in their organisation. They use the information to understand the reason for the employee’s sickness absence and what support they might need to put in place. This can be a starting point in discussions with the employee about the required support and what adjustments might help them return to work.
Employees have information included in their ‘fit note’ from their GP or hospital doctor about how their health or treatments might affect their return to work. Their line manager acknowledges, records and uses this information to start conversations about what arrangements could be put in place to help them return to work when they feel ready.

Source guidance

Definitions of terms used in this quality statement

Evidence of sickness absence
Employees can be asked to produce evidence of their reason for sickness absence if they are ill for more than 7 days in a row. Employers have flexibility over what evidence they accept. If the employee has been assessed by their GP or doctor, they may have been provided with a statement of fitness for work (‘fit note’) advising whether they are ‘not fit for work’ or ‘may be fit for work’.

Support to stay in or return to work

This quality statement is taken from the workplace health: long-term sickness absence and capability to work quality standard. The quality standard defines best practice for managing long-term sickness absence and capability to work and should be read in full.

Quality statement

Employees returning from sickness absence have any workplace adjustments recorded in a return-to-work plan that is monitored and reviewed.

Rationale

Workplace adjustments that are tailored to the employee’s needs and role can help the person to return to and stay in work after sickness absence. The adjustments should be discussed and recorded in a return-to-work plan and include an agreed timeframe for implementation and expected duration. Regular monitoring and review of the adjustments and the return-to-work plan will help to ensure that the needs of the employee and employer continue to be met, and highlight any potential need for amending the duration or additional adaptations. The return-to-work plan should be able to be accessed by the employee as well as the line manager and should not be used to create targets or pressure for employee performance.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of procedures to ensure that employees returning from sickness absence have any workplace adjustments recorded in a return-to-work plan.
Data source: Local data collection, for example review of organisation sickness absence and return-to-work policies.
b) Evidence of procedures to ensure that employees returning from sickness absence have their return-to-work plan monitored and reviewed.
Data source: Local data collection, for example review of organisation sickness absence and return-to-work policies.
Process
a) Proportion of employees returning from sickness absence who need workplace adjustments and have a return-to-work plan.
Numerator – the number in the denominator who have a return-to-work plan.
Denominator – the number of employees returning from sickness absence who need workplace adjustments.
Data source: Local data collection, for example employee HR records.
b) Proportion of employees who have workplace adjustments recorded in a return-to-work plan who have their return-to-work plan monitored and reviewed.
Numerator – the number in the denominator who have their return-to-work plan monitored and reviewed.
Denominator – the number of employees who have workplace adjustments recorded in a return-to-work plan.
Data source: Local data collection, for example employee HR records.
Outcome
a) Employee satisfaction with workplace adjustments on their return to work.
Data source: Local data collection, for example local audit of return-to-work plans, employee surveys.
b) Rates of recurrent sickness absence.
Data source: Local data, for example HR management systems.

What the quality statement means for different audiences

Organisations (senior management teams, including the chief executive, and departmental managers) ensure that systems are in place to discuss, record, monitor and review workplace adjustments needed by employees returning from sickness absence. They ensure that return-to-work plans include timeframes for implementing the adjustments and how long they will last, and mechanisms for regular reviews, on a schedule agreed between the employee and their line manager or another appropriate person. In organisations that do not have formal systems, suitable clear and accessible procedures are developed and explained to all existing and new employees.
Line managers ensure that they discuss, record, monitor and review workplace adjustments needed by employees returning from sickness absence. They make use of return-to-work plans, including timeframes for implementing the adjustments and how long they will last, and mechanisms for regular reviews on an agreed schedule. They ensure that the return-to-work plan is not used to create targets or expectations for employee performance and that any timeframes are adaptable.
Employees discuss with their employer any support and adjustments they might need to help them return to work. They agree the adjustments, the timeframes for implementing them and their duration. They have regular opportunities to discuss and review how the adjustments work for them as well as to discuss and agree any changes they may need. They do not feel that their return-to-work plan is a target for performance or that the duration of their adjustments cannot be extended.

Source guidance

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

Supporting information

Glossary

(common mental health conditions include conditions such as depression, generalised anxiety, disorder, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder and social anxiety disorder)
(programmes delivered by health professionals that do not treat the underlying condition, but that focus on improving the likelihood of people being able to return to, or stay in, work; these programmes may aim to improve a person's understanding of their condition, increase their confidence and improve their ability to function in the workplace, through for example, pain or stress management and building self-esteem and confidence)
(employee assistance programme; an employer-funded programme offering confidential services such as counselling and advice on a range of work and personal issues; although the employer may receive an indication of numbers of employees taking up the service, no personal information is shared with the employer that would enable them to identify which employees access the service or their reason for doing so)
(graded activity aims to increase a person's activity levels gradually using a behavioural approach; typically, people with musculoskeletal conditions attend individually focused training sessions with a gradually increasing exercise programme)
(therapy that involves learning or reactivating problem-solving skills)
(wellbeing is the subjective state of being healthy, happy, contented, comfortable and satisfied with one's quality of life)

Paths in this pathway

Pathway created: January 2014 Last updated: September 2021

© NICE 2021. All rights reserved. Subject to Notice of rights.

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