Report from the expert group that has considered measures to reduce sick leave

English version of Chapter 2 – Summary in the report. 

See also: Press release: Expert group suggests additional measures to reduce sick leave

 

Chapter 2 - Summary

 

2.1 Summary of framework and perspectives

Both employers and employees agree that sick leave in Norway is too high. Total sick leave in the third quarter of 2009 amounted to 7.7 per cent, which is about the same level as in the third quarter of 2001 when the tripartite agreement on a more inclusive working life (the IA agreement) was signed. Although many good things can be said about the IA cooperation, it has not resulted in a 20 per cent reduction in sick leave from the 2001 level. Furthermore, we have seen an increase in disability pensions among young people, particularly for mental illnesses. On the positive side, the average retirement age has risen by about a half year since 2001.

Does having an inclusive working life automatically entail such a high sick leave rate? Many would say that there is an inherent conflict of objectives between an inclusive working life (high employment) and low sick leave. Even though a high percentage of our workforce is employed, particularly among women and older people, this alone does not explain the high sick leave rate. Approximately the same percentage of women participate in the labour force in Sweden, but the sick leave rate is lower. Several countries have approximately the same general employment figures as Norway, but lower sick leave. Nor have the percentages of women and older people in the workforce increased so much over the last 10-15 years that this could explain the rising sick leave trend. While a number of factors influence this trend, we see that Norwegian municipalities with high employment have lower sick leave rates than municipalities with low employment. Therefore, we believe that Norway can reduce sick leave without making working life less inclusive, as long as we apply the correct measures.

There are many differing opinions on the possible causes of the variations in sick leave over the last 15 years. It is difficult to discern general public health causes of the changes in sick leave. We are heavier, we drink more and we are less physically active, but we also live longer. While some people do have to wait for treatment in Norway today, the quality and volume of patient treatments has never been higher. Somewhat higher numbers of women and older people in the workforce can only explain a small portion of the change in sick leave in recent years. Although we cannot rule out the possibility that greater work demands and pressure to change during the period leads to expulsion, regular surveys provide no clear basis for saying that working life has become more “brutal”.

The vast majority of countries pay less than 100 per cent wages during sick leave, and the OECD points out that the high level of sick leave and disability pension in Norway is a result of generous benefits along with a gatekeeper function that is not sufficiently effective. The expert group believes that there is no doubt that a reduction in pay during sick leave will reduce overall sick leave. However, there is also no doubt that a significant reduction in sick leave can also be achieved through other measures. It is also important to be aware of the potential social consequences associated with reduced wage compensation during sickness.

There are a number of myths linked to sick leave: ” You have to be 100 per cent healthy to work.” ”Working while sick is hazardous to your health.” ”It’s always good for the sick person to be on doctor-certified sick leave.” ”You shouldn’t start to work again until the doctor says it’s OK.”

Many people think that you have to go on doctor-certified sick leave if you become ill. However, for most people in the working population, there is no definitive line between healthy and sick, in practice. Medical examinations of working people often reveal similar diagnoses and health ailments as among people on sick leave, but people on sick leave normally have more ailments. Moreover, the health problems that are common in connection with sick leave are often long-lasting, and the diagnoses and ailments are often evident both before and after the doctor-certified sick leave. Therefore, it can be difficult to standardise the duration of sick leave for these types of ailments.

The most common sick leave diagnoses are associated with muscular-skeletal pain and minor psychological ailments. Whether or not the employee requests doctor-certified sick leave for such ailments depends on a number of personal, family-related and job-related factors. The regular GP issues most doctor-certified sick leaves and surveys indicate that doctors rarely turn down patients’ requests for sick leave. There is, however, considerable variation between sick leave-certifiers as regards the length of the sick leave and use of graduated (partial) sick leave.

Sick leave that is too high is unfortunate in at least three ways:

1. The person on sick leave: Activity through work (partial sick leave or no sick leave) has a therapeutic effect on many health problems (such as back pain or some types of minor mental ailments). Long-term sick leave also increases the risk of permanent expulsion from working life, and reduces future income, even if the person eventually returns to work.

2. The society ties up funds that could be used for other good purposes. High sick leave rates also increase social differences.

3. Enterprises incur both direct and indirect costs.

Measures designed to promote increased use of graduated (partial) sick leave were introduced in 2004, along with the obligation to consider activity after eight weeks. Use of active sick leave was simultaneously reduced. These measures contributed to a sharp (more than 20 per cent) decrease in sick leave. The expert group believes that a pronounced shift from full to partial sick leave is expedient based on four different considerations:

1. For the dominant health problems experienced by people on sick leave, activity is usually more rehabilitating and promotes better health than passivity. Most people can achieve better health by continuing to work part-time (or full-time).

2. Continued contact with the workplace, with utilisation of the person’s remaining ability to work, helps prevent permanent expulsion from the workplace, and thus promotes one of the other purposes of the IA agreement.

3. Early focus on the right and obligation to utilise the individual’s ability to work can contribute to uncovering potential working environment problems in the workplace, as well as promote inclusion and force necessary improvements and organisation needs in a timely manner.

4. A requirement for utilising the person’s remaining ability to work will offset excessive use of sick pay, and thus reinforce the legitimacy of the sick pay scheme.

The expert group believes that the sum of the measures introduced in 2004 contributed to a marked decline in sick leave. At the same time, it must be said that the intentions of the measures have only partly been followed up in practice. In spite of an attempt to make activity the main rule and increase the use of partial sick leave, only a minority of doctor-certified sick leave is graduated (partial). The expert group believes that the objective should be for partial sick leave to be more common than full sick leave for all doctor-certified sick leave, and that partial sick leave should consistently dominate all sick leave in excess of eight weeks.

The expert group believes that a reduction in both short-term and long-term sick leave is desirable. The high rate of long-term sick leave is most serious, as it can lead to expulsion from the job market.

2.2 Summary of the expert group’s proposed administrative measures

The expert group hereby submits proposed measures that we believe will contribute to a significant reduction in sick leave, without increasing expulsion from the job market. These measures can be divided into six main groups:

2.2.1 Active participation and return-to-work reform

The expert group proposes initiating an active participation and return-to-work reform with the aim of ensuring that graduated (partial) sick leave becomes the main rule for sick leave; furthermore, that 100 per cent sick leave should only be used in exceptional cases in connection with absence in excess of eight weeks.

Under this item, the expert group proposes a merger and acceleration of the checkpoints during sick leave follow-up, tighter requirements for graduated sick leave after eight weeks, in combination with a change in the rules for employer financing during the sick pay period. The group also proposes that the rules regarding employers’ duty to facilitate work and the employees’ duty to cooperate are made clearer/more stringent, as well as improved follow-up through inspections and sanctions.

The group proposes simplification and clarification of the checkpoints in the course of a sick leave period:

1. The first 10 days: It is proposed that the employer-financed sick leave period is shortened to 10 days, while simultaneously increasing the number of self-certification days from 3 to 10. The number of self-certification days is made equal to the number of days in the employer period, and it is emphasised that, during this phase, follow-up of sick leave shall be a matter between the employer and the employee. The group proposes that the total framework for self-certification days be increased to 24 days during the course of a 12-month period, as is currently the case under the IA agreement.

2. From the end of the self-certification period (11^th day) to 8 weeks: After the end of the self-certification period, a doctor’s certification is required with an explicit evaluation of the ability to work and the degree of sick leave. The National Insurance will cover the sick pay up to 100 per cent compensation, up to 6 G (G = basic amount in the National Insurance scheme) in this period. Insofar as possible, the sick leave shall be graduated (partial), unless participating at the workplace poses harm to the employee’s own health, or the health of others. In consultation with the employee, the employer shall draw up a follow-up plan within four weeks, at the latest. Within eight weeks (at the latest), a dialogue meeting shall be held on the initiative of the employer, wherein this follow-up plan is the main topic.

3. From and including 8 weeks: As a main rule, sick leave must be graduated after 8 weeks, even if this requires extensive facilitation on the part of the employer and entails significant changes in the employee’s tasks. In order to provide a clear incentive towards the use of graduated sick leave, the National Insurance reimbursement of sick pay is limited to maximum 80 per cent after eight weeks of sick leave. This means introducing a 20 per cent share for employers in those cases where graduated sick leave cannot be implemented. As a basis for approving sick leave longer than 8 weeks, a satisfactory follow-up plan and initial dialogue meeting (dialogue meeting 1) shall be implemented as a general rule, including an indication of when a need for a dialogue meeting with NAV (the Norwegian Labour and Welfare Service) is expected (dialogue meeting 2). NAV is responsible for conducting dialogue meeting 2 after 16‐20 weeks and, if applicable, a third dialogue meeting at the end of the sick pay period. NAV will assess whether the employer has fulfilled its facilitation duty and whether there is a need to implement employment rehabilitation or other measures. The employer, employee and sick leave-certifier/doctor can take the initiative for dialogue meeting 2 at an earlier point in time.

The proposal of assigning employers a partial responsibility for 100 per cent sick leave after eight weeks, combined with a reduced employers’ period from 16 to 10 days, is motivated by a desire to give employers stronger incentives to prevent long-term sick leave and expulsion, while at the same time keeping employer-financing at approximately the same level.

This is a new scheme which gives both employers and employees greater accountability early in the sick leave period, which entails that the principle in preliminary sick leave is expanded to apply to all sick leave in the employer period, except in those cases where the employee’s right to use self-certification has been curtailed.

The current protective schemes for smaller enterprises and long-term or chronic sickness will be continued so that they apply for the entire period during which the employer is responsible for co-financing.

2.2.2 Knowledge-based measures for reduced sick leave

Today, a number of measures are implemented under the direction of the health service, NAV and the employer with the objective of preventing sick leave and helping employees on sick leave return to work. The effect of these measures is largely undocumented and may, to some extent, be counter-productive. For example, in many cases, people with muscular and skeletal ailments are still often advised to rest, not be active and to stay away from work, although we now know that following such advice could have a negative effect on the sick person’s prognosis.

It is the opinion of the expert group that there is a need to both sum up and communicate knowledge about measures that make an effective contribution to returning to work and ensuring implementation of measures with such a documented effect. Measures that have been documented to be ineffective or harmful must be discontinued. There is also a need for more knowledge-based documentation of the effect of various measures designed to prevent and reduce sick leave. Within the health and rehabilitation sector, the expert group proposes that the requirements for documented effect must be enhanced. The knowledge area must be reinforced, both in terms of expertise and organisation.

2.2.3 Expertise boost

To reinforce and promote the proposed active participation and return-to-work reform, a number of measures must be initiated to improve the various players’ expertise surrounding sick leave work. A consensus must be built around the health and social benefits of maintaining contact with the workplace, in spite of sickness or health ailments.

We recommend establishing expert guidelines for sick leave-certifiers, focusing on the use of graduated (partial) sick leave as a policy instrument, with the objective of promoting work ability and health. We also recommend preparing guidelines for working life with focus on facilitation and activity. We recommend strengthening the cooperation between NAV and the sick leave-certifiers, such as regular feedback regarding their own sick leave certification practices, including focus on the use of partial sick leave compared with other relevant doctors/sick leave-certifiers. Furthermore, we recommend a mandatory course for sick leave-certifiers.

2.2.4 Sick leave in connection with termination of employment and lay-offs

The expert group assumes that the purpose of sick pay is to provide compensation for loss of employment income caused by diminished function due to sickness or injury.

The sick pay scheme is not intended to compensate for loss of income due to unemployment or lay-offs. The expert group will recommend further study into how and what type of legislative changes must be made to avoid sick pay being used to compensate for loss of income that is not due to sickness or injury

2.2.5 Reinforcing NAV’s control and recovery activity

The legitimacy of our welfare schemes depends on ensuring that our joint resources go to those who are entitled to benefits. The National Insurance scheme is largely based on trust. To maintain confidence in the system, it is essential that those who abuse it and deliberately receive public funds to which they are not entitled, are exposed. Sick pay fraud causes considerable losses for the public purse every year. The expert group recommends a substantial reinforcement of NAV’s control and recovery activity.

2.2.6 Information strategy

Implementation of the expert group’s proposals should be supported by a well-planned and comprehensive information strategy over several years. The purpose must be to gain acceptance of the basic principle behind the proposed active participation and return-to-work reform.

2.3 Implementation

The expert group emphasises that effective implementation of the proposed measures demands a high level of priority at the policy level, in public administration and on the part of other players, over several years. It is also essential that NAV, as the dominant public player, is able to fill its roles in dispensing support, advice, follow-up and control. Not least, it is a precondition that NAV can quickly put into place an ICT system that can efficiently support both the follow-up process and communication with the other players.