The sick leave service

NHS trusts are increasingly turning to ‘absence management’ as a way of reducing the amount of money they spend on agency staff when permanent team members are sick. Essentially, this means that when nurses and other staff are unable to get into work, they have to telephone a call centre rather than their manager.

They are then triaged by a call adviser who will put them through to a nurse who may give them relevant primary care advice or refer them on to a more specialist service.Such a system obviously has implications on several levels for nursing staff, some that might be seen as positive and others that are potentially more controversial.

• Click here to see seasonal trends for sick leave in 2008

Of the small number of absence management providers currently in the UK, FirstCare and Active Health Partners are two of the most prominent.

Aaron Ross is the director of FirstCare, the only absence management company so far being used by the NHS. Currently 17 trusts of varying sizes – including Lewisham Hospital NHS Trust and Queen Mary’s Sidcup – are already using the company’s services, while another three have signed up to do so.

‘Rather than phoning their manager, they phone us – 24 hours a day, seven days a week,’ Mr Ross told Nursing Times. ‘They come through to our call centre, which is staffed by agents and nurses. And we do two things – first of all we alert their manager or whoever needs to know in their organisation that they are off, and that’s done by automatic notifications – emails, pagers, text messages, and so on.

‘The other side is the primary care of the individual. Does that person need urgent medical attention – if so, let’s signpost them there. Then we capture as much information about the absence as possible to try and help them back to health as quickly as possible, which is an important distinction – it’s not back to work, it’s back to health.’

FirstCare analyses all of the records of absences, whether health-related or not, for trends. ‘The data we send an NHS trust is thousands of charts but they go to the relevant people, so a ward manager will receive a graph of their ward against comparative wards, and a baseline for their organisation. It drills right down,’ Mr Ross explained.

He acknowledged that initially employees were suspicious of the service.

‘The public perception of the service, and quite often when you start talking to someone about it, there is an assumption that you are there to pick up on malingerers and get them back to work,’ he said.

‘But we will never ever qualify sickness, so we’ll never turn around and say: “Yep, that one’s valid or that one’s not valid”. In our mind there is no such thing as an illegitimate absence.’

He added that the system’s reliance on data recording could spot trends that a manager might not – possibly revealing hidden problems of a non-health related nature. ‘It can be anything, from they can’t physically do the job they are being asked to do through to bullying managers, bullying colleagues or domestic situations at home. Being independent and having the data there, we can get to it,’ said Mr Ross.

He claimed that employees quickly changed their mind about the benefits of the service as did unions that were initially ‘a little bit frosty’.

‘If you phone us at 3am on a Monday morning with a back problem – then we won’t wait for 20 days for your manager to refer you into occupational health. If we know you’ve got a back problem and an estimated return to work of more than seven days, then let’s refer you on day one,’ he said.

But Mr Ross admitted it had not all been plain sailing with the NHS.

‘One of the first NHS trusts we started working with were saying they couldn’t fast-track their own staff into physio,’ he said.

‘The waiting lists were getting longer because the staff were absent but there wasn’t a mentality of “we can address this by fast-tracking three people into physio”. Fortunately, they’ve come round to the idea,’ he added.

Nicola Lee, RCN employment relations adviser who also works with the college’s Work Injured Nurses Group, said absence management could be a good thing as long as the company placed the emphasis on ‘primary care advice’ rather than allowing itself to be seen as a ‘big stick’ to get people back to work.

‘There can be advantages for staff,’ she said, citing the opportunity of being referred for services, such as physiotherapy, quickly instead of having to see a doctor and go through the normal system, which could take months.

‘We know that early intervention makes a significant difference and can be very beneficial,’ she said.

Ms Lee added that in the case of the NHS, calling an independent company could actually appear preferable to nursing staff who might previously have received ‘a bit of an interrogation’ from their ward sister or line manager over their symptoms.

Equally, however, there is the danger of a clash between an NHS employee and a nurse working for FirstCare.

‘There are obviously instances where a nurse is particularly anti speaking to a nurse,’ said Mr Ross.

‘They’ll just turn round and say they’re self-caring, and that will be that. We don’t force anyone to take nursing advice. You can’t actually do that. So we offer nursing advice and by and large people take it up – certainly we see the uptake of nursing advice improve as the service continues.’

One of the main drivers for absence management in the NHS was a National Audit Office report, published in 2006, that cited a need for trusts to reduce the cost of bank and agency staff.

Just last month the Department of Health also called for interested parties to help pilot its Fit for Work service programme, which will test out ways of supporting sickness absentees to recover ‘more quickly than would otherwise be the case’.

‘In the current economic climate it’s even more important that we cut the£100bn cost of worklessness caused by ill-health,’ said care services minister Phil Hope.

FirstCare’s service, where it has been in place, suggests some impressive results, which could appear attractive to an NHS under pressure to fall in line with these aims. The average reduction in absence rates across the service’s clients, since its introduction, is 22%.

‘If you look at a 1,700-employee NHS acute trust, we’re saving them around£1.2m a year in bank and agency reduction. For a relatively small acute trust that’s every month a Ferrari in the car park,’ he said.

‘By and large you are looking at one or two days per year per employee saved. Now with those sorts of figures, you would have thought every NHS trust in the country would be banging on our doors, saying let’s do it.

‘Originally we had thought there would be a massive tipping point where we would demonstrate success in a couple of NHS trusts and everyone would come on board. That’s never going to happen and it’s taken me a few years to realise,’ he added.

The barrier to companies like FirstCare, as is common with many initiatives in the health service, is probably the reactive nature of the NHS. There are so many pressures on resources that there is often a reluctance to invest in ideas that could provide savings in the long-term but not immediately – and with no guarantee.

Mr Ross suggests that situations such as influenza outbreaks and norovirus should provide trusts with a ‘compelling’ enough reason to consider absence management.

The data, because it is real-time, can potentially show exactly when such a problem is about to start significantly affecting a trust. It can also show wider trends over time, picking up the relative severity of outbreaks on an annual basis. For example, 52.8% of all absence in the company’s NHS clients in December 2008 was because of colds and flu, compared with 28.4% in December 2007.

Mr Ross said the data from last year had potentially revealed the impact of the credit crunch on the population’s health – starting on 15 September, the day Lehman Brothers investment bank went bankrupt.

‘What we saw from that day was a steady increase that can be graphed to the number of people with coughs, colds and flu,’ said Mr Ross. ‘We couldn’t understand it at the time. Now we’ve understood it’s a pre-cursor to stress – it’s people who are run-down, which is then compounded through the winter months,’ he added.

Of course, because they employ nurses, absence management companies also potentially offer members of the profession a new career outlet in telephone triage – in a similar way to NHS Direct.

At present, FirstCare employs around 20 nurses who spend three-and-a-half minutes on average on each call. However, the company plans to recruit a further 24 whole-time equivalents this year, which could mean up to 40 flexible posts.

While some nurses are present in the office, the majority are based at home and use some ‘very advanced home technology’ to log in to the company’s system remotely.

‘We’ve got ones that log in for four hours before they go and do their A&E shift on Monday morning,’ said Mr Ross. ‘It’s all nice and secure, and means they operate in exactly the same way we do here but they can also go and do their A&E jobs, which is great for us and great for the NHS.

‘We’re quite picky about the nurses because they need to be A&E background, they need to be competent on the phone, they need to be comfortable with IT – we’ve got some fantastic nurses,’ he said.

The company also employs three ‘lead nurses’ who work full-time. Each client has a specific lead nurse who proactively looks after their requirements.

‘One of our NHS trusts recently phoned and said we think we’ve picked up someone with Legionnaires’ disease, and having the nurse with their skill and knowledge of the NHS and environment, they then sat down with our database team to look at putting in the triggers and trends to identify anyone with matching symptoms,’ said Mr Ross.

‘The system was changed within less than two hours to then channel anyone with those symptom categories through to the lead nurse and her team,’ he added.

The RCN’s Ms Lee agreed that absence management offers career opportunities to nurses – for example, for those who have experienced injury or ill-health in the workplace themselves. ‘They provide a career opportunity for nurses who can’t physically nurse anymore,’ she said.

Although FirstCare’s footprint in the NHS may currently be quite small – 20 trusts out of more than 500 – nurses can expect to come into contact with absence management in one way or another, if the company achieves its aims.

Mr Ross said: ‘We want every trust in the UK that employs more than 1,000 employees, whether it’s primary care, NHS acute, mental health or foundation.’

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