Internal Audit
Review: Sickness
Absence
5 Boroughs Partnership NHS Foundation
Trust
1
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Contents
The contacts at KPMG in connection with this report are: Tim Cutler Director KPMG LLP (UK) Tel: 0161 246 4774 [email protected] Rob Jones Senior Manager KPMG LLP (UK) Tel: 0161 838 4637 [email protected] Ben Lazarus Assistant Manager KPMG LLP (UK) Tel: 0161 246 4939 [email protected] Will Hamilton Assistant Manager KPMG LLP (UK) Tel: 0161 2464 566 [email protected] Status of Report
Discussion draft issued: 26 January 2015 Management responses received: 2 March 2015
Final report issued: 3 March 2015
Presentation to Audit Committee: 1 April 2015
Distribution
To (for action):
• Tracy Hill (Director of HR and Organisational Development) • Audit Committee
Page
Section One Executive Summary 2
Section Two Findings 5
Section Three Recommendations 9
Appendix A Interviewees and documents reviewed 11
Section One
Executive Summary
Objectives
Recommendation Raised
We have raised 6 recommendations in relation to this review. These are split as follow
Conclusions
Our overall conclusion for this review is significant assurance with minor areas for improvement. This means that systems and processes are generally well designed however minor improvements could be made and/or some exceptions in its operation have been identified.
Please see the following page for detailed explanation of the KPMG assurance ratings.
Objective Description
Objective one
Review of the ‘Promoting Attendance’
policy
We have reviewed the quality and appropriateness of the Trust’s recently revised ‘Promoting Attendance’ policy and assessed the impact the policy has had across the Trust.
This involved:
• Document review of the policy and any other associated sickness absence and relevant HR policies, procedures and guidance;
• Discussions with management and review of correspondence to clarify how well communicated and managed the roll out of the policy has been; and
• An impact assessment of the revised policy based on levels of awareness, movements in relevant statistics and views of management.
Objective two
Consistency across the Boroughs
Following planning discussions with central HR staff, we identified riskier areas of the Trust for sample testing. For each sampled area we reviewed the levels of
consistency against central process in terms of sickness absence processes, monitoring, management and reporting. Where applicable, highlighted deviations from central policies and communicated any areas not aligned to best practice. This involved:
• Document and process review at a localised level, providing a comparison to central process; and
• Discussions with management to understand localised sickness absence processes and awareness of central policies and procedures.
High Medium Low Total
Raised - 3 3 6
Agreed - 3 3 6
Not agreed - - -
-Significant assurance with minor improvement opportunities Significant assurance with minor improvement opportunities Objective 1 Objective 2 Significant assurance
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Section One
Executive Summary (Cont.)
Background
The ways in which NHS Trusts manage, monitor and report sickness absence is vital to ensuring a productive and effective workforce. In an environment where quality of care is paramount, the workforce is the most valuable asset, critical to delivering a safe and sustainable service. Workforce is also an area of risk identified within various sections of the 5 Boroughs Board Assurance Framework, hence appropriate systems of control and oversight are crucial to the Trust’s success.
In recent months, 5 Boroughs have revised and started to embed through relaunched activity a “Promoting Attendance” policy. This has been accompanied by refresher training for staff and a concerted effort to develop a positive culture around attendance across the Trust.
Whilst the Trust has seen a c1% reduction in sickness absence in the last 12 months, absence levels are still relatively high compared to other health organisations in the region (see Appendix B for details). In addition, the nature of the Trust, split geographically across boroughs and widely differing service models, creates an inherent risk around consistency of processes, control environments and oversight.
This review has assessed the quality and impact of the recently revised “Promoting Attendance” policy. This has included a review of the appropriateness of the policy itself, how well embedded it is and how well different areas of the Trust have utilised it.
We have performed interviews and testing over riskier areas of the business to gain an understanding of levels of consistency in awareness and application of systems across the Trust.
Approach
We undertook initial scoping and risk assessment meetings to identify the needs of the Trust and to isolate particular risk areas to focus testing. This was supported by data analysis to understand the Trust’s overall position and to select specific wards for testing. These were picked on the basis of covering different services and Boroughs to ensure that the testing covers the needs of the Trust. However, it should be noted that, given the scope and length of the review, it has not been possible to test a fully representative sample across all wards.
Assurance level key
Assurance level Definition
Significant assurance
Means the system is well designed and only minor low priority recommendations have been identified related to its operation. Might be indicated by priority three only, or no
recommendations (i.e. any weaknesses identified relate only to issues of good practice which could improve the efficiency and effectiveness of the system or process).
Significant assurance with minor improvement opportunities
Means the systems is generally well designed however minor improvements could be made and some exceptions in its operation have been identified. Might be indicated by one or more priority two recommendations. (i.e. there are weaknesses requiring improvement but these are not vital to the achievement of strategic aims and objectives - however, if not addressed the weaknesses could increase the likelihood of strategic risks occurring).
Partial assurance with improvements required
Means both the design of the system and its effective operation need to be addressed by management. Might be indicated by one or more priority one, or a high number of priority two recommendations that taken cumulatively suggest a weak control environment. (i.e. the weakness or weaknesses identified have a significant impact preventing achievement of strategic aims and/or objectives; or result in an unacceptable exposure to reputation or other strategic risks).
No assurance
Means the system has not been designed effectively and is not operating effectively. Audit work has been limited by ineffective system design and significant attention is needed to address the controls. Might be indicated by one or more priority one recommendations and fundamental design or operational weaknesses in the area under review. (i.e. the weakness or weaknesses identified have a fundamental and immediate impact preventing achievement of strategic aims and/or objectives; or result in an unacceptable exposure to reputation or other strategic risks).
Section One
Executive Summary (Cont.)
Areas of Good Practice
The Trust’s policy is clear and is supported by procedures and a management guide which clearly documents the format of the system.
The policy is supportive and reflects a positive approach to staff attendance. It is supported by appropriate disciplinary actions but is not directly punitive.
Despite the complex structure of the Trust, training on the new policy has been applied and engagement with it has included a range of participants across all levels of seniority. This demonstrates the value that is placed on the policy and indicates awareness within the Trust.
The central HR function and corporate services are well informed of the sickness absence processes and are familiar with the stages, triggers and documentation required.
Though issues have been identified, the documentation of the processes supporting the policy is largely clear and efficient. Sufficient and appropriate evidence has generally been gathered and is stored in a usable format.
The HR department has been proactive with regard to the issue of sickness monitoring. There is an awareness that the Trust underperforms in this area against comparators and an internal review is in process to understand the risk areas at a more detailed level.
Sickness absence headline figures are routinely reported to Board. This provides a manageable level of detail and demonstrates awareness at a senior level.
Areas for Development
Delays have been identified in the performance of return to work interviews in 30% of the cases tested. The policy accepts that a delay of 72 hours may be required due to working hours and availability ofmanagement but recommends that it is performed on the day of return. This process is very important to help support and monitor staff, generate a supportive working atmosphere and to emphasise the value of attendance to the Trust (See Recommendation 1).
Instances were identified where an absence had been recorded on the HR system but for which no documentation had been received and there was no explanation or support for policy being maintained. This may risk staff wellbeing in addition to losing working days (see Recommendation 2).
Through review of the forms used to record and report the detail of absences we have identified various improvements the data collected, the monitoring of absences and the support of the policy (seeRecommendation 3).
The documentation of long term absence monitoring has been inconsistent and at times has been insufficient to comply with the policy (see Recommendation 4).
Stress referrals have not always been performed in a timely manner, particularly where stress is a secondary cause of absence (see Recommendation 4).
Monitoring processes within the sickness absence procedures have not been consistently applied. The processes are important to ensuring that the HR team and Trust management are informed of the current staffing position. Often the required reports are run and the data is used to inform management intelligence and action planning, but they are not being routinely monitored to provide the valuable management intelligence that was intended in their development (see Recommendation 5).
Through inquiry with staff and as supported by testing results, familiarity with and application of sickness absence processes are not consistent across the Trust. Corporate services are better informed but the policy is less well embedded in operational and community-based divisions where sickness absences are also highest. Training has been made available but engagement has been less evident in these areas (see Recommendation 6).5
© 2015 KPMG LLP, a UK limited liability partnership, and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved. Printed Employees must complete a
self-certification form as soon as
reasonably possible, but no later than the first day back at work, to cover them for the 4th to the 7th day of absence. This will not be necessary if the employee has obtained a doctor’s medical certificate that provides cover from the first day of absence. In some instances, employees were able to self-certify a longer absence.
Section Two
Findings (Objective One)
Employee contacts manager via phone to
report sickness on first day of sickness.
Sickness is less than 3 days Sickness is between 4 and 7 calendar days Sickness is more than 8 calendar days No contact No certification
required A medical certificate from the individuals GP/hospital is required from day 8 to cover the remainder of the duration of sickness absence. Certificates must be sent directly to the line manager, who will record and forward to Pay and Staff Services.
Considered as being on unauthorised absence until appropriate contact is made. Where no explanation has been found and no contact has been made managers reserve the right to suspend pay. Managers must write to the individual to confirm this has occurred.
Failure to comply with the notification procedure (including the submission of fit notes, where there is not good reason to do so) may result in an appropriate deduction in pay for those days absent. Disciplinary action may also be taken in accordance with the Trust’s Disciplinary Policy and Procedure
Manager to maintain regular contact. This
contact is not routinely documented
Managers, or their nominated deputy, are required to meet within 72 working hours following a period of sickness absence, which includes part day absence. Through testing, this was not performed in 30% of cases.
Trigger points are used to instigate further action.
• Informal Managers Review Meeting - 6 month review period – has hit an indicator/trigger – the review will last for 6 months;
• Stage 1 Managers Review Meeting - hit a further indicator/trigger – the outcome notice will remain on file for 6 months;
• Stage 2 Managers Review Meeting - has hit a further indicator/trigger – the outcome notice will remain on file for 12 months;
• Stage 3 – Medical Incapability Hearing.
Absences in excess of 4 weeks will normally result in a referral to
Occupational Health. This is unless the absence is related to musculoskeletal and mental health (i.e. stress,
depression, anxiety, etc) when a referral will be made immediately.
Referrals based on stress are not performed as promptly as required.
See Long Term sickness (overleaf) Objective One: Reviewing of the Promoting Attendance policy
Below we set out our observations around objective one in accordance with the terms of reference for the review. Against this objective we have documented our key findings from discussions with relevant Trust officers and review of documentation. We have also referenced to issues and exceptions and given an assurance level over the processes tested.
Sickness Absence Process
Through inquiry of staff and by reviewing the policy, procedures and management guide KPMG has illustrated the ‘Promoting Attendance’ processes as it should be practiced at the Trust.
Absences in excess of 4 weeks will normally result in a referral to Occupational Health. This is unless the absence is related to musculoskeletal and mental health (i.e. stress, depression, anxiety, etc.) when a referral will be made immediately. In some cases, referrals were made but the outcome was not fully documented
Following receipt of the Occupational Health report the employee and their Line Manager will meet to discuss its content.
The employee will be invited, in writing, to attend a welfare meeting to discuss any reports produced by the Occupational Health Service and the advice regarding a return to work.
Managers are required to complete the Record of Welfare Meeting Form at the meeting and both the manager and the employee must sign this document as a true reflection of the meeting. The Manager must
photocopy the signed form and send this to the employee for their records. The Line Manager will continue to monitor the situation, and arrange further meetings as necessary with the employee and their representative. These records were not regularly documented on the employee file.
It may be necessary to implement a phased return to work to support an employee back into their normal working pattern..
Where absence extends beyond a 6 month period then detailed advice must be sought from the Occupational Health Service.
Where the Occupational Health Service advises that the employee is unlikely to return to work in the foreseeable future then consideration must be given to move to a medical incapability hearing where dismissal on the grounds of ill health will be recommended. When neither a reasonable adjustment nor redeployment can be found, there may be no alternative but to consider dismissal. Managers must seek the advice and input of human resources.
When the member of staff returns to work, from long term sickness they will have hit the sickness absence trigger, and will therefore require a Managers Review Meeting.
• Informal Managers Review Meeting - 6 month review period – has hit an indicator/trigger – the review will last for 6 months;
• Stage 1 Managers Review Meeting - hit a further indicator/trigger – the outcome notice will remain on file for 6 months;
• Stage 2 Managers Review Meeting - has hit a further indicator/trigger – the outcome notice will remain on file for 12 months;
• Stage 3 – Medical Incapability Hearing. Managers must conduct at least one welfare meetings a month with the individual, whilst they remain absent from work.
Section Two
Findings (Objective One)
Long term sickness7
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Section Two
Findings (Objective One)
Monitoring
By reviewing the Promoting Absence policy, KPMG identified the following monitoring practices. These were tested to ascertain the operating effectiveness of the control procedure.
Monitoring practice Process for monitoring Responsible group Responsible for monitoring of action plan
Compliance rating and comments
Overall percentage sickness absence are reviewed • Report from ESR Workforce information
Trust Board ESR reports have been produced in performance reports and at Board and divisional analysis shows that sickness has been considered as a factor in performance analysis. Compliance with the Return to Work interviews • Business Managers Information HR Operations AD of Business Stream
Through inquiry and testing (see Objective Two) this process is not regularly and consistently performed (see Recommendation 1). Compliance with the managing short-term absence procedure • Triggers report • Business managers on stages of sickness • HR Operations report HR Operations AD of Business Stream
Monitoring reports are produced though there was little evidence of their usage or utility in managing absence at the Trust.
Compliance with the long-term absence procedure • Long term sickness (ESR report) • Business managers information HR Operations AD of Business Stream
Absences are not consistently regularly monitored and reviewed and, though reports are produced, are not used to maximise the benefit to the staff involved and to the Trust (see Recommendation 4). Compliance with stress risk assessments • Reasons for absence (ESR report) • OHU stress assessment records HR Operations AD of Business Stream
Some stress absences have been managed well via a swift referral and a ready support system however where stress is a secondary issue or is a symptom these referrals have been less consistently applied e.g. bereavement induced stress (see Recommendation 4).
Objective Summary
■ The Trust’s policy is clear and is supported by procedures and a management guide which clearly documents the format of the system.
■ The policy is supportive and reflects a positive approach to staff attendance. It is supported by appropriate disciplinary actions but is not directly punitive.
■ Training has been available to staff across the Trust though attendance has been less consistent in community-based divisions.
■ Awareness of the policy is good amongst staff and sickness absences have reduced by 1% though they remain high.
■ Monitoring and support processes are not reliably performed which would lead to greater awareness amongst staff. This would increase the effectiveness of the policy and would further reduce unnecessary absences.
Section Two
Findings (Objective Two)
Objective Two: Consistency across the Boroughs
Through inquiry with the Trust and analysis of sickness absence data, KPMG identified four risk areas for sample testing. These were designed to cover areas of particularly high levels of non-compliance with the 5% sickness absence target, areas particularly affected by sickness absence levels and to cover a range of different services and Boroughs.
From each of these four risk areas, KPMG selected a sample of 32 instances of sickness absence. These were then agreed to the electronic records and supporting documentation held by the Trust to investigate how consistently the policy had been applied and documented.
The sample is not regarded as being statistically representative due to the time available for the review but is designed to be a test of the Trust’s weak spots regarding sickness absence.
Area tested Consistency
with central process (%)
Comments
Knowsley Adults working age
80% Two cases were identified in which the return to work interview had not been conducted within the 72 hour timeframe allowed in policy. The recommended approach is to complete the interview on the day of return and the 72 hour cut-off is to allow for weekends or absent managers. One patient was identified as having required referral to occupational
health but no referral was documented.
Wigan Older People 50% Two cases showed no evidence of the absence that was being
investigated. This represents a weakness in the documentation process and has a slight impact upon assurance over information reporting. Two cases were identified when the return to work interview had been
conducted outside the 72 hour deadline.
Nursing and quality
(corporate) 60% Two cases showed no evidence of the absence that was being investigated. One of these cases had been declared fit by occupational health shortly before..
One case was identified when the return to work interview had been conducted 8 days after return which is outside the 72 hours deadline. One instance was identified where the staff member had self-certified an
absence above the 3 days prescribed in policy. This should have been certified by the staff member’s GP to be fully compliant.
CAHMS management
100% No issues identified. Area identified for testing due to an unexpected rise in absence in May and June though these cases were found to be fully explained and documented.
Objective Summary
The policy has been applied across the Trust and is the established basis for sickness absence processes. However, levels of awareness and compliance with the detail of the policy vary between Boroughs and divisions.
Training has been available to all relevant staff though uptake rates have been lower in community divisions. Despite views expressed by some staff, no notable difference was identified between the treatment of medical and non-medical staff absences.
Central monitoring processes should be strengthened to provide additional support to areas of the Trust that are at additional risk, particularly community services and divisions experiencing greater stress levels.
There has been a minor improvement in sickness absence rates due to the policy but testing did not show an improvement in documentation in comparison to the period before the policy.
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Section Three
Recommendations
This section summarises the recommendation that we have identified from our work. We have given each of our observations a risk rating (as explained below) and agreed with management what action you will need to take.
Priority rating for recommendations raised
High Priority: a significant weakness in the system or process which is putting you at serious risk of not achieving your strategic aims and objectives. In particular: significant adverse impact on reputation; non-compliance with key statutory requirements; or substantially raising the likelihood that any of the Trust's strategic risks will occur. Any recommendations in this category would require immediate attention.
Medium Priority:a potentially significant or medium level weakness in the system or process which could put you at risk of not achieving your strategic aims and objectives. In particular, having the potential for adverse impact on the Trust's reputation or for raising the likelihood of the Trust's strategic risks
occurring.
Low Priority:recommendations which could improve the efficiency and/or effectiveness of the system or process but which are not vital to achieving the Trust's strategic aims and objectives. These are generally issues of good practice that the auditors consider would achieve better outcomes.
Ref Priority Issue and Recommendation Management response
1
Med
Return to work interview
Instances were identified when return to work interviews have not been performed in a timely manner
Sickness absence training should enforce that the policy requires a return to work interview on the day of the staff members return.
This interview should be conducted by the individual’s line manager and should be a supportive rather than disciplinary process. Procedures reinforce this point, however training should be amended to actively discourage senior staff from conducting these interviews.
Reports detailing returns to work are available and HR should use these to highlight the requirement to line managers on the 3rdday after return.
Management Response
Managers Briefing Note (MNB) to be issued, reminding managers of the required process and timescales for return to work meetings. HR advisor to audit return to work interviews on a quarterly basis.
Responsible Officer and Due Date Head of HR – March 2015
HR Service Manager – June 2015
2
Low
Documentation
Instances were identified where documentation was incomplete or wholly absent from the file. In 22% of the cases tested the documentation was not in line with policy requirements.
For cases reported as absent the central HR team should chase line managers and document that chasing, in the absence of receiving files.
Management Response
People Service Administration team to carry out quarterly audits of information received or inclusion on Personal files and highlight areas for improvement with HRBP
Responsible Officer and Due Date HR Service Manager – September 2015
3
Low
Form adjustments
The current form is detailed but does not collect all information that would be beneficial to track absences and thus generate better management information. This can be used to address core reasons behind absences and to provide additional support where required. The following adjustments are recommended:
•
Update references to ‘managing absence’ on occupational health documentation;•
Require certification to be attached to electronic file and input end date of certification;•
Require detail of which trigger has been activated when appropriate; and•
Require date of referral, if required, to instigate rapid action for the benefit of staff members.Management Response
HR Service Manager, OH Manager and HR Service Team to carry out a review of attendance documentation and records with operational and corporate stakeholders and staff side representatives
Responsible Officer and Due Date HR Service Manager – September 2015
Section Three
Recommendations (Continued)
Ref Priority Issue and Recommendation Management response
4
Low
Long term absences
Insufficient documentation of long term absence monitoring has been maintained and referrals to occupational health, particularly stress, have not always been recorded. 30% of cases tested showed insufficient documentation to fulfill policy and explain the absence.
Per recommendation 2, the Trust should focus resource on the management and monitoring of long term absence to ensure that staff are supported and assisted through their absence and to assist in staff planning.
This recommendation is supported by enhanced
documentation from recommendation 3 which will enable long term absences to be tracked and chased at the key dates.
Management Response
HR Services team to review current arrangements for monitoring processes for Long-Term Sickness (LTS) and consider using the new electronic tracker system for LTS as well as employee relations activity. Responsible Officer and Due Date HR Service Manager – September 2015
5
Med
Monitoring
Monitoring reports are available but are not routinely used as a tool to manage absences and to support the policy. The Trust should assess the value of the monitoring processes and ensure that this is understood by HR staff to develop a greater focus on absences. If there is no value in the process the policy should be updated to reflect this.
Management Response
HRBPS to undertake a review of the reports currently available and determine how these could feed into stakeholder/operational meetings.
Responsible Officer and Due Date HRBPS – June 2015
6
Med
Consistency
Through inquiry with staff and as supported by testing results, familiarity with and application of sickness absence processes are not consistent across the Trust. Corporate services are better informed but the policy is less well embedded in operational and community-based divisions. While we acknowledge that training has been available, this has not been consistently taken up. The Trust should analyse absences (see Appendix B) and focus additional training on divisions which would benefit from the supportive application of the policy, particularly those with higher rates of absence.
Management Response
HRBPS to undertake analysis of boroughs / business stream attendance and work with the HR Service Team to produce a plan to provide targeted training interventions in hotspots.
Responsible Officer and Due Date HRBPS – June 2015
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Appendix A
Interviewees and Documents reviewed
The following Trust officers were interviewed as part of this review in addition to support from junior staff and the Human Resources team in general.
Name Title
Tracy Hill Director of HR and Organisational Development Charlotte Layton Assistant Director of HR
Donna Hargreaves Personal Assistant Angela O’Brien Senior HR Advisor
Chris Manns HR Service Manager
John Crossland Workforce Information Manager
Various Divisional HR personnel
We would like to take this opportunity to thank the Trust’s staff for their help in this review. The following documents were reviewed as part of the audit:
■
Promoting Absence policy■
Supporting procedures and management guide■
Results of internal HR review into sickness absences■
Staff stress and mental wellbeing policy and procedures■
Performance reports as submitted to Board■
Absence data supplied by the Trust and the live ESR system■
Publicly reported data from the Health and Social Care Information CentreThis review was completed in 4 days, in accordance with our 2014/15 Internal Audit Plan as agreed by the Audit Committee.
Appendix B
Analytical review
Analytical reviewIn addition to specific item sample testing, KPMG analysed the sickness absence data produced by the Trust and publicly reported data (Health and Social Care Information Centre) to identify risk areas, inform the context for the review and to provide information useful for the Trust in managing absences.
3.00% 3.50% 4.00% 4.50% 5.00% 5.50% 6.00% 6.50% 7.00% % s ic k nes s abs enc e
Benchmarking of sickness absence data
5 Boroughs NHS Foundation Trust Mental Health and Learning Disability Trusts North-West average England average
As shown above, the north west as a region and mental health as a discipline both demonstrate higher sickness absence rates than the English NHS average. Despite this trend, for the period for which public data is available, 5 Boroughs reported consistently higher figures and reported the 26thhighest rate of absence within the NHS.
Winter pressures are evident across the NHS and are to be expected but the Trust experiences a greater rise in December and January than most Trusts. Particular care for staff wellbeing and monitoring of absences should be taken during this period.
0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00%
Average sickness absence
A v er age abs enc e repor ted i n per iod
North West Comparators by average absence
North West Ambulance Service NHS Trust
Greater Manchester West Mental Health NHS Foundation Trust Calderstones Partnership NHS Foundation Trust
Manchester Mental Health and Social Care Trust
Liverpool Community Health NHS Trust
5 Boroughs Partnership NHS Foundation Trust
Pennine Care NHS Foundation Trust
North-West Average
Warrington and Halton Hospitals NHS Foundation Trust
St Helens and Knowsley Hospitals NHS Trust
Christie NHS Foundation Trust
The above chart compares the mean sickness absence for various comparative Trusts in the north-west. While 5 Boroughs is above the north-west average it has reported lower absence figures than other mental health Trusts in the region. NWAS and Christie have been included as the highest and lowest reported figures for the north-west.
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Appendix B
Analytical review (Cont.)
This graph shows the total FTE days lost in each month before October 2014 organised by the month of the first date of absence. This shows a marked increase in absence rates in April. The Trust should be alert to this trend in terms of staffing but should also monitor the causes of those absences to identify whether any of these absences could be avoided by monitoring, or planning.
Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14
0 100 200 300 400 500 600 Causes of sickness absence
This graph shows the causes of absence within the Trust in the 2013-14 financial year. As shown, gastrointestinal issues have the greatest impact on the workforce with anxiety, stress, depression and other psychiatric issues as the second greatest cause of absence. This absence profile is largely typical across NHS institutions and is to be expected. Monitoring these trends on a rolling basis will generate valuable management information. This will enable the Trust to direct support towards departments suffering elevated levels of stress or to identify opportunities to improve the welfare and wellbeing of staff.
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