In sickness and in work

Sickness absence rates are the lowest on record and a TUC survey shows we have the unhealthy habit of working when sick. So why is the employers' body CBI calling for a clampdown on "malingerers"? And why is a visit to the doctor portrayed as shirking?

Latest figures from the Confederation of British Industry (CBI) show sickness absence at work is at its lowest since its surveys began in 1987. CBI found the number of working days lost fell by 5.7 per cent, down from 176 million days in 2001 to 166 million in 2002 (1).

Impressed? Not the CBI. John Cridland, CBI deputy director general, said many firms worry that up to 15 per cent of absence is not genuine, adding: "Though employers believe most absence is caused by genuine minor sickness, there are serious concerns about the number of staff 'throwing sickies'."

In fact, we are not a nation of malingerers. TUC's January 2004 survey found nearly half the workforce turned in to work last year when too ill. They didn't want to let down their colleagues. They couldn't afford the time off. And they couldn't afford to be on the wrong end of punitive sickness absence policies (Hazards 66).

• Working when sick is infectious

Present incorrect

In a sensible world, workers would feel free to keep their germs at home. Instead, productivity is compromised not by absences, but by the under par efforts of the working wounded. Forget absenteeism; the scourge of the modern workplace is "presenteeism."

The Dublin-based European Foundation says the greater the work pressure, the higher the percentage of people who keep working when feeling sick (2).

A 2000 paper in the Journal of Epidemiology and Community Health found workers providing care or welfare services, or who teach or instruct, have a substantially increased risk of being at work when sick (3).

The study also found workers who faced difficulties in finding a replacement or stand in were more prone to presenteeism. Those occupational groups with higher rates of presenteeism experienced symptoms more often than those without presenteeism, suggesting keeping out of the workplace when sick is the healthiest option.

The 2002 TNO Work Situation Survey found a large proportion of the Dutch work force (63.2 per cent) reported being present at work but feeling sick. Working under pressure was strongly related to presenteeism: the greater the work pressure, the higher the level of presenteeism.

A major study in the Journal of the American Medical Association found one in eight US workers is in pain and loses an average of five hours a week in productivity as a result (4). The November 2003 study found threequarters of these lose productive time due to reduced performance, not due to absence.

A study of sickness absence in UK civil servants, published in August 2003 in the British Medical Journal, concluded "short term absences may represent healthy coping behaviours," with workers were less likely to end up on the long-term sick list (5).

The job is often the cause of sick leave (Hazards 79). In 2003, CBI put sickness absence for 2002 at 166 million days. The Health and Safety Executive estimated 32.9 million days were taken off work that year because of work-related ill-health (6). If these estimates are correct, then about 20 per cent of all sickness absence from work is because of work-related ill-health.

An October 2003 survey by Personnel Today and the Health and Safety Executive suggested 11 per cent of the UK's total sickness absence is due to stress alone.

• Study finds pain at work costs billions

Modern management is bad for you

In 2000, Hazards warned that the major health safety issues of the 21st century workplace were job security, staffing levels, workplace organisation and change, overwork and new management techniques.(7)

New studies have confirmed cut-throat modern management is not just damaging for the workers who are fired, it leaves behind a insecure and unhappy group of workers that are more likely to go sick, more likely to develop permanent, debilitating health problems and that will be much less productive as a result.

Corporate downsizing may increase sickness absence and the risk of death from cardiovascular disease in employees who keep their jobs, shows new research from Finland.(8)

In a British Medical Journal report, published online on 23 February 2004, researchers describe a study of 22,430 municipal employees in four Finnish towns, who kept their jobs during a national recession between 1991 and 1993. Rates of sickness absence and deaths were monitored for over seven years.

Major downsizing - more than 18 per cent reduction in personnel - was associated with an increase in sickness absence in permanent employees but not in temporary employees.

Employees who had experienced major downsizing were also twice as likely to die from cardiovascular disease, particularly during the first four years after downsizing.

In the global economy, downsizing has become an increasingly important trend. Policy makers, employers, and occupational health professionals should recognise that downsizing may pose a severe risk to health, they conclude.

Commenting on the new findings, TUC general secretary Brendan Barber said: "This report confirms what we've been saying all along - unemployment and redundancies are a tragedy for everyone affected.

"Bosses wishing to avoid potentially tragic consequences should aim to work closely with unions whenever job losses loom. By keeping workers informed, helping redundant employees find new jobs quickly, and providing support for those colleagues still in work, employers can help limit the damaging effects of big job cuts."

Depressing news

Australian researchers reporting in the November 2003 issue of the Journal of Epidemiology and Community Health assessed 1,188 employed professionals, aged 40-44 years, for depression, anxiety, physical, and self rated health.(9)

The research team concluded: "The results of this study raise concerns about the adverse health effects in people who might be experiencing both high job strain and high job insecurity."

They add: "As the labour market becomes more globalised and competitive, employees are more likely to encounter these two work conditions simultaneously. Therefore the influence of work on health is an important focus for future population health research, policy and intervention."

And new Health and Safety Executive guide recognises what unions have said all along - restructuring, reorganisation, outsourcing and downsizing are not just buzzwords, they are key safety issues.(10)

The free information sheet for employers in major hazards industries looks at "how to control safety risks in organisational change."

It says changes at workplace and corporate level "can have a significant impact on safety at operational level. The information sheet points to changes to roles and responsibilities, organisational structure, staffing levels and staff disposition as some of the changes that may have an effect on safety."

HSE's Chris Wilby said: "Although organisational changes are a normal and increasingly frequent part of business life, businesses working in major hazard industries must take particular care to avoid risks to their employees and the public."

Signing off

There is lots of pressure for reform. Employers want maximum attendance, GPs don't want to write piles of sicknotes and the government wants to get workers off benefits and into work.

A pilot scheme designed to pave the way for GPs to give up sicknote certification by 2006 could begin by mid-2004, according to the British Medical Association (BMA).

It says the pilots could lead to company doctors and occupational health professionals becoming the first port of call for sick employees. A number of large motor manufacturers are thought to be interested in participating in the pilot, along with a police force, an NHS Plus organisation and at least one other multinational.

Many GPs recognise they are not in a position to determine exactly what a patient's job entails. In most cases, they have neither the time nor the skills. But GPs have a great deal to lose if they relinquish the sicknote role. They may no longer able to prevent a patient having to work when this could be detrimental to his or her recovery.

And the worker loses an independent health advocate from outside the workplace whose sole concern is their health and well-being, not production schedules, staffing shortages or unhealthy industrial relations.

GP or not GP?

In April 2003, TUC warned that any shift to company doctor issued sick notes, would only work if staff believed there was "unbiased and independent advice on treatment" - and that means unions have to be involved in selecting, managing and running workplace occupational health services.

Unions are concerned that some company doctors have closer links to the personnel department than the workforce.

The move would be problematic, anyway. Only 1-in-7 workers have access to comprehensive occupational health support at work and only 3 per cent of companies get top marks for their provision, according to a 2002 study for HSE (11). For many workers, coverage amounts to an occupational health nurse at company HQ, a hundred miles away or more.

The current proposals for occupational health support, produced as part of the government's occupational health strategy, amount to a telephone helpline for firms and individuals and a small firms advice service, but recognise there are no more than 2,000 trained occupational physicians and 7,500 occupational health nurses in the UK - compared to a network of over 38,000 GPs.

One solution could be more resources in GP surgeries. The use of occupational health advisers alongside GPs can lead to dramatic reductions in GP workload.

A January 2003 survey by Leeds Occupational Health Advisory Service found GP referrals to surgery-based occupational health advisers led to 55 per cent of patients saying they made fewer visits to their GP, 30 per cent saying it helped them return to work earlier and over 30 per cent saying it led to "positive action" to improve health and safety at work (12).

Going Dutch?

Workers have a great deal to lose if responsibility for signing sick notes shifts to employers. Holland tried it in 1997 and it was a disaster, with occupational health staff finding sicknote work supplanted preventive occupational health service activities.

A 1999 review of the Dutch system concluded: "In some occupational health services, sickness absence consultation even takes almost 100 per cent of the occupational physician's working time. In comparison with a few years ago occupational physicians spend less time on periodic health examinations, workplace surveys and recommendations regarding work organisation and working conditions." (13)

The move away from workplace based preventive services landed Holland in the European Court last year (14).

The UK government has also failed to meet the minimum legal requirement of the Framework Directive, ensuring all workplaces have preventive occupational health services. Making the occupational health services that do exist switch their focus to sicknote certification will be a step further from compliance.

• What happened in Holland

Making work better

Trade unions and workers should see the current arguments about sickness absence as a way of raising again the complete lack of expertise - and action - on ill-health caused by work in most workplaces.

Policing sickness absence will lead to presenteeism, putting workers' health at further risk and placing responsibility for any damage to health firmly with employers.

Meanwhile the cause of a large part of workers' ill-health, working conditions themselves, needs dedicated time and resources from services guided and monitored by workers and their representatives.

The European Court ruling on the Dutch occupational health services system said internal workplace-based services allow much greater participation by employees in prevention work and that this was the intention of the Framework Directive.

• It's about prevention

REFERENCES

1. CBI. Absence and labour turnover 2003: the lost billions: addressing the cost of absence, AXA PPP healthcare, 2003 [23 April 2003, news release]

2. Presenteeism among sick workers, European Working Conditions Observatory, December 2003.

3. Aronsson, G., Gustafsson, K. and Dallner, M., Sick but yet at work; an empirical study of sickness presenteeism, Journal of Epidemiology and Community Health, vol.54, pages 502-9, 2000.

4. Stewart F and others. Lost productive time and cost due to common pain conditions in the US workforce, JAMA, vol.290, no.18, pages 2443-2454, 2003.

5. Kivimäki M and others. Sickness absence as a global measure of health: evidence from mortality in the Whitehall II prospective cohort study. BMJ, vol.327, pages 364-70, 2003.

6. Jones JR, Huxtable CS, Hodgson JT, Price MJ. Self-reported work-related illness in 2001/2002: Results from a household survey. HSE, 2003. Information sheet and full report 1.7Mb [pdf format]

7. Not what we bargained for, Hazards, factsheet no.69, Jan-March 2000, including a checklist for union reps on workplace change [pdf]

8. Jussi Vahtera, Mika Kivimäki, Jaana Pentti, Anne Linna, Marianna Virtanen, Pekka Virtanen, Jane E Ferrie. Organisational downsizing, sickness absence, and mortality: 10-town prospective cohort study,
British Medical Journal, online reference: doi:10.1136/bmj.37972.496262.0D, 23 February 2004. [abstract]

9. R M D'Souza and others. Work and health in a contemporary society: demands, control, and insecurity, Journal of Epidemiology and Community Health, vol.57, pages 849-54, 2003 [abstract]

10. Organisational change and major accident hazards, HSE, 2003. HSE news release • Full report [pdf]

11. Survey of use of occupational health support, HSE Contract Research Report CRR 445/2002.

12. Reducing work related ill-health in Leeds, Report 2003

13. Weel ANH and others. Recent changes in occupational medicine in the Netherlands. Int Arch Occup Environ Health, vol.72, pages 285-291, 1999.

14. Commission of the European Communities (2003). Case C-441/01. Opinion of the Advocate General in the Case C-441/01 CEC v Kingdom of the Netherlands.
Court of Justice Proceedings • EIRO summary • PDF summary

TUC guide

TUC workSMART sickness absence guide