Evidence
Alert

Workplace interventions may support return to work after sick leave

This systematic review finds that interventions based in the workplace can help to support employees’ return to work following illness or disability. There is evidence indicating that the longer period of sick leave someone takes, the less likely they are to return to work. This review identified interventions to improve return to work, with support and potential adaptations, after sick leave. Government policy has shifted to focus on assessing people’s capacity to work, not just their degree of impairment, therefore supporting return to work enables that capacity to be realised.

The largest body of evidence was for people with musculoskeletal problems, with less evidence available for other conditions such as mental health problems or cancer. This may be because workplace interventions tend to be based around environmental adaptations to support people’s physical return to work. Other conditions may require different and more targeted approaches depending on the nature of the condition. Successful interventions, such as changes to the work environment or working hours, that support timely and sustained return to work would be beneficial both to the individual and may reduce the demands that work absence places on the UK economy.

Why was this study needed?

Sick leave costs UK employers approximately £29 billion a year. The NHS has high levels of sick leave, with 4.4% of workers are recorded as off sick at any one time, compared with 1.8% in the private sector and 2.9% in the rest of the public sector.

Isolated days of sickness due to minor illnesses such as colds are inevitable and largely unavoidable. However, when people are off sick for longer periods of time it can be difficult to support and facilitate their return to work.

Enabling people to return to work has benefits for employers and the economy, but also individuals who draw identity, esteem and income from working, with unemployment carrying social stigma and potential financial disadvantage.

Under the Equality Act (2010), employers in England and Wales are not allowed to discriminate against people because they have a disability and are required to make “reasonable adjustments” to prevent people with disability being at a disadvantage in the workplace. This systematic review investigated the effectiveness of interventions within the workplace that were designed to help people on sick leave to return to work.

What did this study do?

This systematic review included 14 randomised controlled trials of workplace interventions designed to support the return to work of part- and full-time workers aged 18 to 65 years and currently on sick leave from any type of workplace. Workplace interventions were defined as a change to the working conditions or environment – such as supportive equipment, changes to hours – that involved the employee and employer, plus others, if needed. Workplace interventions were compared with either usual care based on legislation and guidelines, or clinical care, such as occupational health interventions. This systematic review was produced by the Cochrane Collaboration and followed their high quality methods. Searches were not restricted to English language studies only.

What did it find?

  • The pooled results of five studies showed that workplace interventions were more effective in getting people back to work sooner than usual care (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.20 to 2.01). This result came from four studies in people with musculoskeletal problems such as back pain (including between 120 and 196 people) and one study of people with mental health problems (including 69 people).
  • Six studies showed that workplace interventions did not significantly reduce the time to “lasting” return to work – defined as four or more weeks back at work (HR 1.07, 95% CI 0.72 to 1.57). However, the quality of this evidence was low, based on studies with variable results and risk of bias, making the comparison less robust. Workplace interventions did have a significant effect in two studies of musculoskeletal problems, but not in the other studies for mental health problems or cancer.
  • Workplace interventions reduced the number of sick days taken by 12 months’ follow-up by a mean 33.33 days compared with usual care (95% CI -49.54 to -17.12). This difference was based on the pooled analysis of seven high quality studies, with the strongest evidence for musculoskeletal problems.
  • Only one study measured recurrences of sickness leave, it showed that there was a higher recurrence of sick leave in the workplace intervention group, 51%, compared with 25% in the usual care group (HR 0.42, 95% CI 0.21 to 0.82).

What does current guidance say on this issue?

Employees in the UK are entitled to “self-certificate” for up to seven continuous days’ sick leave. After this point they must obtain a “fit note” from their GP. The Health and Safety Executive recommends that employers implement a return to work plan for employees following extended sick leave, to ensure a smooth transition back into the workplace. Specific guidance (2013) is available for NHS employers to support employees’ return to work, as well as creating a “healthy workplace” to prevent sick leave absence as much as possible. NICE also produced guidance in 2009 about managing long-term sick leave.

For those employees who become disabled as a result of their sickness, employers are legally required to make “reasonable adjustments” to enable the employee to return to work. These can include offering gradual return to full working hours or changing working hours.

What are the implications?

Workplace interventions can help enable employees to return to work. However, the evidence was of mixed quality, with variable findings across studies. The strongest body of evidence was for musculoskeletal problems, with limited evidence available for other conditions. Interventions supporting return to work should be appropriate to the cause of the illness or disability. Workplace interventions may be more suited to musculoskeletal conditions where environmental changes, such as providing a new chair to relieve back pain or installing a wheelchair ramp to enable building access, can have a big impact on an employee’s ability to work. Other causes of ill health or disability may require different and more targeted interventions with occupational health support.

Citation

van Vilsteren M, van Oostrom SH, de Vet HC, et al. Workplace interventions to prevent work disability in workers on sick leave. Cochrane Database Syst Rev. 2015;10:CD006955.

Bibliography

Donnelly, L. New figures show soaring NHS stress leave, and 15 days sickness a year. London: The Telegraph; 2015.

Government Equalities Office. Equality Act 2010: Duty on employers to make reasonable adjustments for their staff. London: Government Equalities Office.

Government Equalities Office. Equality Act 2010: guidance. London: Government Equalities Office; updated 2015.

Gov.uk. Taking sick leave. London: Gov.uk; 2015.

Great Britain. Equality Act 2010: Elizabeth II. Chapter 15. London: The Stationery Office; 2010.

HSE. Element 5: Agreeing and reviewing a return to work plan. Merseyside: Health Service Executive; 2004.

NHS Employers. Guidelines on prevention and management of sickness absence. London: NHS Employers; 2013.

NICE. Workplace health: long-term sickness absence and incapacity to work. National Institute for Health and Care Excellence; 2009.

Stevens M. Rising sick bill ‘costs UK business £29bn a year’. London: Chartered Institute of Personnel and Development; updated 2013.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Commentaries

Expert commentary

This review provides a useful summary of the evidence that is currently available from randomised controlled trials on the effectiveness of workplace interventions in reducing incapacity for work among people who are on sick leave. Like most Cochrane reviews, it is limited by the criteria that were specified for inclusion of studies and by an assessment method that to some extent sacrifices validity for reproducibility. A full evaluation of current evidence would need to include studies that have used other designs, and to consider the potential magnitude and direction of any biases (not just risk of bias) when coming to conclusions. A further limitation is the restricted scope of the economic evaluation that was possible from the available data. In the absence of clearer evidence for cost-effectiveness, I do not think the findings are an indication for immediate widespread change of practice within the NHS. However, they are encouragement to further research on the economics of interventions that use a case-management approach to reduce time lost from work among workers who go on sick leave.

Professor David Coggon, Professor of Occupational and Environmental Medicine, MRC Lifecourse Epidemiology Unit, Southampton