1. Absence
Management,
a risk management
issue
Absence Management Training programme.
Dr Peter Noone, Consultant Occupational Physician
06/04/12

2. But We’ve been here
before !
“If you think you’re too small to have
impact, try going to bed with a
mosquito”!
Anita Roddick (The Body Shop)
04/06/12 Dr Peter Noone

3. President Clinton
It’s the Economy Stupid !
04/06/12 Dr Peter Noone

4. Absence Management
Guiding value
Keep it Positive……∗∗∗∗∗∗!
04/06/12 Dr Peter Noone

5. “Sickness absence should
be used as an integrated
measure of physical,
psychological and social
functioning in studies of
working populations”
Whitehall Study, Marmott et al 1995
04/06/12 Dr Peter Noone

6. Topics to Cover
Absence as a risk management issue,
Models of Absence,
Types of Absence Management,
Management of Short-term Absence,
Management of Long-term Absence,
Pension eligibility.
04/06/12 Dr Peter Noone

7. Cost of Sickness absence
CBI 1998 UK, £11 billion per annum,
Average cost £478 per employee, €882 IRL
(IBEC - survey) 7.8 days/employee/yr,10.7 days in large companies (>250
employees) €1.4 billion = the estimated cost of absence to IRLorganisations/ yr
Loss of average of 3.7% of working time,
Hocking el al 1994, Australian Telecoms sector,
$2 billion loss from alcohol & smoking
absence alone!
28% of lost work-time in Europe (Euro Foundation for
Improvement of Living and Working Conditions 2000)
04/06/12 Dr Peter Noone

8. Corporate Social Responsibility
04/06/12 Dr Peter Noone

9. Employment Risk Matrix
Wage increases, Absence,
Fraud, Stress,
I Mortality Turnover, retention,
m
p
a Safety, Early Retirement,
c
t Legal Compliance Succession
Planning
Improvement Potential
04/06/12 Dr Peter Noone

10. Risks
accept
retai
n
transfe
r
mitigate
preven control
avoid
04/06/12
t
Dr Peter Noone

11. Accident / Illness,
Resource Loss per Year
Accidents Illness
300 deaths, 100,000
12 million lost deaths,
days/yr 200 million
lost days
04/06/12 Dr Peter Noone

12. THE ENVIRONMENT SOCIAL POLICY
Occupation Education
Pollution of Employment
Air/water/food Social Status
Climate Wealth
Infectious Agents Legislation about
Housing health
THE HEALTH
OF THE
POPULATION
INDIVIDUAL GENETIC HEALTH
LIFESTYLE CONSTITUTION CARE
SYSTEMS
Nutrition Race
Smoking Heredity Prevention
Exercise Predisposition Treatment
Sexual Behaviour Rehabilitation
04/06/12 Dr Peter Noone

13. Impact of unhealthy
workplace
Low Employee Satisfaction
Low Customer Low Morale
Satisfaction
High Effort
Low Commitment Low Reward Low Trust
+
Low Loyalty High Demand Low Retention
Low Control
Low Motivation Low Creativity
Trailing Edge Performance
04/06/12 Dr Peter Noone

14. Taking A Holistic View
04/06/12 Dr Peter Noone

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16. 04/06/12 Dr Peter Noone

17. If you’re not creating
community, you’re not
leading,
Empowering people to
reach their full potential.
04/06/12 Dr Peter Noone

18. Managing Employee Commitment
04/06/12 Dr Peter Noone

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20. 04/06/12 Dr Peter Noone

21. Main Occupational Health
Ethical Positions
Independent impartial medical
examiner/advisor to employer and
employee,
Traditional therapeutic doctor patient
relationship and ? Advocate,
Research, auditor of trends, factors in
working populations.
Ref “Guidance on Ethics for Occupational Physicians” FOM London
1999
04/06/12 Dr Peter Noone

22. Models of Absence
Deviance model- lazy, lack of commitment,
McGregor’s theory X,
Withdrawal- from unsatisfactory working
conditions,
Economic Utility- trade off leisure activities,
outside interests are more valuable,
Cultural- What is the norm for this organisation,
state, societal attitudes.
04/06/12 Dr Peter Noone

23. Non-attendance
Underlying medical condition,
Problems with work colleagues or supervisor,
Family, personal or domestic problems,
Attitude or motivational problem,
Outside interests,
Response to refusal for time off for social,
domestic or family crisis
04/06/12 Dr Peter Noone

24. Types of Absence
Management
Simple draconian – any rapid turnover
low wage employer,
Complex active – any leading multi-
international,
Dithering passive- the Public Sector!
04/06/12 Dr Peter Noone

25. 1. Simple Draconian
No sick pay for first few days of absence,
Frequent short spells treated as conduct
and disciplinary issues,
Dismissal on some other substantial reason
or medical incapacity >6/12 absence,
Rapid turnover, low wage employer,
depends on large pool of replacements,
Lawful, - ethical, - truly cost effective?.
04/06/12 Dr Peter Noone

26. 2. Complex Active
Stable, high skill, well paid and productive workforce,
Risk management and safety led,
Strategic & project based management systems,
Comprehensive health, social, welfare policies and
programmes for employee’s and dependants,
Highly, consistently and transparently managed,
Preventative health programs,
Early interventions for alcohol & drug misuse,
Active management of medium to long-terms illness
04/06/12 Dr Peter Noone

27. 3. Dithering Passive
Generous sick pay schemes,
Absence divided into “genuine” or “not genuine”,
Rudimentary absence data, no analysis by CAUSE,
Recurrence of preventable accidents,
Cosy acceptance of short-terms absence as a safety
valve for working in a “stressful place”,
Major unaddressed workplace health risks,
No clear policy on temporary modified work,
rehabilitation, fast tracking for energetic treatment,
Abuse of ill-health retirement procedures.
04/06/12 Dr Peter Noone

28. Philosophical Position
People prefer and beneficial to be at
work,
Only 3 absolute contra-indications to
work; - imprisonment, coma, death.
Absence is a multi-factorial phenomena,
Best model is bio/psycho/social,
Malingering does not exist
04/06/12 Dr Peter Noone

29. “In order that people are
happy in their work, 3 things
are needed;
They must be fit for it,
not do too much of it and
must have a sense of
success in it”
John Ruskin 1871
04/06/12 Dr Peter Noone

30. Why do we come to work?
04/06/12 Dr Peter Noone

31. Why do We Come to Work?
We want to
We have to,
We need to?
04/06/12 Dr Peter Noone

32. Why come to work?
04/06/12 Dr Peter Noone

33. Why don’t we come to work?
Medical incapacity,
Social incapacity,
We dislike work more than wanting to,
having to or needing to.
04/06/12 Dr Peter Noone

34. Bio-psychosocial
Absence is behaviour,
“Avoidance of workplace is the outcome of
positive and negative medical, emotional
and social influencers”
related to real & perceived conditions of work
(physical & psychosocial), anticipated job
demands, management attitudes and behaviours,
social norms
04/06/12 Dr Peter Noone

35. “Tom had discovered a great law
of human action, namely that in
order to make a man covet a
thing, it is only necessary to
make the thing difficult to attain.
Work consists of whatever a body
is obliged to do and play consists
of whatever a body is not obliged
to do”
Mark Twain, Huckleberry Finn
04/06/12 Dr Peter Noone

36. Factors predictive of absence
Geographical-
 taxation, pension age, social attitude, social insurance,
unemployment, epidemics, health services, regional culture,
Organisational-
 nature of business, size of unit, IR, sick pay, supervisor, working
conditions, HR policies, environ hzds, OHS, labour turnover,
culture & climate.
Personal-
 age, gender, occupation, personality, life crises, family
responsibilities, job satisfaction, social activities, commute time to
work, length of service, gender integration, medical, smoking,
alcohol & substance misuse.
04/06/12 Dr Peter Noone

37. 5 Medical factors predictive of
absence
Health services,
Epidemics,
Environmental hazards,
Occupational health services,
Individual health or medical conditions,
04/06/12 Dr Peter Noone

38. Short-term absence
Bio-psychosocial model predominates,
One question,
 “Is there a single underlying unifying medical cause?”
 either yes or no,
Employer manages this as a “conduct”
issue,
04/06/12 Dr Peter Noone

39. Long term, medical model
Disease---> loss of function--->disability,
Measure loss of function,
Therefore define disability in context of work,
personal, social or recreational terms,
We can adjust the work or the workplace.
04/06/12 Dr Peter Noone

40. Rehabilitation
Relies on medical model of disability and
functional assessment,
Uses positive influencers of bio-
psychosocial model to motivate, sustain and
support workability,
Outcome - more rapid physical recovery.
04/06/12 Dr Peter Noone

41. A Biopsychosocial model of low
back disability
Social Environment
Illness Behaviour
Psychological
Distress
Attitudes
& Beliefs
Pain
Report of a CSAG Committee
On Back Pain May 1994
04/06/12 Dr Peter Noone

42. Probability of RTW LBP
04/06/12 Dr Peter Noone

43. Yellow Flags, Psychological factors
Individual cognitive, emotional, and behavioural factors.
• Distress/depression
• Somatisation
• Fear avoidance
• Passive/-ve coping?
• Dysfunctional beliefs?
• Pain and (re)injury
04/06/12 Dr Peter Noone

44. Blue flags: perceptions about work
Individual attitudes and beliefs about:
• Job dissatisfaction
• No social support
• Attribution (to work)
• Perceptions of demand/control
• Organisational culture/climate
04/06/12 Dr Peter Noone

45. Black flags: not Individual perceptions
Affect all workers equally -
• Sickness policy
• Sick certification
• RTW policy
• Job content
• No modified duties
• Benefit system
Flags are incorporated in occupational health guidelines.
04/06/12 Dr Peter Noone

46. Management Actions (medical model)
Rapid recovery - no action,
Permanent disability
 medical advice,
 redeployment,
Slow recovery
 medical advice,
 temporary modified work,
 rehabilitation
04/06/12 Dr Peter Noone

47. Temporary modified work,
Dr Clive Burges 2001 rehabilitation
Rapid recovery Rehabilitation
Slow recovery
health
Permanent disability
Death
time Time gain
04/06/12 Dr Peter Noone

48. Rehabilitation
Team
employee
Fully functioning team
Person out
sick Locum
04/06/12 Dr Peter Noone

49. Fitness management
Line manager delivers it,
Central functions (HR, OH,
H&S, Risk) provide advice,
monitoring data, policy and
procedural support.
04/06/12 Dr Peter Noone

50. Referral to Occupational health
Manager/HR refers using form OHS 2;
frequent short term absence,
concern about physical fitness to carry out
duties of post,
concern about mental fitness to perform duties,
concern about susceptibility/vulnerability to
workplace exposure(s),
Statutory medical assessment,
Assessment of permanent incapacity on
medical grounds.
04/06/12 Dr Peter Noone

51. Questions frequently asked by
managers of OH
What is the likely date of return to work?
Will there be any disability at that date?
If so how long will it last, will it be temporary or
permanent?,
Will the employee be able to resume their full
range of normal duties on return to work?
Any implications for health, safety & welfare of
employee or others on return to work?
Is he/she likely to render regular, efficient and
effective service in future?,
04/06/12 Dr Peter Noone

52. Role of Occupational health
“If you have to prove your ill, you can’t get
well”,
Occupational health professionals not
required to verify reasons for absence from
work,
Protect the relationship of trust essential for
open honest and effective communication
between the employee and the OH
professional
04/06/12 Dr Peter Noone

53. Temporary modified work
“From passive to active complex”
early and continuous contact, triggers,
thresholds for referral,
superficial enquiry about the BPS
issues,
General feel for the issues,
04/06/12 Dr Peter Noone

54. Less capable
Give modified work,
tolerate decreased performance,
early retirement on actuarially reduced pension,
ill health retiral,
otherwise dismissal route
04/06/12 Dr Peter Noone

55. Decrease in performance
Energetic treatment if health related,
Counsel
Training, Mentoring, support,
Demote?,
Offer old job back if successful.
04/06/12 Dr Peter Noone

56. Five reasons for dismissal
Conduct,
Capability,
Redundancy,
Statutory reason, e.g driving charge,
Some other substantial reason.
04/06/12 Dr Peter Noone

57. Temporary modified work in action
Organisational culture,
Willingness of employee, manager, GP
and Occupational health to participate,
Begins with advisory medical report
from OH,
 indicates when full fitness likely,
 indicates current restrictions,
 states period over which recovery will occur,
 asks manager’s decision.
04/06/12 Dr Peter Noone

58. Temporary modified work
Managers considers feasibility of restrictions
on OH report,
 will return on a phased basis,
 can only return if adjustments made to current post,
 can only return to alternative duties,
 implications of partial fitness on running of
department,
 involvement of employee, work colleagues, external
support workers, job coach,
Decision - yes, no, wait a bit.
04/06/12 Dr Peter Noone

59. Temporary modified duties
If no - OH can do no more,
If wait - OH asks how long?,
If yes - OH reviews employee fortnightly
and monitors incremental progress to
full functionality,
medical restrictions in terms of hours,
content, location, intensity or pace of
work
04/06/12 Dr Peter Noone

60. Difficult topics
Pregnancy & post delivery,
Alcohol and drug misuse,
Investigative meetings/disciplinary hearing,
Conflicting opinion between OHP and
personal physician,
Premature return to work against medical
advice.
04/06/12 Dr Peter Noone

61. Investigative meeting
Fitness to meet different from fit to RTW,
Contribution of health to problem under
investigation- mitigating factor?
Make it easy for employee to attend.
Cannot get on with it until closure
04/06/12 Dr Peter Noone

62. Pregnancy & post delivery
Adjustment of work in normal
pregnancy (physiological state, not an
illness),
Work - home life balance,
Pregnancy related illness.
04/06/12 Dr Peter Noone

63. Alcohol & drugs
Referral under the policy,
 managers index of suspicion,
 admission of problem,
 willingness for treatment.
Occupational health,
 confirms extent of medical problem,
 brokers treatment,
 advises on success of treatment,
 advises on fitness to work.
04/06/12 Dr Peter Noone

64. Conflicting medical opinion
The opinion of OHP usually prevails,
2 questions?
 Did you tell OHP all health problems ?
 has anything changed since consultation ?
Refer back to OHP to try to resolve it or
narrow down areas of conflict.
04/06/12 Dr Peter Noone

65. Premature return to work
Unexpected,
Medical advice,
Restricted employment,
Suspend on pay until investigation of
facts complete.
04/06/12 Dr Peter Noone

66. Barriers to rehabilitation
Links with disciplinary process,
Litigation: work related accidents & ill-
health,UK Assoc of PI Lawyers Code of Practice
on rehab www.apil.com/pdf/publicdocs/RehabRevisedApr03.pdf
Absence linked with carer role,
Absence linked with stress from disciplinary
process.
04/06/12 Dr Peter Noone

67. The “acid test”
Is everything being done that can
reasonably be done by:
 the individual employee themselves,
 the clinical/support services of the organisation,
 the employer/line-manager/HR
What would you want or expect for
yourself?
04/06/12 Dr Peter Noone

68. Medical aspects of Pension
benefits - roles and
responsibilities
OHP – Gains evidence and advises
on capabilities/ adjustments,
– decides if adjustments
Line manager reasonable,
Line manager/HR – determine if alternative duties
available,
– decides if criteria met, signs
Medical adviser off pension advice for probity,
considers appeal
04/06/12 Dr Peter Noone

69. Medical aspects of pension
benefits
A form of dismissal NOT retirement,
irrelevant if “voluntary” or “compulsory”
Employer decision that “incapable of
doing job”,
conflict with disability ground of
Employment Equality ActDDA,
? Consequence of decision.
04/06/12 Dr Peter Noone

70. Pension scheme criteria
Individuals who are permanently incapable of
rendering regular, efficient and effective service in
the duties of their grade by virtue of ill health,
Permanent,
incapable,
Duties,
ill-health,
Regular, efficient, effective, ? safe service
NO suitable alternative duties available.
04/06/12 Dr Peter Noone

71. Pension benefits evidence
Face to face assessment,
Specialist reports,
Evidence of failed early, energetic and effective
treatment or unsuccessful adjustment(s),
Full clinical recovery, coming off benefits and
return to work not always contemporaneous nor
synonymous,
Remove the bio-psychosocial obstacles to RTW
04/06/12 Dr Peter Noone

72. Medical aspects of pension
Recommend IHR only;
 after full investigation and consideration,
 after fully exploring opportunities for recovery and
rehabilitation,
 Should not be made lightly,
 Should not be for motivational factors (non medical
reasons),
 Should not be for managerial reasons (? “greater
efficiency of the service”) to solve management’s
problems
04/06/12 Dr Peter Noone

73. It’s the same each time with
progress, first they ignore
you, then they say you’re
mad, then dangerous….. Then
there’s a pause and you can’t
find anyone who disagrees
with you”
Tony Benn
04/06/12 Dr Peter Noone

74. “The difficulty lies not in
new ideas but in
escaping the old ones
which ramify into every
corner of our minds”
J Maynard Keynes
04/06/12 Dr Peter Noone