Occupational health referrals for advice on cancer-related sickness absence
Abstract
Background Work-related difficulties experienced by employees diagnosed with cancer are widely reported. However, there is limited reliable quantitative evidence that employers treat employees with such diagnoses differently from staff with other chronic disorders.
Aims To assess delays to management referral for occupational health advice for employees on long-term sickness absence attributable to cancer, compared with other common causes of long-term health-related absence.
Methods An audit of management delays to occupational health referral for all employees with a cancer diagnosis who subsequently applied for ill-health early retirement in a large UK public sector employer. Similar data were collected for two control groups, with musculoskeletal or psychological complaints, matched by age, sex, job title and pension scheme membership. Data were collected for the period 2004–07.
Results Twenty-three cases were identified. Referral to the occupational health services for cases with a cancer diagnosis was delayed on average by 187 days compared with cases with a psychological or musculoskeletal diagnosis (P < 0.001).
Conclusions There is evidence that employers differ in their referral practices for employees with a cancer diagnosis, compared with those with other common disorders leading to long-term absence. This may represent a loss of opportunity for effective vocational rehabilitation or timely support for access to health-related benefits.
Key words
Introduction
Some 90 000 people of working age in the UK are diagnosed with cancer annually, and a high proportion of this group achieve a return to work [1]. Recent research has suggested that in the period after diagnosis and during treatment, adults with cancer rate work as their highest concern after concerns for their immediate health and the well-being of their families [2]. Survey data suggest the process of return to work is difficult for a significant proportion of cancer survivors [3]. A number of studies have similarly found cancer survivors reported receiving little useful advice regarding a return to work from their cancer team or general practitioners [2–4]. Occupational health services (OHS) may have a significant contribution to the vocational rehabilitation of employees who develop cancer. A survey of UK occupational health physicians, however, found 45% of respondents felt that line managers referred staff too late for any subsequent occupational health advice to be most effective [5,6].
Return to work issues after cancer diagnosis have been identified as part of the UK National Cancer Strategy as a major area for improvement [7]. The published research relating to the return to work experience of cancer survivors is difficult to generalize due to qualitative design, non-comparable employments and non-comparable terms and conditions of service. The purpose of this audit was to establish whether the time taken for line managers to refer staff on long-term sickness absence (LTSA) caused by cancer was different from that in cases of other common causes of prolonged sickness absence, specifically psychological and musculoskeletal disorders.
Methods
We undertook an audit of a routinely maintained database, recording all submissions for consideration of ill-health retirement (IHR) to the pension scheme-covering employees of a single large UK public sector employer. The organization had ∼17 500 staff working predominantly in social care, education and construction-related employment. All staff were subject to a LTSA policy (LTSA defined as absence of ≥20 working days) with the same ‘trigger points’ for management referral for OHS advice. An audit was undertaken of the records for all employees assessed in the OHS as part of the LTSA policy and for whom a submission was subsequently made for IHR in the period January 2004 to December 2007. Each employee case submitted for IHR because of a cancer diagnosis was matched with a case in each of two control groups, consisting of cases submitted for IHR because of either psychological symptoms or musculoskeletal disorders. Matching was undertaken for age (5 years), sex, job title and pension scheme membership. These broad categorizations were agreed between the authors in each case based upon review of a full medical report returned to the OHS by a pension scheme doctor. The anonymized OH record for each case and control was reviewed to determine the period of time, in working days, which has elapsed between the onset of LTSA and receipt by the OHS of a first referral. Any absence from work attributed to the cause ultimately leading to an IHR application and occurring prior to the episode of absence culminating in IHR application was not assessed.
Data were entered into Excel™ Data Analysis Toolpak. To explore relationships between the diagnostic groups, a matched pair t-test was undertaken between all possible diagnostic groupings.
Results
There were 26 cancer cases resulting in submission for IHR. No OH records were found for two cases, making it impossible to determine the duration of absence prior to OHS referral. A further case, a self-referral following 9 months of absence was excluded. In the remaining 23 cases, the time between the start of the sickness absence and receipt of a management referral by the OHS was determined from the OH records. The frequency of cancers was eight breast (all females), four lung, three haematological, two central nervous system and six other. Over the same time period, 73 submissions for IHR consideration linked to musculoskeletal disorders were identified, although an OH record was not available for one case. It was possible to match one control from this group for each case with cancer. This was undertaken in a sequential manner from the date of submission. Lastly, 30 controls with a psychological diagnosis were identified; of these, it was possible to provide a suitable control for only 19 of the cancer cases.
A Wilcoxon matched-pair test was undertaken to compare delays in average referral (working days) among the different diagnostic/symptom groups (Table 1). Differences in referral delay for employees with cancer compared with psychological (mean 187 working days) or musculoskeletal (mean 187 working days) diagnoses were statistically significant (both P < 0.001). There was no statistically significant difference between means for psychological and musculoskeletal referral delays.
Comparisons between the delay (in working days) to occupational health service referral by managers, following the onset of LTSA
Discussion
This audit found that, even in a large public sector employer with consistent LTSA procedures, managers delayed referral for occupational health advice in employees with a diagnosis of cancer. This is in keeping with the opinions expressed within the large survey of UK occupational health physicians [5]. This study does not provide insight into the reasons for these findings, but a survey of UK line managers suggested a need for greater training and support for line managers in dealing with employees with cancer diagnosis, based on findings of number of ‘fearful attitudes’ and ‘line manager burden’ concerns expressed [8]. The concepts of vocational rehabilitation for chronic medical conditions are largely based upon notions of intervention at a sufficiently early stage to ensure expectations among employees and managers are appropriate and not unduly pessimistic. There is no current robust evidence to support the effectiveness in any health or psychosocial outcomes of early OHS intervention for employees with a cancer diagnosis. However, if the general principles of vocational rehabilitation apply to cancer as well as they do to other chronic health conditions affecting working adults the promotion among employers of a role for occupational health in advising early on all chronic health conditions arising in employees, regardless of their nature, maybe required.
This study assessed only those cases in which staff ultimately applied for IHR and may not be representative of all employees with a cancer, musculoskeletal or psychological diagnosis, who took associated long-term absence. In addition, the OHS assessments in this study population relate only to those arising from the first LTSA management referral to the OHS. Given the delay to this, it is likely that many employees with a cancer diagnosis, who subsequently made a successful pension application, entered a period of ‘half’ or ‘no pay’ during which they may have been financially disadvantaged prior to a decision regarding a pension. Consequently, even in these circumstances, earlier OHS assessment in relation to prognosis and workability may have proven advantageous to both employer and employee.