NIHR Signal Workplace interventions may support return to work after sick leave

Published on 15 December 2015

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.

Workplace interventions may support return to work after sick leave

Share your views on the research.

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.

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.

Workplace interventions to prevent work disability in workers on sick leave

Published on 6 October 2015

van Vilsteren, M.,van Oostrom, S. H.,de Vet, H. C.,Franche, R. L.,Boot, C. R.,Anema, J. R.

Cochrane Database Syst Rev Volume 10 , 2015

BACKGROUND: Work disability has serious consequences for individuals as well as society. It is possible to facilitate resumption of work by reducing barriers to return to work (RTW) and promoting collaboration with key stakeholders. This review was first published in 2009 and has now been updated to include studies published up to February 2015. OBJECTIVES: To determine the effectiveness of workplace interventions in preventing work disability among sick-listed workers, when compared to usual care or clinical interventions. SEARCH METHODS: We searched the Cochrane Work Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO databases on 2 February 2015. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of workplace interventions that aimed to improve RTW for disabled workers. We only included studies where RTW or conversely sickness absence was reported as a continuous outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias of the studies. We performed meta-analysis where possible, and we assessed the quality of evidence according to GRADE criteria. We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 14 RCTs with 1897 workers. Eight studies included workers with musculoskeletal disorders, five workers with mental health problems, and one workers with cancer. We judged six studies to have low risk of bias for the outcome sickness absence.Workplace interventions significantly improved time until first RTW compared to usual care, moderate-quality evidence (hazard ratio (HR) 1.55, 95% confidence interval (CI) 1.20 to 2.01). Workplace interventions did not considerably reduce time to lasting RTW compared to usual care, very low-quality evidence (HR 1.07, 95% CI 0.72 to 1.57). The effect on cumulative duration of sickness absence showed a mean difference of -33.33 (95% CI -49.54 to -17.12), favouring the workplace intervention, high-quality evidence. One study assessed recurrences of sick leave, and favoured usual care, moderate-quality evidence (HR 0.42, 95% CI 0.21 to 0.82). Overall, the effectiveness of workplace interventions on work disability showed varying results.In subgroup analyses, we found that workplace interventions reduced time to first and lasting RTW among workers with musculoskeletal disorders more than usual care (HR 1.44, 95% CI 1.15 to 1.82 and HR 1.77, 95% CI 1.37 to 2.29, respectively; both moderate-quality evidence). In studies of workers with musculoskeletal disorders, pain also improved (standardised mean difference (SMD) -0.26, 95% CI -0.47 to -0.06), as well as functional status (SMD -0.33, 95% CI -0.58 to -0.08). In studies of workers with mental health problems, there was a significant improvement in time until first RTW (HR 2.64, 95% CI 1.41 to 4.95), but no considerable reduction in lasting RTW (HR 0.79, 95% CI 0.54 to 1.17). One study of workers with cancer did not find a considerable reduction in lasting RTW (HR 0.88, 95% CI 0.53 to 1.47).In another subgroup analysis, we did not find evidence that offering a workplace intervention in combination with a cognitive behavioural intervention (HR 1.93, 95% CI 1.27 to 2.93) is considerably more effective than offering a workplace intervention alone (HR 1.35, 95% CI 1.01 to 1.82, test for subgroup differences P = 0.17).Workplace interventions did not considerably reduce time until first RTW compared with a clinical intervention in workers with mental health problems in one study (HR 2.65, 95% CI 1.42 to 4.95, very low-quality evidence). AUTHORS' CONCLUSIONS: We found moderate-quality evidence that workplace interventions reduce time to first RTW, high-quality evidence that workplace interventions reduce cumulative duration of sickness absence, very low-quality evidence that workplace interventions reduce time to lasting RTW, and moderate-quality evidence that workplace interventions increase recurrences of sick leave. Overall, the effectiveness of workplace interventions on work disability showed varying results. Workplace interventions reduce time to RTW and improve pain and functional status in workers with musculoskeletal disorders. We found no evidence of a considerable effect of workplace interventions on time to RTW in workers with mental health problems or cancer.We found moderate-quality evidence to support workplace interventions for workers with musculoskeletal disorders. The quality of the evidence on the effectiveness of workplace interventions for workers with mental health problems and cancer is low, and results do not show an effect of workplace interventions for these workers. Future research should expand the range of health conditions evaluated with high-quality studies.

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