Promoting health and wellbeing and attendance at work

These guidelines have been developed to supplement and reinforce Annex 26 of the NHS terms and conditions of service handbook.

10 November 2023

About the Health, Safety and Wellbeing Group

The Health, Safety and Wellbeing Group (HSWG) is a sub-group of the NHS Staff Council. It is a tripartite group involving staff side representatives from healthcare unions, management side representatives from NHS organisations and specialist members, such as the Health and Safety Executive, and the Institute of Occupational Safety and Health with a remit to do the following:

  • to raise standards of workplace health, safety, and wellbeing in healthcare organisations
  • to promote a safer working environment for all healthcare staff
  • to promote best practice across both the NHS and the Independent sector.
NHS Staff Council - Health, Safety and Wellbeing Group logomark

This guidance was produced through partnership working between unions, management and specialist advisors. The group wishes to ensure this guidance is implemented with the same partnership approach. HSWG recognises that partnership working ensures best outcomes for patients and staff in protecting their health, safety and wellbeing.

Other HSWG resources to support you in your organisation can be found here.


The following guidelines have been developed by management representatives and staff side trade unions, through the NHS Staff Council’s Health, Safety and Wellbeing Group (HSWG) to supplement and reinforce Annex 26 of the NHS terms and conditions of service handbook. They should be implemented at a local level by management and staff side representatives.

Over the last few years, enormous pressure has been placed on our NHS workforce. The massive impact of the pandemic and the future burden of undiagnosed diseases and long-term conditions make it essential that we support the NHS workforce to be healthy and well at work.

A consistently good experience of work is recognised to be a positive health outcome. Good work can truly be good for your health. However, a negative overall experience of work is considered by experts to have a greater impact on health than being unemployed. We recognise that employees are the NHS’s greatest asset and are essential to the sustainability of the NHS, and our aim is to provide the highest possible clinical standards of care.

There have been multiple expert-led reviews concluding that the health and wellbeing of NHS staff impacts quality of patient care, organisational efficiency, and the ability to deliver regulatory targets. Simply put, looking after the health and wellbeing of the NHS workforce enables them to pass on good quality care to patients.

The NHS Constitution commits NHS employers to go beyond the legal minimums in managing the health, safety, and wellbeing of its workforce, by providing opportunities for staff to improve their health and wellbeing. It also commits the NHS to engage staff in decisions that affect them and the services they provide, individually, through representative organisations and through local partnership working arrangements. The NHS Staff Council is committed to partnership working – the NHS terms and conditions of service handbook states that “effective partnership working is crucial in achieving the effective management of sickness absence.”

These guidelines outline key principles that NHS organisations in England should follow to promote health and wellbeing and attendance at work and to signpost readers to sources of further information.

Underlying principles

The Health, Safety and Wellbeing Group has agreed five key principles for the promotion and management of staff health and wellbeing and attendance at work:

  • Initiatives to create healthy workplaces should be undertaken with staff, not done to staff. Workers affected by programmes to create healthy workplaces must be involved in every step of the process, and their opinions and ideas sought out, listened to and where agreed, implemented. Local sickness absence policies and procedures should be developed and agreed in partnership. In relation to addressing workplace hazards, there is a legal requirement to consult trade union safety representatives.

  • Effective and compassionate leadership to create a ‘motivated and sustainable’ workforce is essential to the wellbeing of our staff. A culture of compassionate team leadership is linked with reduced levels of stress, errors, staff injuries, harassment, bullying and violence against staff, staff absenteeism, presenteeism and (in the acute sector) patient mortality.

    Leaders need to model the behaviours and values they want to see in their staff, and build compassionate leadership skills (attending, understanding, empathising, serving/helping).

    Commitment from the board is essential. The NHS health and wellbeing framework outlines actions for high-impact changes for health and wellbeing. One of these actions is to ensure that health and wellbeing initiatives are backed with strong leadership and visible support at board level. Employers also have a legal duty to manage and assess all health and safety risks, and this includes causes of sickness absence. The Health and Safety Executive (HSE) and the Institute of Directors guidance, leading health and safety at work, recognises that health and safety is critical to organisational success. It adds that board members who do not show leadership in this area are failing in their duty as directors.

  • It is important that initiatives to create healthy workplaces and manage sickness absence are monitored and evaluated. Measures should be taken to address gaps in provision and review the effectiveness of initiatives.

  • Access to competent advice is key. Occupational health advisers, health and safety specialists, reablement specialists (for example, physiotherapists, occupational therapists, occupational psychologists), human resource advisers and health promotion experts can all provide advice and support to organisations on creating a healthy workplace and the management of sickness absence, for example, supporting early return to work.

    Advisers need to work closely together, rather than in silos, and engage with staff side representatives, who are specialists too. Strategies such as Growing Occupational Health and Wellbeing Together provide a long-term roadmap to improve the health and wellbeing of our NHS people by growing our occupational health and wellbeing services and people.

Creating healthy workplace cultures

The healthy workplace principle is one that not only prevents ill health, but actively promotes health and reduces sickness absence.

Healthy workplace

The World Health Organization defines a healthy workplace as follows:

“A healthy workplace is one in which workers and managers collaborate to use a continual improvement process to protect and promote the health, safety and wellbeing of all workers and the sustainability of the workplace by considering the following, based on identified needs:

  • health and safety concerns in the physical work environment
  • health, safety, and wellbeing concerns in the psychosocial work environment including organisation of work and workplace culture
  • personal health resources in the workplace
  • ways of participating in the community to improve the health of workers, their families, and other members of the community.”

Physical working environment

  • If not managed, the physical working environment can lead to ill health. Physical and health hazards in the NHS are wide-ranging, from chemical hazards, such as cytotoxic drugs and cleaning substances, to biological hazards, such as blood-borne viruses; ergonomic hazards, such as heavy lifting and blue light driving, and the hazards associated with ionising radiation. The physical infrastructure and facilities within a work building can also lead to health problems and low morale. These include working in hot environments, a lack of changing facilities and a lack of access to drinking water.
  • There is wide-ranging legislation which places a duty on employers to take action to eliminate or reduce exposure to physical hazards and reduce the risks to health. There is also a requirement to carry out proactive checks, known as health surveillance for workers exposed to a number of physical hazards, for example, skin irritants or asthma-causing substances.
  • Take a look at our HSWG guidance to support NHS organisations to improve their provision of staff welfare facilities.

Psychological working environment

Psychological safety, in a work capacity, is all about creating environments in which employees feel accepted and respected. People who feel psychologically safe tend to be more innovative, learn from their mistakes and are motivated to improve their team or organisation. Psychological safety drives effectiveness as it inspires a learning culture beneficial to any individual and the organisation.

The psychosocial work environment includes the organisation of work and the organisation culture; the attitudes, values, beliefs and practices that are demonstrated on a daily basis in the enterprise, and which affect the mental and physical wellbeing of employees. The HSE recognises a number of factors in the workplace that can lead to poor mental health and stress at work.

Employers have a legal duty to assess the risks from psychosocial workplace hazards in the same way they do with physical hazards. Tools and guidance are available from the HSE to help. The HSE guidance provides a benchmark for organisations to meet in order to continuously improve the psychosocial work environment.

There are moral, legal, and business reasons for creating a healthy workplace:

  • society expects good standards of health and safety
  • it is the right thing for organisations to do
  • there are legal requirements to protect workers from the hazards they face at work
  • it makes good business sense.

When an accident occurs, there will be direct and indirect costs associated with the event:

  • direct costs include the time lost through sickness absence, including the recruitment and training of temporary staff to cover the injured party, potential NHS Injury Benefit, and other compensation claims (see the NHS terms and conditions of service handbook), and the subsequent increased insurance premiums (see NHS Resolution).
  • indirect costs, such as the adverse effects on the quality of patient care – a healthy workforce is better able to provide high-quality patient care, and an unhealthy workforce disrupts patient services through high levels of both sickness absence and presenteeism.

Personal health resources

It is increasingly accepted that organisations have an important role in promoting good health in the workforce and giving staff information, resources, and opportunities to improve their own mental and physical health.

It is important to recognise that work conditions can act as a barrier to improving health, for example, physical inactivity may result from long work hours and poor diet from lack of access to healthy snacks or meals at work or time to take meal breaks.

Health promotion activities should be tailored to the needs of occupational groups and be accessible to staff working shifts.

Community participation

Organisations exist in communities and there are opportunities for initiatives to protect and promote the wellbeing of workers to extend beyond the workplace to community settings.

In some parts of the country, the NHS Sport and Physical Activity Challenge, which aims to get NHS staff more active, has been extended to NHS workers families and the wider community.

Dartford and Gravesham NHS trust (DGT) streamlined the approach to health and wellbeing to support staff to stay well.

DGT is one of the largest hospital trusts in Kent, serving a population of around 500,000. DGT has 3,311 employees who provide a wide range of services. Over the last year, the trust has focused on creating a streamlined multi-disciplinary approach to the overall wellbeing of its staff. This streamlining happened by merging the occupational health (OH) and the health and wellbeing teams, which led to the newly formed health and wellness team.

Sickness absence rates due to work-related stress and anxiety in the trust have more than halved to 0.5 per cent. The trust is in the top quartile of organisations for all health and wellness elements in the NHS Staff Survey.

Support for managing sickness absence

This section outlines what to do when people go off sick. It takes an employee and work-focused approach to managing sickness absence.

A work and employee-focused approach:

  • respects employees’ rights to take paid sick leave, within the scope of the relevant sick leave policy, when they are unable to work due to illness or injury
  • recognises that good work is generally good for people’s physical and mental health and wellbeing
  • makes reasonable temporary adjustments to enable an employee to remain in work during personal difficulties or when experiencing mild-moderate conditions that impact upon health and wellbeing in work
  • ensures that managers make reasonable adjustments under the organisation’s reasonable adjustments policy where employees have a disability or serious underlying medical condition.
  • is based on the rational that managers should “know their employees” and be familiar with the issues surrounding the attendance profile and needs of their employees.

The work-focused approach differs from previous approaches because it focuses on what the employee can do or might be capable of doing with reasonable help rather than what they cannot do due to illness or injury. Having meaningful conversations between the manager and employee can often facilitate a more preventative approach to managing attendance.

The following information covers:

  • developing policies in partnership
  • training
  • scope of policy
  • documentation and confidentiality
  • presenteeism / staff becoming ill at work
  • Equality Act and disability discrimination
  • entitlements
  • certification
  • reporting and monitoring
  • managing long-term absence
  • early interventions
  • ill-health retirement and dismissal on the grounds of ill health
  • infection control
  • medical suspension.

Developing policies in partnership

The NHS Constitution commits NHS employers, staff, and staff side representatives to work in partnership. This should include procedures and arrangements for managing sickness absence. The effective management of sickness absence is in the interests of both employers and their staff. Robust sickness absence policies can, if implemented properly, help improve attendance at work, the health and wellbeing of staff and ultimately patient services.

By working together, managers, staff and their trade union representatives can identify issues at an early stage and avoid lengthy time-consuming procedures. Issues could include:

  • previously undiagnosed systemic causes of sickness absence
  • individual members of staff whose attendance record is a cause for concern.

By doing so, both parties can avoid lengthy time-consuming procedures and help to reduce stress or anxieties around absence management on both parts.


To comply with both health and safety and equality laws, employers are responsible for having the right policies in place and for ensuring that managers are trained in their successful implementation. Also, as part of their commitment under the NHS Constitution to work in partnership, employers should involve staff side representatives in any training programme. Where possible, managers and safety and industrial relations reps should be trained together. This will enable all parties to gain a better understanding of each other’s perspectives.

Scope of policy

Employers have a duty to manage sickness absence, regardless of its duration. Sickness absence can be defined as any absence from work due to sickness or ill health. Sickness absence policies should not cover:

  • maternity leave
  • carer’s leave
  • any periods of absence agreed under family-friendly policies any pre-agreed periods of absence to receive treatment (see also the section on the Equality Act and discrimination).

Neither should they cover any unauthorised absence or absence where managers believe staff are abusing sickness absence procedures. These should be managed through disciplinary procedures.

Documentation and confidentiality

Communication between manager and employee regarding the cause of sickness absence should be considered confidential. Although other staff will need to know that their colleague is off work due to sickness, they are not required to know the cause of the absence. The manager should ensure that only those persons who need to know should be given access to relevant information and they in turn should treat that information as confidential. Information should not be disclosed by the manager to a third party without the consent of the employee concerned, except where failure to do so would be contrary to the public interest, or a breach of health and safety or other legal obligations. These records should be kept confidential and retained in accordance with the Data Protection Act.

Please note that documentation may form part of future procedures, so it is imperative that any information is recorded accurately and without prejudice.

Presenteeism/staff becoming ill at work

Although this part of the guidance is primarily about managing staff who have time off through sickness, it is equally important that trusts develop policies to support staff who attend work when they are too ill or unfit to work. The 2022 NHS staff survey showed that 56.6 per cent of staff have come to work in the last three months despite not feeling well enough to perform their duties. Additionally, The Centre for Mental Health estimates that presenteeism due to poor mental health in the United Kingdom leads to a loss of working time nearly 1.5 times that caused by sickness absence due to mental health in the United Kingdom.

If the manager believes the employee may be too ill or unfit to work, they should have a discussion with the employee and risk assess the situation. This assessment should consider the risks to the individual in question, their colleagues, patients, and the organisation. It may be concluded that the risks can be managed by a change to the working environment or a change or an adjustment to the workers duties. If the manager concludes that the employee is too ill to attend work, they should send them home, as their continued attendance at work could put the health and welfare of the employee, their colleagues, or patients at risk.

If an employee is taken ill or suffers an accident while at work which impacts on their ability to perform their duties, they should whenever possible, inform their immediate supervisor or manager without delay. If this is not possible, their colleagues must do so on their behalf. The manager must then risk assess the situation as explained above. If appropriate, the manager should inform the next of kin.

If an employee attends work but then leaves due to sickness, it will be recorded as a full day’s attendance and will not count as a sick day, although if it were to happen frequently it would need to be managed, monitored, and subjected to absence procedures.

The Equality Act and disability discrimination

The Act provides a provision for disabled people to be treated more favourably than non-disabled people. Understanding this, and the reasons for it, is crucial to removing the barriers that continue to deny disabled people equity.

The Equality Act says that a person has a disability if they have a physical or mental impairment which has a long-term and substantial adverse effect on their ability to carry out normal day-to-day activities. As well as previous physical and mental disabilities, this definition includes hidden disabilities (such as diabetes, epilepsy, mental health), and progressive and recurring conditions (such as cancer, HIV and MS). Guidance on what is defined as a disability can be found on the Equality and Human Rights Commission’s (EHRC) website.

The Equality Act defines three types of disability discrimination:

  • Direct discrimination: that is less favourable treatment on the grounds of disability compared to someone without that disability where other circumstances are comparable (note such discrimination cannot be justified by the employer).
  • Indirect discrimination through a provision, criterion or practice applied to everyone, but which puts people with a disability at a particular disadvantage.
  • Treating a disabled person unfavourably because of something arising from their disability.

As well as providing protection against discrimination and harassment due to a person’s disability, the Equality Act 2010 provides protection from direct disability discrimination and harassment where this is based on a person’s association with a disabled person, or on a false perception that the person is disabled. This is of particular relevance to carers of disabled people (children or adults).

Reasonable adjustment

Discrimination against a disabled person occurs where an employer fails to comply with a duty to make reasonable adjustments imposed on them in relation to that disabled person. The duty to make reasonable adjustments is a cornerstone of the Equality Act and requires employers to take positive steps to ensure that disabled people can access and progress in employment. What is considered reasonable will depend on:

  • whether taking any particular steps would be effective in preventing substantial disadvantage
  • the practicability of the step
  • the type and size of the employer
  • the financial and other costs of making the adjustment, compared to the extent of the employer’s resources and disruption caused
  • the availability to the employer of financial or other assistance (such as advice through Access to Work or Occupational Health) to help make the adjustment.

If the adjustment requested is not considered reasonable, the employer should provide a detailed explanation of why and explore alternatives with the disabled member of staff.

Examples of reasonable adjustments include:

  • adjustments to premises
  • allocating some of the disabled person’s duties to another worker
  • transferring the disabled worker to fill an existing vacancy
  • altering interview arrangements, such as location, providing extra time or providing interview questions in advance
  • altering the disabled worker’s hours of work or training
  • assigning the disabled worker to a different place of work or training or arranging working from home
  • allowing the disabled worker to be absent during working or training hours for rehabilitation, assessment, or treatment
  • acquiring or modifying equipment
  • allowing a period of disability leave
  • modifying capability/sickness absence or grievance procedures for a disabled worker
  • adjusting redundancy selection criteria for a disabled worker.

Employers will often need to consider a combination of steps, not just one. Any reasonable adjustments should be through discussion with the employee and understanding their individual needs. Note these needs may change and fluctuate over time, so these conversations should be continuous.

Sickness absence policies and the Equality Act

These policies should not be discriminatory in design. The EHRC says that: “It will often be appropriate to manage disability absence, pregnancy and gender reassignment-related absences differently from other types of absence,” and that “recording the reasons for absence should assist that process.” It also advises that although “employers are not automatically obliged to disregard all disability-related sickness absences, they must disregard some or all of the absences by way of an adjustment if this is reasonable”, and that “if an employer takes action against a disabled worker for disability-related sickness absence, this may amount to discrimination arising from disability”.


Employees on NHS terms and conditions who are absent from work due to illness will be entitled to receive sick pay in accordance with section 14 of the NHS terms and conditions of service handbook.


Sick pay is not normally payable:

  • for an absence caused by an accident due to active participation in sport as a profession
  • where contributable negligence is proved
  • when an employee is absent as a result of an accident where damages are received from a third party.

For further information please see NHS Terms and Conditions of Service Handbook | NHS Employers.

Sickness absence and annual leave

In the event of an employee falling sick while on annual leave, annual leave entitlement should be reinstated so long as the appropriate sickness reporting procedures have been followed. Should an employee wish to go on holiday during a period of long-term sickness absence, then they would need to request annual leave in line with their annual leave policy, and this would normally be agreed as long as the holiday period does not have a detrimental effect on the employee’s rate of recovery.

Carry forward of annual leave due to sickness absence

In recent years, there have been several high-profile legal decisions on the relationship between holiday rights and sickness. Details on the decisions and guidance and frequently asked questions can be found on NHS Employers’ website.

Time off for medical appointments

Employers should facilitate employees’ attendance of all medical appointments, as this is in the interests of all parties.

Time off for antenatal and postnatal care appointments and classes will always be agreed in line with maternity policies.

Employees with ongoing medical problems which may be defined as a disability under the Equality Act, and require disability leave to attend their appointments, should discuss their requirements with their manager (see Equality Act and disability discrimination).

Similarly, any other staff who have suffered injury or illness (whether physical or mental) and require rehabilitative therapy should discuss the time required with their line manager. Such time off will bring the employee back to full fitness sooner. However, the timing of appointments needs to be managed against the requirement to provide a service.

Occupational health appointments should be taken in work time. Where this is not possible, employees should be paid for the time taken to attend. This should be claimed via the normal processes for claiming additional hours or overtime.

Staff awaiting and recovering from operations and other treatments

Once the employee informs the manager of an impending operation or treatment, there should be a discussion as to whether the employee will be incapacitated either before or after the treatment. Amendments to duties, working hours, rota or days worked per week will support the employee and ensure they remain in work where possible.

Managers should be sympathetic to staff who are experiencing attendance problems in the run up to treatment and discuss an adjustment of working patterns, and duties, or taking occasional half days or full days leave in order to ease the situation where possible. For instance, lighter duties may keep the person at work where they cannot perform all of their normal duties as opposed to taking sick leave until the operation, which may exacerbate their condition (see also section under Equality Act and discrimination).

Time off for treatment for conditions not defined as incapacity

Certain operable conditions such as infertility are not, in themselves, defined as incapacity, and therefore staff would not be automatically entitled to sick pay as defined by section 14 of the NHS terms and conditions of service handbook. However, if staff are, as a consequence of the operation or treatment, incapacitated for work, section 14 should apply regardless of the original condition (with the exception of exemptions listed above). Similarly, staff would also be entitled to sick pay if they are incapacitated by some of the causes of infertility, such as ovarian cysts.

Managers should look to support employees during the course of their treatment through regular discussions around, for example, alternative duties to prevent unnecessary stress during the course of treatments.

The following guidance offers a suggested process for doing this:

  • Meet with staff member and manager (plus union representative and HR if required) to explore exactly what the staff member is asking for.
  • Managers should give appropriate consideration to all requests. In making their decision, managers must act in accordance with the trust’s equal opportunities policy and ensure each request is treated in a fair and equitable manner and that due consideration is given to the individual circumstances of each application.
  • If the request is expected to be over the long term, the manager should consider provisions such as the positive use of the flexi-time scheme or appropriate use of accrued lieu time, use of annual leave, or unpaid leave. Permission must be sought from the manager for requests to reasonable paid time off where deemed appropriate.
  • Final agreements should be signed by both the employee and manager and put in the personal file.
  • The situation should be reviewed regularly with the employee and support offered.
  • HR should maintain a log of cases.


The employee has a contractual obligation to ensure that sickness absence is certificated appropriately. The Department for Work and Pensions standard is for self-certification from the third, and medical certification from the eighth day. However, it is the normal practice within most NHS organisations to require self-certification from the first, and medical certification from the eighth day.


If a period of sickness absence lasts more than three days and up to a maximum of seven days, some employers may ask for a self-certification form. Please note that when calculating the above number of days, these include days not normally rostered or contracted to work (for example, weekends for Monday to Friday workers or ‘days off’ for shift workers).

Self-certification forms are available from managers, GP surgeries and community pharmacies. Completed forms should be given to relevant managers no later than the employees’ first day back at work. Managers will retain a copy of the self-certificate on the employee’s personal file and forward the original to paymasters.

Medical certification fit notes

The ‘fit note’ is at the centre of the work-focused approach. The fit note medical statement issued by a healthcare professional either indicates that a person is not fit for work, or that they might be fit for some work.

Under certain circumstances, the healthcare professional will also be able to suggest changes that would assist a return to work.

On the form, the healthcare professional will advise one of two options:

  1. Not fit for work – this means that the healthcare professional’s assessment is that they have a health condition that prevents them from working for the stated period of time. This is just like on the old ‘sick note’ where the doctor advises the employee to ‘refrain from work.’
  2. May be fit for work taking account of the following advice – this means the healthcare professional’s assessment is that although their condition does not necessarily stop them from returning to work, their return is conditional on certain conditions being met.

The form contains the following options:

  • Phased return to work. A healthcare professional will recommend this where they believe that the employee may benefit from a gradual increase in the intensity of their work duties or their working hours.
  • Altered hours. A healthcare professional will recommend this when they believe that the employee may be able to return to work if there is a change to the hours that they work. This may mean either working fewer hours or a change to their working pattern (for example, starting and finishing later to avoid travelling in the rush hour).
  • Amended duties. A healthcare professional will recommend this when they believe the employee may be able to return to work if their duties are amended to take into account their condition.
  • Workplace adaptations. A healthcare professional will recommend this where they believe the employee may be able to return to work if their workplace is adapted to take into account their condition.

The manager should contact the employee to discuss the advice on the note and where possible, facilitate return. If it is not possible for the manager to provide the support to return to work, the statement should be regarded as if the healthcare professional had advised ‘not fit for work.’

A fit certificate is required for all periods of sickness absence which exceeds seven days.

Working for other organisations while off sick

While on sick leave, employees are indicating they are not fit to fulfil their role as an employee, either in full or as adjusted in line with the healthcare professional’s fit note. As such, they should not undertake any paid work elsewhere, including bank or agency work unless given permission by their employer. Where a member of staff is deemed to be sufficiently fit to work elsewhere for their employer, suitable alternative employment should be discussed with their manager in the first instance.

Reporting and monitoring

Managers should keep accurate and up-to-date records of sickness absences for all the staff they are responsible for. It is important that there are clear reporting lines, involving staff, first-line managers, HR, payroll, and occupational health. Responsibilities must be made clear to all involved and, where necessary, training should be given to managers on how to fulfil their role.

For a sickness absence policy to be successful, management should set a time by which staff should report in and nominate a person they should report to. Staff should be made aware that:

  • they may on return have a return-to-work meeting with their line manager or a nominated person
  • they should report in (and to whom) or it will be assumed they are absent without leave (a relative or friend may phone in if necessary).

Staff should provide a brief description of their ailment and say how long they expect to be absent. They should provide a certificate if they are absent for more than one week (see section above).

Managers should pass information on absent staff to a central collating point as soon as it is available. If possible, this should be done daily, but where this is not possible, then on a weekly basis. Monthly absence returns are not acceptable.

When recording sickness absence, managers should record:

  • causes of absence
  • length of absences
  • the identity of those who have been absent.

The causes of absence should be classified in accordance with the Electronic Staff Record (ESR) codes. Under the existing ESR codes approved disability leave should be recorded as ‘approved – paid leave.’ Managers should consider keeping a record of when absence is disability-related for the purposes of demonstrating reasonable adjustments.

When analysing sickness absence data, it is important that as well as identifying who took the time off and for how long, employers should look for patterns such as whether certain parts of the organisation have higher levels of absence than others.

Other duties and responsibilities

Managers, with the support of occupational health services, have a duty to communicate appropriately with absent staff, and provide support and advice for staff when they are off sick, ensuring that appropriate regular contact is maintained with staff for the duration of their absence and on their return to work.

Occupational health services should also be proactive in providing advice on any work-related issues which need to be addressed by management to maintain attendance. This includes monitoring both sickness absence and presenteeism figures to ensure that any underlying causes of ill health are tackled.

Employees in turn are expected to ensure regular attendance at work, communicate appropriately with their employer when absent from work and cooperate fully in the use of the fully agreed sickness absence procedures.

Setting indicators

One of the uses of sickness absence data is to help identify any staff that may need support or intervention from management. Setting such indicators can help determine where and when action is needed. The attendance records of individual employees can then be monitored against these criteria. A partnership case/ management approach to such situations is recommended. Organisations may wish to set:

  • informal arrangements where periodic reviews of an employee’s sickness absence pattern are carried out and it is left to the manager to determine whether action is required
  • more specific absence thresholds, which are used to identify when managers should introduce a formal review, counselling, reference to occupational health service or the taking of further action under the capability procedures.

Indicators may take account of:

  • cumulative number of days absent in a set period
  • number of episodes of absence in a set period
  • combination of days and spells
  • pattern-related absences.

Absence relating to injury in the workplace or ill health caused by work (for example, sharps injuries) should be excluded from indicators triggering action through capability-related procedures. Healthcare associated infections should not be used to trigger absence management procedures but may be considered when looking at the sustainability of attendance.

Organisations may want to consider having a range of such points that are used for recurrent short-term absence or to initiate action by individuals or departments in longer-term absences. However, whatever indicators employers use, they must ensure it is compliant with the Equality Act.

Such indicators should help identify those cases where the level of sickness absence has reached a point where some type of intervention is deemed necessary. The intervention may include providing additional support for the member of staff in question, a change of duties for example, which may help with addressing an underlying health problem.

It is important that employers act in a consistent manner, and this includes transparent procedures, agreed through partnership working. However, these procedures should include a degree of flexibility that takes into account the individual and the nature of their illness.

Managing long-term absence

In recent years, there has been a focus on managing short-term or occasional absence, at the expense of managing long-term absence. However, research has shown that long-term absence accounts for 56 per cent of working days lost, and 70 per cent of the costs of absence.

National Institute of Clinical Excellence (NICE) guidance defines long-term absence as four or more weeks. However, it concedes there is no consensus on how to define long short-term sickness absence, and definitions vary between NHS trusts. Evidence from government research suggests that employers deal most effectively with their long-term sickness absence problems if they assess each individual case on its merits and, where appropriate, take action at the earliest possible opportunity. NICE guidance sets out good practice that can be applied to every stage of an employee’s rehabilitation and return to work following illness. These include:

  • early contact with the employee
  • early and thorough health assessment
  • development of an agreed rehabilitation plan
  • availability of therapeutic interventions
  • flexible return to work options
  • work adaptations and adjustments

Where rehabilitation is considered possible, the occupational health service and human resources will plan to manage the return in whatever manner is considered best for the individual. In most cases, this is likely to be in a staged or graduated fashion, with a change of duties if this is considered necessary.

During the rehabilitation period, employers should allow employees to return to work on reduced hours or work from home without loss of pay. Phased return enables staff to work towards fulfilling all their duties and responsibilities within a defined and appropriate time period, through interim flexible working arrangements, while receiving normal pay. The time allowed should be decided on a case-by-case basis depending on the original cause of absence (See also information on the fit note).

NICE recognises that the workplace may contribute to or cause someone’s absence from work due to sickness and that both employers and employees have an important role in helping people get back to employment after long-term sickness absence and incapacity. It recommends a partnership/case management approach with managers, occupational health services, employees and their trade union representatives working together in deciding what actions to take in relation to adaptations or adjustments. It is important that occupational health has the resources and expertise to provide the appropriate advice. If there are adaptations or changes to an employee’s duties, the employer must remember to do a revised risk assessment. If the employee is disabled and covered by the Equality Act then the new fit note procedures do not alter the duty on the employer to make reasonable adjustments, regardless of what a GP recommends. The DWP has produced a range of guidance on the fit note for employers, staff, and healthcare professionals.

Early interventions

Annex 26 of the NHS terms and conditions of service handbook recommends that in order to avoid premature and unnecessary ill-health retirement, employers should consider interventions as early as possible, and at the latest within one month of an employee going off sick.

Together, mental health problems and musculoskeletal disorders make up nearly 80 per cent of all ill health in the NHS. They are also the main causes of ill-health retirement. Early interventions are key to supporting a timely return to work and most importantly helping to stop conditions such as musculoskeletal disorders worsening or leading to additional health problems such as depression.

In his review of the health and wellbeing of the NHS Workforce, Dr Steve Boorman recommends that there should be “consistent access to early effective interventions for common musculoskeletal and mental health problems in all trusts,” as they are the major causes of ill health among NHS staff. Dr Boorman argues that by allowing staff to access early interventions, disruption to front-line services and patient care are minimised. The recommendations of the Boorman review are supported by the government, and NHS organisations should be implementing these recommendations.

The Boorman recommendations add to both Annex 26 and NICE guidelines on the management of long-term sickness and incapacity, which both recommend early interventions. Annex 26 already states that employers should support return to work by providing staff with direct access through appropriate dedicated resources. The NICE guidelines, which aims to prevent the number of employees moving from short-term to long-term sickness absence and to help employees on long-term absence return to work, says that intervening at an early stage during sickness absence contributes to the success of the intervention. The guidelines in particular recommend targeting those with musculoskeletal disorders and mental health problems.

Early interventions in practice

A number of NHS trusts have seen the business benefits of early intervention and have invested in dedicated services for staff including physiotherapy services and occupational psychologists. Examples of interventions are detailed here.

Cambridgeshire and Peterborough NHS Foundation Trust

At the height of the COVID-19 pandemic, Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) set up a new service providing rapid access to multidisciplinary mental health support for all staff within the five trusts across Cambridgeshire and Peterborough.

The Staff Mental Health Service (SMHS) has had persistently high demand since established. The service contacts patients within 72 hours of referral, and around 80 per cent of referrals are offered an initial assessment within two weeks. It has been shown that patients completing treatment show significant improvements in relation to depression, anxiety and PTSD symptoms.

Infection control issues

In order to comply with infection control guidelines, staff diagnosed with D&V (diarrhoea and vomiting) should not attend work until they are clear for 48 hours in order to prevent the spread of infection. In other examples where an employee is excluded from doing their normal role due to infection control reasons (for example, sores on hands), managers should find suitable alternative duties for a temporary period. Where this is not possible, the employee should not attend work.

Further information and resources

Line management support

The primary responsibility for the management of attendance rests with managers. The rationale for this approach is that managers should “know their employees” and be familiar with the issues surrounding the attendance profile and needs of their employees.

Managers are responsible for ensuring that employees are aware of the range of health and wellbeing support that is available to them in and out of the workplace. In addition, managers should make employees aware that support or advice may be available through Trade Union representatives if required.

Managers must consider the opportunities to return employees to work safely and at the earliest opportunity through supportive mechanisms such as Phased Return / Temporary Redeployment / Reasonable/ Tailored Adjustments.

Managers are responsible for creating an environment, which is conducive to health and wellbeing, and in which a low sickness absence record and regular attendance at work is expected.

A line manager’s response when a staff member calls in sick can make a big difference to how they feel about their work.


Further HSWG guidance to support staff health, safety and wellbeing includes:

NHS Employers Supporting the wellbeing needs of NHS staff guidance supports NHS health and wellbeing leads and managers to prioritise and fulfil staff wellbeing needs.

This easy-to-use and editable resource has been designed with the NHS for the NHS and was inspired by Maslow's hierarchy of needs. It aims to support health and wellbeing and staff experience leads and line managers to understand the importance of implementing and sustaining the wellbeing needs of NHS staff, so they are able and are supported to be healthy at work. Employers can use it as a poster and may wish to provide contact details of relevant wellbeing leads in their trust in the text box at the bottom. 

This can also be used alongside the Back to basics for a healthy working environment infographic which includes statistics and key facts about the impact of hydration, nutrition, sleep, and regular breaks on workforce wellbeing.