A sickening problem: rising absence rates in the public sector

“I was off with stress and was contacted every second day with a view to going back.”

These words, written by a Scottish NHS nurse in the RCN’s new employment survey, shine a light on the pressure both staff and managers are under trying to meet growing demand – nurses having to take sick leave and their bosses struggling to cover shifts without them.

“I felt pressured and had to return before mentally ready,” the nurse reveals.

“I feel physically stressed before, during and after my shift, and worry that things can be missed.”

“We are often told, through health promotions and in training, the importance of your own health,” says another nurse.

“However, if time is taken off, there is a push to get back as quickly as possible as it is an inconvenience to your workplace and other colleagues.

“It feels like a contradiction and when I have been off work unwell, I have been made to feel guilty for being so.”

Absence levels in the NHS, and the public sector generally, are a matter of ongoing concern.

In the NHS, the rates have been getting worse, as pressure on the service has increased.

There has been a 50 per cent rise in stress-related absence in the last four years, according to an annual survey of health boards conducted by Scottish Labour, which also indicates that stress now accounts for nearly 25 per cent of sickness absence.

Some 3.5m staff hours have been lost due to stress, anxiety and other psychiatric illnesses.

Peter Hunter, regional manager of Unison Scotland, which represents workers across the public sector, says: “It’s a subject of conversation with employers that absence levels are high and that the primary causes are stress and mental health problems, and that people are attributing that primarily to work.”

The levels of sickness absence in the public sector are consistently higher than in the private sector.

The Office for National Statistics put the sickness absence rate of public sector employees at 2.7 per cent in 2018, compared to 1.8 per cent for private sector workers, though there are differences between the two sectors and the way each records absence, which may account for some of the difference.

The last five years have heralded a surge in awareness of mental health issues generally, and reduced stigmatisation may have contributed to the rate of absence by giving staff the confidence to come forward with problems and take time off where necessary.

But workload and short-staffing in the public sector are huge ongoing concerns.

“Of all the union learning we provide, by far the biggest is mental health learning and training to give mental health first aid,” says Hunter.

Rising pressures on public services like social work are predictable, he says, given the impact on disadvantaged communities of government policies relating to benefits.

The health service also faces rising demand, as does the not-for-profit care sector, with the expansion of childcare and a rise in the use of addiction services. Other services are struggling after significant staff reductions.

“Tens of thousands of people have left local government employment,” says Hunter.

Absence rates are not as high in the teaching profession as in some areas of the public sector, but that brings its own challenge: presenteeism.

Dave McGinty, national officer for employment relations at the EIS union, says: “What we find is that teachers are going to work when they are ill because there’s no one else to teach their pupils.

“In rural villages, there isn’t a well of supply teachers for the school to draw on. They are actually going to work when they should be taking time out to get better.”

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This naturally adds to stress levels, which are high in the teaching profession, primarily as a result of bureaucracy, planning and assessments.

Stress is not the only cause of work absence. Minor illnesses, like colds and musculoskeletal disorders, are major causes of sick leave that are recorded across all sectors, but the rise in absence related to stress and mental ill-health, and the allied phenomenon of presenteeism, worries employers, unions and campaigners.

Employers across all sectors have improved their support for staff with mental health problems in recent years, but there are still shortcomings with systems for handling absence.

“One of the concerns we have is that many public sector employers offer very strict, procedural, arithmetical ways of recording absence, where people are disciplined and get dismissed after a certain number of absences,” says Hunter.

“That’s potentially discriminatory, potentially unlawful but definitely unhelpful. We need to change the conversation to the root cause of poor mental health at work and allied to that, have a better-informed conversation about wellbeing.”

A crucial part of the solution is effective workforce planning.

Hopes have been raised of tackling unacceptable workloads in the NHS following the passing of the Health and Care (Staffing) (Scotland) Act earlier this year.

The act puts workforce planning tools into law, to ensure safe and appropriate staffing levels in the NHS.

The RCN Scotland, BMA Scotland and other unions have welcomed the legislation but see it very much as a starting point.

The BMA has noted that it “will not create more doctors – or staff of any type – simply by becoming law”, while Theresa Fyffe, RCN Scotland director, has remarked: “All too often, staffing decisions are based on what’s affordable and available, not what’s needed to deliver safe and effective models of care.”

The RCN is pushing the Scottish Government to deliver its integrated workforce plan for health and social care.

The plan is more than a year late, a delay that has been highlighted by Audit Scotland.

Campaigners are pressing the Scottish Government to ensure that the plan, when published, gives detail on how it will meet the aspirations of the act so that the NHS can achieve those desired safe and appropriate levels of staffing.

Hunter agrees: “Workforce planning is wise and responsible when it is followed by resource allocation.

“If you don’t resource the plan at all, it’s pointless, and you also need to have a retention strategy.”

Effective workforce planning requires cash, but it also depends upon a reliable supply of skilled workers, and they are in short supply.

The Scottish Government reduced training places for nurses in 2011 and 2012, against the advice of nurses’ leaders, and has since had to reverse that decision, but vacancy rates are at a record high. There are also shortages of doctors, and teachers in some subjects.

Scotland’s low productivity rate and its demographic deficit – a falling birth rate, growing elderly population and an insufficient number of working-age people – make problems like absence rates at work a matter of grave concern to policymakers.

Although the same problems affect the other nations of the UK, Scotland has historically attracted fewer immigrants than its proportional share, making the impacts of these issues more acute.

Brexit hasn’t helped. Scotland stands to be worse affected by restrictions on immigration from the EU than the rest of the UK.

Norman Provan, associate director of the RCN, said: “Scotland, like the rest of the UK, depends on the contribution of EU nationals working in health and social care.

“In spite of the dedication of nursing staff from Scotland, the EU and beyond, the nursing workforce is under huge pressure, with over 4,000 vacancies in the NHS alone.”

McGinty points to the huge impact Brexit is going to have on the further and higher education sector, by discouraging academics and lecturers from the EU from staying in Scotland and casting doubt on how easy it will be for academics to come to the UK in future.

The care sector, too, stands to be badly hit by Brexit. It is already struggling to meet demand.

The Care Inspectorate’s latest report on vacancy rates, published in January, shows that unfilled posts were reported by 38 per cent of social care services (which include care homes for adults, housing support services and care at home) which is up two per cent on the previous year.

The vacancy rate across all services was six per cent.

Dr Donald Macaskill, the chief executive of Scottish Care, the body representing independent care providers, responded to the figures saying that people working in the care sector were “not sufficiently valued or recognised” and added that “uncertainty surrounding Brexit” could mean more care homes closing because they couldn’t recruit enough staff.

Unison and the EIS believe employment law should be devolved, which is also an SNP manifesto demand.

“We favour the Scottish Government having the power to employ people in public services according to Scotland’s needs and on standards of fairness that are defined in Scotland,” says Hunter.

The SNP has long demanded control over immigration policy so that Scotland’s distinctive needs can better be served.

Nicola Sturgeon wants Scotland to be able to issue work permits and simplify the citizenship process. She also wants it to be cheaper for employers to sign up workers from overseas.

Tackling these problems will require a range of solutions, from reducing workloads to providing better mental health support and boosting immigration. It will not be an easy fix. 

“I found it stressful being off”

Nurse Ann MacCrimmon, 57, took two months off work in Greater Glasgow and Clyde when she was experiencing the symptoms of the menopause, but thinks that stress was also a factor in the way she was feeling.

Like many people, Ann has caring responsibilities which have to be fitted in around work. She has an elderly mother who relies heavily upon her and doesn’t have any siblings to help out.

She says that her boss was very supportive and that the NHS has a wide range of services to support workers’ physical and mental health, but staff are under a lot of pressure.

She says: “There is more and more demand and a lot of it is due to increases in technology and the expectations of the public.

“People are also being treated for diseases that in the past they would have died from. They have more comorbidities, more complex needs.

“There are more roles for nurses available, like demand in care homes and NHS 24. But there’s not the workforce.”

Ann, who works in medical imaging, estimates there has been a tenfold increase in the number of types of X-rays patients can have over the course of her 36 years as a nurse.

“The work has changed, the challenges are different. You’re under more pressure to achieve.”

For Ann, taking time off helped, but it was an unaccustomed feeling for her.

“I found it stressful being off,” she says. “Usually, I am one of those workers who is at work.

“I’m lucky, because I have been granted flexible working, so I can get quality time with my mother.”

A supportive boss and progressive policies to help staff make a big difference: “People need to work, but they also have commitments in their personal lives.

“You feel valued if someone listens to you and tries to accommodate you.”