Sickness absence toolkit

Introduction

Welcome to our toolkit about managing sickness absence.

The below video from our Chief Executive Danny Mortimer gives some context around the toolkit. The toolkit as been updated since the video was put together, so it looks a bit different but the context remains the same.

When staff call in sick

Your response when a staff member calls in sick can make a big difference to how they feel about their work.

Communicate your reporting practices

A clear, well-communicated reporting procedure for when a member of staff calls in sick will help to ensure you get the information you need to keep the service running and tackle any future problems. Making staff aware of the reporting procedure will help to avoid any misunderstandings.

As a manager you will need to know the reporting procedure and who is responsible for reporting and referrals. You should also make sure you know where to find the numbers and referral procedures for occupational health, counselling or rapid access services.

[Top tip] You may wish to discuss the reporting procedure at a staff briefing so that everyone has the opportunity to contribute to how it works. This will also reinforce the message that absence reporting is about looking after staff wellbeing and ensuring the team is supported.

Consistently gather key information

Always ask your staff the following questions:

• What’s the reason for the absence?
• How long do you think you’re likely to be off?
• Is there any work you’ve been doing that needs to be picked up while you’re off?

Your organisation’s sickness absence policy may have suggested questions that you should ask.

Depending on the reason they give, you may also want to find out:

• Are there any adjustments that you could make that would enable to employee to come to work?
• If the illness is infectious, is there a specific period of time that they need to remain off work once they are symptom free?
• If the reason for absence is musculoskeletal, could you refer them to a rapid access service (if you have this available)? 
• If the reason for absence is related to a mental health issue, could you refer them to a counselling service (if you have this available)?
• If they are fit to work but physically unable to come in, is there another area they can work in or could they work from home?

It is your responsibility to maintain records of sickness absences, including conversations with staff while they are off sick and any meetings you have following those absences.

[Top tip] If you notice an error in recording make sure you raise it so it can be corrected.

Over time, accurate records will enable you to spot any patterns of absence or themes within the reasons for absence. This will allow you to have a balanced, fact-based conversation with staff about any worrying trends. It may even help you to facilitate early intervention to prevent bigger problems, for example physiotherapy for a bad back.

Listen and support

Listening at this stage is key. This seems obvious but when you are busy the importance of listening can sometimes be forgotten. If this was you ringing in sick, how would you feel and what would you want your manager to say?

It may be that all you need to do is to listen, wish them well and agree either when they will be back or when you will next be in touch. Listening carefully, reserving judgement and allowing staff the time to discuss things further if needed will ensure they feel fully supported.

Keep in contact

If your employee is going to be off for more than a day you will need to discuss how often you will keep in touch and who will contact who. Knowing when you’ll next be in touch will reassure them and enable you to: 

• review whether you can do anything within the organisation to support them 
• plan how to cover their workload and keep the service running
• discuss dates and options for your staff member’s return to work.

Consider reasonable adjustments

Usually staff will be able to return to their role and work environment. However, you may need to ask if any adjustments could be made to allow them to return to work and/or prevent further absences. The sooner you have this conversation, the more time you will have to arrange for the support, equipment or adjustments needed. Making adjustments could also mean your staff member could return to work sooner.

Frequent sickness

Spotting problems early will enable you to put the right support in place.

As a manager, it is your responsibility to review absence history and discuss any problems with your staff. Identifying potential problems early will enable you to put the right support in place to minimise future absences.

Know what you’re looking for

Short-term sickness is absence that lasts less than 28 calendar days. Everyone has short-term sickness absence during their working lives, often because of common illnesses such as colds and flu. However, frequent, ad hoc absence can, indicate an underlying issue with a staff member or team.

When reviewing absence history, look for patterns to the absence, for example, a collection of Fridays or Mondays or days after a bank holiday. Also look for themes in the reasons given for absence and review any fit notes for recurring information.

Discuss what you find

Where a pattern is identified, speak to the individual about it to see if there is any underlying reason for the absences. Often, just having a conversation is enough to alert staff to the need to address any underlying causes or behaviour. Discuss how they approach health and wellbeing and refer them to any initiatives your organisation supports for health and wellbeing, for example, staff counselling, weight management, exercise classes or discounts for gyms.

In some cases, however, you could have uncovered an underlying health or mental health problem, difficulties within the team or a problem with the working environment. Putting the right support in place early, e.g. referrals to occupational health or physiotherapy available, can help to minimise any potential future absence.

If no underlying issue is evident, you should be clear with your staff member that their attendance needs to improve, how this will be measured, and the consequences if it does not. You may need to refer to your organisation’s sickness absence policy.

Monitor the situation

Keep track of whether an absence pattern is improving or getting worse and look out for any unusual patterns of absence, e.g.if a staff member is experiencing more absences, or more frequent absences than usual. Your observations could enable further discussions and identify emerging issues.

Be sensitive and supportive

Adapting your approach depending on what you find, and your staff member’s reaction, should enable you to be sensitive where necessary and find the right mix of supportive and firm. You need to approach such situations as a line manager and not a clinician. It is important to be mindful of the cost and effects of frequent absence on the workload and the team whilst remembering that there may be personal or sensitive circumstances affecting absence.

If you notice someone is becoming withdrawn and quiet, create a suitable confidential environment to tell them what you have noticed, ask them if they are OK and offer them the opportunity to discuss things.

[Top tip] Appropriate training can assist you with being able to identify changes in employee behaviour that might result in increased absences, and drawing the employee into discussing these.

Know where to go for help

Your organisation will have policies on things like special leave, should your staff require a period of time away from the workplace for personal reasons. Your occupational health (OH) provider can also help with signposting to specialist services, e.g. for drug or alcohol dependency, domestic violence or depression.
The Advisory, Conciliation and Arbitration Service (ACAS) advisory handbook is a useful starting point for handling short-term absence. Consider making reasonable adjustments.

Usually staff will be able to return to their role and work environment. However, you may need to ask if any adjustments could be made to allow them to return to work and/or prevent further absences. The sooner you have this conversation, the more time you will have to arrange for the support, equipment or adjustments needed. Making adjustments could also mean your staff member could return to work sooner.

Long term sickness

Your role is to support your staff to maintain a connection with the workplace.

Long-term sickness absence is defined as a continuous period of absence lasting more than 28 days. The employee must give you a ‘fit note’ (formerly a ‘sick note’) if they’re absent for more than seven days. Hospital doctors or GPs provide these, but may charge a fee if a fit note is requested before seven days. The fit note will say the employee is either ‘not fit for work’ or ‘may be fit for work’.

If the fit note says the employee ‘may be fit for work’, you should discuss any changes with the employee that might help them return to work, such as different hours or tasks. You can get support from your occupational health (OH) provider if you need help and advice on making reasonable adjustments.

Keep in contact

It is important to maintain regular contact with your employee when their absence becomes long term. This will allow you to keep track of their progress and will also provide an important connection for your staff member back to the world of work.

Agree with the employee how and when you will catch up and how they will keep you informed of any developments in their treatment and recovery. You want them to feel that you are sympathetic to their situation, but that you are also keeping them under review so you can support them back into the workplace.

As their manager, you should be aware of what the next step is for the employee, such as a GP review or hospital appointment. Your aim should be to facilitate their return to work, and your staff member should understand this aim.

Manage their workload

Decide whether your team can cover the absent employee’s workload or whether you need to recruit additional staff.

To help you decide, consider:

• how long the absence is expected to be (if known)
• the duties that need to be delegated
• whether these duties could be sustainably covered in the team.

Know your procedures

Find out your organisation’s policies and procedures for supporting and managing long-term absence. This will usually involve discussions with HR and a referral to occupational health (OH).

Check if there is any training available for you in your organisation to help apply the correct procedures and have discussions with your staff about their health.

NICE recommends that you arrange for a more detailed assessment of the employee’s situation by relevant specialists, if necessary. This could be coordinated by a suitably trained caseworker.

NICE also recommends coordinating and supporting any health, occupational or rehabilitation interventions or services received by the employee, and any return-to-work plan agreed with the employee.

Actively manage the absence

The key to actively managing long-term sickness absence is to always know what the next step will be for your employee, even if it is that they have an appointment booked which they are waiting for. This allows you to support your employee as much as possible throughout the absence and helps you to avoid allowing the absence to drift, and the employee to feel forgotten about. 

Organisations are increasingly adopting an active case management approach to sickness absence cases, where HR, OH, the line manager, the employee and - where appropriate - the GP, other medical professionals and/or staff side representatives work together to support the employee and manage the absence.

Agree early on who the case manager will be so they can ensure the process is streamlined, and there are minimal unnecessary delays, such as with sharing information between each party, or getting appointments.

If absence continues

if the absence continues for more than 28 days, you need to meet with them to review their absence and discuss possible options. The purpose of the absence review meeting is to offer you and the staff member the opportunity to discuss the nature of their absence, and next steps for returning to work or continued absence, in a positive and supportive way.

Make sure that your staff understand that this meeting does not constitute part of the disciplinary process. Be open and supportive, and encourage your staff member to bring forward any concerns that might be affecting their attendance. Also ask them for any ideas about what would help them return to work.

If a return to work is not possible, you will need to discuss the options with HR and OH, consulting relevant policies. Encourage your employee to seek support from staff side representatives where appropriate.

Reasons for absence

Some of the most common reasons for sickness in the NHS.

Supporting staff off sick

Ways in which you can support your staff while they are off sick.

Maintain contact

Positive and regular contact with your employee is crucial, and can help them feel supported and valued, and prevent them from feeling isolated.

Talk to your employee about the nature of their illness, its impact on their work and likely duration, as soon as they report their absence from work. If you don’t take their first call, contact the employee at the earliest opportunity to have this discussion.

Weekly contact with employees is recommended for illnesses lasting several weeks, as well as for illnesses that will result in a longer period of absence. However each case will be slightly different due to the nature of the employee’s illness, so the frequency of contact should be discussed and agreed with the employee.

As well as agreeing to the frequency of contact, make sure you also set aside time to fully discuss their absence and any support they may need. Always remind your employee that you will be keeping in contact with them during their absence and that you are there to help facilitate their return to work.

Helpful questions to ask your employee include:

To find out more about providing any help your employee needs, see sections on rapid access to treatment, phased return, making reasonable adjustments and redeployment. 

For longer absences, update the employee about any work changes that have happened during their absence, to prevent them from feeling isolated. Keep your employee in the loop by including them in emails about work, so they can keep an eye on things while they are absent or catch up when they return. This will help them alleviate any worries about their work, and who is covering for them.

Find out if there are organisational policies in place for keeping in contact, and use them. Ensure your team are familiar with reporting procedures so they know what to do and expect when they are absent. If a reporting procedure needs development, get your staff involved as this helps employees feel supported and less worried if they do need to follow the procedure.

Rapid access to treatment

Rapid access to treatment is a system which secures rehabilitation and occupational health treatment for NHS employees with a view to facilitating a return to work which is as fast as is practical and reasonable. Setting up a rapid access scheme could contribute to substantial savings for your organisation, lead to a more consistent and healthy workforce and reduce pressure on colleagues covering sickness absence (and the resulting morale issues). It is not implemented to prioritise the health of NHS staff to the detriment of other patients.

NHS Employers has produced guidance on this subject which is intended for organisation boards making decisions about how to manage rapid access services for staff in their organisation. It supports the core services set out in the NHS Health and Wellbeing Improvement Framework (2011) which emphasised the importance of:

Early intervention such as occupational therapy, physiotherapy or counselling is important for preventing acute conditions becoming chronic and securing successful rehabilitation. Evidence also suggests that earlier interventions in a period of sickness absence are more effective than waiting for an indicator to trigger action.

For example, in cases where appropriate, referral to physiotherapy in the first week of sickness can have your team member rehabilitated back into work by the time they would normally have been having the first review of their case – triggered by an indicator. This benefits the organisation, your team member and your patients.

The benefits of early rehabilitation are as follows:

See NHS Employers website for guidance, along with information on how to create your own rapid access policy, and several case studies from organisations who have implemented their own rapid access schemes and the huge benefits they derived from them.

• timely intervention – easy and early treatment for the main causes of sickness absence in the NHS
• rehabilitation – to help staff stay in work during illness or return to work after illness.
• the organisation can have a member of staff back to work earlier than expected, in some cases performing reduced or light duties, but in many performing full duties. The organisation has shown that it cares for the member of staff and values their contribution
• the member of staff feels valued by a caring employer and will, in all probability, recover more quickly when back in the working environment, than they would at home
• substantial savings for the NHS, in reduced treatments for the employee, but also considerable reductions in agency staffing costs
• getting someone back into work quicker means fewer potential mental health problems such as depression and anxiety, which can begin as early as six weeks into absence
• reduced pressure on your team covering their workload, and improved morale.

Fit note and sick note

The 'Fit Note' is usually a written note issued by GPs or consultants working in conjunction with OH, detailing how an employer can help the employee return to work after a period of absence. It can also be used a statement of not being fit for work. At the GPs discretion it may also contain other pertinent information on the condition of your employee which may affect their ability to work, with suggestions of ways to support them.

There can be confusion around fit notes where managers automatically believe it means an employee is well enough to come back to work - this is not always the case as the fit note can actually be used for one of two things: to state that an employee might be fit to return to work after a period of ill health (may be fit for work), or to sign the person off work sick completely for a defined period of time (not fit for work).

You should receive a copy of the fit note as soon as possible once your employee has received it, so that you know what the reason for their absence is, if there is anything you can do to support them to return to work and set up a return to work plan. Your finance department will usually need this for payment purposes so you should familiarise yourself with your local procedure for this.

If your employee does not provide a copy that details they are unfit for work, then they would be classed as being on unauthorised absence and you would need to speak to your local HR department for further support. It is in the employee's best interest to be open and honest about this, so you can provide or arrange for the support they need.

Where the fit note marks your employee as 'may be fit for work', it means the GP believes that returning to work will aid in their recovery and should also provide details on how to get the employee back into work. It's important that you work with your OH service to ensure everything is covered. Often the fit note may detail alternative duties for the employee until they feel fit to undertake all their usual duties and this should be agreed by all parties.

GP's are often not familiar with their patients work or work environment so it may be possible for your local OH department to suggest alternatives to support staff to return to work. Where you feel this may be an option you should seek further advice from your OH department who would be responsible for contacting your employee to get the required consent and liaising with the GP.

Using your occupational health service

Occupational Health (OH) services are all about making sure your staff are fit for the work they do, and how their work affects their health. Organisations do not legally have to provide OH services, but those that do can offer support and advice in several areas:

As a line manager you should focus on the impact the employee’s health is having on their ability to undertake their role, as opposed to the detailed nature of the health complaint and any treatment they may be receiving. OH can provide you with further support and guidance around how to support your staff and any reasonable adjustments which could be made to allow the employee to remain in the workplace or return to work.

Make sure you discuss with employees the reasons for referring them to OH, so that they understand and are fully aware of the reasons for referral. The employee should also be given a copy of the referral letter.

You need to be aware that confidentiality principles place constraints on OH professionals in regard to the release of the personal medical information of staff. These apply in all cases.

The General Medical Council (GMC) principles are as follows:

It is helpful to familiarise yourself with the referral process for OH so that you know what to do, how to make the referral and likely timeframes so that you can communicate this to your employee too. Often you will receive a letter from them following the appointment detailing their advice and/or recommendations. If you feel you have any questions it is often easier to call the person who saw the employee to discuss it further. It is useful to remember that OH may not know the demands of your department, so the more you can put into the referral the easier it will be for them to understand how the role might impact on the individual and their particular health circumstances.

Despite the increasing use of OH and increasing partnership working employees can still be reluctant or concerned about being referred to OH. It is useful to have this in your mind so that you can reassure your employee about the appointment and how they can help. This may help to reduce any anxiety your team may experience.

• injuries at work due to a slips or trips
• exposure to other long term hazards, such as repetitive strain injuries and stress
• infection prevention of work-related diseases
• safe working practices
• sickness absence management
• workforce health surveillance
• employee assistance programmes (EAP)
• return to work meetings.
• Staff have a right to expect that OH professionals will not disclose any personal information which is learned during the course of their professional duties, unless they give permission.
• When OH professionals are responsible for confidential information, they must make sure that the information is effectively protected against improper disclosure when it is disposed of, stored, transmitted or received.
• When staff give consent to the disclosure of information about them, OH professionals must make sure the employee understands what will be disclosed, the reasons for disclosure and the likely consequences.
• OH professionals must respect staff requests that information not be disclosed to third parties, apart from in exceptional circumstances (for example, where the health or safety of others would otherwise be at serious risk).
• If OH professionals disclose confidential information they should release only as much as is necessary for the stated purposes.
• OH professionals must make sure that the people receiving the information understand that it is given to them in confidence.
• If OH professionals decide to disclose confidential information, they must be prepared to explain and justify their decision.

Impact on the team

It's important to talk to your employee about their illness, and consider:

It is important to work with your team to manage the impact of the absent employee. One way to do this is to make sure other team members know how to carry out each other's duties. Discussing and implementing contingency plans in the event of an absence with your team will not only maintain continuity of workflow but will also empower your team in being actively involved in the solution to the problem. The contingencies will be especially useful in the event of a longer term absence such as a serious or terminal illness, or if the employee decides on early or ill-health retirement.

Make sure you have an open door policy to discuss the impact of the employee's absence. Be clear, positive and supportive when discussing matters with both the person who is off sick and the rest of the team. This will help your team to remain positive and supportive of the person who is away sick, and reduce any gossip.

It is possible that the rise in workload among the team could give rise to feelings of resentment or anger. Lead by example and be supportive, positive and clear with your team (and, if appropriate, the wider organisation), keep them informed as much as possible and openly acknowledge their efforts in maintaining the workflow during the team member's absence.

Your employee may not want colleagues to be informed of their illness. You should respect their need for privacy and be sensitive where possible and within reason, whilst making sure that the service provided is minimally disrupted. Be careful not to burden them with the repercussions of them being off sick as this could give rise to feelings of guilt which could impede their recovery. If the illness could impact upon the team and service you provide, discuss what details should be shared with your HR department.

Be aware that once a person’s condition becomes known, they can be overwhelmed with well-wishes and they might find this uncomfortable – talk to your employee and make a plan you can both agree on to handle this.

Make yourself aware of support policies and programmes available for your team and communicate this to them. Contact human resources and occupational health for further information about these, as well as information about having difficult conversations and support available for all involved, such as counselling and Employee Assistance Programmes (EAPs).

• the length of sickness
• cover options
• what they want others to know
• how regularly they'd like to keep in contact

Ill health retirement

Sometimes one of your employees may become very ill and permanently incapable of doing their current job. In these situations you should always look at options for redeployment or alternative duties in the first instance. However if these options are not possible, your employee may apply for ill health retirement.

To apply for ill health retirement, your employee:

The NHS Business Services Authority has information online to help you guide your staff through the ill health retirement online application, including in-depth information on who is eligible to apply.

You should make yourself familiar with the process, so you can help your employee navigate their way through it as easily as possible. Contact your human resources (HR) or occupational health (OH) departments for information and support.

Your employee should fill out form AW33E if they still work in the NHS, or form AW240 if they no longer work in the NHS but have had two years membership of the pension scheme.

All these forms can be found on the NHS Pensions website and have three sections to fill in:

The application will then be assessed by a medical adviser, and if successful the employee will receive their pension. The pension will be based on their accumulated entitlement, but without any reduction for early repayment.

Should the employee recover and return to NHS employment, the pension will be reduced - this is called abatement.

If your employee is diagnosed with a serious condition and is expected to live no longer than a year, they can apply for a one-off, tax-free lump sum payment.

They will need to have some HMRC personal lifetime allowance (LTA) and fill in form AW341, which can be found on the NHS Pensions website.

• must work for the NHS, or have recently worked for the NHS,
• have at least two years membership in the NHS pension scheme, and
• should be younger than normal state retirement age (65).
• one for the employee
• one for their line manager
• one for the OH department to add the medical details of the employee’s condition.

Returning to work

The range of options available to managers when supporting a staff member back to work.

Making reasonable adjustments

Sometimes reasonable adjustments can be made to enable your employee to remain at work, or, if they are off sick, to return to work. Where this is the case, it is important that you and the employee work together to ensure that any adjustments are practicable. Where needed this may also involve HR, OH or other support available, for example Access to Work. It is important that you discuss any adjustments fully with the employee to see if the adjustment is suitable and would enable them to do the duties they have agreed to without exacerbating their health complaint. The sooner you have this conversation, the more time you will have to arrange for the support, equipment or adjustments needed. Making adjustments could also mean your staff member could return to work sooner.

Reasonable adjustments is an area that often causes concern for line managers due to the requirements of the Equality Act. However, if you approach all employees in the same way and discuss reasonable adjustments openly, seeking advice where necessary from OH or other experts then this should help you handle the process with confidence. You are not expected to know what adjustments should be made but you must consider them and work with the employee and professionals to identify and apply them when required.

Where ill health, injury or other impairment meet the relevant criteria under The Equality Act 2010, discrimination is prohibited and ‘reasonable adjustments’ to working arrangements must be considered. However, considering adjustments where relevant and applying this approach consistently to all employees is the recommended approach.

It is important that advice is sought from OH and HR when determining whether any reasonable adjustments or modifications can be made to the existing workplace and/or duties. A risk assessment should be carried out as appropriate. Some examples include:

The Health Service Executive (HSE) suggests that the following work adjustments can be made to assist an employee’s return to work:

• allowing an employee time off to attend medical appointments
• modifying a job description to take away tasks that cause particular difficulty
• offering flexibility in working hours/patterns, i.e. reduced hours, working from home or a phased return
• transfer of workplace
• acquiring or modifying equipment and ensuring suitable access to premises for people using wheelchairs or crutches, providing taxi to and from workplace or giving access to on-site parking
• social or cognitive support
• extra training and refresher courses
• providing support to overcome barriers to returning to the workplace.
• provide new or modify existing equipment and tools, including IT, modified keyboards
• modify workstations, furniture, movement patterns
• modify instructions and manuals
• modify work patterns or management systems and style to reduce pressure and give the employee more control 
• modify procedures for testing, assessment and appraisal
• provide the employee with a mentor or ‘buddy’ while they regain confidence in the workplace 
• provide supervision
• reallocate work within the team
• provide alternative work.

Health and safety

Health and safety is all about minimising illness or injury in the workplace. It covers many related aspects such as policies, accident reporting, potential hazards and risk assessments, manual handling, violence towards staff from patients, infection control, needle stick injuries and many more. It is the responsibility of all staff to safeguard the health and safety of the workplace and the team.

As a manager, you have a duty of care to your team to ensure that policies and procedures are followed. You should make yourself aware of your local health and safety policy, as different business areas will have different guidance in place to safeguard health and safety - for example, there will be separate advice for staff working in freight and logistics to those working in an office-based environment. You should be aware of where you need to go to gain further support, such as your occupational health (OH) or human resources (HR) departments.

As part of the role of manager, you will need to carry out workplace risk assessments for your work areas and setup preventative measures for any hazards identified. Your OH or HR department can help with any training needed for yourself and your staff to make sure your work area is as safe as possible.

Make links with the team in your organisation responsible for health and safety and find out what you need to do as a manager to keep your team, colleagues and patients safe. The Health and Safety Executive (HSE) also has a number of tools on their website (such as the line manager competency indicator tool) to help you assess your own skill levels as a manager in dealing with health and safety issues. These are very useful in identifying where you may need further training, support and information.

The NHS Staff Council’s Health, Safety and Wellbeing Partnership Group (HSWPG) published a document called 'Workplace health and safety standards'. The standards aim to help organisations comply with health and safety law by pulling together legal requirements and good practice. The document provides practical pointers and signposts for meeting appropriate standards in key areas of workplace health and safety. The HSWPG has also published other useful guidance, research and advice on topics such as, lone workers, sickness absence and the 'Back in work, back pack', which outlines measures to reduce the incidence of work related back and musculoskeletal disorders. All of this can be found on the health and wellbeing section of NHS Employers website. 

Health and safety in the NHS in England is regulated by the Health and Safety Executive (HSE), and the Care Quality Commission (CQC). They have a liaison agreement that allows them to co-ordinate actives and share information relating to health and safety within the NHS. They have a wealth of information on their website, including safety alerts for employers. The HSE also works with other trade regulators such as the General Medical Council (GMC) and have agreements with them on health and safety issues for their members.

Fit notes and sick notes

The 'Fit Note' is usually a written note issued by GPs or consultants working in conjunction with OH, detailing how an employer can help the employee return to work after a period of absence. It can also be used a statement of not being fit for work. At the GPs discretion it may also contain other pertinent information on the condition of your employee which may affect their ability to work, with suggestions of ways to support them.

There can be confusion around fit notes where managers automatically believe it means an employee is well enough to come back to work - this is not always the case as the fit note can actually be used for one of two things: to state that an employee might be fit to return to work after a period of ill health (may be fit for work), or to sign the person off work sick completely for a defined period of time (not fit for work).

You should receive a copy of the fit note as soon as possible once your employee has received it, so that you know what the reason for their absence is, if there is anything you can do to support them to return to work and set up a return to work plan. Your finance department will usually need this for payment purposes so you should familiarise yourself with your local procedure for this.

If your employee does not provide a copy that details they are unfit for work, then they would be classed as being on unauthorised absence and you would need to speak to your local HR department for further support. It is in the employee's best interest to be open and honest about this, so you can provide or arrange for the support they need.

Where the fit note marks your employee as 'may be fit for work', it means the GP believes that returning to work will aid in their recovery and should also provide details on how to get the employee back into work. It's important that you work with your OH service to ensure everything is covered. Often the fit note may detail alternative duties for the employee until they feel fit to undertake all their usual duties and this should be agreed by all parties.

GP's are often not familiar with their patients work or work environment so it may be possible for your local OH department to suggest alternatives to support staff to return to work. Where you feel this may be an option you should seek further advice from your OH department who would be responsible for contacting your employee to get the required consent and liaising with the GP.

Infection prevention

Employees are responsible for managing their own health and deciding whether they are fit enough to be at work or not. However, there are times as a manager when you may need to reinforce to staff whether someone can be at work in line with infection prevention, so that this does not pose any risk to patients, colleagues or the public. The most common illness managers typically have to deal with is diarrhoea and vomiting which in a hospital environment can spread very rapidly if the necessary time frames are not followed.

As a manager, when an employee is off work you should always ask what the nature of the absence is. This allows you to provide support and also to take any steps necessary to ensure prevent or contain the spread of infection. Where staff have been off with an infectious illness you should encourage them to always contact you before returning to work - especially if the illness was caused by any of the following:

diarrhoea/vomiting (should be 48 hours symptom-free before returning)
infectious rashes (Chicken pox / Scabies)
undiagnosed persistent coughs with / without a temperature (Tuberculosis)
influenza.
Should a member of staff call in sick with any of the above, you can seek advice from OH if you are unsure what to do. Ultimately if the employee poses any health risk to other people, they should not attend work until they are well.

Make sure you consult the organisation policy on hand hygiene and make sure your employees are aware of this and practice the guidelines - this reduces the risk of spreading infections.

Rapid access to treatment

Rapid access to treatment is a system which secures rehabilitation and occupational health treatment for NHS employees with a view to facilitating a return to work which is as fast as is practical and reasonable. Setting up a rapid access scheme could contribute substantial savings for your organisation, lead to a more consistent and healthy workforce and reduce pressure on colleagues covering sickness absence (and the resulting morale issues). It is not implemented to prioritise the health of NHS staff to the detriment of other patients.

NHS Employers has produced guidance on this subject which is intended for organisation boards making decisions about how to manage rapid access services for staff in their organisation. It supports the core services set out in the NHS Health and Wellbeing Improvement Framework (2011) which emphasised the importance of:

timely intervention – easy and early treatment for the main causes of sickness absence in the NHS
rehabilitation – to help staff stay in work during illness or return to work after illness.
Early intervention such as occupational therapy, physiotherapy or counselling is important for preventing acute conditions becoming chronic and securing successful rehabilitation. Evidence also suggests that earlier interventions in a period of sickness absence are more effective than waiting for an indicator to trigger action.

For example, in cases where appropriate, referral to physiotherapy in the first week of sickness can have your team member rehabilitated back into work by the time they would normally have been having the first review of their case – triggered by an indicator. This benefits the organisation, your team member and your patients.

The benefits of early rehabilitation are as follows:

• the organisation can have a member of staff back to work earlier than expected, in some cases performing reduced or light duties, but in many performing full duties
• the organisation has shown that it cares for the member of staff and values their contribution
• the member of staff feels valued by a caring employer and will, in all probability, recover more quickly when back in the working environment, than they would at home
• substantial savings for the NHS, in reduced treatments for the employee, but also considerable reductions in agency staffing costs
• getting someone back into work quicker means fewer potential mental health problems such as depression and anxiety, which can begin as early as 6 weeks into absence
• reduced pressure on your team covering their workload, and improved morale.

Phased return

Phased return to work allows the member of staff to gradually return back to the workplace over an agreed period of time, and research suggests that it also aids recovery. Not everyone who has been off on long-term absence will need or require a phased return. Normally the employee will be able to return to work with zero or minimal reasonable adjustments. However a phased return may be required particularly where the employee needs to build up their stamina. Taking annual leave and slowly building up time the employee spends at work is the usual way of doing this.

Times allowed for rehabilitation vary from organisation to organisation and does of course depend upon the original cause of the absence and will need to be decided on a case-by-case basis. You should consult occupational health (OH) and your local policy to ensure that you are working within the appropriate guidelines.

You should discuss with OH professionals the best course of action with the employee, considering:

• the nature of the condition the employee is suffering from
• what level of work they can or cannot do
• how many hours they are reasonably capable of doing
• over what period of time they should work towards achieving a full-time return to work
• any modifications that would help them return to work faster, including special equipment or re-training
• time needed to continue any ongoing medical treatment such as physiotherapy, counselling, hospital/GP visits
• regular reviews of the situation
• compliance with the Equality Act.

Using your occupational health service

Occupational Health (OH) services are all about making sure your staff are fit for the work they do, and how their work affects their health. Organisations do not legally have to provide OH services, but those that do can offer support and advice in several areas:

As a line manager you should focus on the impact the employee’s health is having on their ability to undertake their role, as opposed to the detailed nature of the health complaint and any treatment they may be receiving. OH can provide you with further support and guidance around how to support your staff and any reasonable adjustments which could be made to allow the employee to remain in the workplace or return to work.

Make sure you discuss with employees the reasons for referring them to OH, so that they understand and are fully aware of the reasons for referral. The employee should also be given a copy of the referral letter.

You need to be aware that confidentiality principles place constraints on OH professionals in regard to the release of the personal medical information of staff. These apply in all cases. The General Medical Council (GMC) principles are as follows:

It is helpful to familiarise yourself with the referral process for OH so that you know what to do, how to make the referral and likely timeframes so that you can communicate this to your employee too. Often you will receive a letter from them following the appointment detailing their advice and/or recommendations. If you feel you have any questions it is often easier to call the person who saw the employee to discuss it further. It is useful to remember that OH may not know the demands of your department, so the more you can put into the referral the easier it will be for them to understand how the role might impact on the individual and their particular health circumstances.

Despite the increasing use of OH and increasing partnership working employees can still be reluctant or concerned about being referred to OH. It is useful to have this in your mind so that you can reassure your employee about the appointment and how they can help. This may help to reduce any anxiety your team may experience.

• injuries at work due to a slips or trips
• exposure to other long term hazards, such as repetitive strain injuries and stress
• infection prevention of work-related diseases
• safe working practices
• sickness absence management
• workforce health surveillance
• employee assistance programmes (EAP)
• return to work meetings.
• Staff have a right to expect that OH professionals will not disclose any personal information which is learned during the course of their professional duties, unless they give permission.
• When OH professionals are responsible for confidential information, they must make sure that the information is effectively protected against improper disclosure when it is disposed of, stored, transmitted or received.
• When staff give consent to the disclosure of information about them, OH professionals must make sure the employee understands what will be disclosed, the reasons for disclosure and the likely consequences.
• OH professionals must respect staff requests that information not be disclosed to third parties, apart from in exceptional circumstances (for example, where the health or safety of others would otherwise be at serious risk).
• If OH professionals disclose confidential information they should release only as much as is necessary for the stated purposes.
• OH professionals must make sure that the people receiving the information understand that it is given to them in confidence.
• If OH professionals decide to disclose confidential information, they must be prepared to explain and justify their decision.

Return to work meeting and plan

When carried out effectively, return to work meetings are proven to be the single most effective measure for reducing short-term sickness absence. They indicate to employees that their absence was noticed and that they were missed, and that the employer wants to take the time to find out how they are. They also serve to indicate that managing sickness absence is a priority for the employer. Below we highlight some key aspects to consider when conducting a return to work meeting.

The return to work meeting is an opportunity to confirm the reason for an employee's absence and gives you the opportunity to discuss with your employee how they are, and if there is anything you can do to support them in the workplace. Reassure the employee that they were missed, and that you and the team are glad they have returned.

A return to work meeting should be carried out after every instance of sickness absence – even one day. Shorter frequent absences could mask a health concern which may go unnoticed if return to work meetings are not conducted.

To be effective, return to work meetings should be carried out in a fair and consistent way, and approached in a supportive way. They will usually be informal and brief.

You should follow your organisation’s policy around conducting the return-to-work meeting but see below for some general principles you can follow.

Organisations usually provide managers with a template to use for the return to work meeting as a guide and to promote consistency, including questions to ask and as a template to record the discussion and any agreed actions. Contact your HR department for this.

In addition, when conducting a return to work meeting, you may also want to consider the following points.

A record of the meeting should be kept, which should be agreed with the employee and signed off by both parties as a fair record of what was discussed.
When a line manager, in collaboration with the employee, HR and OH, has identified all of the ways in which the employee can be assisted back into the workplace they need to agree a return to work plan.

The stage at which this plan should be formulated will vary depending on the circumstances of the individual and should be based on the expected date of return reflecting any medical and safety advice that has been received. It is helpful to start discussions about a return to work as soon as possible, usually before your member of staff returns to work. However, this will depend upon the nature of the illness and the ease of making the arrangements necessary to facilitate the return to the workplace. Early discussions about a return to work reinforce the fact that you do want your employee to return and make sure that this is part of the overall planning process.

A return to work plan might include:

It is important for all parties to keep the plan under review to ensure that it delivers what is intended and to allow for agreed changes to be made if it is found to be unsuccessful in any way. Lessons learned from implementing return to work plans should be shared with other managers, OH and HR in order to learn from them and improve the process for other employees in the future.

• welcome the employee back to work and ask how they are
• clarify the reason for the absence
• confirm that the employee is fit to return to work and has taken appropriate leave where infectious illnesses have been the cause of an absence
• consider any changes or adjustments which should be made to accommodate the employee in their return to work
• consider the appropriateness of a referral to occupational health
• discuss this episode of sickness in the broader context of other absence, and what the procedure is and when this may be applied
• consider whether there are any patterns of absence occurring e.g. absences always falling on the same day of the week, prior to a bank holiday etc.
• engage in a wider conversation about the employee’s health and wellbeing
• discuss the value of the employee in terms of the team and the impact sickness absence has on the ability to deliver high quality consistent patient care
• update the employee on any changes that have occurred while they have been away
• ensure the absence has been recorded and reported accurately
• ensure the self-certificate or ‘Fit Note’ has been provided, if necessary
• take the opportunity to clarify and/or update reporting procedures and re-circulate these
• where the absence is related to an infection control issue, consider whether the employee has been away from the workplace for a sufficient period of time to prevent spread of infection? Is further clarification required from occupational health?
• ensure you have considered the need to undertake any risk assessments prior to the employee resuming full duties
• if the absence was as a result of an slip/trip or fall, has this been reported through any relevant incident reporting system
• if the absence is related to a musculo-skeletal issue, make the employee aware of any rapid access to treatment options or recommended that they seek OH advice or support
• if the absence is related to mental health issues, consider whether the employee is getting appropriate support, and/or have you discussed a referral to OH
• will your employee require a change to their duties upon their return?
• the expected date of return 
• details of any steps that need to be taken prior to the employee returning, e.g. risk assessment, ordering equipment, change or transfer of duties etc.
• details of any therapeutic return plan e.g. agreed times that the employee will pop into work to have a coffee with colleagues, attend a team meeting etc.
• the agreed detail of any phased return including the duration of this and expectations of what they will be able to do when this has been completed, e.g. return to their substantive role fully recovered
• the period of time covered by the plan
• when the plan will be reviewed and by who
• will the plan have any effect on the terms and conditions of the employee and is there any change to their pay
• who has been involved in drawing up the plan
• details of reasonable adjustments and when they should be reviewed.

Redeployment

Many organisations using rehabilitation as part of their sickness absence management policies have found that it is not always possible to rehabilitate staff back into their original post in the short term. This may be due to or to the nature of their illness or the requirements of their role. For instance, musculoskeletal problems may need time to heal without the risk of further damage.

In these circumstances, a widely used alternative is redeployment.

Redeployment is seen as an important mechanism that can assist in the retention of experienced and skilled staff in the NHS. An effective redeployment policy can help minimise the need for redundancies, not only as a result of organisational change, but to help retain staff unable to do their own job through ill health or injury.

This can be used in the short term, while an employee is recovering from a period of ill health before returning to their usual job full time, or permanently for staff who have no likelihood of returning to their original role.

In some cases, redeployment requires re-training or further inductions, and it is good practice for this to be provided as part of a package devised and managed by the occupational health service and human resources.

Risk assessments

The purpose of a risk assessment is to identify and prioritise risks arising from workplace duties and to put practical measures in place to eliminate or reduce identified risks. Undertaking a risk assessment is the employer’s responsibility and it is important for you to regularly review and update risk assessments in collaboration with your team and their representatives.

Operational managers are usually responsible for ensuring risk assessments are carried out in their own work areas. Competent advice and assistance should be sought where necessary (for example by a health and safety advisor) and input from employees can provide a valuable perspective in addressing any new or job specific issues that may arise.

You may find it useful to visit the Health and Safety Executive’s website which contains a range of resources on risk management. This includes a risk assessment and policy template along with frequently asked questions. Five steps on how to undertake a risk assessment are:

• identify the hazards
• decide who might be harmed and how
• evaluate the risks and decide on precaution 
• record your findings and implement them
• review your assessment and update if necessary.

Preventing absence

Health and safety

Health and safety is all about minimising illness or injury in the workplace. It covers many related aspects such as policies, accident reporting, potential hazards and risk assessments, manual handling, violence towards staff from patients, infection control, needle stick injuries and many more. It is the responsibility of all staff to safeguard the health and safety of the workplace and the team.

As a manager, you have a duty of care to your team to ensure that policies and procedures are followed. You should make yourself aware of your local health and safety policy, as different business areas will have different guidance in place to safeguard health and safety - for example, there will be separate advice for staff working in freight and logistics to those working in an office-based environment. You should be aware of where you need to go to gain further support, such as your occupational health (OH) or Human Resources (HR) departments.

As part of the role of manager, you will need to carry out workplace risk assessments for your work areas and setup preventative measures for any hazards identified. Your OH or HR department can help with any training needed for yourself and your staff to make sure your work area is as safe as possible.
Make links with the team in your organisation responsible for health and safety and find out what you need to do as a manager to keep your team, colleagues and patients safe. The Health and Safety Executive (HSE) also has a number of tools on their website (such as the line manager competency indicator tool) to help you assess your own skill levels as a manager in dealing with health and safety issues. These are very useful in identifying where you may need further training, support and information.

The NHS Staff Council’s Health, Safety and Wellbeing Partnership Group (HSWPG) published a document called 'Workplace health and safety standards'. The standards aim to help organisations comply with health and safety law by pulling together legal requirements and good practice. They provide practical pointers and signposts for meeting appropriate standards in key areas of workplace health and safety. The HSWPG has also published other useful guidance, research and advice on topics such as lone workers, sickness absence and the 'Back in work, back pack', which outlines measures to reduce the incidence of work related back and musculoskeletal disorders. All of these documents can be found on the health and wellbeing section of NHS Employers website. 

Health and safety in the NHS in England is regulated by the Health and Safety Executive (HSE), and the Care Quality Commission (CQC). They have a liaison agreement that allows them to co-ordinate actives and share information relating to health and safety within the NHS. They have a wealth of information on their website, including safety alerts for employers. The HSE also works with other trade regulators such as the General Medical Council (GMC) and have agreements with them on health and safety issues for their members.

Sickness absence coding

Sickness absence codes are a useful tool you can use to spot sickness trends in your team. Making sure these are used and recorded properly can help identify problem areas to target with interventions, such as infection prevention and teams under a lot of stress or other mental health issues. If correct codes are used, you can use them to create metrics and compare them to national sickness absence rates to see how your organisation is doing.

Once you have a benchmark for your organisation, you can make contacts with organisations that have lower absence rates and look to improve your own. This could all result in lower sickness absence rates and staff who feel more supported and able to deliver better patient care.

As a line manager you are responsible for recording accurately any sickness absence for the staff you manage, which could help you spot trends in absenteeism and address any potential issues within your team. This means that you must use the agreed process within your organisation, and know what you need to do to follow this. You must also ensure that any sickness absence report is accurate in terms of length of time off, and use the right ESR code for the absence. Failure to do this could impact on your employee's sick pay entitlements, and mean they do not receive the help or support they might need.

The ESR sickness codes are nationally agreed and should be used to identify the absence reasons for employee sickness. This can usually be done during and after the return to work meetings where you can get a good idea of the absence reason. In all cases you should try to use both ESR codes to drill down to the most appropriate reason. If you are not clear on the code to use or need guidance, you can ask your OH and HR departments to help you.

Sometimes employees may not wish to disclose the nature of their absence, making it hard to give them support. In this case, you should ask them if there is another person they feel more comfortable discussing this with i.e. HR, OH, a manager of the same sex etc. If they still do not want to discuss the issue, perhaps show them the codes and ask them to point out the reason without explaining. It’s important you get the code right and can arrange for further help, and that trigger points are activated appropriately for any HR intervention needed.

Appraisal

The appraisal process is one way for managers to assess an employee’s health and wellbeing. There are many factors that impact on our health and wellbeing, including lifestyle choices and work-life balance. Many such choices take place outside of the working environment, many will impact employees at work, e.g. having too little sleep, being overweight, dealing with financial pressures. However, beginning a dialogue with your team members can help to identify what improvements can be made to create a healthier workplace.

As a manager you cannot directly influence all the factors which will impact on the health of your staff, however you can create a positive environment in which your employees feel able to discuss some of these issues. This is an important element of supporting health and wellbeing and helping employees to feel valued.
Your organisation may wish to include some specific questions in appraisal documentation to broaden the appraisal discussion to include staff health and wellbeing. Here are some ideas which you may wish to consider as part of your employee appraisals:

Each of the questions above is designed to begin a dialogue through which you can raise issues of concern about health and wellbeing and work towards answers that can benefit the whole team.

You may also then want to find out what is happening within your organisation or where you can direct staff to find out about other activities and groups which might support and encourage their wellbeing approach.

• Are there any barriers to the health and wellbeing of your staff?
• How do you believe your staff are feeling?
• How do you think this is affecting the work of your team?
• How can you work together to support the health and wellbeing of the team more effectively?
• Are you aware of team members that are showing signs of stress? What do you think you can do to assist them?
• Are you aware of the organisation’s health and wellbeing strategy and your role in delivering it?
• Have you assessed the health and wellbeing needs of your team? Do you know who to go to for assistance in doing this?
• Do you have a plan for improving the health and wellbeing of your team and have you shared it with them and discussed how it is to be achieved?

Resilience

Resilience is all about maintaining your own high performance and a positive sense of wellbeing, even when facing difficult times, high pressured workloads or misfortune. As a manager you can help your team become more resilient and bounce back from problems by helping them avoid the issues associated with rust-out (not enough work, boredom, no challenge) and burn-out (too much work, pressure, stress). Try to help your team as a whole to maintain a balance in between rust-out and burn-out to keep them engaged, in control of their workloads and foster their own sense of purpose.

You can use the strengths of your team by:

• focusing on areas that are working well, develop clear team values and goals
• developing the strengths of your staff alongside any weak points
• fostering positivity, make your staff feel good when they are doing what they are good at to give them a sense of purpose
• ensuring your team know where they can get support, and help them to maintain a good work-life balance by promoting health and wellbeing activities/information.
• being flexible, adaptable and open to ideas and change
• identifying and spotlight staff in your team who are strong in one of the following - problem solving / decision making / interpersonal skills / motivation - variety will make your team stronger.

Role of the line manager

As a line manager you can have a significant influence on the health and wellbeing of your staff. Best practice and research shows that competent line managers can contribute positively to the experience of employees. Many organisations are beginning to provide further training for managers on how best to manage their staff, alongside the softer skills required to support this. Improving these skills will assist you in managing sickness absence, developing the health and wellbeing of your employees and being seen to 'walk the talk'. Here are some useful pointers that you could be doing or working towards:

• deal with staff who are ill in a fair, sensitive, consistent and confidential manner
• keep accurate records of your team sickness absence using organisation policies and systems
• analyse sickness absence data looking for trends or warning signs
• lead by example by following policies correctly i.e. flexible working, taking breaks
• escalate issues and source support for staff where appropriate in a timely manner
• ensure your team know the policies, behaviour and engagement expected of them
• ensure your team know to take responsibility for their own health and wellbeing
• foster an open and inclusive culture in your team and workplace
• don't put off difficult conversations
• don't cancel meetings with your staff unless completely avoidable.

Effective management

There are simple ways to manage your team more effectively. They don’t require time or money, and most you can start right away. Supporting your staff by saying thank you for a job well done and creating a culture of openness can make a difference in promoting wellbeing among your staff.
Make time for positive reinforcement for example, say 'Thank you', or 'Tough shift, thanks for your support' etc.

If you have time say well done, ask what positives they will take away from today, or what they are most pleased about. This allows them to reflect on their personal sense of achievement and allows you the opportunity as their manager to say well done. We automatically focus on the negative and the one thing we could have done better. Let your staff leave work focussing on what they did well, and that they had the opportunity to share this with you.

Using metrics

Metrics are all about making raw and basic data easy to interpret and understand. They help you recognise good practise and spot areas that you need to improve on. They can be anything from a simple spreadsheet to a really complex set of data and formulae. They are readily available and used regularly by analysts as well as all sorts of managers within the NHS who find them invaluable. Using metrics lets you create simple visual summaries of important information, allowing you to present them clearly and flexibly to people who really need to see it, such as your board.

A good example of metrics in use are the national sickness absence rates that the Health and Social Care Information Centre (HSCIC) create every quarter. These spreadsheets are full of data but are still easy to read and categorised into organisation, organisation type, and area. They show clearly which organisations have low sickness absence and which ones are not doing so well. These are publicly available and free to download from their website and are very useful to compare your own organisation with others in terms of absence rates. This data shows which organisations are doing well, so you can make contact with them and improve your own policies and wellbeing programmes and reduce absence rates.

Metrics enable you to understand what is the current position of your organisation, but only become useful when you do something with the data you have gathered, such as planning your wellbeing strategy, challenge and inform your board, and help you map engagement for key stakeholders. Health and wellbeing can be measured using a number of metrics such as:

• staff sickness absence
• top five reasons for absence
• return to work meeting numbers
• vacancy establishment
• HR / OH interventions and referrals
• agency and bank staff usage
• staff survey response rates
• appraisal rates
• mandatory training rates
• induction rates.

All the above is really useful data, allowing you to target important areas and hot spots for interventions and developments. Key questions to ask are what impact is this metric having on my staff, or patient care? Do I need to talk to my staff about this metric so I can understand the context of this and the impact this is having?

Engagement and communication

Engaging staff during a period of major change is a huge challenge for NHS organisations. Research shows that rapid change may lead individuals to feel overwhelmed or left behind. This section covers how best to communicate with your team and explains the benefits of developing resilience.

Engaging staff during a period of major change is a huge challenge for NHS organisations. Research shows that rapid change may lead individuals to feel overwhelmed or left behind. This is especially true in the NHS where many staff have worked there for many years. Concerns are also heightened when some changes are outside of the control of individual organisations or may even result in the organisation they work for being abolished. There are some actions that can be taken to mitigate the impact of change and seek to engage staff:

Presenteeism

Some staff struggle to cope with the day-to-day challenges of the job, stress, cost and budget cutting and organisational restructures - and feel that they must attend work even when they feel ill, or work beyond their usual working hours to meet deadlines. This is known as presenteeism, and it is occurring more often in the NHS today.

Presenteeism can be especially prevalent in: 

A decline in absenteeism may seem to be positive, but not when it shifts to an increase in presenteeism. For instance, if a sick staff member is coming into work when they really should be recovering at home, it could expose them to further sickness. It could also lead to serious mental health issues for the person who is trying to do more work. The pressure of pushing themselves to work though ill health or do more hours can lead to exhaustion and can easily mount up, with them ultimately being unable to perform their duties fully, resulting in a loss of productivity for the team as a whole.

As a line manager you are crucial to solving the problem of presenteeism, as staff can often feel under pressure from managers to work whilst they are ill and not let the team down. Quite often there can be a culture within a team to project a certain 'image' or for an individual to feel uncomfortable asking for help and support.

A key point to managing this problem is challenging the attitudes of your team. Make sure your staff have a balanced workload with a sense of control over how it is delivered. Good working relationships are also vital, so have an open door policy in place with your staff to help you maintain communication. Your staff should be able to take the time off they need to recover, handing over duties to other team members and they need to be aware of this expectation from you as a manager.

• close-knit teams - such as friends or family, long time colleagues
• teams with competitive cultures or strict targets/deadlines (i.e. sales)
• caring occupations offering services to others – doctors, nurses, carers
• roles where an individual feels they cannot be replaced or their work cannot be covered should they be absent
• teams that are under intense pressure to succeed.