Continuing at work
Edited by Mehtap Akgüç
Continuing at work
Long-term illness,
return to work schemes and
the role of industrial relations
Edited by
Mehtap Akgüç
Continuing at work
Long-term illness, return to work schemes and the role of industrial relations
Continuing at work
Long-term illness,
return to work schemes and
the role of industrial relations
Edited by
Mehtap Akgüç
European Trade Union Institute (ETUI)
ETUI publications are published to elicit comment and to encourage debate. The views expressed are those
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Brussels, 2021
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D/2021/10.574/21
ISBN: 978-2-87452-608-4 (print version)
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5Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Contents
Mehtap Akgüç (with contributions by Ziv Amir and Paula Franklin)
Introduction
Returning to work aer chronic illness: elevating the role of the social partners ............................ 7
Mehtap Akgüç and Leonie Westho (with contributions by Nina Lopez Uroz)
Chapter 1
The EU-level policy framework and stakeholder perspectives on returning
to work aer chronic illness ................................................................................................................................... 21
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westho
Chapter 2
Shaping an evolving framework on return to work: the role of the social partners
in Belgium ...................................................................................................................................................................... 39
Marti Taru and Triin Roosalu
Chapter 3
Why do individualised industrial relations mean the underutilisation of policy tools?
Workers who fall ill in Estonia ............................................................................................................................... 59
Margaret Heernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Chapter 4
In search of a coordinated national framework: opportunities and challenges
for returning to work aer chronic illness in Ireland ................................................................................... 77
Ilaria Armaroli, Maria Sole Ferrieri Caputi and Lorenzo Maria Pelusi
Chapter 5
Over-expectation and underprovision: overcoming the voluntarist and irregular
approach of Italian social partners to the return to work ......................................................................... 99
Adela Elena Popa, Felicia Morândău, Radu-Ioan Popa and Mihai Stelian Rusu
Chapter 6
Missing a framework for returning to work: the role of the social partners in Romania .......... 121
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations6
Barbora Holubová, Marta Kahancová, Mária Sedláková and Adam Šumichrast
Chapter 7
Return to work practice in Slovakia: matching best practice with the scope
of social partner activity ....................................................................................................................................... 143
Mehtap Akgüç
Conclusions
Return to work aer chronic illness and the way ahead ........................................................................ 163
List of abbreviations ................................................................................................................................................ 171
List of contributors ................................................................................................................................................... 173
Acknowledgements .................................................................................................................................................. 177
7Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Introduction
Returning to work after chronic illness:
elevating the role of the social partners
Mehtap Akgüç
With contributions by Ziv Amir and Paula Franklin
1. Context
Demographic change, including ageing and longevity, together with the transforming
world of labour, have implications for the proper functioning of labour markets across
European countries. According to recent estimates, one-third of the population in
Europe is expected to be aged 65 or older by 2070 (compared to one-fth in 2019),
while life expectancy is expected to increase to 86 for men and 90 for women by the
same date.
1
As the population gets older and working lives increase, it may be expected
that a growing number of workers will face health conditions that might lead to their
absence from work or to them working on while ill (EU-OSHA 2016).
In the meantime, demographic change is likely to create societal challenges such as a
shrinking workforce or the sustainability of social security systems, calling for policy
action to sustain economic growth while ensuring inclusive and prosperous European
economies. Some policy measures include extending working lives via increases
in the retirement age, or active ageing, as well as promoting the return to work and
the reintegration and retention of individuals who have been absent from work due
to chronic health conditions or disability. Other workplace support and adjustment
measures, alongside underlying legislation, are preconditions for facilitating the
reintegration of individuals with chronic illnesses (or disabilities) into the labour
market (Amir et al. 2010). It is this notion of the return to work that is at the core of
this book.
In relation to this, Principle 17 of the European Pillar of Social Rights specically states
that ‘people with disabilities have the right to income support that ensures living in
dignity, services that enable them to participate in the labour market and in society,
and a work environment adapted to their needs.
2
While the Pillar refers to disabled
people, the dividing line between chronic illnesses and disability is blurred and long-
term sickness absence is often a precursor of disability (OECD 2010). In either case, the
extent to which policies are implemented or relevant services put in place to facilitate
the return to work, or reintegrate workers with chronic diseases or disabilities which
limit their abilities to perform their work, is an open question.
1. For more detail, see the dedicated website on the impact of demographic change in Europe:
https://ec.europa.eu/info/strategy/priorities-2019-2024/new-push-european-democracy/impact-
demographic-change-europe_en
2. https://ec.europa.eu/info/sites/info/les/social-summit-european-pillar-social-rights-booklet_en.pdf
Mehtap Akgüç
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations8
Meanwhile industrial relations structures and actors, representing the interests of
workers and employers, constitute key components of labour markets contributing to
their smooth functioning and improving the working environment. Since industrial
actors aim to strike a balance between the needs of employers and workers, the
involvement of the social partners in tackling the implications of demographic change
in the workplace and dealing with the return to work calls for in-depth investigation.
In this context, this book brings together two strands of research, one on the return
to work and the other on industrial relations, with the objective of developing our
expertise on the role which industrial relations structures and actors play at EU level
and in member states in addressing and facilitating the return to work and retaining
workers experiencing chronic illness in the workplace.
1.1 Chronic diseases and illness
Centers for Disease Control and Prevention, a US agency, denes chronic diseases
broadly as ‘conditions that last one year or more and require ongoing medical attention
or limit activities of daily living or both.’
3
Chronic diseases are the leading causes of
death and disability worldwide and are understood as those of long duration (with
or without a cure) and slow progression. Prominent examples include cardiovascular
diseases, cancer, diabetes, musculoskeletal diseases and mental illnesses. The World
Health Organization states that most chronic diseases are linked by common biological
risk factors – notably high blood pressure, high blood cholesterol and obesity – and are
preventable with policies that address the determinants of the related behavioural risk
factors (e.g. unhealthy diet, physical inactivity and tobacco use).
4
Such diseases imply
a signicant burden on the health and well-being of the workforce; constitute the main
cause of mortality and morbidity in the EU (Guazzi et al. 2014); and have considerable
economic consequences for individuals, such as lower pay or rates of labour force
participation (Busse et al. 2010), and for national economies through reduced labour
supply and outputs (e.g. absenteeism), lower tax revenues and lower returns on human
capital investments.
5
Eurofound (2019) states that over a quarter of the working population of the EU reports
living with a chronic disease and that the prevalence of chronic diseases has increased
over the last few years for all age groups but particularly for older individuals. Research
has indeed shown that older workers are more prone to develop chronic diseases; for
example, Eurofound (2019) reports that workers over the age of 50 are more than twice
as likely to have a chronic disease compared to workers below the age of 35.
Mental health issues related to various psychosocial factors such as stress and/or
anxiety, musculoskeletal disorders, cancers, cardiovascular diseases, respiratory
3. www.cdc.gov https://bit.ly/3qRsH46
4. https://www.who.int/chp/chronic_disease_report/media/Factsheet1.pdf
5. https://ec.europa.eu/jrc/en/health-knowledge-gateway/societal-impacts/costs
Introduction – Returning to work after chronic illness: elevating the role of the social partners
9Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
problems and diabetes have been among the most prevalent chronic diseases in
Europe (European Commission 2017). While work-related cardiovascular diseases are
responsible for nearly one-quarter of deaths globally (Takala et al. 2014), the impact of
musculoskeletal disorders on work is also considerable as they decrease productivity
and increase sickness absence (EU-OSHA 2007), causing almost half of all absences
from work lasting three days or longer in the EU as well as 60 per cent of permanent
work incapacity (Bevan et al. 2013). It may be hard to identify the main cause of chronic
diseases, as a number of factors such as work environment, genetic predisposition
or other individual factors could be jointly at play; however, in some cases, chronic
diseases could be made worse because of work.
Health and disease intersect with gender; in the EU, while men have lower life
expectancies than women, women more often report ‘bad’ or ‘very bad’ general health
and have higher rates of chronic disease (Franklin et al. 2021). Women and men also
dier in terms of the diseases they are more likely to develop; for example, diabetes and
smoking have a greater weight as risk factors in men than in women. Obesity rates are
slightly higher in men than in women, but women are disproportionately aected by
obesity-related cancers (Franklin et al. 2021).
Furthermore, occupational health data show that women in Europe report more
occupationally-related diseases than men (Casse and De Troyer 2021). The issue of
musculoskeletal disorders is notably more likely to aect women. This is linked to the
kind of workplace roles that women occupy which exposes them to risks regarding
biomechanical stress (e.g. repetitive work, lifting people) but also to them having very
little room for manoeuvre and autonomy in their work; that they experience physical
burdens in both their professional and (non-paid) domestic work; and that their
physiology makes them more susceptible to developing certain pathologies (carpal
tunnel syndrome, for example). They are also often exposed to psychosocial risks,
notably in the personal assistance, care and service professions (Casse and De Troyer
2021).
1.2 Chronic diseases and Covid-19
There are several linkages between chronic disease and Covid-19. First, research has so
far shown that having a chronic disease increases the likelihood of experiencing more
severe consequences of Covid-19 (e.g. hospitalisation, a stay in an intensive care unit
or even death).
6
Second, the recent pandemic appears to have played a negative role in
preventive medicine, impeding the advanced detection of chronic diseases that would
have been monitored or diagnosed early in normal times. For example, lockdown
restrictions and the strain put on health systems due to Covid-19 have implied that
cancer care services have been severely disrupted across Europe (and globally),
signicantly delaying early diagnosis and treatment, and having a direct impact on
6. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medicaal-conditions.html
Mehtap Akgüç
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations10
the chances of the cure or survival of many cancer patients.
7
According to the Belgian
Cancer Registry, an estimated 5 000 expected new cancer diagnoses were not made
due to the Covid-19 pandemic during 2020;
8
this is most likely a result of the decreased
availability of medical sta for care services in hospitals other than for Covid-19.
Moreover, lockdowns have proved particularly challenging for mental health, with
concerns expressed by medical professionals from across Europe about the impact of
extended isolation and lack of social contact. This is exacerbated by rising nancial
insecurity and poverty – which is likely to have a disproportionate impact on women
given that, on average, women have lower incomes and are more often in precarious
employment (Bambra et al. 2021). The mental health impacts are also likely to be
stronger for women as school closures have led to increased childcare pressures. This
is particularly challenging for people who already have mental ill-health and given
that women are more likely to suer from anxiety and depression; it is possible that
women’s psychological well-being has suered excessively as a result of lockdown
(Bambra et al. 2021).
The Covid-19 pandemic is an evolving situation, but it is becoming evident that the
new disease can have long-lasting health impacts. Current estimates are that 5-10 per
cent of people who get Covid-19 will develop so-called ‘Long Covid’, in which the signs
and symptoms continue for more than 12 weeks.
9
Long Covid is associated with many
dierent symptoms that can uctuate over time ranging from fatigue and headache to
shortness of breath and neurological problems.
Among a sample of over 20 000 study participants who tested positive for Covid-19 in
the UK, 14.7 per cent of women reported symptoms at 12 weeks compared to 12.7 per
cent of men. This was also highest among those aged 25 to 34.
10
A study by Longfonds,
the Dutch Lung Foundation, in conjunction with the universities of Maastricht and
Hasselt found that, six months after infection, nine out of ten people suered from
more than one symptom and less than 5 per cent were symptom-free. The vast majority
of respondents to the study (94 per cent) were not hospitalised because of Covid-19 but
were ‘mild’ cases. These were relatively young patients with an average age of 48. By
far the largest group (86 per cent) said their health was good before the virus infection
and 61 per cent had no underlying condition.
11
We also know that over half of those
who experience symptoms for more than six months go on to have memory decits
in month seven and new diagnoses may also be developed including diabetes, heart
disease and liver disease.
12
7. https://www.euro.who.int/en/media-centre/sections/statements/2021/statement-catastrophic-impact-of-
covid-19-on-cancer-care
8. https://kankerregister.org/Publications
9. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/le/962830/
s1079-ons-update-on-long-covid-prevalence-estimate.pdf
10. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/
bulletins/evalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/1april2021
11. https://coronalongplein.nl/informatie/zorg-en-onderzoek/six-months-after-infection-almost-all-patients-
study-group-still-have-symptoms
12. https://www.independentsage.org/wp-content/uploads/2021/01/Long-COVID_FINAL.pdf
Introduction – Returning to work after chronic illness: elevating the role of the social partners
11Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
2. The concept of the return to work
The International Social Security Association (ISSA 2013) denes the return to
work as ‘a concept encompassing all procedures and initiatives intended to facilitate
the workplace integration of persons who experience a reduction in work capacity
or capability, whether this is due to invalidity, illness or ageing.’ The World Health
Organization denes rehabilitation as the process of ‘recovering optimal physical,
sensory, intellectual, psychological and social functional levels’ and it consists of
medical, vocational and social aspects (EU-OSHA 2016). All in all, the return to work
is considered to be ‘a complex process, unfolding in time, with many stakeholders and
factors shaping it’ (Akgüç et al. 2019b).
With the increasing age of retirement, many workers are likely to experience longer
working lives but also to face an increased probability of falling ill during their career.
A part of these workers will succeed in returning to work after the proper management
of their disease and recovery. Resuming work can result in signicant economic and
social benets in addition to personal benets as the worker might feel valued or less
isolated after returning to work. However the process of returning is also complex,
involving many actors, and it could be marked by multiple challenges ranging from
limited access to (or lack of) a workplace and workload adjustments to interactions with
colleagues after disease and the risk of stigmatisation or discrimination as a result of it.
For instance, evidence suggests that 55 per cent of people with mental health problems
make unsuccessful attempts to return to work and, of those who return, 68 per cent
have less responsibility, work fewer hours and are paid less than before.
13
Therefore, a relevant policy framework for returning to work and a successful
implementation of this at establishment level are vital in assuring the occupational
reintegration of workers after or with chronic illness. It is also important that the
strategies, polices and actions are gender-sensitive because of the gender dierences
in the prevalence of chronic diseases and implied precariousness.
2.1 Return to work in the Covid-19 context
Some guidance is starting to be issued on the return to work for workers recovering
from Covid-19, for example for health and safety professionals
14
and, in respect of Long
Covid, for healthcare professionals.
15
The importance of developing rehabilitation
services has also been acknowledged.
16
It is clear that occupational health and safety
protection in respect of the return to work will (and should) be further developed as
part of the pandemic response. Here, an analysis of prolonged Covid-19 symptoms
in a survey by a patient-led research team found that one of the reasons for people
13. https://ec.europa.eu/health/sites/health/les/mental_health/docs/compass_2017workplace_en.pdf
14. https://www.som.org.uk/COVID-19_return_to_work_guide_for_recovering_workers.pdf
15. https://www.fom.ac.uk/wp-content/uploads/longCOVID_guidance_03_small.pdf
16. https://www.sll.se/verksamhet/halsa-och-vard/nyheter-halsa-och-vard/2021/03/sa-ska-patienter-med-post-
covid-fa-vard/
Mehtap Akgüç
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations12
not sharing their personal stories was the fear of being stigmatised, especially in the
workplace, linking the issue directly to equal opportunities and discrimination.
17
All in all, the impact of Covid-19 on the return to work operates in countervailing ways.
On the one hand, the pandemic-related expansion of telework and the exibility that
this entails might oer new possibilities for returning to work for workers experiencing
particular chronic diseases. On the other hand, as individuals with chronic disease
are more prone to suer from Covid-19 severely, and might even experience long-term
scars as a result of it (e.g. Long Covid), returning to work might be more compromised
than it otherwise would have been had the pandemic not occurred. Therefore, issues
around employment and occupational rehabilitation are of great importance for people
aected by Covid-19. Evidence derived from the current study might be relevant for
this new population.
2.2 Industrial relations systems and their role in the return to work
European social dialogue is host to dierent industrial relations systems with dierent
traditions across member states, each of which might have dierent priorities and
mechanisms that can enable (or not) the ecient application and creation of new
policies, including those on returning to work. According to Bechter et al. (2012), we
can distinguish between the following industrial relations systems in the EU: Nordic
organised corporatism (Denmark, Finland, Sweden); western liberal pluralism
(Cyprus, Ireland, Malta); southern state-centred industrial relations (France, Greece,
Italy, Portugal, Spain); central-western social partnership (Austria, Belgium, Germany,
Luxembourg, the Netherlands, Slovenia); and a mixed central-eastern European
system (Bulgaria, Croatia, Czechia, Estonia, Hungary, Latvia, Lithuania, Poland,
Romania, Slovakia).
18
While deviations possibly exist, industrial relations arrangements in most European
countries have historically relied on at least one of four institutional pillars:
(i) strong or reasonably established social partners;
(ii) negotiated wage setting via sectoral or higher-level collective bargaining;
(iii) a fairly generalised arrangement of information, consultation and co-determination
at company level;
(iv) institutionalised practice of tripartite policy-making and involvement of the
social partners in tripartite policy arrangements (Akgüç et al. 2019a; European
Commission 2009; Streeck 1992; Visser 2006).
These pillars remain relevant in the context of return to work and related policy
implementation.
17. https://patientresearchcovid19.com/research/report-1/
18. We note that the countries of central and eastern Europe actually have diverse industrial relations systems
within their group and that there could be at least two sub-groups: those with an embedded neoliberal system
(Croatia, Czechia, Hungary, Poland and Slovakia); and those with a neoliberal system (Bulgaria, Estonia, Latvia,
Lithuania, Romania). For more detail see Akgüç et al. (2019b).
Introduction – Returning to work after chronic illness: elevating the role of the social partners
13Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Against this background, Scharpf’s `actor-centred institutionalism’ is taken as the
underlying framework underpinning this study of how industrial relations actors
facilitate the return to work at EU and national levels across countries. In this
framework, ‘social phenomena can be explained as the outcomes of interactions among
actors, acknowledging that such interactions are structured and that outcomes are
shaped by the characteristics of the institutional setting in which they occur’ (Scharpf
1997; Akgüç et al. 2019b).
As a result, this book adopts an actor-oriented perspective in which the perceptions
and experiences of industrial relations actors, as well as their interactions with other
relevant stakeholders in given institutional settings, industrial relations systems and
return to work policy contexts, are placed at the core of the analysis.
3. Research questions and methodology
The key research questions which the book aims to address revolve around the
approaches of dierent industrial relations stakeholders to return to work policies in
practice and their implementation at supranational (EU), national and company level
across dierent industrial relations systems in Europe. So far little is known about how
representatives of governments, employers and employees approach the issue of the
return to work within the framework of industrial relations and how these stakeholders
support workers in work retention and labour market reintegration following chronic
illness.
While the focus is on the roles of trade unions and employer associations in the return
to work process and policy-making across Europe, the role of additional stakeholders
such as NGOs, campaigning and patient support organisations or occupational doctors
are also investigated to evaluate the emerging opportunities to negotiate or improve the
implementation of return to work policies across dierent industrial relations systems
and national legislative and policy frameworks.
After an overview of existing national policies and relevant legislation on the return
to work, the book addresses the issues at a more granular level, looking at company-
level interactions between employer and employee representatives to see whether
these support individuals through information, consultation or co-determination
of the processes under which they return to work. Specically, the perspectives and
experiences of company-level stakeholders are investigated to evaluate their role in
dealing with the implementation of the return to work at establishment level.
The company-level analysis is complemented with an analysis of the perspectives of
workers facing chronic health conditions and undergoing returns to work (or who
are likely to undergo a return to work after the diagnosis of a chronic condition) to
shed light on how they perceive the relevance or role of the industrial relations actors,
especially trade unions, in supporting and accompanying them during the return to
work process and in helping to prevent the risk of marginalisation, discrimination and
the threat of poverty.
Mehtap Akgüç
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations14
3.1 Scope of the analysis
A recent EU-OSHA report (2016) provides a comprehensive assessment and overview
of return to work policies across European countries, categorising them into four
groups based on dierent approaches:
(i) Group 1 – comprehensive approach: in this group, countries usually have a
developed framework on the return to work, oriented towards inclusiveness, with
features such as emphasis on early intervention as well as progressive and planned
returns. Examples include Austria, Denmark, Finland, Germany, the Netherlands,
Norway and Sweden.
(ii) Group 2 – stepwise approach: in this group, countries have a developed
framework for the return to work with emphasis on early intervention but with
limited coordination between stakeholders. Examples include Belgium, France,
Iceland, Italy, Luxembourg, Switzerland and the UK.
(iii) Group 3 – ad hoc approach: in this group, countries are characterised by
a less-developed framework for the return to work with limited (or missing)
coordination between stakeholders and room for ad hoc initiatives implemented by
various actors. Examples include Bulgaria, Estonia, Hungary, Ireland, Lithuania,
Portugal, Romania and Spain.
(iv) Group 4 – limited approach: in this group, countries generally oer
rehabilitation only for people with disability status, with no formalised or planned
measures to facilitate the return to work for individuals with specic chronic
diseases. Examples include Czechia, Greece, Croatia, Cyprus, Latvia, Malta,
Poland, Slovenia and Slovakia.
This book provides an in-depth analysis of six countries – Belgium, Estonia, Ireland,
Italy, Romania and Slovakia. While the selection of countries reects diverse approaches
to the return to work and dierent systems of industrial relations, they are not always
representative of dominant policies in Europe. Countries have diering rates of return
to work depending on the legislative tools and practices in place. With this in mind, the
following box provides a brief snapshot of three countries from Groups 1 and 2 above,
which are larger than those covered in the book, to provide a benchmark.
Benchmarking: the return to work experience in France, the Netherlands and the UK
This benchmarking exercise aims to expand the study sample by briefly describing the return to
work experience from three large countries: France, the Netherlands and the UK. These countries
have exercised significant influence on EU-level policies (as for the UK, prior to Brexit) and have
well-developed and comprehensive return to work frameworks. Yet they differ in their industrial
relations systems and particular approaches through which the return to work after chronic illness
is facilitated.
Return to work policies and frameworks are strongly developed, comprehensive and
integrated in all three countries. The Netherlands has the most inclusive policy framework while
eligibility criteria determine workers’ access to return to work policies in France and the UK. The
policies focus on minimising the duration of work absences due to chronic illness. However, the
elements of prevention, early intervention and maintenance of work abilities during sick leave,
Introduction – Returning to work after chronic illness: elevating the role of the social partners
15Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
next to a well-functioning coordination of the roles of various stakeholders, are most prominent in
the Netherlands. In France and the UK, work reintegration is mostly dealt with towards the end of
sick leave, with moderate coordination between the stakeholders involved and between the steps
of the work reintegration process.
Existing coordination mechanisms among the various national stakeholders are the main
factors contributing to the effectiveness of the return to work process in these countries. Neverthe-
less, the role of the social partners differs: while employers are fully integrated into return to work
processes in all three countries, only the Netherlands has achieved a high level of social partner
collaboration, based on definitions of the responsibilities of each stakeholder involved. Compared
to the Netherlands, the UK and France lack an encompassing and coordinated return to work poli-
cy framework. In the UK, the National Health Service mainly focuses on the medical aspects of the
return to work while France’s strategy in the occupational health plan for 2016-2020 introduced
a greater role for social dialogue in supporting health promotion measures. This attempt at sim-
plifying legislation and at connecting health and safety with the quality of working life represents
the first step in France’s transition towards a more comprehensive return to work policy.
Although employers are at the core of the return to work process in all three countries, the
incentives offered to employers within the policy framework are different: only in the Netherlands
are employers offered risk-free insurance for the retention in work of people who have experienced
a chronic illness while such motivation for employers is non-existent in the UK. In France, employers
receive a limited financial incentive to reintegrate workers after chronic illness.
As regards the role of collective bargaining in addressing long-term sickness absence and
return to work, a few differences may be identified in how bargaining is undertaken in the three
countries. Bargaining in the Netherlands and the UK covers a wide range of topics, including those
related to disability. In contrast, in France, bargaining relevant in this context is restricted to pay
issues and occupational health and safety measures within the social and economic committees
which have operated in the workplace since 2018. Nevertheless, collective bargaining and
agreements are significant factors affecting national policies in these countries even though the
return to work and vocational rehabilitation are not always covered by negotiations.
3.2 Methodology and data collection
The methodology used in the chapters is based on a mixed-method approach relying
largely on qualitative tools such as literature reviews and policy analysis. The chapters
also benet from an empirical analysis of primary data collected via three online surveys
distributed to national social partners (targeted at ten social partners per country) across
the EU (25 countries), and to company representatives such as human resources or line
managers (targeted at 60 responses per country) and workers (targeted at 50 responses
per country) in six EU member states.
19
Data collection through interviews and surveys
19. The surveys were distributed in the context of the REWIR project, established to study negotiation of the return
to work in an era of demographic change. This book is, however, entirely separate from the REWIR project and
has been independently developed. Response rates to the REWIR surveys show variance across the individual
surveys and between member states and the samples are non-representative of the overall populations in the
respective countries; the results presented in the following chapters should be read with these limitations in
mind. More detail on the survey results per country as well as the survey questionnaires can be found in various
reports accessed via the following link: https://www.celsi.sk/en/projects/detail/64/
Mehtap Akgüç
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations16
took place between June 2019 and May 2020 with the majority concluded prior to the
outbreak of Covid-19 in Europe which went on to disrupt survey response rates.
In addition to desk research of academic and policy documents, a total of 16 semi-
structured interviews were conducted at EU level with representatives of European-
level social partners and European institutions as well as academics and campaigning
and patient support organisations or other relevant civil society organisations given
their involvement in the issues of return to work and chronic illness. At national level,
54 interviews in total were organised across the six member states with government
representatives and relevant stakeholders including campaigning and patient support
organisations, employment oces, social security authorities, medical practitioners,
academia, NGOs and charities participating in shaping and/or implementing return to
work policies.
Beyond data collection through semi-structured interviews with stakeholders or the
online surveys distributed to various actors, a number of events were organised to
garner further insights and understand the perspectives of the range of actors involved
in return to work processes at national and company levels. These events included
six roundtable discussions with national stakeholders as well as twelve stakeholder
discussion groups with representatives of companies and workers at company level
in the six member states. This process resulted in strong engagement with key
stakeholders (e.g. social partners, company representatives, government ocials and
campaigning and patient support organisations) on issues raised by the return to work
as well as more broadly of the role of occupational health and safety at national and
company levels.
All the information and insights collected during these events and in the various data
collection phases have been consolidated, analysed and fed into the respective country
chapters. All interview information has been anonymised and, in some chapters,
anonymised quotes from interviews are included to help illustrate the analysis.
4. Structure of the book
The rest of the book is divided into three main parts. The rst begins at EU level and
provides an overview of the existing or relevant EU-level policy framework on the return
to work. It then describes the involvement and experience of EU-level stakeholders
from a broader set of industrial relations actors on return to work issues after chronic
disease or with chronic illness.
In the second part, the EU-level framework is followed by country chapters including
national-level analysis which explores not only the national legislative and policy
framework but also goes deeper to look at company-level and worker-level perspectives
in the selected member states. This national-level analysis provides perspectives and
experiences from each of the six member states, each of which has their own specic
legislative settings and policy frameworks for dealing with return to work, summarised
here in turn.
Introduction – Returning to work after chronic illness: elevating the role of the social partners
17Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
In Belgium, the return to work after sick leave has become an important issue on the
political and social agenda since the 2010s as an increasing number of incidences of
absence due to chronic illness have come hand-in-hand with soaring social security
expenditure. As governments have sought to address this issue by means of new
activation policies, the social partners have participated in the design of a new formal
reintegration procedure targeted at employees seeking to return to their former
occupational activity. The social partners have been able to inuence the legislation by
putting forward some key principles and procedures around the role of the occupational
health specialist and of the health and safety committee at company level, but they
remain critical of the eectiveness of the new procedure and the implementation
questions raised by it.
In Estonia, there is good policy provision in support of the return to work but this
lacks implementation. The majority of interventions supporting the return to work
belong to the category of active labour market policies which assist employers as
well as employees directly or by oering relevant know-how. A lack of employer-
level strategies discourages the reporting of illness while low expectations regarding
managerial support make the smallest adjustments seem satisfactory to workers with
chronic diseases, even if it probably comes nowhere near to meeting their needs.
However, there is no complaining: trade unions are weak and have other priorities;
campaigning and patient support organisations are focused on patient rights; and
employer organisations feel their ad hoc solutions are sucient. Building awareness
about access to support measures needs to gain attention.
In Ireland, the main chronic diseases facing workers are musculoskeletal disorders,
cancer and cardiovascular disease. Early intervention, timely and proactive use
of organisational procedures, communication between key stakeholders and
multidisciplinary coordination across government departments and agencies and
at workplace level emerge as the most important factors in managing the return to
work after chronic illness. A key nding in the chapter is that there is no `one size ts
all’ formula for workers’ return to work after chronic illness. However, there is broad
agreement on ending the existing fragmented approaches and creating a national
return to work framework through social dialogue and the introduction of a statutory
sick pay scheme for all workers.
The chapter on Italy sheds light on a fragmented legal and contractual framework
on return to work, with many provisions applying to people with chronic illness only
where they are aected by disabilities and with scant knowledge and interest in the
topic being demonstrated by the social partners amidst their own limited role in policy-
making. Nonetheless, there are a few positive experiences at local and company level
resulting from collaboration between the social partners and other stakeholders, and
these are highlighted.
Despite generous provision regarding sick leave duration and benet, returning to
work after chronic illness is insuciently regulated by law in Romania. Research
indicates that, among the industrial relations actors, it is the state that has the most
substantial role in designing return to work policies: employers and trade unions are
Mehtap Akgüç
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations18
either not active or are not involved in this process to their full potential. The same can
be said about policy implementation as current legislation stipulates a rather minor
formal role for the social partners. Yet the chapter highlights that there is space for
improvement for all industrial relations actors even in the absence of a dedicated and
specic return to work policy.
In the context of economic growth and labour shortages in Slovakia prior to 2020,
the reintegration into work of people after chronic illness has become increasingly
important. Nevertheless there is little evidence of return to work after chronic illness,
especially of workers without formal disability status. This chapter argues that trade
unions and employer organisations do not yet use their full potential in engaging in
return to work policy-making and in the actual facilitation of return to work processes,
but there is interest in closer stakeholder cooperation both at national and workplace
levels.
In the third part, the closing chapter takes stock of EU-level and national experiences
in understanding the role being played by industrial relations actors and relevant
stakeholders dealing with and facilitating returns to work. It provides concluding
remarks and discusses policy options and the way forward.
References
Akgüç M., Martišková M., Szüdi G. and Nordlund C. (2019a) Enhancing the eectiveness of social
dialogue articulation in Europe (EESDA) Project No. VS/2017/0434. Stakeholders’ views on
and experiences with the articulation of social dialogue and its eectiveness, Brussles, Centre
for European Policy Studies.
Akgüç M., Kahancová M. and Popa A. (2019b) Working paper presenting a literature review on
return to work policies and the role that industrial relations play in facilitating return to work
at the EU, national and sub-national levels, REWIR Project No. VS/2019/0075, Bratislava,
Central European Labour Studies Institute. https://celsi.sk/en/projects/detail/64/
Amir Z., Wynn P., Fong C., Strauser D., Whitaker S. and Luker K. (2010) Return to work aer cancer
in the UK: attitudes and experiences of line managers, Journal of Occupational Rehabilitation,
(20), 435-442.
Bambra C., Albani V. and Franklin P. (2021) COVID-19 and the gender health paradox, Scandinavian
Journal of Public Health, 49 (1), 17-26.
Bechter B., Brandl B. and Meardi G. (2012) Sectors or countries? Typologies and levels of analysis
in comparative industrial relations, European Journal of Industrial Relations, 18 (3), 185-202.
Bevan S., Quadrello T. and McGee R. (2013) Reducing temporary work absence through early
intervention: the case of MSDs in the EU, London, The Work Foundation. https://www.bl.uk/
collection-items/reducing-temporary-work-absence-through-early-intervention-the-case-of-
msds-in-the-eu#
Busse R., Blümel M., Schneller-Kreinsen D. and Zentner A. (2010) Tackling chronic disease in
Europe: strategies, interventions and challenges, Observatory Studies Series, Copenhagen,
European Observatory on Health Systems and Policies.
Casse C. and De Troyer M. (eds.) (2021) Gender, working conditions and health, what has
changed?, Report 143, Brussels, ETUI.
Introduction – Returning to work after chronic illness: elevating the role of the social partners
19Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
EU-OSHA (2007) Work-related musculoskeletal disorders: back to work report, Luxembourg, Oce
for Ocial Publications of the European Communities.
EU-OSHA (2016) Rehabilitation and return to work: analysis report on EU and Member States
policies, strategies and programmes, Luxembourg, Publications Oce of the European Union
Eurofound (2019) How to respond to chronic health problems in the workplace?, Luxembourg,
Publications Oce of the European Union.
European Commission (2009) Industrial relations in Europe 2008, Luxembourg, Oce for Ocial
Publications of the European Communities.
European Commission (2017) Communication from the Commission to the European Parliament,
the Council, the European Economic and Social Committee and the Committee of the Regions
-Safer and healthier work for all - Modernisation of the EU occupational safety and health
legislation and policy, COM(2017) 12 final, 10 January 2017.
Franklin P., Bambra C. and Albani V. (2021) Gender equality and health in the EU, Luxembourg,
Publications Oce of the European Union.
Guazzi M., Faggiano P., Mureddu G.F., Faden G., Niebauer J. and Temporelli P.L. (2014) Worksite
health and wellness in the European Union, Progress in Cardiovascular Diseases, 56 (5),
508-514.
ISSA (2013) Guidelines on return to work and reintegration, Geneva, International Social Security
Association.
OECD (2010) Sickness, disability and work: breaking the barrier: a synthesis of findings across
OECD countries, Paris, OECD Publishing.
Scharpf F.W. (1997) Games real actors play: actor-centered institutionalism in policy research,
Boulder, Westview Press.
Streeck W. (1992) National diversity, regime competition and institutional deadlock: problems in
forming a European industrial relations system, Journal of Public Policy, 12 (4), 301-330.
Takala J. et al. (2014) Global estimates of the burden of injury and illness at work in 2012, Journal
of Occupational and Environmental Hygiene, 11 (5), 326-337.
Visser J. (2006) The five pillars of the European social model of labour relations, in Beckert J.
Ebbinghaus B., Hassel A. and Manow P. (eds.) Transformationen des Kapitalismus: Festschri für
Wolfang Streeck zum sechzigsten Geburtstag, Frankfurt am Main, Campus Verlag, 315-335.
All links were checked on 28.05.2021.
21Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Chapter 1
The EU-level policy framework and stakeholder
perspectives on returning to work after chronic illness
Mehtap Akgüç and Leonie Westho
With contributions by Nina Lopez Uroz
1. Introduction
Labour markets have undergone signicant transformation due to demographic
changes such as longevity and declining birth rates. Policies to extend working lives
and promote labour market inclusion are essential for ensuring the sustainability
of European social security systems and the functioning of labour markets. In this
context, measures to facilitate the return to work of individuals after chronic illness are
a key policy instrument. As described in the introductory chapter of this book, chronic
diseases are understood as those of long duration and slow progression, examples of
which include cancer, cardiovascular diseases, diabetes, musculoskeletal disorders
(MSDs) and some mental disorders (Akgüç et al. 2020). These diseases represent
a considerable burden on labour markets and are the main cause of morbidity and
mortality in the EU (Guazzi et al. 2014). For instance, while it can be dicult to isolate
the precise factors behind the disease, cancer has been identied as a primary cause of
work-related deaths in the EU (European Commission 2017).
The prevalence of chronic disease is a signicant issue in Europe. Various studies
have shown that older workers are more prone to develop chronic diseases. According
to EU-OSHA (2016), work-related health problems are more prevalent in older age
groups. Therefore, with the ageing of overall populations and longer working lives, it
is expected that more working age people will have chronic conditions in the years
to come. Indeed, between 2010 and 2018 the proportion of working age individuals
(between 16-64) reporting a longstanding illness or health problem increased from
24.8 per cent to 29.3 per cent across EU-27 countries.
1
The incidence of chronic
morbidity varies across European countries, as illustrated in Figure 1.
The concept of chronic illness is closely related to that of disability where a disabled
person is understood as ‘an individual whose prospects of securing, retaining and
advancing in suitable employment are substantially reduced as a result of a duly
recognised physical or mental impairment.’
2
Long-term sickness absence can often be a
precursor of disability (OECD 2010) and the line between chronic illness and disability
can be blurry. Accordingly the European Court of Justice has made several rulings
suggesting that some chronic diseases may be included in the denition of disability
(Eurofound 2019).
1. Source: Eurostat, hlth_silc_04, extracted on 10 November 2020.
2. https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C159
Mehtap Akgüç and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations22
The prevalence of chronic illness is a signicant challenge to labour market integration.
In EU-27 countries, almost 30 million individuals are limited in the amount of work
they can do due to longstanding health problems or diculties in performing basic
activities.
3
Chronic illness increases the likelihood that an individual will withdraw
from the labour market either temporarily or permanently through disability, long-term
unemployment or early retirement (Eurofound 2019; EU-OSHA 2016). According to the
OECD (2016) ‘the employment rate of people who have one or more chronic conditions,
and particularly people aged 50-59, is much lower than those who do not suer from
any disease.’ In addition to absence from work, chronic illness is also associated with
presenteeism at work; that is, the inability of the worker to function fully due to illness
or other medical conditions. Presenteeism is estimated to cut individual productivity
by one-third or more (Hemp 2004).
Reduced individual productivity and potential loss of employment have negative
consequences at individual and societal levels. For employees with a chronic illness,
work is important as it allows them to be nancially independent, develop social contacts
and contribute to society (Vooijs et al. 2018). As such, the loss of work is associated with
negative nancial and mental health consequences. Moreover, there is a further impact
on caregivers, often women, that may also be forced to drop out of the labour market
to assume caring responsibilities (European Parliament 2018). Negative employment
impacts are particularly relevant for women of pre-retirement age (50-64 years) of
whom only 48 per cent providing long-term care are in employment. Informal caring
duties can also lead to early retirement for older carers, particularly women.
4
3. Source: Eurostat, hlth_dlm150, extracted 16 November 2020.
4. https://eige.europa.eu/publications/gender-equality-index-2019-report/informal-care-older-people-people-
disabilities-and-long-term-care-services
Source: Eurostat, hlth_silc_04, extracted on 10 November 2020. Data for individuals aged 16-64.
Figure 1 Proportion of population suffering from a longstanding illness
or health problem, 2018
0%
10%
20%
30%
40%
Finland
Germany
Estonia
United Kingdom
Norway
Portugal
Switzerland
Austria
Slovenia
France
Iceland
EU27
Sweden
Latvia
Hungary
Poland
Cyprus
Netherlands
Czechia
Denmark
Croatia
Spain
Lithuania
Luxembourg
Slovakia
Malta
Belgium
Ireland
Bulgaria
Greece
Romania
Italy
The EU-level policy framework and stakeholder perspectives on returning to work after chronic illness
23Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Furthermore, the return to work can be a challenging process for businesses,
particularly for micro and small companies with lower worker turnover and diculties
in adjusting workow (European Commission 2017). On a macroeconomic level,
signicant productivity losses may be incurred due to foregone labour force potential.
For instance, recent estimates suggest that, while the direct costs of work-related cancer
in terms of healthcare, sickness and disability benets and productivity losses amount
to €4-7 billion, the indirect costs can reach up to €350 billion annually (European
Commission 2017).
Against this background, this chapter has two key objectives. First, it provides a policy
framework as well as analysis on the return to work after chronic illness at EU level
by overviewing the existing legislative and non-legislative structures and relevant
policy instruments. Second, by analysing primary data collected from key stakeholders
including EU-level social partners as well as representatives of European institutions,
campaigning and patient support organisations and academia, it focuses on the role
of EU-level industrial relations structures and actors in addressing the return to work
after chronic illness.
2. Returning to work after chronic illness in the EU:
existing policy framework and tools
Facilitating a return to work for individuals who have suered from chronic illness
aligns closely with the core principles of the European Union. Article 26 of the Charter
of Fundamental Rights of the EU
5
emphasises the ‘right of persons with disabilities to
benet from measures designed to ensure their independence, social and occupational
integration and participation in the life of the community’. While this does not directly
refer to individuals who experience chronic illness, there can be a signicant overlap
between individuals with certain chronic diseases and those who are disabled.
More recently the European Pillar of Social Rights (2017)
6
stresses the right to equal
opportunity in the workplace, active support in employment and a healthy, safe and
well-adapted working environment.
As there is no specic EU legislation or regulation addressing return to work, and as
most social and employment policies remain a primary competence of member states
due to the subsidiarity principle, the EU does not directly intervene in specic return
to work policies in member states. Nevertheless, the EU can inuence return to work
policy through the establishment of minimum standards in occupational health and
safety, providing guiding principles and serving as a platform for the exchange of best
practice. Moreover, while the EU approach in this context is fragmented, reecting
the diversity of policies and practices across member states, there are two key EU
policy areas that are relevant for addressing the return to work: occupational health
and safety policy; and social inclusion policies with particular reference to equal
5. https://www.europarl.europa.eu/charter/pdf/text_en.pdf
6. For more details on the principles of the European Pillar of Social Rights, see https://ec.europa.eu/info/
strategy/priorities-2019-2024/economy-works-people/jobs-growth-and-investment/european-pillar-social-
rights/european-pillar-social-rights-20-principles_en
Mehtap Akgüç and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations24
opportunities and the treatment of disabled individuals in the labour market (EU-
OSHA 2016; Eurofound 2019). In what follows, we address these policy areas in turn.
2.1 Occupational health and safety policy
Within the eld of employment and social aairs, health and safety at work is one of the
most developed aspects of EU policy. In this context, return to work is a relevant issue.
For instance, the 2007 Community Strategy on Health and Safety at Work envisioned
that national and EU-level policies should aim to create working environments
that enable workers to contribute to their jobs until they reach old age (European
Commission 2007). In particular, the Strategy encouraged member states to develop
measures to support the reintegration and rehabilitation of workers excluded from the
workplace for a long period of time due to accident, occupational illness or disability.
On the legislative side, EU policy action within the realm of occupational health and
safety tends to focus on the prevention of occupational accidents and diseases rather
than the return to work. The Framework Directive 89/391/EEC on the introduction
of measures to encourage improvements in the health and safety of workers at work
and the 23 subsequent individual directives constitute the EU’s occupational health
and safety acquis.
7
This delivers generalised provisions to improve health and safety in
the workplace as well as sector-, worker- and hazard-specic requirements to ensure
protective working environments. A recent evaluation of the acquis concludes that,
while it remains relevant today, it requires modernisation in the face of transformed
labour markets and emerging risks (European Commission 2015). For instance,
recommended measures include stepping up the ght against occupational cancer,
psychosocial risk prevention and assisting businesses, particularly micro and
small enterprises, to comply with occupational health and safety rules (European
Commission 2017).
Overall, occupational health and safety directives relate to the return to work and
integration in that they protect workers against risks and promote measures that
contribute to accident prevention. However, the reintegration of workers after chronic
illness is not specically addressed in EU legislation. As such, the return to work may
also be addressed through non-legislative EU action. In recent EU policy documents,
returning to work after chronic illness is acknowledged as a signicant issue in the
area of occupational health and safety. Specically, the EU Strategic Framework on
Health and Safety 2014-2020 emphasises the importance of adapting workplaces
and work organisation to the needs of ageing workers and identies reintegration and
rehabilitation measures as key to avoiding the permanent labour market exclusion of
workers (European Commission 2014; Eurofound 2019).
Building on the previous framework, the European Commission published the
renewed Strategic Framework on Health and Safety 2021-2027 in June 2021, following
7. For the full list of directives in occupational health and safety, see Table 1-1 in European Commission (2015).
The EU-level policy framework and stakeholder perspectives on returning to work after chronic illness
25Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
stakeholder contributions to the consultation on the Framework.
8
For instance, the
position statement of the European Trade Union Congress (ETUC 2019) highlights the
need to address the situation of workers who return to work after sick leave and calls
for the Framework to promote occupational health services enabling workers with
long-term illnesses to retain employment; encourage the development of an action
plan on returning to work; facilitate analysis of the current state of play in member
states; and establish best practice and concrete tools to enable workers to return to
work. As a result, the Strategic Framework includes guidance on securing health and
safety at work as well as highlights the role of ‘vocational rehabilitation schemes for
people experiencing chronic diseases or people who have been the victim of accidents.’
There is also an emphasis on actively supporting reintegration, non-discrimination
and adaptation of working conditions of workers experiencing cancer.
2.2 Social inclusion and disability policy
In addition to occupational health and safety policy, a further policy eld that is relevant
to the return to work is social inclusion and disability policy. Individuals with chronic
illnesses tend not to be specically targeted by EU legislation but rather included in
policies focusing on the employment of disabled people. Indeed, chronic illness often
leads to limited working capacity as well as potential degrees of disability. Accordingly
the European Court of Justice has, in some cases, ruled that chronic illness can be
included in the denition of disability (Eurofound 2019). However, from this legal
perspective, the denition of disability does not automatically include the concept of
(chronic) illness and legal rulings on this issue diverge (Eurofound 2019). This implies
that the inclusion of workers with chronic illnesses in disability policies is not legally
guaranteed.
Internationally, organisations such as the United Nations (UN), International Labour
Organization (ILO), World Health Organization (WHO) and the Organisation for
Economic Co-operation and Development (OECD) have all worked on the subject
of the return to work in recent decades with the objective of promoting the social
inclusion of disabled individuals (EU-OSHA 2016). The ILO denes a disabled person
as ‘an individual whose prospects of securing, retaining and advancing in suitable
employment are substantially reduced as a result of a duly recognised physical or mental
impairment.’ ILO Convention No. 159 on Vocational Rehabilitation and Employment
(Disabled Persons), adopted in 1983, foresees the inclusion of nancial incentives
for employers to improve and adapt workplaces and work organisation to increase
employment opportunities for disabled individuals (EU-OSHA 2016).
9
In addition, the
UN Convention on the Rights of Persons with Disabilities (UN 2006),
10
to which the EU
has been party since 2011, forms the international framework for the rehabilitation of
disabled people (EU-OSHA 2016) and encompasses general principles of rehabilitation
8. For more information, see: https://ec.europa.eu/info/law/better-regulation/have-your-say/initiatives/12673-
EU-Strategic-Framework-on-Health-and-Safety-at-Work-2021-2027-
9. https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C159
10. https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html
Mehtap Akgüç and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations26
and career protection. Finally, the OECD has produced a number of studies promoting
the participation of disabled individuals in social and economic life (OECD 2003;
OECD 2010). In particular, it provides policy recommendations for member states on
the development of eective return to work strategies for people with disabilities and/
or chronic conditions, emphasising the importance of better coordination between
dierent actors including employers, medical sta, social security agencies and the
social partners (OECD 2010).
Against this international background, the EU has taken legislative action on disability
and inclusion. In particular, it adopted Directive 2000/78/EC
11
establishing a general
framework for equal treatment in employment and occupation (the Employment
Equality Directive), specically covering disability. The directive requires employers
to make ‘reasonable adjustments to accommodate disabled people.’ These are relevant
for workers returning to work after chronic illness, especially where that leads to
disability or impairment resulting in the limitation of work capacity and capability.
However, these provisions do not specically cover workers returning to work after
chronic illness where this does not result in the individual having explicit disability
status (EU-OSHA 2016).
Another relevant piece of EU legislation is the Work-Life Balance Directive
12
that
entered into force in August 2019. While the main focus of this directive is on
improving access to family leave, it also has several elements pertaining to exible
work arrangements that could be relevant for the employment protection of caregivers
of workers experiencing chronic illness.
In addition, the European Commission has been active in the development of strategies
for improving the rights of disabled people. The 2010-2020 Disability Strategy
13
identied eight main areas for action, including employment and health, specifying
that the EU would support national eorts to analyse and improve the labour market
situation of disabled people, reduce the risks that might exacerbate disabilities in
the workplace and support their reintegration into work. An evaluation of the 2010-
2020 Disability Strategy highlighted employment as one of the most important topics
to be addressed in the future (European Commission 2020). In particular, position
papers on the continuation of the disability strategy by the ETUC (ETUC 2020) and by
the European Disability Forum (EDF 2020), as well as a resolution by the European
Parliament (European Parliament 2020), highlight the importance of reintegration
measures and guidelines on reasonable accommodation for the labour market
inclusion and reintegration of disabled people. The European Parliament specically
sought to ensure that the new strategy should address the lack of clarity regarding the
inclusion of chronic illness within the denition of disability and pay attention to the
needs of individuals suering from chronic illness, including targeted measures on
employment activation.
11. https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=celex%3A32000L0078
12. https://data.consilium.europa.eu/doc/document/PE-20-2019-INIT/en/pdf
13. https://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM%3A2010%3A0636%3AFIN%3Aen%3APDF
The EU-level policy framework and stakeholder perspectives on returning to work after chronic illness
27Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
The new Strategy for the Rights of Persons with Disabilities 2021-2030 was published
by the European Commission in March 2021.
14
The Strategy highlights employment
policy as one of the key areas in which action may be taken to improve the rights
of people living with disabilities and emphasises measures promoting reasonable
accommodation in the workplace for disabled people. In particular, it announces a
agship initiative to improve the labour market outcomes of disabled people, to be
presented in 2022. This initiative is set to include guidance and support for member
states in a variety of areas including vocational rehabilitation schemes in the case of
chronic illness or serious accidents. The new disability rights strategy thus represents a
step forward in taking policy action at EU level regarding the return to work. However,
there is relatively little elaboration in terms of how far individuals with chronic illness
are included in the denition of disability and, therefore, whether these policies apply
to them specically.
Focusing more specically on workers with chronic illness, the Committee on
Employment and Social Aairs of the European Parliament published a comprehensive
report in 2018 on pathways for the reintegration of workers recovering from injury
and illness into quality employment (European Parliament 2018). The report calls on
the European Commission and member states to develop guidelines on best practice
and to draw up advice for employers on how to develop reintegration plans, ensuring
dialogue between the social partners and facilitating exchange between member states
and other stakeholders.
In addition, in February 2021, the European Commission released the ‘Europe’s Beating
Cancer’ Plan,
15
a comprehensive action plan against cancer. The plan emphasises issues
that cancer survivors have in returning to work and proposes a variety of actions,
including the promotion of up- and re-skilling programmes for cancer survivors and
the launch of a new study in 2022 focusing on the return to work of cancer survivors.
This initiative represents an example of an initial concrete EU policy action on the topic
of the return to work after chronic illness.
In summary, concrete legislation or other policy action on the return to work after
chronic illness has been comparatively scarce at EU level. Policy areas such as
occupational health and safety and social inclusion and disability are relevant
to the issue of returning to work after chronic illness but policy action remains
underdeveloped. Moreover, chronic illness tends to be addressed within the category of
disability and suers from a lack of specic policy recommendations or the recognition
that such a framework may not be appropriate for all chronic illnesses. Some actions
have been taken to address the issue of returning to work after chronic illness, such as
the ‘Beating Cancer’ Plan, but specic policies on chronic illness that comprehensively
address the issue of the return to work are still lacking.
14. https://ec.europa.eu/commission/presscorner/detail/en/qanda_21_813
15. https://ec.europa.eu/health/sites/health/les/non_communicable_diseases/docs/eu_cancer-plan_en.pdf
Mehtap Akgüç and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations28
3. Returning to work and the EU policy framework: the role
of social dialogue
In order to explore further the EU policy-making process on the return to work, as well
as the potential role of social dialogue in this, 16 semi-structured interviews with EU-
level stakeholders – covering EU social partners as well as European institutions, non-
governmental organisations (NGOs), campaigning and patient support organisations
and academics – were conducted between December 2019 and May 2020.
16
Table 1
summarises the interviewee types.
The diversity of organisations interviewed reects the multidisciplinary characteristic
of the return to work. While not all these actors are part of formal EU social dialogue
channels, they belong to a tripartite plus industrial relations setting and are highly
relevant in the overall return to work context. All actors interviewed closely interact
with policy-makers and have engaged in research, policy or advocacy work in the eld.
In what follows, we rst briey describe the functioning of EU-level social dialogue,
embedding the diverse industrial relations systems operating in it. We then turn to
the various actors involved in EU-level return to work policy and describe their level of
involvement in it. Subsequently, we analyse the nature of the interactions between the
various stakeholders before nally providing some perspectives on forward-looking
actions and future policy options at EU level on the return to work.
3.1 Brief overview of EU-level social dialogue
Social dialogue plays an important role in the European policy-making process. The role
of national collective bargaining systems has been emphasised in terms of improved
labour market performance (among others, OECD 2018). At EU level, bipartite and
tripartite social dialogue has contributed to improved working environments through
the interest representation of workers and businesses over recent decades. In addition
to formal social dialogue platforms, open consultation with stakeholders is key to
16. Interview data was collected before some of the recent policy developments referenced in section 2, particularly
the publication of the recent Disability Rights Strategy and the ‘Beating Cancer’ Plan.
Type of organisation
European social partners (total)
- Trade unions
- Employer organisations
European institutions
NGOs, campaigning and patient support organisations
Academia
Total
Count
7
5
2
2
6
1
16
Table 1 Summary of stakeholder interviews
The EU-level policy framework and stakeholder perspectives on returning to work after chronic illness
29Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
the development of EU-level legislation and binding tools (e.g. directives) as well as
other non-legislative tools such as recommendations and guidelines. Here, there are
both cross-sectoral and sectoral social dialogue committees where the social partners
come together to discuss, negotiate and sometimes reach consensus on diverse issues
relevant to the proper functioning of labour markets and workplaces.
17
Several EU-level
social partner organisations – including, for instance, the ETUC and Business
Europe – participate in EU cross-sectoral social dialogue committees addressing a
variety of labour market issues. EU sectoral social dialogue includes social partners
representing trade unions and employer organisations from all member states. There
are currently 43 EU-level sectoral social dialogue committees representing more than
80 per cent of the EU workforce (Kerckhofs 2019).
Various EU policies and strategies put an emphasis on social dialogue. For example, as
part of the Fair Working Conditions chapter of the European Pillar of Social Rights,
Principle 8 on social dialogue and the involvement of workers states the following:
‘The social partners shall be consulted on the design and implementation of
economic, employment and social policies according to national practices. They
shall be encouraged to negotiate and conclude collective agreements in matters
relevant to them, while respecting their autonomy and the right to collective
action. When appropriate, agreements concluded between the social partners
shall be implemented at the level of the Union and its Member States.’
Previous EU strategy also referred specically to the role of social partners in promoting
and implementing the European occupational health and safety framework, as stated
in the following (European Commission 2017):
‘Social dialogue has made a huge contribution to improving health and safety, at
EU, national, sectorial and company level. It has not lost any of its relevance in
today’s context. On the contrary, social dialogue will be crucial in implementing
the actions contained in this Communication.’
Meanwhile, Europe is host to a diverse set of industrial relations systems, as
summarised in various studies (among others, Bechter et al. 2012; Akgüç et al. 2019b,
2020). This diversity of regimes is to the benet of European industrial systems but it
can also constitute a challenge to the setting of minimum standards in an environment
where reaching agreements can take a longer time as a result of this diversity and the
dierent processes, tools and national practices. This is also why most of the EU-level
social dialogue agreements or outcomes tend to remain rather general in nature, leaving
room for member states to implement a tailored version in view of their national and
sectoral contexts.
17. For more detailed analysis of European social dialogue at cross-sectoral level, see Akgüç et al. (2019a).
Mehtap Akgüç and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations30
3.2 EU-level stakeholder engagement in the return to work
Turning next to interview data on the issue of the return to work after chronic illness, all
the EU-level stakeholders perceived returning to work and reintegration as a relevant
topic in the face of demographic change and the prevalence of chronic illness in the
EU. Inactivity among workers who have suered from a chronic disease implies a large
pool of wasted talent. In addition, it was highlighted that the return to work is not only
an issue of economic productivity but also of inclusion. Despite its broad relevance,
however, the specic topic of the return to work does not always appear at the top of the
agenda of EU-level stakeholders while the level of involvement diers strongly between
the dierent types of stakeholder.
From the side of the European institutions, the level of engagement with return to work
policy has been limited. Beside the European Commission and Parliament, the main
bodies dealing with the return to work are the European Agency for Safety and Health
at Work (EU-OSHA) and the European Foundation for the Improvement of Living
and Working Conditions (Eurofound). In particular, EU-OSHA has been working on
return to work issues over the last decade, focusing research on return to work after
MSDs and cancer, considering that work should not make existing health conditions
worse but that, at the same time, it can promote health and well-being. In most of
these projects, health and safety is considered within a multidisciplinary framework
and the idea is to look for best practice in adapting workplaces for people with chronic
conditions. These projects are coordinated and promoted jointly with the European
Commission and Parliament. As regards the work of the European Commission, the
bulk of its policy development work has focused on the prevention of accidents at work
and, more recently, on work-related diseases. Nevertheless, there is a growing interest
in the return to work, particularly in the context of MSDs, psychosocial risks and
demographic change in Europe. Overall, the main role of the European institutions
in return to work policy has been limited to information sharing, dissemination of
research and awareness-raising in the EU, as well as providing a platform for the
exchange of information and best practice.
Turning to the role of the EU-level social partners, the issue of the return to work after
chronic illness is considered to be relevant in the face of demographic change such
as ageing, or labour market developments such as labour and skill shortages, but the
issue is not on the agenda of the social partners as yet. In some cases, this is due to
limited resources while in others it is an issue of prioritisation with the main focus
of work being on the prevention side of occupational health and safety, as is the case
for other European institutions. While prevention has traditionally been concerned
with occupational accidents, there has been a shift over time towards an emphasis on
work-related diseases. In parallel to prevention, risk assessment and the promotion of
healthy workplaces are also within the focus of social partners. For instance, the cross-
sectoral social partners attempted to address the issues of active ageing and workplace
accommodation in the Autonomous Framework Agreement on Active Ageing and an
Inter-Generational Approach (Business Europe et al. 2017). Furthermore, European
The EU-level policy framework and stakeholder perspectives on returning to work after chronic illness
31Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
social partner agreements, such as the framework agreements on work-related stress
18
and harassment and violence at work
19
might well have some relevance to people with
chronic illnesses even though neither specically addresses the return to work.
However, there is also a perception that returning to work and chronic illness will
become more relevant on the social dialogue agenda in the near future, particularly
in certain sectors such as construction and woodwork that are more deeply aected by
work-related diseases. Sectoral trade union representatives highlighted unfavourable
working conditions, bad work posture and ergonomics, the manipulation of heavy
loads, stress and exposure to chemicals as leading factors in MSDs and cancer in some
particular sectors with, latterly, a rising prevalence of chronic conditions.
Despite this increasing trend, nor is the return to work high on the agenda of the sectoral
social partners at EU level yet. One way for this to change might be to consider working
conditions and their relation to the prevalence of chronic diseases from a dierent
angle. For instance, night shifts are common in sectors such as cleaning and studies
have shown a link between night shifts and cancer. Thus, one way to draw attention
to the prevalence of chronic illness and the related return to work issues among social
dialogue committees would be through the working time dimension. Another example
of the health impact of poor working conditions is stress in the workplace, which is
shown to be linked to chronic conditions;
20
around one-half of European workers
consider workplace stress to be common, contributing overall to almost one-half of
all lost working days.
21
An emphasis on workplace stress could thus be another way to
address the subject of chronic illness in social dialogue.
In some cases, employers would prefer to dismiss employees with chronic illness.
Trade unions are, however, able to inuence the employer side through social dialogue
and, where the issues of chronic illness and the return to work appear on the agenda
of social dialogue committees, this might represent a way of avoiding such outcomes.
Additionally, lobbying European institutions to make sure these issues are put high on
agendas also works: once the European institutions place importance on an agenda
item, it tends as a consequence to get discussed by the social partners.
Campaigning and patient support organisations and NGOs are key stakeholders
in EU-level return to work policy. They invest resources in raising awareness about
people experiencing chronic illness and provide a mapping of the prevalence of such
conditions; they also acknowledge the impact that chronic illness has on economic and
health systems. Their belief is that eective policy requires a shift in mindset to focus
on a person’s abilities rather than their limitations, considering that inactive people
with a disability or a limiting illness constitute an untapped reserve of talent and
skills. Some organisations prefer to advocate disability angle in policy-making on the
return to work, pushing for a collective eort behind the full implementation of the UN
18. https://www.etui.org/sites/default/les/ez_import/Framework%20agreeement%20on%20work-related%20
stress.pdf
19. https://www.etuc.org/en/framework-agreement-harassment-and-violence-work
20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5877081/
21. https://osha.europa.eu/en/themes/psychosocial-risks-and-stress
Mehtap Akgüç and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations32
Convention on Disabled Persons, with particular reference to Article 27 on reasonable
accommodation in the workplace. All in all, these stakeholders mainly focus on the
health side of the issue but they value exchanges with policy-makers, social partners
and other campaigning and patient support organisations to discuss other dimensions
such as employment and social policies.
The possible challenges faced by micro-enterprises and SMEs compared to larger
companies in the context of the return to work is also worthy of mention. A major
obstacle for these companies when dealing with the return to work is that it is often
the case that no two employees have the same tasks; thus, reorganisation can be very
dicult to allow the possibility for a worker, absent for a long time due to chronic illness,
to come back. Moreover, most SMEs do not have the nancial capacity and human
resources to adapt the workplace to accommodate and facilitate the return to work of
workers following chronic illness. In larger companies, there is often a more established
human resources management structure, and hence a return to work is more likely, but
some chronic diseases (e.g. chronic headaches) are not always recognised even there as
an issue to be addressed.
3.3 Interactions between industrial relations actors and other stakeholders in
return to work policy
Generally, while the nature of interactions between the social partners can sometimes
be adversarial, they frequently cooperate on health and safety issues. Common ground
can often be found here as a healthy workforce and well-functioning labour markets
are in everyone’s interests. It is also acknowledged by most social partners that trade
unions are generally more in favour of legislative solutions while employers are rather
reluctant when it comes to binding agreements. In interactions between the two there
has not, however, been any specic discussion of the return to work as this issue is not
present on the agenda of EU social partners.
This is also the case for interactions on the issue between EU-level social partners
and the European institutions. The social partners are part of the tripartite Advisory
Board on Health and Safety at Work and, as such, they are regularly consulted by the
European Commission to provide opinions on topics related to health and safety. In
addition, they are part of the tripartite governing board of EU-OSHA which must draw
up its work programme through consensus. In these interactions, an atmosphere of
cooperation usually prevails as they are based on knowledge exchange and the search
for joint actions and compromises. Nevertheless, the return to work is not addressed
specically.
Turning to interactions between campaigning and patient support organisations and the
social partners, engagement has also been limited. While the campaign organisations
state that they are seeking opportunities to cooperate with the social partners on the
return to work, they have had limited success so far as the social partners are more
focused on issues relating to prevention. Where there has been some form of interaction,
this appears not to have resulted in any particular policy action on the return to work. The
The EU-level policy framework and stakeholder perspectives on returning to work after chronic illness
33Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
limited interest of the social partners may result from trade unions seeking to advance
conditions for all workers whereas the specic needs of individual workers, or those
who are inactive, cannot always be collectivised; while employer organisations might
have greater awareness of the issues but lack knowledge about potential adjustments
and are focused on cost. The reason why both are hesitant on this issue might also be
due to not wanting to put at risk the terms of existing collective agreements.
Involving the social partners in return to work policy would increase the legitimacy
accorded to this topic in discussions with policy-makers. Consequently there is
signicant interest from campaigning and patient support organisations in further
exchanges with the social partners in terms of educating them about medical facts and
the importance of the issue, convincing employers that adjustments are not always
costly and discussing their policy recommendations openly with both sides. However,
greater exibility and openness from the social partners might be needed to increase
fruitful exchanges between social partners and NGOs on the return to work issue. Due
to their limited success at engaging with the social partners, campaigning and patient
support organisations and NGOs are therefore more focused on interactions among
themselves and with European institutions where there is more active cooperation, in
particular with the Commission and the Parliament, including discussions with policy-
makers and the organisation of joint events.
3.4 Future potential for EU action and social dialogue on the return to work
The data collected in these interviews suggests that the EU does have a future role in
return to work issues, both in developing policies and in raising general awareness.
However, its role here is distinct from that of national member states as employment
and social policies are national prerogatives in the context of subsidiarity. Given the
large variation in national labour market and social policy systems, specic legislation
on the return to work should perhaps be developed on a more disaggregated basis
comprised of national, sector and company levels. In contrast, the EU could provide at
least an overarching policy framework on the return to work. There also appears to be
room for the industrial relations actors to take part, subject to all sides being willing.
One of the key added value aspects at EU level is indeed the potential development
of a European charter on the return to work and chronic illness, collecting good
practice and creating minimum standards and common guidance in particular for
member states and employers. Diversity in handling return to work issues in member
states means that having European standards as a practical guide could serve those
member states who lag behind. In addition, having practical guidance approved at EU-
level can lend legitimacy to the issue and encourage further action in member states.
Employers would also benet from this as most are not sure of how to deal with the
issue, taking sector-specic considerations also into account. In this context, one of the
key transmission mechanisms could be the amount of interaction such a charter would
generate between the EU and the national social partners. Achieving a level playing
eld across all member states might not be possible but convergence in facilitating the
return to work can perhaps be aimed at.
Mehtap Akgüç and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations34
An additional and potentially useful EU policy tool is the European Semester process.
As a benchmarking tool, this process could be useful in terms of the collection of further
data on the return to work since the absence of data can lead to an underestimation
of the scale of the problem. Furthermore, greater emphasis could be put on health
and safety topics in country-specic recommendations as part of the national reform
process. For example, there are existing EU instruments that address the long-term
unemployed. One idea could be to add an annex to such instruments to include people
who are absent from work because of a chronic illness (or disability). There is also
room for the social partners to participate in the European Semester. Even though
there are divergences in the extent of actual experience with the process thus far
(Akgüç et al. 2019a), the social partners have started to be involved in the process and
can contribute their perspectives on the return to work as part of it. The roles of the
European Social Funds and the European Structural and Investment Funds are also a
means of supporting member states and employers to adjust workplaces and facilitate
return to work arrangements.
Another area where EU action is relevant is EU-funded research projects and
programmes, such as Horizon 2020. These joint research and innovation activities
contribute to our understanding on chronic diseases and the societal challenge of
demographic change, and they inform policy-makers drafting initiatives and strategies
on employment and health policies. There is also an EU budget line for the social
partners to participate in various projects to improve expertise on industrial relations
and on the specic challenges which wider society faces. All such EU activities are
considered to be valuable in engaging the various actors and advancing knowledge in
relation to the return to work after chronic illness.
The social partners are relevant at all levels but there is a need to dierentiate the roles
that they play. At the level of the EU, the focus of the social partners is the generation
and co-ordination of overall policy. In contrast, national social partners can address
return to work issues through legislation or collective bargaining within member states,
considering the context of national legislation and social security systems. Furthermore,
the sectoral social partners can address specic industry-wide issues as returning to
work does require a more tailored consideration in some sectors (e.g. construction,
cleaning or the chemical industry). Finally, interest representation at company level is
also important as the success of any return to work policy elaborated at higher levels
boils down to practical implementation in enterprises where representatives can serve
as intermediaries between workers and the company.
The main role of the EU-level social partners in contributing to policy development
on the return to work therefore lies in providing information and exchanging best
practice, thus raising awareness among their members at national level, and capacity
building. In addition, they can lobby the European institutions in order to bring the
issue higher up the European policy agenda which would also result in making it more
prominent in the European social dialogue. The social partners have an important role
to play in making sure that issues related to health and safety and to employment enter
the relevant European and national strategies. Here, the return to work tends to be
addressed through disparate policy angles such as health and safety, employment and
The EU-level policy framework and stakeholder perspectives on returning to work after chronic illness
35Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
social inclusion with the result that dierent policy elds dealing with the issue, such
as ageing, discrimination, disability and occupational health and safety, are at times
disconnected. One of the roles of the EU-level social partners could be to bring these
dierent policy angles together to promote a more holistic and joined-up approach.
In addition to awareness-raising and information exchange, the EU-level social partners
could also include the return to work in formal social dialogue negotiation. However,
EU-level regulations on this issue are not necessarily desirable as their outcomes tend
to remain rather general in nature. It is rather the national-sectoral level of social
dialogue – perhaps the most inuential channel to achieve binding agreements in view
of the centrality of national legal frameworks, industrial relations settings and sector-
specic risks and conditions – which is arguably the most important.
4. Conclusion
In the context of demographic and economic change, the labour market integration of
individuals who are returning to work after chronic illness is a signicant social and
economic challenge. This chapter has sought to elucidate the EU policy framework on
return to work and the contributions to it of the EU-level social partners, as well as
stakeholders’ views on current and future EU return to work policy. As set out in this
chapter, EU-level initiatives and industrial relations actions on the return to work have,
so far, been limited but there are several relevant actions that are worth acknowledging.
At EU level, there have as yet been no concrete policy agreements on the return to
work although some EU agencies, such as EU-OSHA, have conducted research on it.
The return to work is relevant to several EU policy elds, the most prominent among
which is health and safety, and social inclusion and disability. Within the health and
safety policy nexus, however, the focus of policy up to now has been on the prevention
of occupational accidents and occupational diseases. The new EU Strategic Framework
on Health and Safety at Work for 2021-2027 addresses the return to work more
explicitly by highlighting the importance of vocational rehabilitation of people with
chronic illnesses. As regards the eld of social inclusion, chronic diseases tend to be
subsumed under the heading of disability. On the legislative side, the most signicant
development in this regard is the Employment Equality Directive and its proposition
for reasonable accommodation to be made in the workplace for employees suering
from a disability. Generally, chronic illness tends not to be specically addressed in
EU policy documents but the recently-released Strategy for the Rights of Persons with
Disabilities 2021-2030 does include a specic reference to workplace rehabilitation for
workers who suer from chronic illness. In addition, the EU ‘Beating Cancer’ Plan is
a rst concrete initiative that addresses the return to work of individuals with cancer.
Hence, the topic appears to have started to attract more attention on the European
policy agenda.
The EU-level social partners have, so far, engaged with the topic of the return to work
after chronic illness only to a very limited extent. While autonomous framework
agreements, such as those on active ageing or work-related stress, address concepts
Mehtap Akgüç and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations36
relevant to workplace rehabilitation, specic policy engagement with the return to
work concept has, up to now, been lacking. Our research suggests that the return to
work could become more prominent on the agenda of the EU-level social partners in
the future, with the stakeholders interviewed agreeing that the social partners have a
key role to play in developing return to work policy at EU level.
In particular, there are several ways in which the social dialogue actors might function
at EU level to address the return to work. One of the main ones here is to raise
awareness, share information with national members and engage in capacity building.
Such eorts could be further enhanced by increased cooperation with other actors such
as campaigning and patient support organisations. The EU-level social partners could
also inuence European institutions to help the development of a more coordinated
and holistic European strategy on the return to work.
While the return to work may be discussed in both cross-sectoral and sectoral social
dialogue committees, the conclusion of binding agreements at EU level on the return to
work may be less appropriate. In other words, one of the common messages is that social
dialogue at European level should mainly have an awareness-raising role, providing
general information on the topic, but that all the practicalities should rather be left to
the member states and particularly to the sectoral actors due to national competence
and the diversity of legal and industrial relations settings. Rather than new legislation
at EU level, a better interpretation of the existing legislation, as well as more practical
guidance for member states, could provide a more functional way forward. Here it is
the national-sectoral level which appears to be the one most appropriate for specic
social dialogue outcomes to be agreed on return to work issues while, going one step
further, the enterprise level is the one where the practical and day-to-day management
decisions on the ground are taken in relation to return to work matters.
References
Akgüç M., Martišková M., Szüdi G. and Nordlund C. (2019a) Stakeholders’ view on and experiences
with the articulation of social dialogue and its eectiveness, EESDA Project
No. VS/2017/0434, Brussels, Centre for European Policy Studies.
Akgüç M., Kahancová M. and Martišková M. (2019b) Enhancing the Eectiveness of Social
Dialogue Articulation in Europe (EESDA) – Comparative report, EESDA Project
No. VS/2017/0434, CELSI Research Report 30, Bratislava, Central European Labour Studies
Institute.
Akgüç M., Kahancová M. and Popa A. (2020) Working paper presenting a literature review on
return to work policies and the role that industrial relations play in facilitating return to work
at the EU, national and sub-national levels, REWIR Project No. VS/2019/0075, Bratislava,
Central European Labour Studies Institute.
Bechter B., Brandl B. and Meardi G. (2012) Sectors or countries? Typologies and levels of analysis
in comparative industrial relations, European Journal of Industrial Relations, 18 (3), 185-202.
The EU-level policy framework and stakeholder perspectives on returning to work after chronic illness
37Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
BusinessEurope, CEEP, ETUC and UEAPME (2017) European social partners’ autonomous
framework agreement on active ageing and an inter-generational approach.
https://www.businesseurope.eu/sites/buseur/files/media/reports_and_studies/with_
signatures_framework_agreement_on_active_ageing_0.pdf
ETUC (2019) ETUC position on a new EU Strategy on Occupational Safety and Health.
https://bit.ly/3qSKnwq
ETUC (2020) ETUC position on a new European disability strategy. https://www.etuc.org/en/
circular/etuc-position-new-european-disability-strategy-0
Eurofound (2019) How to respond to chronic health problems in the workplace?, Luxembourg,
Publications Oce of the European Union.
European Commission (2007) Communication from the Commission to the European Parliament,
the Council, the European Economic and Social Committee and the Committee of the Regions
- Improving quality and productivity at work: Community strategy 2007-2012 on health and
safety at work, COM (2007) 62 Final, 21 February 2007.
European Commission (2010) Communication from the Commission to the European Parliament,
the Council, the European Economic and Social Committee and the Committee of the Regions
- European disability strategy 2010-2020: A renewed commitment to a barrier-free Europe,
COM (2010) 636 Final, 15 November 2010.
European Commission (2014) Communication from the Commission to the European Parliament,
the Council, the European Economic and Social Committee and the Committee of the Regions -
An EU Strategic Framework on Health and Safety at Work 2014-2020, COM (2014) 332 Final,
6 June 2014.
European Commission (2015) Evaluation of the Practical Implementation of the EU Occupational
Safety and Health (OSH) Directives in EU Member States. https://ec.europa.eu/social/
BlobServlet?docId=16897&langId=en
European Commission (2017) Communication from the Commission to the European Parliament,
the Council, the European Economic and Social Committee and the Committee of the Regions
- Safer and healthier work for all – Modernisation of the EU occupational safety and health
legislation and policy, COM (2017) 12 Final, 10 January 2017.
European Commission (2020) Evaluation of the European disability strategy 2010-2020,
SWD(2020) 289 final/2, 27 November 2020.
European Disability Forum (2020) EDF input to the European disability rights agenda.
https://mcusercontent.com/865a5bbea1086c57a41cc876d/files/a21f8190-ecf7-4e59-
8b79-7237b7f461e3/EDF_input_to_the_European_Disability_Rights_Agenda.docx
European Parliament (2018) On pathways for the reintegration of workers recovering from injury
and illness into quality employment, Committee on Employment and Social Aairs, Report
A8-0208/2018, 12 June 2018.
European Parliament (2020) European disability strategy post-2020. P9_TA(2020)0156.
https://www.europarl.europa.eu/doceo/document/TA-9-2020-0156_EN.html
EU-OSHA (2016) Rehabilitation and return to work: analysis report on EU and Member States
policies, strategies and programmes, Publications Oce of the European Union, Luxembourg.
Hemp P. (2004) Presenteeism at work – but out of it, Harvard Business Review, October 2004,
1-10.
Guazzi M., Faggiano P., Mureddu G.F., Faden G., Niebauer J. and Temporelli P.L. (2014) Worksite
health and wellness in the European Union, Progress in Cardiovascular Diseases, 56 (5),
508–514.
Mehtap Akgüç and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations38
ISSA (2013) ISSA guidelines: return to work and reintegration, Geneva, International Social
Security Association.
Kerckhofs P. (2019) European sectoral social dialogue: facts and figures, Luxembourg, Publications
Oce of the European Union.
OECD (2003) Transforming disability into ability: policies to promote work and income security for
disabled people, Paris, OECD Publishing.
OECD (2010) Sickness, disability and work: breaking the barriers. A synthesis of findings across
OECD countries, Paris, OECD Publishing.
OECD (2016) Health at a glance: Europe 2016 – State of health in the EU cycle, Paris, OECD
Publishing.
OECD (2018) OECD Employment outlook, Paris, OECD Publishing.
UN (2006) Convention on the rights of persons with disabilities. https://www.un.org/
development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities/
convention-on-the-rights-of-persons-with-disabilities-2.html
Vooijs M., Leensen M. C. J., Hoving J. L., Wind H. and Frings-Dresen M.H.W. (2018) Value of work
for employees with a chronic disease, Occupational Medicine, 68 (1), 26-31.
All links were checked on 01.06.2021.
39Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Chapter 2
Shaping an evolving framework on return to work:
the role of the social partners in Belgium
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westho
1. Introduction: chronic illness and employment in Belgium
Belgium faces longlasting challenges regarding the labour market activation of
vulnerable groups, including sick and disabled people, notably due to persistent
inactivity traps (Hufkens et al. 2017). Only three out of four people of working age
(20-64) are active in the labour market (74.5 per cent), below the EU average of
78.7 per cent in 2019 (European Commission 2019). Meanwhile, before the Covid-19
pandemic, labour market shortages had become more acute, creating skills shortages
and impeding the smooth functioning of the labour market especially in Flanders
(European Commission 2019). Sickness and disability have become signicant reasons
for inactivity: the share of inactive people not seeking employment due to their own
illness or disability increased from 10.7 per cent in 2007 to 19.1 per cent in 2019.
1
Furthermore, the share of private sector salaried employees
2
absent from work as a
result of long-term illness increased signicantly between 2008 and 2015, and has
been continuing more recently albeit at a slower rate (Securex 2018). Population ageing
and the related alignment of the statutory retirement age, as well as increased female
participation in the labour market and the associated higher eligibility for benets,
seem to explain an important part of the increase in invalidity benet claimants (Saks
2017).
3
Associated with the extension of working lives, the incidence of chronic illness among
the working population poses important challenges for the proper functioning of
the labour market in Belgium. Chronic illness is associated with stigma and taboos,
and often leads to social exclusion thereby producing a considerable burden on the
workforce. Musculoskeletal and mental health problems are the primary causes of
absenteeism, explaining about two-thirds of the signicant increase in long-term sick
leave and representing 67.3 per cent of sickness and disability insurance beneciaries
(Mutualités Libres 2019b). According to a study conducted between 2013 and 2017
by health insurer Mutualités Libres (2019c), over half of ‘new’ disability insurance
beneciaries already suer from at least one chronic illness, depression being the most
frequent. On the other hand the incidence of other types of chronic conditions, such as
cardiovascular illness and cancer, has decreased (Saks 2017).
1. Source: Eurostat, lfsa_igar, extracted 15 December 2020.
2. This gure only includes rms with less than 1 000 employees. Long-term illness refers to absences of more
than one year (Securex 2018).
3. There is also evidence showing that women have a higher rate of reported poor health (Franklin et al. 2021).
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations40
This situation became more acute with the Covid-19 pandemic in early 2020 as Belgium
reached its highest number of invalidity benet recipients.
4
Covid-19 is estimated
as likely to cause long-term health issues for 10 to 20 per cent of infected people
(WHO 2020), leading to signicant alterations in patients’ ability to work and raising
important issues of rehabilitation and reasonable accommodation in the workplace for
those experiencing Long Covid. More broadly, the pandemic has made the return to
work more dicult for people suering from chronic illness as they face higher chances
of developing severe complications from Covid-19. At the same time, however, the
spread of remote working due to the pandemic might have eased the reintegration of
some workers returning from sick leave.
Nevertheless, people suering from a chronic condition in Belgium tend to face
signicant diculties in terms of integration into the labour market and with their
well-being. The gap for those at risk of poverty or social exclusion for people with and
without disabilities amounts to 17.7 per cent, signicantly higher than the EU average
of 9.7 per cent (European Commission 2018). Only in February 2018 did a Belgian
court apply, for the rst time, the principle of non-discrimination based on disability
and the associated duty on employers to make reasonable accommodation for people
with chronic illness, as stated in the jurisprudence of the European Court of Justice
(Eurofound 2019; CSC 2019). It should be noted here that Belgian legislation uses the
concept of invalidity more than disability (CNT 2015).
Perceived as a threat to the sustainability of the social security system, this evolution is
reected in the Belgian government’s increasing concern over the risk of incapacity for
work. Increased awareness of this issue has been noticed over the past decade, while
the switch from welfare to workfare has also been experienced in the area of incapacity
(Houwing and Vandaele 2011). The increasing incidence of long-term incapacity for
work has led to mounting social security costs as spending on disability increased from
1.9 per cent of GDP in 2005 to 2.6 per cent in 2016 (Pacolet 2019). In 2018 the combined
spending on disability and sickness benets exceeded for the rst time the expenditure
on unemployment benets, probably due to a ‘communicating vessels’ eect between
the various schemes for early withdrawal from the labour market (Pacolet 2019). The
government has, since 2015, been seeking to address the economic impact of sickness
absence and the mismanagement of the return to work leading to unemployment,
disability pensions or early retirement. Notably the mutuelles/mutualiteits (insurance
providers) are being encouraged to increase the rate of employment of the beneciaries
of long-term sickness insurance and to provide incentives for them to return to work.
New pieces of legislation on work reintegration also address the challenge of supporting
the return to work, where feasible, of workers with a chronic illness (i.e. where they are
‘able’ and have the ‘capacity’ to get back to work) (Securex 2018).
This context makes Belgium a relevant case study in understanding the role that
industrial relations actors can play in designing and implementing return to work
4. Source: La Libre, 18/11/2020, L. Gérard, ‘Invalidité: Le Covid peut faire exploser la casserole à pression en 2021-2022’
https://www.lalibre.be/belgique/societe/invalidite-le-covid-peut-faire-exploser-la-casserole-a-pression-en-2021-
2022-5fb427307b50a6525b6661c6
Shaping an evolving framework on return to work: the role of the social partners in Belgium
41Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
policies, even more so given the country’s industrial relations and welfare state regime.
Belgium has a strong tradition of a Bismarckian continental welfare system, corporatist
arrangements and social pacts as solutions in the case of social conict (Houwing and
Vandaele 2011). The Belgian industrial relations system is characterised by a strong role
for the social partners, a high union density rate and signicant collective bargaining
coverage. Dialogue with the state also plays an important role in the social dialogue
process and unions are involved in social security management and in the development
of social and employment policy at federal and regional levels.
This chapter rst outlines the policy framework on the return to work in Belgium. It
then evaluates how the social partners shape and view policy on the return to work
at national level and at company level, consolidating and analysing the data collected
through interviews with relevant stakeholders, at stakeholder events and via online
surveys distributed to social partners, managers in companies and workers.
2. Policy framework on the return to work in Belgium
According to a typology of rehabilitation and return to work systems in Europe, Belgium
is classied by EU-OSHA (2016) as part of the group of ‘European’ countries, together
with France, Iceland, Italy, Luxembourg, Switzerland and the United Kingdom. These
countries are characterised by well-developed frameworks for rehabilitation and the
return to work but with limited coordination between the dierent stakeholders.
The return to work is considered as the period of sickness absence comes to an end
and with only limited possibilities for early intervention. Nevertheless recent policy
developments have shifted the Belgian approach to the return to work.
2.1 Sickness and the invalidity benefit system
Belgium has a ‘pillarised’ social security system composed of separate regimes for
salaried workers (sometimes dierentiated by blue collar and white collar workers),
self-employed and civil servants (Pacolet 2019). Trade unions, insurance providers
and employer organisations co-decide various aspects of these social security regimes.
Each regime has a dierent framework and coverage regarding sickness, disability
insurance and the return to work. Dierent regimes also exist depending on the cause
of the illness. While Agence fédérale des risques professionnels/Federaal agentschap
voor beroepsrisico’s (Federal Agency for Occupational Risks; FEDRIS) manages
benets in relation to occupational accidents and diseases, it is the federal institution
Institut national d’assurance maladie-invalidité/Rijksinstituut voor ziekte- en
invaliditeitsverzekering (National Institute for Health and Disability Insurance;
INAMI/RIZIV) which is responsible for non-occupational illness. As the coordinator
of the sickness and disability insurance benet system, INAMI/RIZIV works in
collaboration with the accredited insurance providers who act as intermediaries with
the insured and as key gatekeepers in terms of access to sickness and disability benets
(OECD 2013). This chapter focuses on the schemes coordinated by INAMI/RIZIV for
salaried workers.
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations42
Unlike in most other countries within the OECD, sickness and disability benets
in Belgium are integrated into one single system managed by INAMI/RIZIV. To be
eligible for incapacity benets, the employee must have fullled several contributory
requirements. Work incapacity is divided into two periods: incapacité de travail
primaire/primaire ongeschiktheid (primary work incapacity), corresponding to
sickness benets during the rst year of sickness; and invalidité/invaliditeit (the
period of invalidity), corresponding to the disability benets which are applicable after
one year of incapacity. An employee on sickness leave receives a guaranteed salary
during the rst month of absence (or 15 days for blue collar workers), paid by his or
her employer. Following the rst month, INAMI/RIZIV takes over the management
of incapacity benets, covering 60 per cent of the worker’s salary up to a certain
maximum annual amount. After one year of incapacity, the period of invalidity may
be prolonged by a decision of the Conseil médical de l’invalidité/Geneeskundige raad
voor invaliditeit (the Invalidity Medical Council of INAMI/RIZIV) on the basis of a
medical report written by a physician from the insurance provider. The payment of
invalidity benets can continue until retirement, depending on how the employee’s
health condition evolves. During the period of incapacity, the beneciary is not allowed
to work unless the insurance provider’s occupational physician authorises part-time
work.
In 2018 incapacity benets amounted to €1.8 billion and invalidity benets to
€5.8 billion. Between 2013 and 2018, invalidity benets increased by 7.8 per cent per
year on average (Mutualités Libres 2019b, based on INAMI/RIZIV data).
2.2 Provisions for rehabilitation and return to work support
The Belgian incapacity and invalidity benet system encompasses several pathways
into work based on activation and vocational rehabilitation. The federal and regional
governments have focused over the last few years on increasing tness for work among
workers on long-term sickness leave and improving the incentive structure for the return
to work. The policy framework on the return to work applies to several legislative areas,
including legislation on social security, labour market regulations, well-being at work
and disability (CNT 2015). It forms a major part of the Code du bien-être au travail/
Codex over het welzijn op het werk (1996 Act on Well-being at Work, as amended)
which extended the concept of health and safety at work to cover all aspects of well-
being in the work environment. This put a legal obligation on the employer to take
all necessary measures to protect employee well-being such as risk assessments and
medical check-ups conducted by external or internal prevention services. In addition
the Law of 3 July 1978 on employment contracts included important provisions on the
consequences for the employment contract of work incapacity, partial return to work
and permanent work incapacity; while the Law of 14 July 1994 on compulsory health-
care and indemnity insurance also included provisions on invalidity and incapacity
benets which can have an impact on the return to work. Furthermore the Anti-
discrimination Law also encourages an employer to make reasonable accommodation
for a disabled worker as advised by the occupational physician and forbids any
employment-related discrimination due to health or disability status.
Shaping an evolving framework on return to work: the role of the social partners in Belgium
43Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Returning to work gradually while keeping partial invalidity or incapacity benets has
been possible since 1996. The insurance provider’s occupational physician must rst
authorise medical part-time status or adjustments to the workload (Mutualités Libres
2019a) and this is dependent on two conditions: that incapacity remains at least 50 per
cent; and that the job does not jeopardise the person’s health. The physician also decides
on the intensity and duration of part-time work which can be gradually increased until
the beneciary is ready for regular or full-time work. Adjustments can be related to
working hours (longer breaks, shorter week, fewer hours per day); work organisation
(telework, slower work pace, change in tasks); workspace and equipment; the provision
of specic training; and putting in place support by a coach, colleague or line manager.
Benets are adjusted according to the number of hours worked in a week. The medical
part-time option was rarely used in the past but the number of authorisations of a
partial return to work is now on the increase (OECD 2013; Mutualités Libres 2019b).
A new trajet de réintégration/re-integratietraject (formal return to work/reintegration
procedure) was implemented in 2016 as a new chapter of the 1996 Act.
5
Informal
dispositions regarding the return to work existed before this reform, such as the visite
de pré-reprise du travail/bezoek voorafgaand aan de werkhervatting (voluntary
medical appointment) with the occupational physician, implemented in 2004 (SPF
Emploi 2018). However, the 2016 legislation added a formal procedure for the return to
work, requiring physicians from insurance providers to assess the possibilities for the
return to work within the rst two months of sickness absence. Beyond systematising
early intervention and individual case management, thereby strengthening the
insurance providers’ role in sickness monitoring, the reform provided a series of steps
to follow for voluntary, gradual and adapted return to work.
The goal of the new procedure is to reintegrate the worker with an employment contract
within the same company so that he or she can return to a familiar environment. The
procedure outlines a sharing of responsibilities between the main stakeholders on a
practical level and foresees a collective framework for the return to work after sick
leave to be developed at company level, for example by the Comité pour la prévention
et la protection au travail/Comité voor Preventie en Bescherming op het Werk (health
and safety committee). It also claries the use of ‘medical force majeure’ to terminate
an employment contract which can now be invoked only where the employee has gone
through a formal return to work procedure. In 2016, 4 801 formal return to work
procedures were initiated with 5 015 being undertaken in 2017 (Mutualités Libres
2019b, based on INAMI/RIZIV numbers).
Réinsertion ou réhabilitation socio-professionnelle/socioprofessionele re-integratie
(occupational rehabilitation) is targeted at workers declared unt to return to their
former company as well as at unemployed or self-employed workers (Mutualités Libres
2019a). This enables the individual to attend a training or rehabilitation programme
to update their skills or acquire new ones. INAMI/RIZIV cooperates with several
regional public employment services on this matter as they are responsible for labour
market activation policies and training. Regional agencies specialised in vocational
5. Royal Decree of 20 December 2016 amending the Royal Decree of 28 May 2003.
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations44
rehabilitation for disabled workers (e.g. GTB - Gespecialiseerd Team Bemiddeling;
Service PHARE - Personne Handicapée Autonomie Recherchée; AViQ - Agence
pour une Vie de Qualité) are also involved. Financial incentives are attached to this
procedure: participation fees are covered by INAMI/RIZIV and participants receive
a lump-sum payment of €500 at the end of the training. However, participants can
lose their entitlement to disability benets within six months of the training which can
act as a disincentive. Furthermore in 2018 the federal government introduced in its
Deal pour l’Emploi/Arbeidsdeal (Job Deal) the right to an outplacement payment of
up to €1 800 paid by the employer in cases where the latter has invoked medical force
majeure to terminate the employment contract.
Some nancial and technical support is available for employers at regional level in the
case of an employee’s recognised permanent functional limitation (e.g. the Vlaamse
ondersteuningspremie in Flanders; SPF Emploi 2018). Regional nancial support
also includes adjustments to the work environment, the coverage of work and living
expenses, paid interpreters in the case of hearing impairment and a premium for
companies oering mentoring support to a returning disabled worker. In 2014 INAMI/
RIZIV created a training course for ‘disability managers’, subsidised by the state but
paid for by the company, to support the return to work process at company level (INAMI
2019). This is based on disability management methodology aimed at maintaining
employment and facilitating a quick and adapted return to work. Additionally, INAMI/
RIZIV also runs pilot programmes, such as the Individual Placement and Support
programme for people suering from mental health issues. This follows a ‘place
then train’ model and consists of the provision of early and continuous support for
the return to work, including after the start of the job. Depending on the results of
the pilot programme, this model could be implemented as an alternative to existing
rehabilitation schemes.
3. Involvement of the social partners in shaping return to work
policy at national level
3.1 Industrial relations structures and return to work policy
This section focuses on the involvement of the social partners in the design and
implementation of return to work policies at national level. The analysis relies on
interviews with key stakeholders and the survey targeted at national social partners
referred to in the Introduction as well as a literature and policy review.
Belgium is characterised by a strong social dialogue tradition involving established
industrial relations structures and actors.
6
The country has a relatively high
unionisation rate amounting to more than 50 per cent while collective bargaining
covers approximately 90 per cent of employees. At national level, workers are mainly
6. For a brief overview of the industrial relations system in Belgium, see www.worker-participation.eu/National-
Industrial-Relations/Countries/Belgium/Trade-Unions provided by the European Trade Union Institute (ETUI)
(last updated in 2016).
Shaping an evolving framework on return to work: the role of the social partners in Belgium
45Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
represented by three large trade union confederations: ACV/CSC (Confederation of
Christian Trade Unions); FGTB/ABVV (General Federation of Belgian Labour); and
CGSLB/ACLVB (Confederation of Liberal Trade Unions of Belgium). On the employer
side, the main national association for employers is FEB/VBO (Federation of Belgian
Enterprises). In addition, craft and trade sector employers, the self-employed and
small and medium enterprises are represented by UNIZO in the Flemish-speaking
region and UCM in the French-speaking region. The membership rate of employer
organisations in Belgium is above 80 per cent (ETUI 2016).
National social dialogue takes place within thematic advisory bodies: Conseil National
du Travail/Nationale Arbeidsraad (National Labour Council; CNT/NA); Conseil
Central de l’Economie/Centrale Raad voor het Bedrijfsleven (Central Council of the
Economy); and Conseil Supérieur pour la Prévention et la Protection au Travail/Hoge
Raad voor Preventie en Bescherming op het Werk (High Council for Prevention and
Protection at Work), an advisory body focused on matters related to the well-being at
work legislation (ETUI 2016). The CNT/NA has a cross-sectoral remit extending to the
whole of Belgium and covering all companies and sectors, with a composition divided
equally between representatives of the main employer associations and trade unions.
Its principal functions are to provide advice and deliver opinions to a minister or the
two chambers of the legislature (upon request or on its own initiative) on general issues
of a social nature. It also provides a platform for collective bargaining agreements and
performs an important role in policy evaluation.
Since the beginning of the 2010s, the CNT/NA has been working on the topic of the
return to work. It has followed a coordination role as a ‘Platform for consultation
between the actors involved in the process of the voluntary return to work of people
with health problems’ (CNT 2015). This platform on the return to work was set up as a
structural consultation framework bringing together the social partners and the other
institutions (e.g. INAMI/RIZIV, Ministry of Labour, FEDRIS) involved in the process
of the voluntary return to work. Its goal was to develop an integrated approach to the
return to work after chronic illness, considering the social security aspects as well as
employment and health and safety issues, gathering all the institutions involved in the
issue. As regards the government, the Ministry of Labour and the Ministry of Social
Aairs have been involved in the issue of the return to work and were jointly responsible
for the Royal Decree of 2016 on the new return to work procedure. Discussion and
negotiation with the social partners in preparing legislation at federal level is of key
importance to the wider process.
Before the start of the CNT/NA’s consultation platform, the focus of the social partners
was mainly on prevention in terms of health-related issues in the workplace. Since then,
the return to work has been rather high on trade union agendas. This was accentuated
when the social partners noticed the adverse social consequences of the 2016 reform,
notably the sharp increase in the number of contract terminations due to medical force
majeure (CNT 2018c). However, it is still taking time for them to incorporate this issue
fully into their programmes. The social partner survey noted that nearly two-thirds
of social partners had only marginal and ad hoc involvement in return to work policy-
making or policy implementation but would like to have a more active involvement.
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations46
This additionally suggests that the initiative to come up with a policy on the return to
work was taken by other bodies (rather than the social partners themselves), such as
the government.
A key role for the national social partners is to inform and support their local members
in understanding how the new procedure works, for example via study days and
training courses or booklets (CSC 2019; FGTB 2019). Indeed, company-level industrial
relations structures matter in facilitating the implementation of national legislation at
a more local level since they serve as intermediaries between the high-level decision-
making bodies and the regions and companies where policies are implemented.
Equally they are responsible for collating the issues observed at local levels and raising
them for discussion and negotiation at national level. This important bottom-up
function follows the pyramidal structure of trade unions: local branches are in contact
with company-level union members and run the regional social rights oces (Oce
régional de droits sociaux), providing legal and strategic support to workers facing
problems with their employers. Information and complaints can then be channelled
to the sectoral and cross-sectoral levels. Regional stakeholders share information with
national stakeholders, enabling them to negotiate on legitimate grounds.
3.2 Interaction between industrial relations actors and other stakeholders in
return to work policy
The nature of the interaction between the key industrial relations actors is generally
reported as cooperative while discussions on return to work policy tend to be
constructive. All the opinions issued by the CNT/NA have been unanimous, showing
the social partners’ willingness to display a ‘united front’ to give strength to their
recommendations so as to inuence the government. They especially agree on the
need to ensure that the return to work is a voluntary process and happens early, to
change mindsets on the issue and to give a key role to the occupational physician in the
process. Even so, there have been several disagreements between the social partners,
one example being the nancial responsibility carried by the employer: trade unions
asked that they cover the salary for the rst two months of sick leave but employers
opposed this as it would place small and medium-sized enterprises (SMEs) in a dicult
situation.
There has also been some disagreement between the social partners and the govern-
ment, which intensied after the disclosure of gures on the increase in contract
termination due to medical force majeure. Trade unions condemned these adverse
social consequences in the media and the issue became increasingly debated in the
public sphere. Furthermore it is a matter of regret for the social partners that none
of their recommendations have been implemented, a situation partly related to the
political stalemate that Belgium encountered until the formation of the De Croo
government in September 2020. Up to that point, the government had mainly taken
responsibility only for current aairs (Gouvernement d’aaires courantes/Regering
in lopende zaken) and had limited competence in diverse policy areas. Another bone
of contention was the government’s draft legislative proposal in May 2018 which
Shaping an evolving framework on return to work: the role of the social partners in Belgium
47Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
planned to impose nancial sanctions where employers and employees had failed to
full their responsibilities regarding the new return to work procedure. The proposal
was strongly rejected by the CNT/NA (CNT 2018b). The CNT/NA was also critical
of the introduction, as part of the Job Deal in 2018, of a new general compensation
measure for employees declared unt to return to their former job. This measure was
seen as insuciently individualised and lacking in tailored support from the regional
employment services (CNT 2018d).
Interactions on the return to work in Belgium can become complex due to Belgium’s
multilevel governance. Return to work issues cut across policy areas which are assigned
either to the federal (social security) or the regional (active labour market policy)
levels. Designing a comprehensive common policy framework can thus be a challenge.
There is a major need to increase cooperation between the various stakeholders so as
to facilitate the implementation of legislation on the return to work following chronic
illness.
3.3 Outcomes of social dialogue regarding return to work policy
One of the main outcomes of social dialogue at national level on the return to work
was the key role played by the CNT/NA in supporting the overhaul of legislation on the
matter via the forum it established on the return to work. The overhaul of the policy
framework originated around 2010 when INAMI/RIZIV put the issue of the return to
work on the agenda following the sharp increase in the number of long-term sickness
insurance beneciaries. In doing so, the Institute called for a more active approach
towards workers on sickness leave who are able to perform some level of occupational
activity, on the grounds that this would be benecial for their recovery prospects as
well as for the sustainability of the Belgian social security system. In 2015 the CNT/
NA published a report on the results of the forum’s work, laying down some basic
principles for legislation which embodied the need for a collective approach to the
return to work, concrete incentives, a voluntary procedure, clarication on the use
of medical force majeure and identifying the key role of the occupational physician.
These discussions and agreements were later adopted as part of the Royal Decree in
2016.
7
By subsequently consulting experts and civil society stakeholders during its
evaluation of the 2016 legislation, the CNT/NA also gathered relevant information on
return to work policy and the potential gaps that needed to be addressed. However, it is
unclear whether and how the 2016 legislation will be modied following the CNT/NA’s
evaluation (as well as that performed by a group of academics).
8
Beyond inuencing the legislation, it is clear that the Belgian social partners could do
more on the topic of the return to work such as issuing common practical guidelines
for health and safety committees, employers and union representatives on how to
7. For more details on the Royal Decree, see the legal documentation (in French): www.ejustice.just.fgov.be/
cgi_loi/change_lg.pl?language=fr&la=F&cn=2016102808&table_name=loi
8. For more information on the evaluation conducted by researchers from KU-Leuven and ULB: https://emploi.
belgique.be/fr/projets-de-recherche/2018-evaluation-de-limpact-de-la-nouvelle-reglementation-sur-la-
reintegration
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations48
implement a company-level return to work policy. The social partners could also work
at sectoral or cross-sectoral levels on collective bargaining agreements specically on
the return to work which has not happened so far.
However, the outcomes of social dialogue at sectoral level are more dicult to
determine. Sectors follow divergent approaches on the return to work as they face
dierent prospects in nding adjustments in terms of the tasks which may be carried
out by workers experiencing chronic illness. In this respect, the presence of a diversity
of tasks within a sector may actually act as a facilitator in the return to work. For
instance, rms in the construction sector tend to have well-established procedures
on the return to work and the potential for adjustments in task allocation. Here, a
progressive return to work into the workplace is possible, for example, by allocating
fewer physically demanding tasks to a worker returning after sickness absence. Other
sectors face more diculties in proceeding to reasonable accommodation such as the
voucher-based parts of the service sector (including cleaning and homecare services),
which is characterised by a high incidence of musculoskeletal diseases. Trade union
representatives here have tried to react to the negative consequences of the return to
work procedure by putting the issue on the sectoral negotiation agenda.
3.4 Views of the industrial relations actors on the policy framework
for the return to work
Returning to work after (or indeed with) chronic illness is evidently a salient issue
in Belgium. A clear formal return to work procedure is welcome on the basis that
stakeholders tend to agree that action is needed in the face of the high prevalence of
chronic illness and the scale of long-term sickness absence and rising expenditure
linked to sickness and disability benets. However, there is also consensus that a
more thorough ex ante impact assessment should have been conducted and that the
procedure should be revised.
Trade unions and employers share the view that informal procedures oer a more
ecient and exible approach to the return to work in which the occupational physician
can give advice instead of making binding decisions. Moreover, informal procedures
allow for a case-by-case approach, taking into account sectoral and company-level
considerations as well as those specic to the worker’s health and preferences. Formal
procedures might then only come to be used where other informal options have been
explored or if there is a conict between the employee and the employer. Employers
are also prone to criticise the return to work procedure as too cumbersome in terms of
administration as well as over-formalised and slow. Together, the social partners also
underline the primary importance of prioritising prevention in company-level social
dialogue so as to avoid chronic diseases such as mental and musculoskeletal disorders.
Another common criticism relates to the frequency with which formal return to work
procedures lead to a contract termination for medical reasons; these can result from a
decision by the occupational physician that the employee is permanently unt to return
Shaping an evolving framework on return to work: the role of the social partners in Belgium
49Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
to the former job (i.e. a category C or D decision, as designated in the legislation).
9
Such criticism is particularly oered by trade union representatives who describe the
legislation as having been drafted without having considered the potential unforeseen
impacts of the procedure for contract termination. Consequently trade unions
sometimes advise their members not to engage in the formal procedure. This aspect
was also referred to in one of the CNT/NA’s unanimous opinions (2018b). Available
data from 2018 (CNT 2018c) shows that the large majority of decisions taken by
occupational physicians were category D decisions (68 per cent), i.e. that the worker is
denitively unt to return to work in the same company. There is no systematic support
provided to this type of worker and little is known about their situation after dismissal.
Support measures and procedures exist for them, such as initiatives by INAMI/RIZIV
and the regional employment services, but the social partners underline the need for a
coordinated and systematic approach to raise awareness on this aspect.
The lack of public, reliable data on the return to work after chronic illness has also
been raised by the social partners as it renders evaluation of the new policy more
dicult (CNT 2018c). This is partly a reection of the lack of data on the situation of
former employees who have been dismissed for medical reasons following a category
D decision. However, the lack of consistent data also hampers an analysis of the
situation of employees who have been reintegrated into their company, for example
regarding adaptations in terms of workload, working time and work tasks. Better data
availability would allow a measurement of the impact of the return to work on the
careers of employees whether or not they return to the same company. It would also
enable a better understanding of the gendered implications of the return to work, as
some female-dominated sectors tend to allow for less exibility in terms of tasks and
display more atypical and precarious forms of employment, such as the cleaning sector.
It is also clear that the public debate tends to be over-focused on sanctions and the
assignment of responsibilities and insuciently on incentivising employers and
employees to engage actively in the return to work. Stakeholders from both trade
unions and employer organisations also regret the absence of support mechanisms
to accompany stakeholders or guide them along the return to work process, including
inside the rm. The cost of return to work procedures can be a burden on employers,
especially on SMEs who often lack the human resources required to implement a return
to work procedure and reorganise a team where the returning employee does so on a
medical part-time basis. Another issue highlighted by trade unions is that employers are
not strongly incentivised to invest in prevention or create opportunities for adapted work
in the company given the short duration of the guaranteed salary period. One avenue
suggested by the social partners is to revise the legislation to make specic provision for
SMEs and to provide them with further support to implement reasonable adaptations.
9. As part of the work ability assessment, the occupational physician declares whether the employee is temporarily
unt or permanently unt to perform his or her former job. If the employee is declared t, the doctor then
evaluates whether an adapted job can be performed in the meantime within the company (category A decision)
or not (category B decision). If the employee is declared permanently unt to perform his or her former job, the
doctor also evaluates if an adapted job or another job can be performed in the meantime within the company
(category C decision) or not (category D decision). A Category E decision means that the employee is not yet
ready for a return to work and will be re-examined every two months.
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations50
The social partners in the CNT/NA are also agreed on several recommendations for
modications (CNT 2018c). They argue for more consultation with stakeholders before
the occupational physician takes a category C or D decision and for the provision of
support from a trade union representative or a member of the company’s health and
safety committee during the procedure. In addition the social partners have asked for
a change in the timing of the procedure, which currently leaves either too much or too
little time for dialogue and consultation, while asking that the occupational physician
better underlines the remaining capabilities of the employee in the work ability
assessment. The social partners also tend to agree with campaigning and patient
support organisations on the lack of centralised access to information for employers
and employees.
Furthermore there is evidently a need to enhance cooperation between doctors.
Multiple specialists are involved in examining a worker’s medical le, including
occupational physicians, medical experts from the insurance providers and the
general practitioner treating the worker. In most cases, decisions on the tness of the
worker to go back to work are not coordinated between these specialists as a result
of condentiality reasons, data sharing constraints and the lack of time. Therefore,
the social partners have requested the creation of a digital tool that could help with
data sharing and coordinated follow-up between the dierent health professionals and
institutions involved in the return to work process. In parallel, pilot projects such as
the ‘Trio groups’ project have been implemented by professional medical associations
to address this lack of multidisciplinary collaboration between the three professions.
This is a means to the organisation of common training events and dialogue (Lenoir
2017).
Finally there is a need for cultural change to avoid the stigma around the return to
work. There is a growing consensus that going back to work following chronic illness
can be good for the health of the worker and can prevent social exclusion. This, however,
requires a shift in mindset towards focusing on and building on the remaining abilities
of the worker. Therefore, the social partners – via the CNT/NA – have underlined that
the ‘disability case manager’ training organised by INAMI/RIZIV should be more
widely promoted among rms (CNT 2018c). This would help raise awareness within
HR services about good practice regarding absenteeism and the return to work.
4. The return to work process at company level and the
involvement of the social partners
4.1 Workers’ experiences of the return to work process
Analysis of the survey and interview data helps us obtain a fuller assessment of the role
of the social partners in shaping the return to work in Belgium, their involvement at
company level and their impact on the return to work experience of employees within
the rm. However, it is important to acknowledge the limitations of the survey data
given the small size of the sample.
Shaping an evolving framework on return to work: the role of the social partners in Belgium
51Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
From the perspective of workers returning to work following chronic illness, support
from and the involvement of their boss, colleagues and health professionals appear to
play important roles. Family seems to do likewise, but only in combination with these
other actors. Workers indicated, however, that trade union or employee representatives,
rehabilitation institutes and NGOs play only a minor role in facilitating the return to
work after sickness leave.
10
There is thus a mixed picture as regards the role of trade unions in facilitating the
return to work at company level. Trade unions emphasise the central role of their local
representatives but others, including employer organisations, state that the role of trade
unions at company level is rather weak on the basis that the return to work is more of an
individual than a collective issue. More than half of respondents in the worker survey
were trade union members, with almost two-thirds stating that they had access to a
trade union or other employee representative in their workplace. Nevertheless workers
are generally not satised with the support oered by trade unions in their return to
work and only one in ve receive the expected level of advice or guidance from their
trade union. Accordingly trade union representatives are generally not regarded by
workers as important in the return to work process.
One explanation for this limited role is that personal health matters are seen to be
too sensitive to be handled through social dialogue. Local representatives often do not
have access to information on employees struggling with return to work issues unless
they are directly approached, given both the condentiality concerns and that the
employer has no obligation to communicate with union representatives on this matter.
Most workers state that they did have concerns about returning to work. These include
the potential lack of employer support where productivity or concentration levels did
not fully meet managers’ expectations, the unwillingness of the employer to adjust
working conditions post-illness and an expectation that they would continue to
work long hours, as they had done previously, immediately upon returning to work.
Although some employees have positive experiences, the majority express feeling left
alone in the return to work process with a lack of support from their employer but also
from the trade union. Several employees report that, ultimately, they changed their job
after resuming work. Some also express frustration with the regulations governing the
return to work process.
The majority of surveyed workers beneted from few adjustments upon returning
to their jobs. The most common adjustments were made in the formal work contract
(e.g. from full-time to part-time work) together with the oer of exibility to facilitate
medical appointments, but only about one-third of workers received reasonable or
extensive support on this. The postponement of work deadlines seemed to happen only
in a few cases. The clear majority of respondents (60 per cent) receive limited or no
support in adjusting their work environment, their daily working time (in terms of long
or night shifts) or their tasks so as to share responsibilities with colleagues.
10. More detailed analysis of the survey results can be found here: http://www.celsi.sk/en/projects/detail/64/
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations52
4.2 Perspectives of company actors on the return to work process
at company level
Most companies indicate that employee absence does have an eect on the organisation.
In particular, the worker might not be replaced in the rst instance but workow has
to be rearranged and job tasks divided between other employees. Such adjustments
are, as we have reported already, especially dicult for SMEs which lack the capacity
to redirect workow. During the return to work process, companies consider certain
resources to be helpful, specically legal advice during sickness leave and external
counselling from doctors or therapists as well as professional associations. However,
external counselling, information on workplace adjustments and guidance on nancial
strategies in dealing with sickness leave are sadly lacking.
The work culture in Belgium and the continuing stigma around workers with chronic
illness does inuence workers’ ability successfully to return to work and many
employers are indeed unwilling to adjust tasks for returning employees. Employers
do not perceive workers to be less committed after being diagnosed with a chronic
illness but they do feel that an employee returning to work on reduced duties would
increase the workload of colleagues and a majority disagree that workers should have
the right to a gradual return to work on full pay. However, employers also regard that
workers should be entitled to adjusted working duties at the organisation’s discretion
(70 per cent) or as a legal entitlement (55 per cent). Moreover, most agree that staying
in touch with an employee during their absence was important (89 per cent) while most
also believe that returning to work during treatment should be encouraged wherever
possible.
Return to work is addressed in company-level collective agreements in only a minority
of companies (20 per cent), but 60 per cent conrm that they consult on their
organisation’s return to work issues with trade unions or employee representatives. In
most cases, these interactions are of a regular nature with a trade union representative
being part of a health and safety committee that discussed return to work. Praised
outcomes from interactions with union representatives on the matter include training
sessions for managers on interacting with chronically ill employees and informal
agreements on the role of employee representatives in supporting the management of
the return to work process. Specic return to work provisions in collective agreements
are also seen as benecial outcomes of interaction with union representatives.
4.3 Interactions between employer and employee in facilitating
the return to work
From a worker’s perspective, it seems that experience of the return to work process is
quite individualised with little being coordinated at company level. Most employees
declare that adjustments in their tasks or responsibilities are not negotiated between
their trade union or employee representatives and their employer. Therefore,
negotiations at company level do not seem to play an important role in the return to
work process. Employees are also rather critical of the degree of coordination between
Shaping an evolving framework on return to work: the role of the social partners in Belgium
53Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
health professionals and employers as well of the preparedness of their company to
make reasonable adaptations upon their return. Although half feel welcome at their
workplace, only a few receive guidance or mentoring from their employer (26 per cent)
or their trade union (13 per cent) during their return to work.
Reecting on these results, while procedures do exist at company level they are often
not well implemented and can be dicult to understand for the worker. In addition,
the creation of a welcoming social environment in the company, while crucial, can be
challenging particularly as colleagues might be sceptical of reintegration given that the
reorganisation of workow may well increase the burden on them.
Most managers say they have regular interactions with workers on sick leave (70 per
cent) and in an informal setting, i.e. via phone calls, friendly conversations or indirect
information via colleagues (77 per cent). Similarly, qualitative data emphasises the
importance of informally keeping in touch with workers in facilitating their return
to work although employers clearly have to be careful not to give the impression of
‘harassing’ the employee. A majority of managers in the survey declare that, during
sick leave, the company generally keeps employees informed about work-related issues
but does not involve them in work-related planning and decisions.
Informal coordination between the employee and employer is the preferred way of
dealing with the return to work after sick leave. This entails thorough discussion and
planning of reintegration before the employee’s return to work, from which to develop a
joint strategy, as well as cooperation with external organisations on occupational health
and safety. Managers perceive that ad hoc adjustments in working time and exibility in
workload are quite widespread and that, in general, they are understanding, declaring
that they do not expect workers to come back to their pre-illness productivity levels.
Measures implemented less often include common standard procedures and a dened
adjustment plan for each employee discussed in the health and safety committee –
even though it is now mandatory in medium and large companies to have a company-
level policy on employees’ return to work. Medical returns are, however, only rarely
discussed by health and safety committees in practice.
Overall, the results from the company survey are somewhat at odds with those from
the interviews and discussions with social partners and other key stakeholders, with
the latter reporting that many companies struggle to oer substantial adjustments to
employees and that employers often expect full productivity upon return especially
since they lacked the incentives to oer adjustments given the current legislation. This
may be due to selection bias in that those companies which are more interested in the
issue of the return to work, and more committed to facilitating it for their employees,
are more likely to participate in a survey and contribute to research on the topic.
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations54
4.4 Views on the future potential for social dialogue to support the creation
and implementation of return to work policies at company level
As regards the future role of social dialogue to support return to work policy at
company level, employees favour a stronger role for trade unions, agreeing that trade
unions should continue to be involved in health-related issues and that the return to
work should be part of the agenda for social dialogue negotiations. Employees seem,
however, to prefer the negotiation of binding agreements with the employer on making
reasonable accommodation during the return to work and tend to be indierent to
individual consultation with trade unions.
On the one hand, results from the social partner survey indicate that trade union
representatives strive for more active involvement in the implementation of return to
work policy in Belgium. On the other hand, representatives of employer associations
are more split on their preferred level of involvement: a quarter are satised with the
current situation although another quarter wish for greater involvement. Employer
organisations similarly tend to see return to work as an individual rather than a
collective matter, where unions only play a limited role; while trade unions emphasise
the potential for social dialogue at company level to inuence return to work processes.
According to managers, there are a few elements that should change in their companies
regarding the return to work such as better interpersonal relations with employees
to deal directly with employee reintegration, and better cooperation with health
professionals and campaigning and patient support organisations to facilitate the
return to work process. Managers also tend to agree that organisational policies should
be improved. One avenue for improved organisational policies is the development
of a return to work strategy in health and safety committees, as already mandated
by national legislation since 2016, where the social partners can be involved in the
process of discussion. Managers do, however, report a sceptical outlook on the current
legislation which none regard as providing good guidelines for company-level action.
At the same time, managers do not wish for more specic legislative provisions on
company-level return to work policies; instead they prefer exibility.
5. Discussion of research findings and conclusion
This chapter has analysed the role of social partners in Belgium in the design and
implementation of policies on return to work for workers after, or with, chronic illness.
This became an important issue on the political agenda in Belgium in the 2010s with
an increasing number of cases of sick leave due to chronic illness and soaring social
security expenditures. The current Covid-19 pandemic appears to have added further
challenges on the return to work, causing health complications for chronically ill
workers. Faced with increasing concern over incapacity for work, absenteeism (mainly
due to mental health and musculoskeletal illnesses) and the nancial sustainability of
the Belgian welfare state, governments have sought to address the economic impact of
sickness absence by means of activation policies, i.e. by oering more opportunities to
previously sick employees to come back to work. This resonates with the objectives of
Shaping an evolving framework on return to work: the role of the social partners in Belgium
55Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
the Europe 2020 strategy which is aimed at a gradual increase in the presence at work
and tness for work of previously ill employees, facilitating their longer involvement in
the labour market.
The analysis in this chapter has shown that the social partners assume a signicant and
multi-faceted role in the development and implementation of return to work policies in
Belgium. Social dialogue has helped substantially in developing a new framework for
the return to work, even though this has important limitations. After INAMI/RIZIV
put on the agenda the need to improve the reintegration of employees suering from
chronic illness, the social partners – via the CNT/NA – participated in the design
of a new return to work procedure targeted at employees seeking to return to their
former occupational activity. The social partners were able to inuence the legislation
by putting forward some key principles, such as the concept of a voluntary return to
work process, the key role to be occupied by the occupational physician and the need
for both collective return to work and concrete incentives. However, the 2016 reform’s
unforeseen consequences have also been criticised, especially by trade unions, mostly
regarding the issue of contract termination for medical reasons.
Since EU-OSHA established its typology of systems in the return to work (2016), our
ndings show that the Belgian policy framework has evolved towards early intervention
and a case management approach. This is exemplied by the new obligation on health
insurance providers to assess, at the start of the period of invalidity, options for
the return to work based on the employee’s medical condition. While the nancial
incentives for employers to engage in early planning of the return to work have not
been substantially changed, employers now have clearer responsibilities regarding the
creation of an individualised return to work plan for the employee and of a company
policy on return to work. Employees can benet from transitional work options based
on the work ability assessment performed by the occupational physician. However,
there are still coordination problems between health professionals and the stakeholders
involved at company level.
Eective social dialogue can certainly help with the return to work, but sectoral and
rm characteristics play a more important role in determining the success of the
return to work itself. Also, return to work following chronic illness can be dicult to
tackle via social dialogue, given its sensitive and private nature, while it also involves
workers shifted to the margins of traditional social dialogue as they are excluded from
occupational life during the period of their illness. However, employers can play a key
role at rm level, beyond human resources and occupational health services, in ensuring
smooth reintegration for example by involving colleagues and line managers in the
process. Some instruments and legal dispositions are in place, such as the obligation
to discuss annually within the health and safety committees a company procedure
on the return to work. However, these dispositions are not well implemented on the
ground. Similarly, trade union or employee representatives are accorded an important
role in the new legislation (CSC 2019). They can perform important functions such as
oering emotional support during the return to work process and providing legal advice
to the employee in the case of conict with the employer as well as strategic guidance
on the complexity of the procedure and during negotiations with the employer on the
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations56
reintegration plan. Additionally they can act as a mediator between HR and the employer
as well as with colleagues. Trade union representatives can also put return to work on
the agenda of health and safety committees which have the capacity to assess company
return to work policies based on the quantitative and qualitative evaluations provided
by the occupational physician. As part of these committees, trade union representatives
can also contribute to the evaluation of the company policy and its implementation on
the ground. However, there is substantial room for improvement in this area especially
due to a lack of information on the part of union representatives and employees, as well
as because of the sensitive nature of people returning to work with chronic illness.
Our ndings highlight that a tailored company-level approach tends to be more
ecient when combined with a broad national framework enforcing basic rights and
requirements regarding return to work procedures. Informal procedures are often
praised as a more ecient and exible approach to the return to work in which the
occupational physician can give advice instead of making binding decisions. In parallel,
social partners at the federal level could coordinate via the CNT/NA to issue guidelines
based on best practice as a means of helping companies and local union representatives
design company-level return to work procedures. Return to work after sick leave could
also be tackled at sectoral or cross-sectoral level in a similar approach to that used by
the social partners in addressing burnout (CNT 2018a). Ultimately, however, gathering
reliable and systematic data on the outcomes of the return to work and the situation of
chronically ill employees is the issue that needs to be prioritised most of all.
References
Akgüç M., Kahancová M. and Popa A. (2020) Working paper presenting a literature review on
return to work policies and the role that industrial relations play in facilitating return to work
at the EU, national and sub-national levels, REWIR Project No. VS/2019/0075, Bratislava,
Central European Labour Studies Institute.
CNT (2015) Avis N° 1.923: Plate-forme de concertation entre acteurs impliqués dans le processus
de retour au travail volontaire des personnes présentant un problème de santé – Avant-projet
de loi portant dispositions diverses en matière d’assurance indemnités et d’emploi [Opinion
N° 1.923 : Platform for consultation between stakeholders involved in the process of the
voluntary return to work of people with a health problem - Dra law on various provisions on
benefit and employment insurance], Brussels, Conseil National du Travail. www.cnt-nar.be/
AVIS/avis-1923.pdf
CNT (2018a) Avis N° 2.080: Accord interprofessionnel 2017-2018 – Burn-out [Opinion
N° 2.080: Cross-sectoral agreement 2017-2018 – Burn-out], Brussels, Conseil National du
Travail. www.cnt-nar.be/AVIS/avis-2080.pdf
CNT (2018b) Avis N° 2.090: Plate-forme de concertation entre acteurs impliqués dans le
processus de retour au travail volontaire des personnes présentant un problème de santé –
Avant-projet de loi portant la promotion de la réinsertion socioprofessionnelle des personnes
en incapacité de travail [Opinion N° 2.090: Platform for consultation between stakeholders
involved in the process of the voluntary return to work of people with a health problem – Dra
law on the promotion of the socio-occupational reintegration of people with incapacity for
work], Brussels, Conseil National du Travail. www.cnt-nar.be/AVIS/avis-2090.pdf
Shaping an evolving framework on return to work: the role of the social partners in Belgium
57Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
CNT (2018c) Avis N° 2.099: Plate-forme de concertation entre acteurs impliqués dans le
processus de retour au travail volontaire des personnes présentant un problème de santé –
Evaluation et propositions relatives à la réglementation en matière de réintégration [Opinion
N° 2.099: Platform for consultation between stakeholders involved in the process of the
voluntary return to work of people with a health problem – Evaluation and proposals for
reintegration regulations], Brussels, Conseil National du Travail. www.cnt-nar.be/AVIS/avis-
2099.pdf
CNT (2018d) Avis N° 2.108: Deal pour l’emploi [Opinion N° 2.108: Job Deal], Brussels, Conseil
National du Travail. www.cnt-nar.be/AVIS/avis-2108.pdf
CSC (2019) Remettre en selle: De retour au travail après une maladie de longue durée [Getting
back on track: Returning to work aer long-term illness], Brussels, Confédération des Syndicats
chrétiens. https://bit.ly/3wCwCmX
ETUI (2016) Industrial relations in Belgium: background summary. https://www.etui.org/covid-
social-impact/belgium/industrial-relations-in-belgium-background-summary
EU-OSHA (2016) Rehabilitation and return to work: analysis report on EU and Member States
policies, strategies and programmes, Luxembourg, Publications Oce of the European Union.
Eurofound (2019) How to respond to chronic health problems in the workplace?, Luxembourg,
Publications Oce of the European Union.
European Commission (2018) Country Report Belgium 2018 - 2018 European Semester:
Assessment of progress on structural reforms, prevention and correction of macroeconomic
imbalances, and results of in-depth reviews under Regulation (EU) No 1176/2011,
COM(2018) 120 final, 7 March 2018.
European Commission (2019) Country Report Belgium 2019 - 2019 European Semester:
Assessment of progress on structural reforms, prevention and correction of macroeconomic
imbalances, and results of in-depth reviews under Regulation (EU) No 1176/2011,
COM(2019) 150 final, 27 February 2019.
European Commission (2020) Country Report Belgium 2020 - 2020 European Semester:
Assessment of progress on structural reforms, prevention and correction of macroeconomic
imbalances, and results of in-depth reviews under Regulation (EU) No 1176/2011,
COM(2020) 150 final, 26 February 2020.
Federal Public Service for Social Security (2019) Social security: everything you have always
wanted to know (in Belgium), Brussels, Federal Public Service for Social Security.
FGTB (2019) Retour au travail après une maladie de longue durée: Guide pratique pour les
délégués en entreprise [Returning to work aer long-term illness: A practical guide for lay
representatives], Brussels, Fédération Générale du Travail de Belgique. https://bit.ly/3e2uX3A
Franklin P., Bambra C. and Albani V. (2021) Gender equality and health in the EU, Luxembourg,
Publications Oce of the European Union.
Goorts K., Vandenbroeck S., Rusu D., Du Bois M. and Godderis L. (2018) Screening for the risk on
long-term sickness absence, Journal of Public Health Research, 7 (2), 1419.
Guazzi M., Faggiano P., Mureddu G. F., Faden G., Niebauer J. and Temporelli P. L. (2014) Worksite
health and wellness in the European Union, Progress in cardiovascular diseases, 56 (5),
508-514.
Houwing H. and Vandaele K. (2011) Liberal convergence, growing outcome divergence?
Institutional continuity and changing trajectories in the ‘low countries’ in Becker U. (ed.)
(2011) The changing political economies of small West European countries, Amsterdam,
Amsterdam University Press, 125-148.
Mehtap Akgüç, Nina Lopez Uroz and Leonie Westhoff
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations58
Hufkens T., Buysse L., Van Mechelen N. and Verbist G. (2017) Fit for the labour market? An eort
to reduce inactivity traps in the transition from benefit to work in the Belgian sickness and
disability system, CSB Working Paper 17/11, Antwerp, Herman Deleeck Centre for Social
Policy.
Lenoir E. (2017) Les groupes Trio [Trio Groups], Santé Conjuguée, 81, 22-24. www.maisonmedicale.
org/Les-groupes-Trio.html
Mutualités Libres (2019a) Reprendre le travail pendant une période d’incapacité [Returning to
work during a period of incapacity]. www.mloz.be/fr/publications/brochures/reprendre-le-
travail-pendant-une-periode-dincapacite
Mutualités Libres (2019b) Reprendre le travail: quels facteurs de succès? [Going back to work:
what are the success factors?]. www.mloz.be/sites/default/files/publications/factsheet_
reprendre_le_travail.pdf
Mutualités Libres (2019c) Reprendre le travail: quels facteurs de succès? [Going back to work:
what are the success factors?], Health Forum, 39, 6-17. www.mloz.be/sites/default/files/
publications/hf_39_fr.pdf
INAMI (2019) Disability Management: de la formation à la certification [Disability Management:
from Training to Certification], Brussels, Institut national d’assurance maladie-invalidité.
www.inami.fgov.be/SiteCollectionDocuments/brochure_disability_management_formation_
certification.pdf
OECD (2013) Mental health and work: Belgium, Paris, OECD Publishing.
Pacolet J. (2019) ESPN Thematic report on financing social protection – Belgium, European
Social Policy Network (ESPN), Brussels, European Commission. https://ec.europa.eu/social/
BlobServlet?docId=21869&langId=en
Saks Y. (2017) A better understanding of developments in the numbers claiming disability
insurance, NBB Economic Review September 2017, 55-68. www.nbb.be/doc/ts/publications/
economicreview/2017/ecorevii2017_h5.pdf
Scharpf F. W. (1997) Games real actors play: actor-centered institutionalism in policy research,
Boulder CO, Westview Press.
Securex (2018) L’absentéisme en 2018 [Absenteeism in 2018], 5 juin 2019. www.securex.be/fr/
publications/white-papers/absenteisme-en-2018
SPF Emploi (2018) Retour au travail après une absence longue durée pour raison médicale.
Prévention et réintégration. [Federal Public Service for Employment and Social Dialogue,
Returning to work aer a long-term absence for medical reasons: Prevention and
reintegration], Brussels, Service public fédéral Emploi, Travail et Concertation sociale. https://
emploi.belgique.be/fr/publications/retour-au-travail-apres-une-absence-longue-duree-pour-
raison-medicale-prevention-et
WHO (2020) What we know about the long-term eects of COVID-19, Coronavirus Update 36.
https://www.who.int/publications/m/item/update-36-long-term-eects-of-covid-19
All links were checked on 31.05.2021.
59Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Chapter 3
Why do individualised industrial relations mean
the underutilisation of policy tools?
Workers who fall ill in Estonia
Marti Taru and Triin Roosalu
1. Introduction
Estonia is a small, post-socialist country with a population of 1.3 million. People have a
longer working life than in most other European countries: the duration of working life
in Estonia in 2019 was 39 years compared to an EU-28 average of 36.4.
1
Moreover, the
number of employed people aged 15-74 has been increasing over time, from 568 000
in 2010 to 671 000 in 2019 (an increase of 18 per cent),
2
despite the population staying
relatively stable.
3
While the share of those aged 65-74 in the total population has
remained roughly the same, at 10 per cent,
4
the share of ‘elderly workers’ between these
ages has increased from 15 per cent to 27 per cent. The unemployment rate in Estonia
has also been relatively low, at 5 per cent or below between 2015 and 2019.
Longer working life comes from the increased employment of elderly people who also
are likely to suer from chronic conditions. In 2016, the self-rated health condition of
the Estonian population was relatively poor in general, with health being assessed as
good or very good by 53 per cent of the population compared to an average of 68 per
cent across the EU-28 (OECD and European Commission 2018). In relation, the
number of expected healthy years in 2018 in Estonia was notably lower than in the
EU on average, meaning that a relatively high share of elderly employees had some
kind of health problem. The chronic morbidity rate in Estonia signicantly exceeds
that of the EU average at around 50 per cent in Estonia in 2018 compared to lower than
40 per cent in the EU. All these imply that more people of working age are likely to face
health problems during their career, making the return to work – or reintegration –
a relevant issue in Estonia. Additionally the relatively low unemployment rate implies
that companies have a strong interest in hiring or retaining people including those with
reduced work capability arising from health conditions.
Despite the relatively poor condition of health, the number of days per year and per
person compensated because of absence from work due to illness was, between 2000
and 2018, lower on average in Estonia than in the OECD, uctuating between 7.3
and 11.3 days in the former but averaging 12 days in the latter.
5
Public spending on
incapacity, which refers to spending due to sickness, disability and occupational injury,
1. Eurostat. Table LFSI_DWL_A. Duration of working life - annual data.
2. Statistics Estonia. Table TT0202. Employed persons by age group and economic activity (1989-2019).
3. Statistics Estonia. Table RV021. Population by sex and age group, 1 January.
4. Statistics Estonia. Table RV021. Population by sex and age group, 1 January.
5. OECD.Stat. Health Status: absence from work due to illness, https://stats.oecd.org/index.
aspx?DataSetCode=HEALTH_STAT#.
Marti Taru and Triin Roosalu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations60
was around 2 per cent (close to the OECD average) between 2010 and 2017.
6
People not
taking more days o work, even if they need to, is likely to be a sign of workers’ weak
labour market position.
Estonia has a poorly developed framework for the return to work with very limited (or
a lack of) coordination between stakeholders and a restricted amount of institutional
support but with ad hoc initiatives implemented by various actors. In this chapter we
demonstrate that the return to work in Estonia is best understood as an integrated
policy eld that comprises measures in several areas including medical, labour market,
social welfare and rehabilitation services. In terms of policy provision, there is greater
visibility of the healthcare dimension. Although a reasonably solid institutional support
system has been developed in respect of measures to ease labour market integration
and specically the return to work, employers and employees do not seem to have
enough information about this and thus no faith that such support would actually exist
in practice. Based on our analysis this seems to translate into rather meagre workplace
level provision when it comes to return to work arrangements and, at least in part, this
owes to an unsupportive organisational culture and a lack of organisation-level trade
union activity.
The discussion in this chapter is based on desktop research of relevant documents
such as legislative acts, research reports, policy plans and reports, and the mass
media. Empirical eldwork was also conducted based on interviews and roundtable
discussions held with relevant national stakeholders, group discussions with employers
and trade unions and three online surveys distributed to social partners, workers and
company managers in Estonia.
7
The chapter is structured as follows: in the next section, we introduce the policy
framework on the return to work before exploring more closely the involvement of the
social partners in shaping return to work policy at national level, thereafter discussing
the issue at company level. The last section provides concluding remarks.
2. Policy framework for the return to work in Estonia
In Estonia, public policy discussions and issues surrounding the return to work
following chronic illness fall mainly into the area of regulating and supporting the
employment and economic activity of people with a work capability lower than 100 per
cent. Such a condition may be temporary or permanent and it may be induced by work-
related circumstances although not necessarily so. In general there are three reasons
for reduced work capability:
— disability, which a person has been living with since before the start of that person’s
working life, probably but not necessarily since birth;
6. OECD. Public spending on incapacity, https://data.oecd.org/socialexp/public-spending-on-incapacity.htm.
7. For a more in-depth overview, see the Estonia country report by Taru and Roosalu (2021).
Why do individualised industrial relations mean the underutilisation of policy tools? Workers who fall ill in Estonia
61Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
— occupational illness which has led to a temporary or permanent condition of
reduced work capability; and
— occupational injury which has led to a temporary or permanent condition of
reduced work capability.
Return to work is supported by a mix of several sectoral policies: healthcare;
employment relationships; active labour market policies; social welfare; and social
care policies. The main legal acts that frame employment, illness, sickness leave and
the return to work after treatment include the Employment Contracts Act,
8
the Health
Insurance Act,
9
the Work Ability Allowance Act
10
and the Occupational Health and
Safety Act.
11
In addition a range of other legislative acts regulate various aspects of
employment contracts.
12
Meanwhile, there are two national-level policy documents
that address chronic diseases and their prevention:
— the Disease Prevention Development Plan 2016-19 (from the Estonian Health
Insurance Fund); and
— the National Health Development Plan 2020-30 (Ministry of Social Aairs, now in
the process of development), listing chronic diseases as a separate category within
the wider disease prevention plan.
The legislative act that regulates employment when an employee falls ill or is injured is
the Employment Contracts Act. This allows an employer to terminate an employment
contract extraordinarily where the employee has not been able to perform the duties of
the job, due to his or her state of health, for more than four months (para. 88). However,
before the termination of the employment contract, in particular on the basis of a
health condition, the employer must oer other work to the employee. This includes
organising, if necessary, in-service training, adapting the workplace or changing the
employee’s working conditions where such changes do not incur disproportionately
high costs for the employer and where the oer of other work may, considering the
circumstances, be reasonably expected.
The Health Insurance Act denes the categories of insured persons. All employed
and self-employed people are covered by insurance. The Work Ability Allowance Act
denes the access to employment of people with reduced work capability caused by
long-term health damage and ensures an income for them under the conditions and to
the extent provided by law. The Occupational Health and Safety Act frames the area of
occupational health and denes the role of medical professionals such as occupational
health doctors, occupational health nurses and other medical professionals which are
relevant actors in the return to work context.
8. Employment Contracts Act, https://www.riigiteataja.ee/en/eli/ee/Riigikogu/act/529122020003/consolide.
State Gazette 2009, 5, 35.
9. Health Insurance Act, https://www.riigiteataja.ee/en/eli/ee/504062020003/consolide/current, State Gazette
19.06.2002, 62, 377.
10. Work Ability Allowance Act, https://www.riigiteataja.ee/en/eli/530042020009/consolide State Gazette
13.12.2014, 1.
11. Occupational Health and Safety Act, https://www.riigiteataja.ee/en/eli/ee/527052014007/consolide/current.
State Gazette, 1999, 60, 616.
12. Labour inspectorate homepage, https://www.ti.ee/et/tookeskkond-toosuhted/oigusaktid-viited.
Marti Taru and Triin Roosalu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations62
In 2016, the work ability reform
13
was launched bringing together all labour market
participation and employment-related services and transfers under one institution
– Eesti Töötukassa (the Estonian Unemployment Insurance Fund; ET). Since mid-
2016, work capability has also been assessed by the ET. The reform was rooted in the
excessive nancial burden on the public budget arising from state-paid pensions to
disabled persons and to people with permanent partial or full loss of work capability, as
well as in the nding that a considerable percentage of those with a medical condition
did not benet from state support. An audit carried out by the National Audit Oce of
Estonia in 2010 showed that the number of the disabled and reduced capacity pensions
had been increasing since 2004, rising to over 200 000 by 2010 (Uder 2010) in a
country of 568 000 economically active people.
Expenditure on disability had been increasing at a relatively high pace, from
€56 million in 2000 to €279 million by 2010. This was a nearly ve-fold increase and
a disproportionally high one as two other large areas of social benets had increased
less: expenditure on old age pensions had increased 2.5 times and that on healthcare by
a factor of three. Expenditure on disability had reached 12 per cent of all social benet
expenditure by 2013, a doubling of the 6.6 per cent which was the case in 2000.
14
This
was alarming and commanded policy-makers’ attention.
Veldre et al. (2012) established that the Estonian regulations and policies meant
to support people with reduced work capability due to medical condition were
comparatively inecient and needed signicant amendment. The main problem was
that the focus until then had been on health loss instead of a person’s capacity for work.
Furthermore the assessment of work capacity needed to be prospective and to include
recommendations of appropriate support measures that would help the person get back
into the labour market. Essentially, this meant a transition from the previous system,
in which a person with a loss of health was seen as a passive beneciary of state aid, to
one in which a person with reduced work capacity, as well as that person’s employer,
were seen as active agents supported by state services. Additionally the assessment of
health condition, work capability, employment opportunities and support measures
was regarded as in need of better coordination with each other in order to be eective;
hence the aim of co-locating all these services in one institution instead of several as
had been the situation until then. Preparation of the reform took several years but, in
2016, it was ready to be launched.
As the key institution in the landscape of labour and health, ET implements signicant
aspects of labour market policy in Estonia. It oers a range of measures to employees
who need support at the workplace because of their health condition as well as to
employers on health-related issues. As a public institution, the ET board consists of six
members: according to the law, two members are named by the national government,
two by the national employer organisation and one each by the two national-level trade
13. For more on the work ability reforms see the homepage of the Estonian Unemployment Insurance Fund,
https://www.tootukassa.ee/eng/content/work-ability-reforms; and that of the Ministry of Social Aairs,
https://www.sm.ee/en/new-working-ability-support-system.
14. Statistics Estonia, table SKK02: Expenditure on Social Benets by Indicator, Function and Year.
Why do individualised industrial relations mean the underutilisation of policy tools? Workers who fall ill in Estonia
63Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
union confederations. The tripartite nature of this body means that the issues that ET
regulates (including those related to the return to work) are the object of national-level
social dialogue.
At establishment level, health and workplace-related issues are addressed by
töökeskkonna volinik (working environment commissioners). By law, every organisa-
tion with more than 150 employees (and in others if the labour inspectorate so requires)
should establish a working environment committee with the responsibility of ensuring
occupational health and safety. Such a council needs to consist of representatives of
management as well as those of employees. The working environment commissioners
elected by employees have a responsibility for all occupational health and safety
issues. Such mandatory committees are meant to foster social dialogue and are legally
comprehended on the basis of an understanding that trade unions are not present in
every organisation.
Occupational health and safety is thus one of the rare themes on which the state has
made social dialogue compulsory. This does not mean that it works very well across
all organisations and frequently it is the illusion of industrial relations which has
been created under this framework rather than actual social dialogue (see also Ost
(2000) on the emergence of illusionary corporatism in central and eastern Europe).
The election of mandatory representatives creates an image of worker representation
but, where there are no trade unions, the infrastructure for those representatives to
engage meaningfully with workers to establish common grounds for what to negotiate
with the employer is lacking. Thus every elected representative approaches the role
foreseen by the law as they please – and, in the case that they are too busy with other
tasks, the return to work may be not among their priorities; while, if their role is less
valued by workers than by the management, this further decreases their chances of
being ecient either bargaining or in consultation (see Kallaste et al. 2007).
While company-level dialogue is not always ecient, the legal regulations set down
quite decent conditions for employees to apply for workplace adaptations. Yet there
are still no specic measures on the return to work for workers with chronic illness.
Additionally, with the exception of tuberculosis, there are no specic provisions for
dierent kinds of diseases. In general, when an employed person falls ill and needs
to be away from work, a doctor will issue a certicate for sickness leave to validate
it. Based on this certicate, the employer and Eesti Haigekassa (the Estonian Health
Insurance Fund; EH) pay benets for temporary incapacity for work, commencing on
the ninth day of illness. Sickness benet is paid at a rate of 70 per cent of daily income
and is subject to income tax. Although sickness benet is paid for 182 consecutive
days (240 days in the case of tuberculosis), employment protection lasts for only four
months. It is possible that better terms may be agreed upon at company level, but most
sectors do not have any provisions of this kind in sector-level collective agreements.
Thus we can conclude that there is no legal obligation to hire or retain workers with
chronic illnesses. ET, with its national-level tripartite social dialogue and its oer of
both benets and services to employers and employees in general, does support hiring
people with reduced work capacity which may encompass those with chronic illnesses.
Marti Taru and Triin Roosalu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations64
At organisational level, the law foresees a position to be responsible for addressing
health- and workplace-related issues – the working environment commissioner.
However, low trade union density and the priorities of employee representatives around
fundamental issues of membership growth and improved legitimacy (Kall 2020)
mean
that return to work issues occupy a rather lower level of priority.
3. Involvement of the social partners in shaping return to work
policy at national level
In terms of its industrial relations structure, Estonia belongs to the neoliberal
industrial relations system common to central and eastern European countries (EU
OSHA 2016; Akgüç et al. 2019). Industrial relations are mostly developed at national
level and much less so at the sectoral or company level (Kall 2020) while only a small
fraction of workers are trade union members: Estonia has the lowest union density
rates in Europe, declining from 94 per cent in 1992 to 4 per cent in 2017 (Visser 2019).
Collective bargaining coverage, at about 20 per cent, is signicantly lower than the
OECD average and far lower than in those countries which have the highest coverage.
Negotiations on the minimum wage, the main issue in social dialogue in Estonia, are
held by Eesti Ametiühingute Keskliit (the Estonian Trade Union Confederation; EAKL)
and Eesti Tööandjate Keskliit (the Estonian Employers’ Confederation, ETK). EAKL
has 17 sectoral trade unions as its members; while, as of 1 November 2020, ETK has 23
sectoral employer organisations and 127 individual companies as members, from all
economic sectors.
15
ETK is actively involved in public policy processes including those
which fall within the remit of ET and EH.
Our research highlights that the return to work in Estonia is best understood as an
integrated policy eld comprising measures in a range of areas including medical,
labour market, social welfare and rehabilitation services. Being such a fairly complex
eld, public policies related to the return to work are, however, perceived dierently by
the various stakeholders.
A representative of the Estonian Chamber of Commerce and Industry perceives the
return to work as belonging to the domain of workforce diversity, acknowledging that
a considerable part of employees either have a medical condition or other reasons why
they can work only under restricted conditions and who may need support to be able
to work; and that helping people with reduced work ability nd a job suits them and
benets the employer. A trade union representative thinks of return to work as an
additional area of social security for workers which could potentially contribute to their
(material) well-being. However, such thought processes are couched in nancial terms
– how much it would cost employers and the state to institute another form of insurance
and what it would mean in terms of new taxes or tax rates – while the representative
notes that employees as well as employers are more interested in discussing the level
of (minimum) wages rather than occupational health, disease or injury problems.
15. https://www.employers.ee/meist-2/liikmed/
Why do individualised industrial relations mean the underutilisation of policy tools? Workers who fall ill in Estonia
65Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Representatives of the Ministry of Social Aairs, as well as ET, tend to think of return
to work as a eld within the wider area of policy measures targeting occupational
health as part of the overall framework of employment and social heterogeneity. They
also view potential advances in the return to work from a longitudinal perspective –
measures that evolve together with other policy measures on social security and well-
being – while also observing the importance of the context set down by the 2016 work
ability reform.
Return to work policy has not been a distinct topic in social dialogue (except as part of
the joint operation of ET). This is most likely to be the result of a lack of communication
on the issue between stakeholders. Hence it is hard to describe the involvement of the
actors in discussions which are focused solely on return to work policies; the involvement
of stakeholders is based on other topics of social dialogue (where representatives agree
that they are suciently involved). The main reason behind such a level of involvement
has been that stakeholder participation in policy processes is one of the core principles
of public administration in Estonia. In particular, one of the aspects of the Estonian
system is the signicant role of the state as a mediator – or rather the initiator – of
policies in the return to work. Social dialogue on labour relations and employment in
general is organised and carried out by the Ministry of Social Aairs which assures that
trade unions, employer organisations, medical doctor organisations, organisations for
people with reduced work capability and representatives of the national organisations
responsible for relevant support services, such as ET, EH and the Social Insurance
Board, are involved.
However, social dialogue in Estonia has tended to revolve around other themes and
issues than the return to work. The main topic is wages and, in most sectors, this means
the minimum wage. Occupational health matters are advanced mainly at the initiative
of the Ministry of Social Aairs using participatory policy processes but outside the
format of regular social dialogue between trade unions and employers. Awareness of
the national-level return to work policies and measures in Estonia is, nevertheless,
considerable and they are considered for the most part as quite elaborate although
stakeholders had expected trade unions to be more active in return to work policy, an
expectation that was not imposed similarly on employer organisations.
The involvement of stakeholders in EU-level social dialogue structures can be
considered as sucient: all of our interview partners had participated in EU-level
social dialogue structures. Despite this involvement, the awareness of specic EU-
level return to work policies is very low. At the same time, stakeholders had expected
somewhat more initiatives from the EU when it came to the development of return to
work policies at national level.
Return to work policies within Estonia are thus developed with a varying degree of
involvement of the dierent social dialogue partners. The social partners see the role of
the state (and the EU) as important, if not central, to policy development on the return
to work, considering such policies to be of low priority for them. Their reasons for
not being involved more intensely in policy processes are quite organisation specic.
When it comes to applying return to work policies, organisations have been involved in
Marti Taru and Triin Roosalu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations66
implementation only occasionally and are not planning on increasing their involvement.
Hence those organisations that are involved in social dialogue are inclined towards
involvement in policy development issues rather than in practical implementation.
There is an evident lack of cooperation between stakeholders, with the existence of
several obstacles being reported during the research. Likewise, the implementation
of return to work policies does not always go smoothly. This is an indication of the
presence of bigger challenges to cooperation, not merely that of communication, with
problems of occupational health, health insurance and return to work not being put
on the table in regular social dialogue. There is no erce opposition to stakeholder
cooperation but, instead, a clear need to explain better its relevance to policy-making
and even more so to policy implementation.
Our research indicates the need for a more active approach in return to work policy-
making among both trade unions and employer organisations even though the latter
do seem to have been relatively more involved. The same holds for involvement in
implementing return to work policies. Such a conguration looks natural in the context
of a national institutional set-up in which employers have managed to establish several
umbrella organisations covering virtually all employers and enterprises while only a
tiny number of employees are trade union members. While lobbying as a policy tool
has been utilised, other options such as providing assistance to individual workers,
engaging in collective bargaining or raising workers’ awareness of their return to work
rights through information campaigns have, however, also been deployed.
The lack of activism seems rather to be a problem of a lack of initiative in this particular
policy area from both sides. Consequently the potential for future action on return
to work measures in Estonia remains bleak. Trade unions have longstanding general
interest in making progress on the issue but there is no profound interest in doing so
as a result of other issues occupying a more active priority. Even so, trade unions could
potentially pick up the issue of occupational injury insurance, covering those health
problems which result from work accidents. Meanwhile employers are not interested
in bringing return to work to the negotiation table as it would lead to an increase in
their costs. Employers see that they have already taken the initiative of addressing the
situation of people with reduced work capability. They see that return to work policies
could be part of a workforce diversity approach and they acknowledge that not all
workers are equal and that some require specic support. For employers, the return
to work theme is thus primarily a workforce diversity issue rather than a health issue.
Within that framework, health conditions are just one factor requiring attention.
What does need bringing forward is the central role of the state administration in the
process of supporting the employment of people with chronic illness. Returning to
work is one strand of action on a wider agenda of interventions aimed at supporting
people with reduced work capacity. Here, it is the Ministry of Social Aairs, ET and the
Social Insurance Board which are the central players in this respect. Trade unions do
seem interested in being more involved but the employer organisations are quite happy
with how things are.
Why do individualised industrial relations mean the underutilisation of policy tools? Workers who fall ill in Estonia
67Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
4. The return to work process and the involvement of the social
partners at workplace level
4.1 Workers’ experiences with the return to work process
A majority of workers with chronic illness are concerned about their return to work. This
does not dier systematically based on the type of illness reported. Two major types
of fear can be distinguished: one associated with not being able to meet productivity
standards after illness; the other associated with being left without adequate, or
indeed any, support. The most common chronic disease reported by respondents is
cardiovascular disease followed by other chronic diseases such as cancer, mental
disorders and musculoskeletal diseases.
Among those who are only recently diagnosed, a sizable share of workers do not
intend to take time o from work because of their illness. One of the reasons for this
is where employers’ reactions to employees’ sickness leave had not been supportive.
Nevertheless the majority of employees with a recent diagnosis of a chronic illness did
have an arrangement with their current employer to return to the same position after
treatment and, indeed, many of those with more longstanding conditions had actually
been able to return to the same job.
In general, the team leader/line manager is considered to be the most important
person in supporting a worker’s return to work and is also the primary point of contact
when support measures come under discussion. Company management, trade unions
and the relevant labour inspectorate are far less usual in this respect. Indeed, people
returning to work had mostly been in contact with their colleagues and/or with their
line manager. In all, this suggests a very scattered picture with no certainty and more
reliance on informal relationships (with one’s colleagues, for example) than a standard
procedure followed with the involvement of human resource professionals, therapists
or trade union representatives.
While workers mostly return to work on their own initiative, the role of medical doctors
in the making of this decision is important as is that of their family. This pattern
gives the impression of a lack of active interest on the part of the workplace. Workers’
experiences reveal that adjustments to tasks and duties, probably in terms of reduced
workload and part-time work as well as modications in the working environment,
are the most common changes after illness while those which occur least are the
postponement of deadlines as well as adjustments in daily working time. However,
once a decision is taken, colleagues also have an important role in facilitating return to
work after illness together with friends, family and the general practitioner. The role
of management as well as trade unions in supporting the return to work is reported to
be small and there are deciencies in advice and support from the employer as well as
from the trade union.
Regarding the role of trade unions in the return to work, this is in in stark contrast
with workers’ vision of the potential. Trade unions are expected to be ready to address
the health-related issues of workers and to support the return to work by negotiating
Marti Taru and Triin Roosalu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations68
binding agreements with the employer, e.g. in terms of reducing working hours, stress
and workload for people after long periods of sickness leave. Evidently expectations
do not match the reality and very few workers have experienced help from their trade
unions.
In general, the overall experience of returning to work is moderately satisfactory.
Despite a level of dissatisfaction with the process, most people feel welcome when
returning to work after chronic illness.
4.2 Perspectives of managers on the return to work process
Managers are in agreement that an employee with a serious illness is likely to cause
signicant problems for company operations. They underline that such an individual
would be replaced, perhaps not immediately but certainly were the problems to persist,
and that that this would be done before serious nancial consequences had emerged
for the organisation.
Meanwhile managers consider information/advice on adapting the workplace and
working spaces in general, as well as specialist direct advice, e.g. from doctors and
therapists, to be useful when dealing with workers’ sickness leave. Information on the
nancial strategies to deal with absences related to sickness leave, legal advice and
external counselling/cooperation with dedicated professional associations and/or
patient organisations are options mentioned less frequently. When it comes to making
arrangements to support the return to work, three ideas are highlighted by managers:
— the worker should be entitled to the adjustment of their working duties (working
time and workload) but at the organisation’s discretion;
— workers should be entitled to a phased return to work on full pay;
— the worker should be legally entitled to adjustments to working duties (working
time and workload).
The adjustment of working time and workload is perceived to be eective by the
largest number of managers. These actions were also among the most frequent oers
to employees returning to work. There certainly are many managers who do accept
working part-time and the possibility of unexpected interruptions, but it turns out that
not all managers accept such arrangements in practice. However, relatively few line
managers and team leaders hold the opinion that the employment of a person with
reduced work capability would bring about additional challenges associated with the
reorganisation of workow. The main challenges that were mentioned, however, are:
— taking time o;
— a lack of recognition of the diculties that lower-level managers face in connection
with workers’ absence;
— that a worker returning to work with reduced duties increases the workload of
other colleagues;
— staying in touch with the worker during that person’s absence.
Why do individualised industrial relations mean the underutilisation of policy tools? Workers who fall ill in Estonia
69Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Very few managers believe that a person returning to work after illness and treatment
will be less valuable than other workers. In general, managers are quite supportive and
prepared to adapt the working conditions of people returning to work with a chronic
condition. However, most managers are unaware of organisational practice in terms of
supporting the return to work.
Moreover return to work issues are not addressed in company-level collective
agreements. In this vein, managements do not have regular contact with the trade
union regarding the return to work and further diculties are caused by the lack of
organised representation on the health and safety committee responsible for dealing
with return to work issues.
4.3 Interactions between employer and employee in facilitating
the return to work
Employees generally do feel welcome at work when they return after illness. However,
there are no other major positive experiences: employees do not perceive their
companies to be well-prepared to accommodate the necessary adjustments; the
returning employee does not receive extensive mentoring and guidance from the trade
union or the employer; and the return to work is often not well organised.
Employees do recognise that their employers are not fully unprepared: the two most
common oers to people returning to work are the possibility of a phased return
process and the establishment of a formal procedure for managing the situation. Here,
companies may oer adjustments to work tasks and working time, along with informal
procedures, a thorough discussion and individualised plan, workplace adaptations and
training for the returning worker.
A somewhat dierent picture emerges from the managerial point of view. Here, half
of managers say that contact with the worker on sickness leave is regular although a
similar number say it is irregular and, in one case, there was a confession of no contact.
One could thus conclude that there are some companies where there is some regularity
in interactions between the management and employees on sickness leave while in
others such contacts are irregular. In any case, such contact as does exist tends to be
rather informal. Regarding the content of communications, for the most part this is
reported as being designed to keep the worker informed of work-related issues.
4.4 Experiences in facilitating the return to work
Over the entire 2015-19 period, the unemployment rate in Estonia was 5 per cent or
below. This means that companies have had a strong interest in retaining people and
this also holds for people with reduced work capacity: in a tight labour market situation,
companies have an interest in providing employees with support so that they can work.
Marti Taru and Triin Roosalu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations70
However, there is not a lot of information available on good practice in the return to
work. Making use of national-level policy measures should be listed among these,
since there is not much beyond that oered by individual employers – and, often, even
existing policy measures are not considered despite the availability by law of a range
of in-cash, in-kind and on-demand measures. Awareness of these measures, and then
consequently of how to take advantage of them in practice, is low. The claim has been
made that employers, especially managers, have little awareness of the possibilities
available in supporting the return to work and that they may also suer from a lack of
research time.
Given the paucity of evidence of good practice, we have extracted some examples.
We dene a good experience as a situation in which an employee has experienced a
supportive employer environment when returning to work after chronic illness or with
a chronic disease and encountered no problems in this regard. An example of good
practice is where an employer (i.e. manager) is able to discuss existing cooperation with
a trade union in the return to work context and expresses a preference to access more
support. We describe below the experiences of workers who have returned to work as
well as those who had as yet no practical experience of this but who had nevertheless
been diagnosed with a chronic illness.
Considering workers who had been diagnosed only recently and who thus did not
yet have return to work experience, we examined the responses they received from
the employer and from the trade union representative when they announced their
treatment and the need for a period of sickness leave. The following pattern appears:
— The best return to work experience: upon announcing the need for treatment and
sickness leave, there was a generally supportive response from the employer and
from the trade union, even though no help or support might have been oered
during the period of sickness leave. Where the employee was not a trade union
member, he or she reported that they had thought about joining the union since
their diagnosis in order to get proper support when returning to work.
— Trade-union supported return to work: there was a generally supportive response
from the trade union (even though no help or support might have been oered
during the period of leave) but an indierent response from the employer with the
company, in the worker’s view, only caring for its business and not for the well-
being of employees.
— Unsupported return to work: in this case, the employee either did not plan to
take extended leave and/or did not feel condent enough even to announce the
need for long-term absence to the employer as they feared losing their job. One
worker volunteered in response to an open-ended question: ‘Anything like that
always makes the employer panic’. In such cases, either there was no trade union
representative at the workplace to whom the employee could turn or, alternatively,
the employee did not tell the representative of the need for long-term absence.
In the most supportive return to work model, people would contact the human resources
department of the company for support while, in the trade union-supported model, the
contact point might, instead, be a psychologist or occupational therapist from outside
Why do individualised industrial relations mean the underutilisation of policy tools? Workers who fall ill in Estonia
71Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
the company who would assume the role of most important person to support their
return to work. This highlights that support may well rely on professional suggestions
from people outside an organisation.
Among workers who do have a personal return to work experience, in terms of evaluating
the level of satisfaction with the help and support received from the employer and from
the trade union, approximately half are satised while the other half feel that the support
that they had received was insucient. The key aspect that most distinguishes the best
return to work experiences – where the employee is satised with both the employer
and with the trade union – seems to be being made to feel welcome upon returning.
Among other determinants of good return experiences is the employee actually having
relatively low expectations: since employer support for adjustments upon the return
to work appears mostly to be rather weak, this might contribute to the avoidance of
disappointment. Another more important factor for dening a good return experience is
that the employee did not feel worried about their return. This can be related to the kind
of illness experienced but also to their position in the organisation being more secure.
4.5 Views on the future potential for social dialogue to support the
development and implementation of return to work policies at
company level
Employer organisations’ preferred way of organising the return to work, based on
the perceived need for improvement at organisational level, can be divided into two
groups. One group seems to prefer better cooperation with external stakeholders
(medical doctors, therapists, patient organisations and so on) in facilitating returns,
perhaps accompanied with (even) better legislative and institutional support. This
group suggests that they have already done everything they can at company level
and thus need external insight, or perhaps a push, to go a step further. The second
group seems to be interested in looking for internally-oriented solutions on the return
to work, some of them more informal ones (better interpersonal relations between
managers and employees, leading to a better handling of workers returning from long-
term sickness leave) and some more formalised ones (better organisation-wide policies
and activities).
The main benets of cooperation between management and trade unions, seen from
the point of view of managers, are training sessions for managers directly exposed
to interaction with workers with chronic illness, input from trade unions in company
internal policies, informal agreement on the role of employee representatives in
supporting the management of return to work processes and specic return to work
provisions in collective agreements.
Managers overall perceive the legislation to be too general to be useful to an organisation.
The legislation may set out a general framework but it does not specify the arrangements
that need to be undertaken by an organisation. It thus appears that managers do not
regard the legislation in Estonia to be particularly helpful in arranging return to work
adjustments or in regard to the development of their company policies. Some managers
Marti Taru and Triin Roosalu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations72
would welcome more specic provisions to guide their organisation in its approach
to the return to work. However this is not a general perception as a small subset of
managers do think that the legislation provides quite sound guidelines for company-
level actions. We are also aware that some managers would prefer the legislation to
be more exible and leave more space for company-level managerial decisions on
return to work issues while another group think it sucient that the return to work is
contextualised as part of a broader set of policies on the labour market integration of
people with chronic illnesses.
Thus there are some companies that perceive the legislation to be sucient, as they
would like to arrange return to work matters at their company themselves; while there
are others that would prefer to receive more specic indications about what they should
do to arrange return to work after chronic illness.
From a workers’ perspective, trade unions should be occupying a signicant role in
the process. A large share believe that support for the return to work needs to be an
important element on the agenda of negotiations between trade unions and employers;
while a similar share think that the unions need always to be ready to address the
health-related issues of workers. The preferred form of support from unions is the
negotiation of binding agreements with the employer, e.g. in terms of reducing working
hours, stress and workload for people after long periods of sickness leave. Only a small
subset of workers think that their unions could not do more or hold the opinion that
their unions were simply not powerful enough. Unfortunately none were able to identify
any good examples of how a trade union had been helpful in the return to work process.
Hence from the employee side the prevailing view is that trade unions should be doing
more than they have been doing. Ultimately, however, the perception of workers about
the role of the union in facilitating the return to work is dependent on whether the
actual return experience was one that had been supported by the employer or the trade
union.
Workers with an employer-supported return to work experience in which trade unions
were absent and who had initially been more concerned about their return agree
that unions should be prepared to address health-related issues. This implies a need
to empower trade unions as a precondition for them being able to adopt a greater
role in the return to work process. However, those who were initially not concerned
about their return – implying that they were more condent about making their own
arrangements with their employer – suggested that trade unions could already start
to work on facilitating returns in Estonia without rst needing to accrue more power.
In the case of people with a union-supported return to work experience, this might have
led the individual to disagree that trade unions in Estonia were insuciently powerful
to facilitate the return to work. They are able to assert that unions could facilitate
returns, preferably by negotiating binding agreements with the employer but also by
oering individual consultation. These workers also somewhat agree that trade unions
should always be ready to address the health-related issues of workers and that support
for the return to work should be an important element on the negotiations agenda.
Why do individualised industrial relations mean the underutilisation of policy tools? Workers who fall ill in Estonia
73Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
5. Conclusions
This chapter provides evidence of how the return to work after chronic illness is
supported in Estonia. Estonia is characterised by an open labour market – it is
relatively easy to lose a job as well as to gain a new one – which frames the situation in
which illness forces one to stop working. Against such a background, the employment
contract is often, although not always, terminated by the employer. Small companies,
which constitute the absolute majority of enterprises in Estonia, cannot redistribute
work tasks among other workers and thus need to hire a new person so that these may
be continued. There is no obligation to re-employ a worker after medical treatment.
After treatment, individuals returning to the labour market may nd their personal
work capacity is reduced as serious illness and/or a chronic condition is one of the
reasons why a person loses work capability. It is primarily this situation that is being
addressed by public policies which seek to support the nding and retention of a job
for a person with reduced work capability. Covid-19 oers a window of opportunity to
emphasise return to work issues but this is yet to emerge on the policy agenda amidst
all the others; thus far, the existing return policy measures have neither been discussed
nor reformed and nor have any new initiatives yet been put forward for discussion.
The employment of people with reduced capacity for work is supported by a range
of policy measures. Institutionally the central role in developing and implementing
policies with relevance for the return process has been played by the Ministry of
Social Aairs (specically the Work and Pensions Department) and its associated
organisations. Since 2016, when the work ability reform was launched, implementation
of all the benets and services supporting people with reduced work capacity has
come under the remit of the ET while oversight of the subsequent legally-binding
regulations is provided by the labour inspectorate, an agency of the Ministry of Social
Aairs dealing with the area of governance. The current policy mix addressing people
returning to work after illness or with a chronic condition has been developed at the
initiative of the same ministry. Its Work and Pensions Department has been behind
the policy processes in which all stakeholders have had an opportunity to have a say on
the topics and themes related to the return to work after serious illness and/or with a
chronic condition.
Currently there is a wide range of support measures which are oered both to
employees with reduced capacity for work and to the companies that employ them. The
mix includes support in terms of time (boundaries on working time and shifts), in-kind
assistance (various support services, consultations for employees and employers as
well as job training programmes) and cash benets (for both employees and companies
that employ people with reduced capacity for work). A very important milestone in the
evolution of the policy mix is the work ability reform which saw all support measures
transferred to ET so that the assessment of a person’s degree of work capability, the
planning and oer of support measures, the review of the eectiveness of the measures
oered and all other related activities are carried out by a single organisation.
Neither trade unions nor the employer organisations have taken much initiative in these
policy processes. Trade unions have not focused on return to work or occupational health
Marti Taru and Triin Roosalu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations74
because of a more signicant interest in wages, expressly the level of the minimum
wage. Given that return to work policy is rather scattered between dierent elds, as
well as the rather low unionisation rate and the weak state of sectoral social dialogue,
trade unions and employer organisations are mainly mobilised by the Ministry of
Social Aairs since the social partners’ own interest in engagement is relatively low:
they do not feel notable dissatisfaction with the present situation; they have stronger
interests elsewhere; and they feel that they have made their contribution already.
While national employer and employee associations are represented on international
discussion forums, the debates seem not to have managed to initiate spill-over eect
to local levels via the usual policy trails. Analysis suggests that income will probably
continue to be the central concern for trade unions. Unions might consider raising the
issue of occupational injury insurance but the likelihood of even that taking place is
not high. For their part, the employer associations have developed a dierent frame of
reference for addressing people with reduced work capability – the workforce diversity
approach. From this point of view, people with reduced capacity for work because of
a health condition constitute one category of the diversied workforce. Returning to
work after a serious illness and/or with a chronic condition is one of the processes that,
among others, needs to be approached appropriately. Employers do feel that they are
doing enough to employ and support people with reduced capacity.
Overall, the social partners in Estonia consider the current state of public policy aairs
to be quite satisfactory and they do not perceive that there is a need for considerable
changes. Neither trade unions nor employer associations have clearly-dened goals
and agendas in the area of return to work and they do not express a wish to set them.
Although the state has put in place rather generous regulations and support measures,
there may well be problems with following these through in daily practice. Employees
as well as employers lack information about their rights and duties and the available
support measures. Relatively many employees in the situation of returning to work
after an illness and/or with a chronic condition do not feel condent about turning
to their employers to discuss support measures or to contact other institutions.
Employees expect trade unions to be more active in occupational health and return
to work matters. Yet trade unions in Estonia are generally weak and present only in a
handful of sectors.
Employees did not express any signicant amount of open discontent with the
functioning of the return to work system in recent years. There might be two
explanations for this. First, it might be that the majority is, to a large degree, content
with the existing system and services. Indeed, the state has been allocating a good
deal of resources to support people in going back to work with reduced capability.
The system of labour market benets and services has been growing and improving
substantially in the last two decades while the work ability reform signals a general
trend towards greater agency on the part of employees (as well as employers). Second,
employees might fear losing their jobs. Although the Estonian labour market is exible
and open, the situation might be complicated for certain categories of people such as
those with reduced capacity for work who might experience more hardship in nding a
new job than the average worker.
Why do individualised industrial relations mean the underutilisation of policy tools? Workers who fall ill in Estonia
75Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
The ndings of the chapter suggest that the way things are now arranged is likely to
persist without major change. This means that the central role of the public sector in
policies relevant to the return to work will continue and that the social partners – trade
unions, employers and other players – will continue with their limited role, participating
in policy processes mostly initiated by the Ministry of Social Aairs without their own
clear goals and agenda. It is worth noticing, however, that national-level discussions
– which are crucial in representing workers in industrial relations – are particularly
visible to the public as they attract media exposure. Moreover, when only national (and
sometimes also sector-level) trade union organisations engage in negotiations, there is
a higher likelihood that they have sucient qualied human resources to secure both
expertise and media coverage. Focusing social dialogue on the national level, instead of
the sectoral or company level, might thus have even greater potential to change policies
on the return to work after, or with, chronic illness. This might both compensate for
the lack of company-level trade union activity around these issues and support such
discussions being developed. With Covid-19 making the issues related to the return to
work much more prominent in everyone’s social reality as well as on the policy agenda,
more attention could be expected in reconciling the interests of the social partners in
this regard.
References
Akgüç M., Kahancová M. and Popa A. (2019) Working paper presenting a literature review on
return to work policies and the role that industrial relations play in facilitating return to work
at the EU, national and sub-national levels, REWIR Project No. VS/2019/0075, Bratislava,
Central European Labour Studies Institute. https://celsi.sk/en/projects/detail/64/
Estonian Health Insurance Fund (EH) (n.d.) Eesti Haigekassa haiguste ennetamise arenguakava,
https://www.haigekassa.ee/sites/default/files/uuringud_aruanded/ennetuse-
arengukava_2016-2019.pdf
EU-OSHA (2016) Rehabilitation and return to work: analysis report on EU and Member States
policies, strategies and programmes, Luxembourg, Publications Oce of the European Union.
Kall K. (2020) Fighting marginalization with innovation: turn to transnational organizing by
private sector trade unions in post-2008 Estonia, PhD dissertation, Tallinn, Tallinn University.
https://jyx.jyu.fi/handle/123456789/71099
Kallaste E., Jaakson K. and Eamets R. (2007) Two representatives but no representation – an
analysis of two cases from Estonia, Working Paper series 48, Tartu, Tartu University Press.
Ministry of Social Aairs, Rahvastiku tervise arengukava 2020-2030. https://www.sm.ee/et/
rahvastiku-tervise-arengukava-2020-2030
OECD and European Commission (2018) Health at a glance: Europe 2018: state of health in the
EU cycle, Paris, OECD Publishing, 99.
Ost D. (2000) Illusory corporatism in Eastern Europe: neoliberal tripartism and postcommunist
class identities’, Politics & Society, 28 (4), 503-530.
Taru M. and Roosalu T. (2021) Shaping return to work policy: the role of industrial relations at
national and company level. Country report for Estonia, REWIR Working Paper.
https://celsi.sk/media/datasource/REWIR_report_cover-Estonia-merged.pdf
Uder L. (2010) Riigi tegevus puuetega inimeste ja töövõimetuspensionäride toetamisel, Tallinn,
Riigikontroll.
Marti Taru and Triin Roosalu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations76
Veldre V., Masso M., Osila L. and Kruus P. (2012) Töövõimetuse hindamine, asendussissetuleku
võimaldamine ja tööalane rehabilitatsioon Eestis ja viies Euroopa Liidu riigis Uuringuaruanne.
Tallinn, Praxis. https://www.sm.ee/sites/default/files/content-editors/Ministeerium_
kontaktid/Uuringu_ja_analuusid/Sotsiaalvaldkond/praxis_toovoimetus_eestis_5_el_riigis_
v1.2_01.pdf
Visser J. (2019) ICTWSS Database on institutional characteristics of trade unions, wage setting,
state intervention and social pacts in 55 countries between 1960 and 2018, Version 6.1 -
November 2019, Amsterdam, Amsterdam Institute for Advanced Labour Studies - University of
Amsterdam http://www.uva-aias.net/en/ictwss
All links were checked on 04.06.2021.
77Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Chapter 4
In search of a coordinated national framework:
opportunities and challenges for returning to work
after chronic illness in Ireland
Margaret Heernan, Eugene Hickland, Aurora Trif and Tish Gibbons
1. Introduction
The prevalence of chronic diseases has been growing in Ireland over the past few
decades. The main work-related health problems are musculoskeletal disorders, cancer
and cardiovascular disease. Cardiovascular disease is the most common cause of death,
accounting for 36 per cent of all deaths (Turner et al. 2018) followed by cancer. There is
also a growing incidence of mental health disorders, with depressive mental illnesses
projected to be the leading cause of chronic illness in high income countries by 2030
(WHO 2008). This rise in chronic illness, in the context of an ageing population, has a
signicant impact on labour supply in terms of workforce participation, turnover and
early retirement.
There is no specic legal framework in Ireland for employees with chronic illness
as the regulations concerning people with disabilities generally cover their rights as
well as the obligations of employers. In 2015 the government launched its ten-year
Comprehensive Employment Strategy for People with Disabilities 2015-2024 (CES)
to increase the proportion of people with disabilities in employment. The National
Disability Authority
1
(2005) reported that people with disabilities were two and a
half times less likely to be in work than those without disabilities while 85 per cent of
working-age people with a disability or chronic illness had acquired their condition
while employed, thereby highlighting the importance of eectively managing retention
in employment. A strategic priority of CES was the promotion of job retention, with
strategies for intervention in the early stages of absence from work due to acquired
disability. Ireland has a long way to go to achieving its target: in 2017 it had one of the
lowest employment rates for people with disabilities in the EU (26 per cent) and one
of the highest gaps in employment between people with and without disabilities in
employment (45 percentage points) (European Commission 2019).
Healthcare systems are critical in addressing the management of individuals with
chronic illness. Health spending per capita in Ireland is higher than in most other EU
countries: in 2015 Ireland spent €3 939 per head on healthcare compared to the EU
average of €2 797 (OECD 2019). Even so, only around 70 per cent of health spending
is publicly funded, which is well below the EU average. The Irish healthcare system
has a complex dual-tiered system of both public-funded and private health insurance
schemes; 46 per cent of the Irish population has some form of private health insurance.
1. This is the independent statutory body that provides information and advice to the government on policy and
practice relevant to the lives of people with disabilities.
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations78
This dual system does not provide equitable access either to primary or acute hospital
care or to a universal healthcare in which patients are treated based on need rather
than ability to pay (Connolly and Wren 2019). The need to adopt a chronic care
model has been recommended (Darker et al. 2015), which should seek to incorporate
patient, provider and system-level interventions focusing on both the prevention and
management of chronic illness through investment in primary care – a critical factor
in ensuring successful re-integration into the workplace; but there has been little
progress.
This chapter examines the barriers to, and facilitators of, employees returning to work
after experiencing chronic or long-term debilitating illness within Ireland’s voluntary
industrial relations system. The discussion is drawn from primary and secondary data.
The primary sources consist both of qualitative data (semi-structured interviews with
key national stakeholders and two stakeholder discussion groups) and quantitative
data (surveys of workers, managers and social partners).
The rest of the chapter is structured as follows: background information and national
policy frameworks are presented in the next section before proceeding to discuss the
role of the social partners in shaping such policy at national level. Finally it examines
the role of actors at enterprise level who seek to facilitate the return to work of employees
with chronic illness.
2. Policy framework on the return to work in Ireland
There is no overarching policy on rehabilitation and the return to work in Ireland.
However, an exploration of policy frameworks indicates four distinct areas,
administered separately and mostly uncoordinated, that are relevant in the context:
(i) occupational sick pay schemes;
(ii) the sickness and invalidity benet system;
(iii) managing disability; and
(iv) provisions for rehabilitation and support for the return to work.
2.1 Occupational sick pay schemes
Ireland is one of only ve EU countries in which there is no statutory entitlement to an
occupational sick pay scheme, except when provided for in a contract of employment
or negotiated by collective agreement. Otherwise the duration and level of sick pay
is at the discretion of the employer. The Covid-19 pandemic has prompted the Irish
government to launch a public consultation on the need to introduce occupational sick
pay schemes. Many employees, particularly those who are on low incomes, have no
legal right to sick pay, a fact highlighted by the National Public Health Emergency Team
and the acting Chief Medical Ocer as ‘a problem in controlling outbreaks’ of Covid-19
(Wall 2020).
Opportunities and challenges for returning to work after chronic illness in Ireland
79Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Public sector and semi-state employments all provide some form of employee sick pay,
although most of these were reduced in scope during the three years of the Troika
Programme.
2
The Public Service Sick Leave Scheme was introduced in March 2014
in the majority of sectors in the public service and in September 2014 in education. It
standardised, for the rst time, paid sick leave arrangements across the generality of
public services but eectively halved paid leave, the cost of which had been perceived
as unsustainable, while also introducing a provision for extended leave in the case of
critical illness or injury. Most public sector sickness schemes now consist of payment
for a maximum of 13 weeks (92 days) on full pay in a rolling one-year period, followed
by a maximum of a further 13 weeks (91 days) on half pay in a rolling one-year period.
In total, sick pay is subject to a maximum of 183 days paid sickness leave in a rolling
four-year period.
Two processes were key to this new scheme, namely Temporary Rehabilitation Remu-
neration and the Critical Illness Protocol. Temporary Rehabilitation Remuneration
is a non-pensionable discretionary payment that can be paid to public servants who
have exhausted access to sick leave at full and half pay and who are likely to be able to
resume work. The Critical Illness Protocol denes eligibility criteria for the granting of
extended sick leave for critical illnesses, while leaving the decision to award extended
leave to the HR manager following consultation with the occupational health physician.
The development of the scheme was carried out in consultation with the Public Services
Committee of the Irish Congress of Trade Unions (ICTU). However, one consequence of
the contraction of public sector sick pay schemes in the wake of the Troika Programme
has been the increase in public sector employees taking out private insurance policies
to cover long-term illness and income continuity while sick.
In the private sector there is a wide range of sick pay schemes in operation ranging from
full pay for 12 working days in the retail sector up to a maximum of 12 weeks identied in
the manufacturing sector. A survey by the Chartered Institute of Personnel Development
(CIPD 2019) reported that 44 per cent of private sector companies who participated in the
survey did have some form of sick pay scheme, conrming thereby that the majority do
not oer a company scheme leaving their employees solely reliant on the state for sick pay.
2.2 Sickness and invalidity benefit system
Under the Social Welfare Consolidation Act 2005, all working people in Ireland have
an entitlement to some social benets (social welfare) from the state while absent from
work or if they are experiencing chronic illness. The various schemes are administered
by the Department of Social Protection,
3
with eligibility being dependent on having
2. On 28 November 2010, the European Commission, European Central Bank and the International Monetary
Fund, colloquially called the European Troika, agreed with the Irish government a three-year nancial aid
programme in order to cut government expenditure.
3. In Ireland, government departments can be, and are, re-organised to cover dierent administrative functions
according to the priorities of the government at the time. The Department of Social Protection (DSP) was
previously known as the Department of Employment Aairs and Social Protection.
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations80
paid sucient national insurance contributions. The applicable rate in 2020 was
€190.55 per week which may be paid continuously for up to two consecutive years in one
claim, except for certain diseases such as tuberculosis where the duration is unlimited.
Employees who do not qualify for this benet are assessed for a Supplementary Welfare
Payment, which is a discretionary scheme. In addition there is a state welfare payment
called the Occupational Injuries Benet Scheme for those who do not get paid from
a company sick pay scheme. This is available for people who have had an accident at
or going to work. The scheme also covers people who have contracted an illness or a
disease as a result of the type of work they do.
2.3 Managing disability
Irish policy frameworks do not necessarily address chronic illnesses specically but
instead incorporate it into the ‘disability’ category. The CES 2015 strategy outlined six
priorities:
(i) build skills, capacity and independence;
(ii) provide bridges and support into work;
(iii) make work pay;
(iv) promote job retention and re-entry into work;
(v) provide coordinated and seamless support; and
(vi) engage employers.
The only strategic priority to focus on people already in employment was the promotion
of job retention and re-entry into work, with the key actions detailed in the report in
support of this priority extended to the following:
— develop guidelines to promote intervention in the early stages of absence from
work;
— pilot new approaches to integrating work into the recovery model for mental
health integration, including job coaches in mental health teams;
— a continuing programme to train trade union ‘disability champions’ to support
colleagues returning to work following the onset of disability.
To support this strategy, a number of initiatives have been introduced. Firstly the
government funded a new online service for employers, entitled Employers Disability
Information Service, which began as a three-year pilot in 2016.
4
This service was
managed by a consortium of employer organisations including Chambers Ireland,
the Irish Business and Employers Confederation (IBEC) and Irish Small and Medium
Enterprises, and was funded through the National Disability Authority. The purpose of
the Service was to provide employers with advice and information on employing and
retaining sta with disabilities, and to provide a network to encourage best practice.
The National Disability Authority, in collaboration with the Institute of Occupational
4. See more information at http://www.employerdisabilityinfo.ie/
Opportunities and challenges for returning to work after chronic illness in Ireland
81Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Safety and Health, was tasked to disseminate guidance for employers and employees
on job retention and re-entry into work.
Secondly ICTU, under the Disability Activation Project,
5
was selected to develop
training programmes for ‘disability champions’: trade union representatives and shop
stewards intended to assist employers support employees with a chronic illness in the
return to work.
Thirdly a report was commissioned by the National Disability Authority examining
good practice in organising national vocational rehabilitation services across a number
of jurisdictions (McAnaney and Wynne 2017).
The nal strategic action focused on promoting and supporting strategies for
intervention in the early stages of absence from work due to acquired disability, based
on coordination between the Health Service Executive
6
(HSE) and the Department of
Social Protection.
Whilst a number of these actions have proceeded, a key criticism is that no single
government department is leading on the delivery of the CES. Furthermore, the
resources which have been made available for the implementation of the strategy are
perceived to be insucient.
Other signicant developments in the Irish policy landscape focusing on chronic
illness and disability include The National Disability Inclusion Strategy 2017-2021
that sets out a whole-government approach to improving the lives of people with
disabilities (Department of Justice and Equality 2017). This identied a number of key
areas including education, employment and the need for joined-up policies and public
services. A key area was employment and for people who acquire a disability to be
given the support needed to remain in or return to work. Some of the actions set out
in this strategy document have been achieved. Since it was developed, reforms have
been made to the Partial Capacity Benet Scheme. Other actions are in progress to
address access to, or the aordability of, the necessary aids, appliances or assistive
technologies required for everyday living for those people with disabilities whose entry
to, retention in or return to work could be jeopardised due to unaordability.
2.4 Provisions for rehabilitation and return to work support
In Irish employment law, chronic illness is encompassed within the denition of
disability. The main legal instruments in the area of rehabilitation and return to
work are the Employment Equality Acts and the health and safety legislation. The
5. In 2012 the Minister for Social Protection announced funding of just over €7 million for a range of projects
under the Disability Activation Project. Their aim was to increase the capacity and potential of people receiving
Department of Social Protection disability or illness welfare payments to participate in the labour market.
Funding for these projects ceased in 2015, much to the disappointment of key NGO groups such as Inclusion
Ireland.
6. The HSE provides all of Ireland’s public health services in hospitals and communities across the country.
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations82
Employment Equality Acts include disability and obliges employers to make reasonable
accommodation for people with disabilities. For an employee returning to work after
long-term illness, an employer must take ‘appropriate measures’ to meet the needs of
that person. Meanwhile the Safety, Health and Welfare at Work Act obliges employers
to create a safe and healthy workplace.
There are a number of government funding initiatives available to organisations to
support an employee’s return to work. One is the Employee Retention Grant Scheme
that aims to help private sector employers keep employees who acquire an illness,
condition or impairment (occupational or otherwise) that aects their ability to carry
out their job. Another is the Reasonable Accommodation Fund for the employment of
people with disabilities which includes workplace equipment and adaptation. Other
initiatives include nancial assistance schemes to encourage employers to employ
people with disabilities including the Disability Awareness Support Scheme and the
Wage Subsidy Scheme.
In addition to workplace regulation, there is a range of uncoordinated voluntary activities
being undertaken by trade unions, employers and non-governmental organisations
(NGOs), including information and awareness-raising campaigns; employee well-
being programmes; work-life balance programmes; employee assistance schemes; and
some family friendly policy initiatives.
Overall, the policy framework in Ireland can be characterised as fragmented compared
to other EU states. Provisions relating to long-term absence have evolved but can
still be seen as overly complex, partly because long-term absence procedures occur
at the intersection of dierent sectoral responsibilities and government departments:
employment; health and disability; and equality and social inclusion (McAnaney and
Wynne 2017). Any initiatives introduced (e.g. the Employers Disability Information
Service or the Disability Activation Project) are often short-term projects: indeed,
neither were still in operation as of 2020.
Social protection agencies in Ireland focus on the unemployed or economically inactive
rather than those who are absent from work due to a chronic illness. There is little
evidence of state-funded and state-run occupational rehabilitation services which
support the return to work of employed people with chronic illness. A number of pilot
programmes have taken place, however, driven by campaigning and patient support
organisations under the now-defunct Disability Activation Project (co-funded by the
European Social Fund and the Department of Social Protection) to support workers’
return to work after long-term absence due to chronic illness. These include the Working
with Arthritis: Strategies and Solutions programme developed by Arthritis Ireland;
and Work4You by the Peter Bradley Foundation, in conjunction with Acquired Brain
Injury Ireland, which set up three vocational assessment teams to support people with
Acquired Brain Injury to remain in or re-enter the workforce (McAnaney and Wynne
2017).
The view of NGOs is that many of the strategic actions outlined in government policies
are often left to them to implement without adequate government funding.
Opportunities and challenges for returning to work after chronic illness in Ireland
83Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
3. Social partner involvement at national level
3.1 Demise of social partnership and consequences for the return to work
Social partnership was a formal process of dialogue that began life in 1987 as a form
of corporatist pay/income tax bargaining arrangement. It ran consecutively for over
20 years and produced seven national agreements. Premised on voluntary dialogue
between the state and multiple stakeholders, many elements of the national agreements
went, in the latter stages, beyond pure scal matters to encompass a wide range of
social policy areas. However, social partnership extinguished itself during, and as a
direct consequence of, the global nancial crisis (for an overview, see McDonough and
Dundon 2010). As a consequence there has been no national-level process of social
dialogue since 2009 except for the continued existence of two cross-industry advisory
bodies: the National Economic and Social Council; and the National Competitiveness
Council. Some bilateral engagements have, however, taken place in that IBEC, ICTU
and NGOs lobby the government on specic areas of concern at the time of the annual
budget or as part of the law- and policy-making process. Return to work procedures
have continued to play out in the workplace and at individual level, as explored later,
rather than through collaborative policy development at national level.
In October 2016, the Irish government re-established a limited form of national-level
social dialogue entitled the Labour Employer Economic Forum which brought together
employers, trade unions and the government to discuss views and policies over matters
of mutual concern. With the emergence of important national issues such as Brexit
and Covid-19, they have met weekly and even daily in many instances as high-level
stakeholder forums to agree on approaches and policies, e.g. the Return to Work Safety
Protocol: Covid-19 Specic National Protocol for Employers and Workers (Government
of Ireland 2020).
Nonetheless, IBEC and ICTU ocers felt that the ending of social partnership deprived
them of access to national social dialogue on important issues. For many, social dialogue
was viewed more broadly than just a wage bargaining device but as one which should
encompass a range of societal issues such as the return to work following chronic illness.
Instead what now exists are sporadic issue-specic events highlighting a particular
deciency or failure in response to which a government department will establish a
committee of inquiry and seek public views on the matter, or a government minister will
amend an existing programme or measure of support. By and large it is the activities of
NGOs in lobbying and publicising issues that have brought about change in the area of the
return to work which, in eect, means that measures are developed in a piecemeal and
uncoordinated fashion.
3.2 Subsequent stakeholder activity
Union ocers would welcome social dialogue on establishing a national return to work
framework and, in its absence, have frequently lobbied the government individually
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations84
on the issues which it raises. One union ocer expressed to us a common theme
articulated by many:
‘In an ideal situation all union workplaces would have extensive collective
bargaining agreements and provide for RTW policies and the like, but employers
just will not engage with us on new agreements.’
NGOs and patient groups could be a critical pillar in social dialogue on the return
to work, although NGOs report that they do not have a strategy to engage with other
social partners, particularly the government, on such issues. The primary reason for
this is resource constraints. Many groups work directly, albeit on an ad hoc basis,
with employer groups, unions and health services to raise awareness of chronic illness
and patient needs. NGOs such as the cancer charity, the Marie Keating Foundation
(2019), have produced a guide for employers and employees on returning to work after
cancer, in partnership with Chambers Ireland. Arthritis Ireland, together with Fit
for Work,
7
has developed a guide for employers that provides practical information
and guidance to help them understand arthritis and musculoskeletal disorders, the
eects on employees and the support they need. Another example is the Pocket Guide
to Returning to the Workplace (SEE Change 2020) on returning to work after or with
mental health issues due to Covid-19, produced by SEE Change and Mental Health
Ireland. IBEC has also partnered with SEE Change to produce a guide for line managers
on mental health and well-being as part of their KeepWell programme.
Both IBEC and the ICTU pinpoint examples of the input they have had in policy
development at national level, particularly regarding the Comprehensive Employment
Strategy. Each acknowledge that they would often engage on topics jointly, for example
in the area of mental health, working together on awareness-raising activities such
as the Reasonable Accommodation Passport (ICTU 2019). The aim of the Passport is
to allow structured conversations about the impact of disability and chronic illness
and to ensure that the necessary employee and workplace supports are facilitated. The
Fit for Work coalition, spearheaded by Arthritis Ireland and facilitated by the ICTU,
IBEC and Irish Small and Medium Enterprises, along with key health stakeholders,
is seeking better alignment of the work and health agendas in Ireland. Guideline
documents for both employees and employers have been developed by this coalition
for key stakeholders.
3.3 The potential for future action
There is an appetite among all stakeholders to examine the topic of return to work, but
there is a lack of consensus on what needs to be done. In the Fit for Work coalition,
debate has arisen around replacing the sickness certicate supplied by medical doctors
to employees to give to their employers a ‘t to work’ note similar to that in the UK, but
7. Fit for Work Ireland is a coalition of patients, physicians, health professionals, employer associations,
trade unions and policy-makers working to improve the early detection, prevention and management of
musculoskeletal disorders (MSDs) in the workplace.
Opportunities and challenges for returning to work after chronic illness in Ireland
85Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
no agreement has been reached. Employers fear that other stakeholders (e.g. unions
and government) want employers to meet the costs associated with the return to work,
e.g. of rehabilitation and providing sick pay.
Brexit and especially Covid-19 has prompted some dialogue regarding national
(governmental) economic, social and health policies. Evidence has emerged that
return to work has become a priority for industrial relations actors, with one employer
association claiming it was ‘pushing an open door’ on the topic. It is also clear that there
is an understanding among the social partners that comprehensive return to work
policies and architecture are absent in the Irish health and social protection systems
but could be developed as part of the activities of the Labour Employer Economic
Forum. Therefore the potential does exist for a comprehensive approach through social
dialogue for more strategic and coordinated return to work policies in Ireland.
4. At the level of the enterprise
Evidence cited in this chapter
8
shows that return to work processes at company level
occur generally as part of a company’s absence and attendance management policies.
In some organisations, line managers are responsible for implementing absence and
sickness leave policies; in others, line managers and human resources (HR) departments
work together to support employees who are on extended leave and to support them
in returning to work. Managers do acknowledge the increasing occurrence, as well as
the importance, of employees on long-term sickness leave. Some indicate that their
organisations hold occupational health insurance, in which the insurance company
becomes the case manager during illness-related absence from work, working with HR
throughout the process.
Some additional detail regarding the worker experience, management perspectives
and the level of interaction between each of these are explored below.
4.1 The worker experience
The major chronic illnesses reported by workers in our survey are cancer (27 per cent),
cardiovascular, musculoskeletal and mental illnesses (15 per cent each) and other
(23 per cent). The majority report they had already returned to work after chronic
illness, with only a small share indicating they had been diagnosed recently and that
their treatment had either just started or was about to start shortly.
Among workers who had already returned to work, a large majority report feeling
concerned about their return. Campaigning and patient support organisations highlight
major concerns: the unknown expectations of an employer; a fear of acceptance back
8. For further details on this study, please refer to the REWIR Ireland report here: https://www.celsi.sk/media/
datasource/National_Report_Ireland_merged.pdf
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations86
into the workforce; and that the employer would not understand their particular
circumstances. Workers’ major concern is focused on the need to return to work at full
productivity with no adjustment period (45 per cent), closely followed by a fear that
there would be nobody available to support them if they experienced work problems due
to recent treatment and sickness leave. The absence of adjustments to work conditions
and working hours are also reported as key concerns (each by 30 per cent).
Two-thirds of workers return to the same job while one-third receive adjustments
to daily working time and formal work contracts. Adjustments to tasks and the
postponement of deadlines are, however, reported as receiving limited or no attention.
We can clearly highlight the importance of providing reasonable accommodation for
individuals returning to work such as redesigning a job description; redeployment or
the reassignment of duties; exible working; job sharing; and modied workstations
or adaptation of buildings. The Reasonable Accommodation Passport (developed by
ICTU and IBEC) evidently provides important guidance in terms of structuring what
could be a dicult conversation. This guidance assists in the method and organisation
of conversations between workers and employers to ensure that adjustments are put in
place which help them full their role in a way that works both with them and for them.
More than two-thirds of workers who had returned to work report that they had been
in touch with a general manager or HR department during their absence. Slightly less
than half were in touch with work colleagues, followed closely by a line manager (more
than one-third). Over 80 per cent indicate that they had returned on their own initiative,
with one in ve reporting that this had been initiated by medical professionals. When
we examine experiences with the return to work, over half of workers report not being
satised, or being only partially satised, with the support they had received while
nearly two-thirds report dissatisfaction with the help and support received from their
trade union.
Workers pinpoint medical actors (e.g. a general practitioner or specialist) as the
most important contributor in return to work processes, closely followed by family,
friends and work colleagues. The importance of social interaction with colleagues is
an important theme in the return to work process in the sense of considering how the
group will reintegrate a returning worker (Tjulin et al. 2011), yet trade unions have
little formal involvement in the process. Communication is usually between the HR
department (or line manager) and the employee, with no information being shared
with union representatives on an employee’s health problems or return to work. A
union would only become involved if an employee approached them directly, or if a
situation escalated and disciplinary proceedings were being introduced due to absence
or performance issues. Even a worker’s manager is rated as less important than work
colleagues in the return to work, although the manager is identied as important in
successful reintegration, in combination with other actors.
In the majority of instances, the HR department manages cases on a day-to-day
basis while the relevant line manager deals with the granular detail. Many managers,
however, do not wish to deal with the sickness leave process, leaving it to HR to manage
Opportunities and challenges for returning to work after chronic illness in Ireland
87Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
through regular ‘check-ins’ with employees, etc. and then through working in tandem
with healthcare professionals to facilitate the return to work. Indeed, 70 per cent of
workers report liaising with their HR department during their treatment and absence,
followed by work colleagues (48 per cent) and the line manager (40 per cent). Healthcare
professionals, such as occupational therapists, are seen by many stakeholders as
being the linchpin of a successful return to work due to their proactivity in setting
out a roadmap for returning, checking on individuals’ readiness, thinking about the
practicalities, liaising with the employer on adjustments and motivating individuals to
go back to work.
Return to work policies tend to be developed at the level of the individual enterprise.
The more successful approach often lay in being able to persuade a local line or HR
manager to:
‘See the need for compassion for an employee. It is not an ideal situation that
relies on hard cases and compassion and not an agreed process for all.’
Evidently line and HR managers do, for the most part, have the ability to grant exibility
to employees with a serious illness but it does underscore the broad situation in Irish
workplaces that, without a national scheme or framework on the return to work, many
employees have to rely on the decency and pastoral care of individual managers.
4.2 Managerial perspectives
More than half of managers indicate that they would not replace an absent employee
due to illness but would rearrange workow and job tasks. Some report absence having
a serious impact on the business (25 per cent), leading to nancial consequences (25 per
cent) or having other eects on clients and/or customer relationships (25 per cent).
Employer associations highlight that the business impact of an employee absent from
work for a prolonged period is particularly pertinent in respect of small and medium-
sized enterprises due to limited resources and competitive pressures.
Managers perceive information and advice on adjusting workplaces and workspaces,
nancial strategies in dealing with sickness absence and external counselling, e.g. from
doctors and therapists, to be the most valuable resources in supporting workers
returning to work after chronic illness. A key barrier noted among campaigning and
patient support organisations and occupational therapists is, however, insucient
knowledge of workplaces and specic illnesses, leading to a lack of clarity about who
takes responsibility and which healthcare professional should start the discussion
on the return to work. The absence of a national vocational rehabilitation service or
framework available to all workers on sickness leave due to chronic illness is a major
problem. Research consistently shows that timely access to related support services,
or a framework available to all, is critical in a successful return process for people
diagnosed with chronic illness. Lund et al. (2008) established that the longer the
duration of absence due to illness, the greater the future risk of receiving a disability
pension and of permanent exclusion from the labour market.
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations88
The attitudes of managers towards workers with chronic illness have been highlighted
in previous research as having a signicant impact on a successful return to work (Amir
et al. 2008). Most of the managers we spoke to disagree that workers with chronic
illnesses were less committed to their work. More than half believed that employees, at
the employers’ discretion, should be entitled to an adjustment to their working duties
due to chronic illness, although only a small share are in favour of a legal entitlement
to this. However, they also report that having a worker with a chronic illness did lead
to an increase in the workloads of their colleagues. Most managers also stress the
importance of staying in touch with a worker on sick leave while, interestingly, half
believe that senior managers in their organisation do not recognise the diculties
faced by lower-level managers in managing a worker’s absence and attendance.
Managers believe that it should be the HR department that formally deals with absence
management and long-term sickness leave, together with the return procedure, leaving
the line manager to be mainly responsible for handling the actual return process. This
does not always happen, however. Fearful attitudes, the burden on line managers and
poor relationships are signicant barriers explaining why a manager may not become
involved in the return to work process. Fearful attitudes encompass both a fear of
discussing the illness and of how the employee might respond as well as a fear of being
misinterpreted, with the latter being particularly pertinent during communications
with an employee absent from work; for example, a ‘check-in’ phone call might be
interpreted as putting pressure on an individual to return to work. The burden on line
managers includes the additional demands placed on them in managing the tensions
between providing support for employees who are ill while fullling statutory and
company procedural requirements; furthermore, this is often reinforced by a lack of
training and limited HR support.
4.3 Employer-employee engagement and outcomes
The return to work following chronic illness is a complex process with no ‘one size
ts all’ formula. It can be impeded by a number of factors: organisational; personal;
medical; and the timely access to related support services.
A large majority of managers believe that a common standard procedure is needed to
manage the return to work for all employees. Here, an absence management policy is
vital as it gives clarity to everyone about the process. Some organisations do indeed
have a specic sickness absence management policy and procedures which clearly set
out what happens when an employee is absent through illness. Where such a policy
exists, it typically sets out:
(i) detail of the sick pay scheme and the income continuity plan (if one exists);
(ii) notication and certication requirements; and
(iii) the requirement to attend a doctor nominated by the employer for medical
assessment, and guidelines for the return to work.
Opportunities and challenges for returning to work after chronic illness in Ireland
89Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Return to work policy is perceived as an important part of the employee’s rehabilitation
process (Higgins et al. 2012). However, the way in which sickness absence is managed
could be seen as punitive. Taylor et al. (2010: 274) argue that a shift in sickness absence
management must be seen against the background of decades of neoliberalism ‘which
has unambiguously strengthened managerial prerogative’.
Most managers highlight the potential in their organisations for a phased return with
the close cooperation of other external organisations e.g. occupational health services.
In terms of the improvements which could be made to this process, more than one-half
of managers cite better interpersonal relations between the managers and employees
dealing with the return to work and better cooperation with the external stakeholders
(e.g. doctors and occupational therapists) involved in facilitating returns.
External stakeholders are indeed critical in the return to work process at company level.
In this respect, an income protection policy is vital under which an employee unable to
work due to an identiable illness is paid until they return to work or reach retirement.
These insurers, such as Irish Life, take on the case after a number of weeks, assess the
claim and work on rehabilitation and return to work programmes. The return to work
process is thus moved outside the organisation, with the insurance company managing
the case.
In the view of managers themselves, interactions between managers and workers
on sick leave happen quite regularly (both formally and informally). More than half
of managers indicate that they keep the worker informed about work-related issues
although only one in ve report involving the worker in actual decisions. This may be
due to a fear that contact could be misinterpreted as pressurising the employee to re-
connect with work.
Having no clear workplace procedures can lead to perceptions of unfairness and a lack
of transparency, compounded by a lack of consistency in the implementation of sickness
leave and return policies even within an organisation. van den Bos and Lind (2002) argue
that workers pay greater attention to fairness during times of uncertainty such as when
on sick leave or returning after, or with, a chronic illness. It follows that interventions
that yield reductions in perceived injustice for the returning worker should be associated
with more positive outcomes. A national framework on the return to work is one such
intervention which may set clear procedural rules for managing the return process.
Communication in the return to work – ensuring a thorough discussion with the worker
and putting in place a prior plan for their return – is clearly important. Discussions with
occupational therapists and consultants working in this area reinforce the importance
of agreeing an individual plan before the employee returns. The plan should include
any adjustments to workload or work patterns that might be needed. Over half of
companies do oer some form of adjustments in working time, work tasks, workload
and workspaces. Few, however, oer training to co-workers in how to treat a colleague
returning to work after long-term illness. One rare example is provided by a cancer
patient organisation which had been approached by a manager requesting training on
how to support a key employee returning after cancer treatment.
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations90
The introduction of the General Data Protection Regulation (GDPR) in 2018 is a new,
complicating issue in facilitating the return to work. For an employer, the processing
of a medical report is necessary to ensure they deal with sick pay or can assess tness
to return, identify reasonable accommodations for the returning employee and ensure
they adhere to employment law. GDPR, however, places constraints on the processing
of data which means that employers can only insist on the following information from
a doctor or occupational health physician: that the employee is unt to work; how long
they will be unt for; and when they are medically t to return. Some managers think
that this has a negative impact on their ability to work with the employee to support a
successful transition back into work as they do not have full details of the illness and
cannot plan for reasonable adjustments to workload or the workplace. Occupational
specialists also express concern about this; communication and cooperation between
healthcare professionals and employers are clear facilitators in the planning of a
successful return, but knowledge of the chronic illness is a requirement to implement
such a plan. Campaigning and patient support organisations highlight, however, how
individuals are dierent and that many do not want to be labelled or stigmatised due to
their illness. For some employees, this results in uncertainty regarding the disclosure
of their illness to their employers. A consequent challenge lies in balancing the needs
of the worker and those of the employer by ensuring condentiality for the worker and
then looking to facilitate adaptations and allow others to understand the workplace
diculties that may occur.
A number of managers and employer representatives raise the issue of sickness
certication, required in Ireland to conrm that an individual is ill. A study by King
et al. (2016) found that Irish general practitioners report signicant diculties in
relation to sickness certication. Over half the respondents in their study indicated a
preference for introducing a ‘t to work’ note as the current system had an excessive
focus on disability. In their view, a key strength of the ‘t note’ is thus its shift away
from disability towards empowering sick patients to go back to work.
The nature of an employee’s illness is a concern both for employers as well as for
employees, illnesses having both visible and invisible elements. For example, a stroke
patient returning to work may have visible changes such as mobility issues. However,
cognitive changes such as diculties with memory, data processing and language, in
turn causing fatigue and anxiety, are less visible. Many interviewees report mental
health illness to be the most complex illness, entailing a fear on the part of the employer
of how to manage it and on the part of the employee with regard to being stigmatised or
considered less valuable as a worker.
4.4 Identification of good practice
The coordination of the return to work requires an understanding both of the worker
with an illness and of the work environment as well as the presence of an individual
work plan. There is some evidence of organisations (both public and private sector)
which provide employees with appropriate plans and accommodation. Here, however,
having a good understanding of the chronic illness in question and its side eects is
Opportunities and challenges for returning to work after chronic illness in Ireland
91Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
critical. If the return to work is to be eective, it must be seen as a process not just an
event. Such a perspective allows for clarity in the management of expectations on how
quickly an employee could ‘return to normal’ and also facilitates the discussion about
any necessary adjustments. The needs of workers with chronic illnesses vary according
to the type of illness: cancer survivors might well have dierent needs and require
dierent adaptations than those experiencing a stroke or mental illness.
A second point of good practice emerges in connection with communicating with
the employee at various points in the process. One campaigning and patient support
organisation stresses that:
‘It is really important to signpost for people… [so that they] Know where to go and
ask questions. What resources are available.’
Clearly outlined and agreed communications should begin at the point of diagnosis
and/or the start of sickness leave and continue both in its duration and prior to the
return to work in terms of planning how and when the employee will return. Employees
suggest that conversations should also take place after their return in order to review
their return process and the eectiveness of any adjustments made for them in the
workplace. One manager commented to us on the importance of relationships within
the organisation, too:
‘These processes depend largely on how workers get along with the team, and the
manager’s human practices and thinking.’
Beatty and Joe (2006) highlighted that an understanding and supportive supervisor
is the most signicant factor contributing to a successful return to work experience.
The importance of a work plan is particularly critical. Best practice examples show
that there should be a meeting six weeks in advance to work out a phased return. This
meeting should agree on a number of issues such as the targets to be met, hours to
be worked, etc. and with a clear discussion of capabilities and adjustments, and full
disclosure about medical appointments during work hours. It is, however, acknowledged
that such best practice could constitute an onerous cost for small and medium-sized
enterprises who generally do not have extensive HR expertise, especially in managing
an employee absent due to chronic illness. Challenges are also acknowledged around
the capacity of a small and medium-sized enterprise to accommodate a phased return
or redeployment to other work tasks. Operational factors may additionally limit the
extent to which employers can make reasonable work plan adjustments in working
hours and/or job content. High risk settings are particularly problematic in situations,
for example, of high temperatures, electromagnetic activity, toilet facilities on higher
oors or an absence of the availability of lighter duties.
The public sector may well be better equipped to demonstrate best practice and there
are a number of examples of public bodies providing reasonable accommodations to
employees with chronic illness. The Health Service Executive (HSE) has published a
recent update of its Rehabilitation of Employees Back to Work After Illness or Injury
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations92
Policy & Procedure in order to bring it ‘in line with international evidence-based best
practice in the area of workplace rehabilitation’ (HSE 2020). In some public sector
organisations, disability liaison ocers or occupational therapists are responsible for
supervising the provision of reasonable accommodations.
4.5 The future potential of social dialogue in the return to work
The creation of cooperation between stakeholders is certainly critical in facilitating
the implementation of return to work programmes. However at company level there
is a lack of consensus around the role of trade unions in the return to work. Workers
point to limited engagement by trade unions, although over 60 per cent of respondents
in the study were not union members. Even so, almost nine in ten stated they had
not thought about joining a trade union in search of support for their return to work
since their diagnosis. More than three-quarters nevertheless agree that support for the
return to work should be an important element in negotiations between trade unions
and employers, followed closely by trade unions being ready to address the health-
related issues of workers.
Some managers told us that, despite their companies being unionised, there are no
return to work provisions in collective agreements. A report by the European Agency for
Safety and Health at Work (EU-OSHA 2016) claims that the implementation of collective
agreements regulating the reintegration of workers following sickness absence can be
as eective as a national integrated framework for the return to work. Some evidence
of this can be found amidst the consensus that enterprises with longstanding collective
bargaining agreements, in manufacturing and nancial services, provided the best
arrangements in dealing with chronic illness and the return to work. One example is
Baxter Healthcare, a pharmaceuticals manufacturer, where an agreement was made in
2018 to expand sick pay entitlement to eight weeks at full pay and six weeks at 75 per
cent pay. One ocer from the Services, Industrial, Professional and Technical Union
(SIPTU) stressed that Baxter could aord extra sick pay and was willing to do so but
that many other, and smaller, rms in Ireland did not have the ability to pay. One trade
union ocer related that, outside of the big supermarket chains:
‘Many retail workers did not have any form of sick pay scheme and had to rely on
State benets.’
In instances where a collective bargaining agreement does not have return to
work provisions, return thus usually becomes an ‘individualised’ issue. In these
circumstances, union ocers represent an employee with an HR manager and seek
a personal agreement for the union member to have paid time o for treatment or
adaptations on their return. One SIPTU ocer reported:
‘When the collective bargaining agreement, if it exists at all, does not cover how
to deal with employees with serious illness, we have to make individual without
prejudice agreements with companies for individual union members that cannot
be applied in other instances.’
Opportunities and challenges for returning to work after chronic illness in Ireland
93Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
In such instances, however, the presence of collective agreements at workplace level
means that the actors involved in the return to work process — employer, workers, HR
and trade union representatives — are more easily able to reach consensus since they
are familiar with collaborating on issues related to well-being at work.
Turning to attitudes towards the role of trade unions in the return to work, more than
half the managers we interviewed indicated the presence of a trade union or some form
of employee representation. Among those who are unionised, however, return to work
is not an issue addressed commonly in company-level agreements. A little less than
one-half of managers do not consult with trade unions on these sorts of issues although
one-third report that the committee addressing occupational health and safety (and
which is also responsible for dealing with return to work issues) contains a union
member. Over half report that cooperating with unions or employee representatives
had previously led to additional requests being attached to return to work stipulations.
There appears to be consensus among managers that the current Irish legislation is
sucient; one manager declared to us:
‘We have a very successful return to work practice which is very employee centric.
Current legislation is also highly adequate in preserving workers’ rights in this
area and in fact places a big burden on organisations which may not have the same
resources as ours to manage such a dicult situation.’
However, the lack of specicity over the stages of the return to work process is
highlighted as an issue in a further comment that:
‘It would be helpful to look at this from an employer perspective and develop
an innovative set of provisions that can allow employers to more easily manage
long-term illness cover for their organisation and bring some more certainty in
supports and plans for their business while still retaining adequate supports to
employees. A big ask, I know.’
4.6 Return to work and Covid-19
The Covid-19 pandemic has had a signicant impact on workers with chronic illness.
Beyond the employment-related issues, it has had major implications for their access
to healthcare, particularly primary care, in seeking to manage chronic illness. Many
organisations providing essential follow-up care are Section 38 and 39 NGOs
9
and
voluntary groups established with the support of charitable donations. Fundraising
has collapsed during Covid-19 and many charities report their nances to be uncertain
9. The HSE has arrangements with other organisations to manage and deliver health and personal social services.
The HSE provides annual funding for the delivery of a range of services to agencies (known as Section 38
agencies) and organisations. Section 38 arrangements involve organisations funded to provide a dened level
of service on behalf of the HSE, while under Section 39 the HSE grant aids a wide range of organisations to a
greater or lesser extent.
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations94
or in diculty. A survey by The Wheel found that 82 per cent of charities are ‘very
concerned’ about whether they will have sucient funds to provide their services in
2021 (The Wheel 2021). This also shines a light on how reliant the state is on such
organisations to provide critical services including cancer support, mental health
services and stroke rehabilitation.
More broadly this disruption in health services due to Covid-19 has paused work in
many parts of Irish Health provision
10
and patients are either not getting diagnosis
or treatment or are postponing or avoiding attending hospitals or family doctors. For
example, the Irish Cancer Society estimate that 450 cancers and 1 400 pre-cancers
were not detected in Ireland up to July 2020 due to Covid-19. This suggests a ‘Covid
hangover’ in terms of delayed diagnosis and treatments that may have signicant
short-term and long-term impacts on the health of Irish workers.
Covid-19 poses signicant challenges in particular for people with chronic illness and
concerning their ability to work. However, several initiatives and policies emerged in
the early stages of the outbreak in 2020. In May 2020, the Department of Enterprise,
Trade and Employment published a Return to Work protocol developed through social
dialogue, which was a signicant and positive development. This protocol allows
everybody to work from home wherever possible; and it gives individuals with health
conditions guidance to remain at home where practical, that accommodations will
have to be introduced to keep them safe (2m distance at minimum) on their return
to work and that they would be the last group of workers returning to the workplace.
All employees are, prior to returning, required to complete a Covid-19 Pre-Return To
Work form at least three days in advance of their physical return. Individuals are asked
on the form if they have any concerns around their return to work. Anecdotally it is
reported that this has raised concerns for both employers and workers. For workers, it
raises the problem of disclosure: people who may have an underlying health problem
are worried about Covid-19 and returning to work in that, up to now, they may have
been managing without disclosing their condition to their employer. For the employer,
this forced disclosure requires them to acknowledge and manage what has then been
reported.
A major question raised by the Covid crisis concerns the assumptions which underpin
policy-making in the area of work. Covid-19 has amplied the structural inequality
that exists in the labour force. As mentioned in section 2, Ireland is an EU outlier in
that it does not have a statutory sick pay scheme. This lack of statutory sick pay has
emerged as a signicant topic of public interest during Covid-19. Due to its absence,
many workers who were sick went to work, as did those who should have quarantined
due to being a close contact. The government has promised to introduce legislation by
the end of 2021 and consultations are taking place with unions and employers.
10. For example, the national cervical screening programme was paused for over three months from March to July
2020.
Opportunities and challenges for returning to work after chronic illness in Ireland
95Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
5. Conclusion
There is no national framework in Ireland which guides the reintegration of employees
with chronic illness back into the workplace. Largely this is due to Ireland traditionally
taking a voluntarist and decentralised approach to the regulation of employment
terms and conditions. Instead there are a number of important, albeit relevant, ad
hoc initiatives from government and other state bodies, trade unions, employer
associations and campaigning and patient support organisations. Unlike in other
countries, the passive welfare approach to social protection, mainly through income
replacement or nancial benet, has been adopted in Ireland. Employees not covered
by a collective agreement or as part of an employment contract have no statutory right
to an occupational sick pay scheme.
The evidence gathered for this chapter suggests that chronic illness is an important
issue at national level. It does seem that supporting people with chronic illness in
Ireland is focused on the preventative and medical care aspects rather than on the
mechanisms supporting the return to work. Where chronic illness is captured in a work
context, it typically tends to come under the umbrella of disability. Non-traditional
industrial relations actors, like campaigning and patient support organisations, play
an important role in the development of return to work policies and guidelines. They
have their own distinct focus on a singular chronic illness and therefore have dierent
needs and priorities. The strength of patient support groups is their knowledge of the
needs of workers with specic health problems. However, they face barriers due to the
lack of resources, most of which come from voluntary donations, although there are
some cases of organisations being funded by the government. This has placed a critical
limitation on their ability to provide services and advocate on behalf of their patient
cohort.
Overall, Irish social partners report strong awareness of the importance of the return
to work. However, there is no evidence of national social partner involvement in
return to work policy except in the public sector where there is evidence of negotiation
with unions on the Public Service Sick Leave Scheme. Whilst we did nd evidence
of social dialogue, it was ad hoc and fragmented and often short-term due to the
lack of funding. Our ndings show that the company level is where return to work
procedures are developed but there is limited evidence of trade union involvement in
the implementation of return to work policy.
A number of key barriers and facilitators relating to the return to work emerge from the
research. The Irish benets system as a whole is seen as a complex system to navigate,
especially when simultaneously dealing with a chronic illness. At dierent points in
the process, workers must engage with multiple government departments and bodies,
many of whom do not coordinate with each other. Having a clearly signposted policy
around the return to work is critical to the re-entry process and to workers’ subsequent
adaptation. Eective return procedures require a high level of workplace coordination
and communication as well as coordination with external services including medical
services, rehabilitation providers, etc. Interactions with HR and line managers in
particular surface as critical in a successful return to work process.
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations96
When discussing reasonable accommodations, organisations need to communicate
their policies and procedures on this eectively so that all employees understand them
and are able to navigate the process. Organisations also need a process for regularly
reviewing reasonable accommodations as the employee’s needs, their environment or
their work duties change. These challenges – of navigating benets, communicating
between stakeholders and negotiating accommodations before the return to work –
were identied by Hoefsmit et al. (2013) as bottlenecks that can hamper the return to
work.
This chapter has set out the Irish national framework and experience of various actors
on the return to work. A major nding is that the majority of stakeholders accept that
returning to work with, or after, chronic illness is an important issue. Early intervention,
the timely and proactive use of organisational procedures, communication between key
stakeholders and multidisciplinary coordination across government departments and
agencies and at workplace level emerge as the most important factors in managing the
return to work after chronic illness. Furthermore there is no ‘one size ts all’ formula
for such workers: ultimately, it is the needs of workers, as inuenced by their illnesses,
that are the most important consideration.
References
Amir Z., Neary D. and Luker K. (2008) Cancer survivors’ views of work 3 years post diagnosis:
a UK perspective, European Journal of Oncology Nursing, 12 (3), 190-197.
Beatty J.E. and Joe R. (2006) An overlooked dimension of diversity: the career eect of chronic
illness, Organizational Dynamics, 35 (2), 182-195.
CIPD (2019) CIPD-IRN private sector pay survey 2019, Dublin, Chartered Institute of Personnel
Development.
Connolly S. and Wren M.A. (2019) Universal health care in Ireland: what are the prospects for
reform, Health Systems & Reform, 5 (2), 94-99.
Darker C., Whiston L. and O’Shea B. (2015) Chronic disease management in Ireland: perspectives
from patients and clinical stakeholders - implications and recommendations for the Irish
healthcare system, Dublin, Trinity College.
Department of Health and Children (2008) Tackling chronic disease: a policy framework for the
management of chronic diseases. https://www.iccp-portal.org/system/files/plans/IRL_B3_
Policy%20Framework-Tackling_chronic_disease.pdf
Department of Justice and Equality (2017) National disability inclusion strategy 2017-2021.
http://www.justice.ie/en/JELR/dept-justice-ndi-inclusion-stratgey-booklet.pdf/Files/dept-
justice-ndi-inclusion-stratgey-booklet.pdf
EU-OSHA (2016) Rehabilitation and return to work: analysis report on EU and Member States
policies, strategies and programmes, Luxembourg, Publications Oce of the European Union.
European Commission (2019) Country Report Ireland 2019, including an in-depth review on the
prevention and correction of macroeconomic imbalances. https://ec.europa.eu/info/sites/
info/files/file_import/2019-european-semester-country-report-ireland_en.pdf
Government of Ireland (2015) Comprehensive employment strategy for people with disabilities
2015-2024. https://assets.gov.ie/18906/1120bc6ad254489db9571c74e8572f44.pdf
Opportunities and challenges for returning to work after chronic illness in Ireland
97Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Government of Ireland (2020) Return to Work Safely Protocol: Covid-19 specific national protocol
for employers and workers. https://www.gov.ie/en/publication/22829a-return-to-work-
safely-protocol/
Hoefsmit N., de Rijk A. and Houkes I. (2013) Work resumption at the price of distrust: a qualitative
study on return to work legislation in the Netherlands, BMC Public Health, 13, 153.
https://doi.org/10.1186/1471-2458-13-153
HIA (2019) 2019 annual report and accounts, Dublin, Health Insurance Authority.
Hickland E., Heernan M., Trif A. and Gibbons T. (2021) Shaping return to work policy: the role
of industrial relations at national and company level, Country report for Ireland, Negotiating
return to work in the age of demographic change through industrial relations (REWIR) Project
no. VS/2019/0075 Deliverable 3.1, REWIR Working Paper January 2021, Dublin, Dublin City
University.
HSE (2020) Rehabilitation of employees back to work aer illness or injury policy & procedure,
Dublin, Health Service Executive.
ICTU (2019) Reasonable accommodation passport, Dublin, Irish Congress of Trade Unions.
www.ictu.ie/download/pdf/reasonable_adjustments_disability_passport.pdf
King R., Murphy R., Wyse A. and Roche E. (2016) Irish GP attitudes towards sickness certification
and the ‘fit note’, Occupational Medicine, 66 (2), 150-155. https://doi.org/10.1093/occmed/
kqv161
Lund T., Kivimäki M., Labriola M., Villadsen E. and Christensen K.B. (2008) Using administrative
sickness absence data as a marker of future disability pension: the prospective DREAM study of
Danish private sector employees, Occupational and Environmental Medicine, 65 (1), 28-31.
Marie Keating Foundation (2019) Back to work aer cancer, Dublin, Marie Keating Foundation.
McAnaney D. and Wynne R. (2017) International good practice in vocational rehabilitation: lessons
for Ireland, Dublin, National Disability Authority.
McDonough T. and Dundon T. (2010) Thatcherism delayed? The Irish crisis and the paradox of
social partnership, Industrial Relations Journal, 41 (6), 544-562.
OECD (2019) State of health in the EU. Ireland: country health profile 2019, Paris, OECD
Publishing.
National Disability Authority (2005) Disability and work: the picture we learn from ocial
statistics. http://nda.ie/nda-files/Disability-and-Work-The-picture-we-learn-from-ocial-
statistics.pdf
SEE Change and Mental Health Ireland (2020) A new reality living with Covid-19: a pocket
guide to returning to the workplace, Dublin, Mental Health Ireland. https://www.
mentalhealthireland.ie/wp-content/uploads/2020/09/Returning-to-the-Workplace.pdf
Taylor P., Cunningham I., Newsome K. and Scholarios D. (2010) ‘Too scared to go sick’:
reformulating the research agenda on sickness absence, Industrial Relations Journal, 41 (4),
270-288.
The Wheel (2021) The impact of the Covid-19 crisis: members survey. https://www.wheel.ie/
policy-campaigns
Tjulin A., MacEachen E., Edvardsson Stiwne E. and Ekberg K. (2011) The social interaction of
return to work explored from co-workers experiences, Disability and Rehabilitation, 33 (21-22),
1979-1989.
Turner N., Donoghue O. and Kenny R.A. (eds.) (2018) Wellbeing and health in Ireland’s over 50s
2009-2016, Dublin, The Irish Longitudinal Study on Ageing.
van den Bos K. and Lind E.A. (2002) Uncertainty management by means of fairness judgments,
Advances in Experimental Social Psychology, 34, 1–60.
Margaret Heffernan, Eugene Hickland, Aurora Trif and Tish Gibbons
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations98
Wall M. (2020) Meat sector not prepared to have sick pay scheme on table – Siptu, The Irish
Times, 1 September 2020. https://www.irishtimes.com/news/ireland/irish-news/meat-sector-
not-prepared-to-have-sick-pay-scheme-on-table-siptu-1.4344212
WHO (2008) The global burden of disease: 2004 update, Geneva, WHO.
All links were checked on 28.05.2021.
99Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Chapter 5
Over-expectation and underprovision:
overcoming the voluntarist and irregular approach
of Italian social partners to the return to work
Ilaria Armaroli, Maria Sole Ferrieri Caputi and Lorenzo Maria Pelusi
1
1. Introduction
In line with the majority of European countries, Italy is experiencing a slow, though
quite steady, increase in the percentage of people aected by chronic illness.
2
In 2019,
40.9 per cent of Italian residents (compared to 38.6 per cent in 2010) said they had
been suering from at least one chronic disease. Chronic-degenerative pathologies are
more frequent in older age groups: 54.1 per cent of Italian people aged 55-59 already
experience chronic illness and, among the over-75s, the share reaches 85.4 per cent.
3
Projections indicate that, by 2030, the number of patients with a chronic disease
will rise above 26.5 million while those with more than one will number 14.6 million
(Università Cattolica Sacro Cuore, Istituto Sanità Pubblica 2020).
As regards the interplay between chronic illness and work, the share of the Italian
working population aected by at least one chronic disease increased from 30.1 per cent
in 2009 to 34 per cent in 2019. That same year, 78.3 per cent of Italians experiencing
at least one chronic disease left the labour market, a total signicantly higher than
for people in good health (38.7 per cent). These data seem to conrm for Italy a trend
which has been registered in many countries, i.e. an increase in the proportion of
people requesting sick leave, taking early retirement and living on long-term disability
allowances (EuroHealthNet 2017; Tiraboschi 2015).
In this scenario, the long-term eects of the Covid-19 pandemic must also be carefully
monitored. In a survey conducted by Fondazione Policlinico Universitario Agostino
Gemelli IRCCS on 143 patients in Rome who had recovered from Covid-19, 87.4 per
cent of those interviewed (on average 60.3 days after the onset of the rst symptoms)
had at least one persisting symptom, particularly fatigue (53.1 per cent) and shortness
of breath (43.4 per cent) (Car et al. 2020). It is reasonable therefore to expect that the
delayed return to usual health for Covid-19 patients may lead to a protracted absence
from everyday life, including work.
1. The authors thank Dr. Margherita Roiatti and Dr. Pietro Manzella for their valuable comments and language
revision, and Dr. Mehtap Akgüç and all the participants in the European project ‘Negotiating Return to Work
in the Age of Demographic Change through Industrial Relations’ (REWIR) for coordination and feedback. This
chapter is dedicated to Dr. Lorenzo Maria Pelusi who passed away prematurely in August 2020.
2. Eurostat, People having a long-standing illness or health problem, by sex, age and labour status [hlth_silc_04],
http://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=hlth_silc_04&lang=en [Accessed on 30.12.2020].
3. Istat, Aspetti della vita quotidiana: Stato di salute – età dettaglio, http://dati.istat.it/Index.
aspx?QueryId=15448# [Accessed on 30.12.2020].
Ilaria Armaroli, Maria Sole Ferrieri Caputi and Lorenzo Maria Pelusi
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations100
These trends need to be adequately addressed since the participation of people aected
by chronic illness in the labour market is considered important for a number of reasons.
In the rst place this is expected to reduce the impact on patients and help them
successfully manage their condition in everyday life, thus fostering functional capacity,
psychological well-being and even recovery (EuroHealthNet 2017). It is therefore no
wonder that, according to dierent surveys on cancer (La Stampa 2011; Istituto Piepoli
2008), most Italian patients themselves consider work as a fundamental means of
facing up to illness. The return to work of people with chronic illness is also essential in
tackling the decline in labour supply (given the decrease in birth rates) and shortages of
skilled labour, as well as combating the pressures on public health and pension systems
induced by the dramatic ageing of the workforce (Tiraboschi 2015; OECD 2009).
Moreover, workplace accommodation of the needs of workers with chronic illness can
have a positive impact on the quality of work produced and its sustainability through
lower levels of work intensity and stress, as well as better work-life balance (Vargas
Llave et al. 2019).
The social partners are, as key players in labour markets, required to play a highly
important role in activating exible solutions and favouring return to work processes
(Tiraboschi 2015). However, their contribution in this eld, also with specic reference
to the Italian case, is largely neglected in the literature.
Italy, which belongs to the ‘southern’ cluster of industrial relations in Europe
(Caprile
et al. 2017), boasts quite positive and steady values in collective bargaining coverage
(80 per cent in 2016)
4
and in trade union density (34.4 per cent in 2018).
5
Even so, Italy
is also characterised by an irregular involvement of the social partners in public policy
formation, a scant development of employee representation in the workplace (Caprile
et al. 2017), a generalised abstention of the law and a high degree of voluntarism in
industrial relations (Leonardi 2017; Leonardi et al. 2017). The latter conditions have
progressively made larger organisations subject to pressure and opposition; this tends
to compromise the development of cooperative industrial relations and has paved the
way for the growth of independent autonomous unions (Colombo and Regalia 2016)
and the multiplication of national collective labour agreements (NCLAs) (CNEL 2019).
These are the features which make up the institutional framework for industrial
relations in Italy and which potentially have an impact on their role in return to work
processes.
This chapter relies on information and data gathered via various tools, including
documentary research, surveys with workers, managers and social partners, semi-
structured interviews with national stakeholders and group discussions with
employers and workers’ representatives at company level as well as a roundtable with
stakeholders.
4. OECD.Stat, Collective bargaining coverage, https://stats.oecd.org/Index.aspx?DataSetCode=CBC [Accessed on
03.06.2020].
5. OECD.Stat, Trade union density, https://stats.oecd.org/Index.aspx?DataSetCode=TUD [Accessed on 3.06.
2020].
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
101Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
2. Legal policy framework on the return to work
The Italian legislation supporting people with chronic illness in returning to work is
neither homogeneous nor specically targeted. This is mainly due to the Italian system
lacking a clear denition of chronic disease in legal terms and there is a trend, both in
literature and case law, to equate illness with ‘disability’ (Fernandez Martinez 2017).
Even though workers with chronic illness are generally not given specic rights, there
are some provisions on the return to work and some protections which derive from
being recognised as disabled. However, even this has taken dierent forms in the Italian
legal system according to the objectives pursued from time to time by the legislator. As
a result, there is an overlap in this eld between various notions which have dierent
meanings (e.g. ‘handicapped
6
people’, ‘untness’, ‘disability’, etc.) and their related
pieces of legislation. Furthermore, the traditional inuence of biomedical evaluations
(focused on a person’s condition and need for healthcare) has given rise to a number
of legal provisions almost exclusively devoted to ensuring assistance and protection
(e.g. through paid leave and benets) to people falling within these specic categories
(Bono 2020). It is only with Legislative Decree No. 216/2003, the Italian transposition
of Council Directive 2000/78/EC, that a broader, more dynamic and inclusive notion
of disability has entered the legal system, paving the way for jurisprudential guidelines
supporting the principles of social justice and non-discrimination at work (with an
important role to be played by the employer in terms of the (re-)integration of disabled
people) regardless of the specic causes of the disability.
2.1 Sickness and invalidity benefit system
Paid sickness leave for workers is met by the employer during the rst three days of
absence and thereafter by Istituto Nazionale Previdenza Sociale (National Institute
for Social Security; INPS) up to the 180
th
day. It is proportional to the normal wage
but progressively decreases. This compensation is provided to workers experiencing
illness and who cannot perform their job tasks.
7
Important rules concern the calculation of the length of the so-called protected period,
made up of the overall number of days of absence from work during which employees
cannot be dismissed. These rules are either established by law (for white collar workers)
or set in NCLAs at sectoral level (for blue collar workers). Many NCLAs extend the
duration of the protected period in the case of certain illnesses.
When chronic illness leads to disability or an inability to work, as ascertained by public
healthcare and the social security authorities, people are provided with an incapacity
benet (where there is an absolute and permanent impossibility of performing any
work activity) or a civil invalidity benet. In addition to the latter, a further mobility
allowance is provided to those who cannot move about independently.
6. We are using the word as it appears in the Italian law.
7. INPS does not pay sickness compensation for certain categories of worker, including white collar workers in
industrial sectors and managers in the industrial and craft sectors; in these cases it is the employer that pays the
compensation.
Ilaria Armaroli, Maria Sole Ferrieri Caputi and Lorenzo Maria Pelusi
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations102
In addition, occupational insurance for work-related accidents and occupational
diseases, potentially applying also to workers with chronic illness, is nanced through
contributions paid mandatorily by employers to Istituto Nazionale per l’Assicurazione
contro gli Infortuni sul Lavoro (National Institute for Insurance against Accidents at
Work; INAIL) in respect of all employees and lavoratori parasubordinati (project-
based contract workers). INAIL’s assistance measures include: a daily allowance for
temporary absolute inability, targeted at people injured at work or aected by an
occupational illness if they are unable to work for a period of time; compensation for
functional impairments; and an allowance for people with mesothelioma contracted
after exposure to asbestos, regardless of whether this was at work or elsewhere.
INAIL has also been entrusted by Law No. 190/2014 with the task of supporting
the return process for workers with occupational illnesses. In 2016 INAIL therefore
adopted a regulation on the return to work of people with work-related disabilities
through which it launches public calls to nance work integration projects for disabled
or unt workers following an accident at work or an occupational illness. In addition
to notifying INAIL of their availability to participate in these processes, employers can
directly present projects of their own and apply for funding. However, trade unionists
have pointed to procedural issues which inhibit access to these funds and a lack of
knowledge in companies about the availability of nance for return to work projects,
leading to the resources being little used.
INAIL also nances and conducts research on health and safety at work in collabora-
tion with the social partners and, according to Budget Law 2019, it may fund projects
presented by the social partners for informing and training workers and employers as
regards the return to work of people aected by work-related disability.
2.2 Provisions for rehabilitation and return to work support
In addition to INAIL’s role in respect of work-related illnesses, the return to work is
favoured by a number of legislative provisions. The most important of these, specically
targeted at people with ‘severe chronic and degenerative pathologies’, is the right to
switch the employment relationship from full-time to part-time (Legislative Decree
No. 81/2015).
Other relevant opportunities derive from the potential for collective bargaining to
complement and adapt certain legislative provisions in response to specic situations.
For instance, ‘smart working’, regulated by Legislative Decree No. 81/2017, allows
people to perform their job from home or other locations after signing an individual
agreement.
8
Moreover, Legislative Decree No. 151/2015 introduces the possibility for
8. During the Covid-19 pandemic, the Italian government introduced a new right to work from home for disabled
or immunosuppressed workers, as well as for those with a disabled or immunosuppressed person in their
family. This right is meant to be temporary, up to the end of the health emergency, and is also dependent on
whether this way of working is compatible with the characteristics of the activity being carried out. In addition,
workers suering from serious and proven diseases and who have reduced working capacity must be oered the
possibility of working from home as a priority comparative to other workers.
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
103Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
workers to give some of their accrued but unused time-o to colleagues who need to
take care of disabled or ill children. The above statutory provisions are frequently
complemented by collective bargaining which sometimes expands their scope to people
with chronic illness.
Those workers who are disabled (under the denition of Council Directive 2000/78/
EC) also have the right to reasonable accommodation in the workplace in order to
ensure they have working conditions equal to those of other employees (Legislative
Decree No. 216/2003).
Further opportunities may apply to people with chronic illness as far as their condition
ts the legal notions of ‘disability’ (here interpreted in a narrow sense and essentially
based on biomedical evaluation), ‘untness’ and ‘handicap’, that have to be ascertained
by the healthcare and social care authorities. These include the right for workers with
disabilities amounting to more than 50 per cent of capacity to 30 days leave per year for
treatment (Legislative Decree No. 119/2011); the obligation on the employer to assign
a worker who has been assessed as unt to perform a specic task by the occupational
physician to an equivalent, or lower-level, task without loss of remuneration (Legislative
Decree No. 81/2008); the right for a worker with health problems to refuse night shifts
(Legislative Decree No. 66/2003); the right for ‘handicapped’ workers to paid leave of
two hours per day or three days per month and, supplementarily, the right to choose (or
be transferred to) a workplace closer to their home (Law No. 104/1992).
Financial incentives apply to employers in the public and private sectors who hire
disabled people on open-ended contracts (Law No. 68/1999), while the same law also
establishes a legal obligation for employers to hire and retain disabled workers in a
number proportionate to the dimensions of their enterprise (from one in companies
with 15-35 workers to 7 per cent of the workforce in companies with more than 50
workers). The employer can comply with these provisions by hiring temporary agency
workers as long as their contract duration is at least 12 months (Legislative Decree
No. 151/2015) or, on the basis of the rules established in specic regional agreements
signed by public job centres, trade unions and employer associations (Article 14
of Legislative Decree No. 276/2003), by contracting out certain activities to social
cooperatives pursuing the integration of disadvantaged people.
One policy slowly spreading in larger companies is the creation within HR departments
of a ‘disability manager’ specically devoted to inclusion and the management of
disabilities at work. The role of a person ‘responsible for the inclusion at work’ of
disabled people is envisaged by Legislative Decree No. 151/2015
9
and the related costs
may be partially reimbursed through funds established in each Italian region for the
9. As regards private workplaces, precise guidelines for the job placement of disabled people, based on a set of
important principles including the promotion of an ad hoc professional gure, should have been designated
within 180 days of the adoption of Legislative Decree No. 151/2015, but these remain missing. In public
administrations with more than 200 employees, the introduction of a professional gure for the inclusion at
work of disabled people has been made compulsory (Legislative Decree No. 165/2001, as modied by Legislative
Decree No. 75/2017).
Ilaria Armaroli, Maria Sole Ferrieri Caputi and Lorenzo Maria Pelusi
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations104
employment of disabled people.
10
In addition, these funds may partially reimburse
the expenses incurred by companies making reasonable workplace adjustments for
workers whose level of incapacity exceeds 50 per cent.
Competences in terms of labour policy are also attributed to Italy’s regions and
autonomous provinces in the light of which, on top of these national provisions, there
are some regional or more local activities which are relevant to the return to work.
Examples include the SIL 22 job integration service in Verona, aimed at promoting
the employment of disabled people by oering information, vocational training, career
planning, job matching and placement, and other services; and the EMERGO plan, a
programme promoted by the municipal authorities in Milan for disabled people aimed
at facilitating their labour market participation through services supporting training
or other return to work activities.
3. Involvement of the social partners in shaping return
to work policy at national, local and company level
3.1 Industrial relations actors and return to work policy
Return to work policies for people with chronic illness may involve a great number of
actors including public authorities, employer associations, trade unions, campaigning
and patient support organisations, public job centres and private employment agencies,
research organisations and companies.
By and large, the industrial relations actors are perceived as very important in the
return to work by most of the stakeholders involved, especially considering the
fragmented legislative framework and workers’ needs for assistance and representation
during their return process. Here, trade union representatives act as more or less a
link between the worker with chronic illness and the other relevant stakeholders in
accompanying the worker throughout the process. Moreover, both trade unions and
employer associations provide support to workers and companies in the return to
work and also collaborate with each other (mainly through collective bargaining at
national, regional or company level) to establish solutions that facilitate return to work
processes.
The social partners are becoming increasingly aware of the importance of returning
to work for people experiencing chronic illness. However, there is a long way to go,
since 75 per cent of trade union and employer representatives responding to our survey
declare they have no knowledge of any national policy in this eld. Neither are return
to work issues perceived as a priority by many: while they acknowledge that they
have only limited involvement in policy-making and implementation, representatives
10. The obligation for Italian regions to establish a fund for the employment of disabled people was rstly
introduced via Law No. 68/1999 and then slightly modied by Legislative Decree No. 151/2015. Each fund is
nanced out of the nes paid by companies not complying with the rules on the mandatory hiring of disabled
people, contributions from companies not subject to the rules, private donations, etc.
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
105Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
exhibit a rather ambivalent attitude concerning their possible greater engagement,
some wanting to focus mainly on other issues of interest representation although
50 per cent do strive for a more active stance. Overall, the impression is that employer
associations are largely indierent towards these issues whereas, in some cases, trade
union ocials display a rather greater interest.
At workplace level, employers tend to regard workers with chronic illness as no
longer ecient or productive which could lead some to violate or circumvent certain
of their obligations. In turn, this could contribute to endorsing the perception, which
is widespread among HR and line managers, that the legislative framework in this
eld is more of a limitation than an opportunity. Furthermore, some important
legislative provisions, including those referring to reasonable adaptation, seem to be
unknown by many employers and HR managers. The inclination of small companies to
implement organisational solutions for return to work processes is further jeopardised
by a lack of economic resource compared to larger companies. Furthermore, in
some SMEs, workers’ relocation to other tasks is more dicult given the scarcity of
available alternative activities. At the same time, local trade unionists and workers’
representatives are regarded by some HR managers as lacking specic knowledge on
dierent chronic pathologies that aect workers in various ways depending on age,
contractual relationship and the personal characteristics of the worker. Therefore,
worker representatives are regarded as applying rather generalised solutions and
simply focus on helping people receive the benets which are appropriate for their level
of incapacity. Overall a reactive, rather than a proactive and preventive, approach to
the issue seems to prevail within both companies and trade unions.
Training and awareness-raising initiatives are advocated as a means of overcoming
these problems and boosting the involvement of the industrial relations actors, while
better dialogue and cooperation between all the stakeholders involved are well-
regarded in terms of further spreading, improving and coordinating return to work
practices. However, it is worth specifying that these sorts of belief are shared mainly
among those who are actively engaged in return to work processes, whereas most of
the representatives of the social partners who had no direct experience to report in this
eld were generally apathetic towards the potential for multi-stakeholder cooperation
to facilitate the return to work.
3.2 Interactions between industrial relations actors and other stakeholders
in return to work policy
Examples of how multi-stakeholder cooperation can overcome prejudices and the
information gaps constraining the return to work are provided in the positive impact
that public job centres and private employment agencies may have on employers
dealing with the return to work of workers experiencing chronic illness. Companies are
often unprepared for the requirements of Law No. 68/1999 which obliges the hiring of a
certain percentage of disabled workers according to the size of the enterprise and often
look to employment agencies for help and assistance. Employment agencies do not
only recruit workers for the employer but (especially when equipped with personnel
Ilaria Armaroli, Maria Sole Ferrieri Caputi and Lorenzo Maria Pelusi
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations106
specialised in the workplace inclusion of disadvantaged people) they can support the
employer in the implementation of organisational solutions, working time exibilities
and the necessary task adjustments to ensure a worker’s successful (re-)integration.
One professional from a private employment agency told us:
‘Our work consists of discussing with the company and trying to erase
preconceptions, by proving that certain limits can be overcome thanks, for
instance, to the allocation of the worker to a dierent position. It happens very
often that diseases described as unbearable by companies can actually be handled.’
Another example is provided by Mestieri Lombardia Bergamo, an employment agency
specialised in the job placement of disadvantaged people. This is a non-prot entity
which, by participating in the local consortium Sol.Co Città Aperta, has become a
benchmark for other cooperatives in the consortium in dealing with a disabled person
or a worker with chronic illness: if a return to the workplace is not possible, Mestieri
Lombardia Bergamo helps identify entities both within and outside the consortium
that may be available to oer opportunities to the worker.
In contrast, the collaboration between industrial relations actors and campaigning and
patient support organisations is still underdeveloped. It is not by chance that two in
three representatives from private employment agencies underline the need for patient
support organisations to be further engaged in return to work policies as many are
essentially concentrated on aspects related to treatment. In this sense Associazione
Italiana Sclerosi Multipla (Italian Multiple Sclerosis Association; AISM) represents
a positive exception as it has cooperated both with Merck Serono (a pharmaceutical
company) and Prioritalia (a trade union foundation) in the organisation of dierent
training courses. It has also reached a local partnership agreement with the employer
association Unindustria of Rome, the ASPHI Foundation (which promotes the
inclusion of disabled people through digital technologies), Merck Serono and local
trade union organisations FILCTEM-CGIL, FEMCA-CISL and UILTEC-UIL with the
aim of facilitating the recruitment of workers aected by multiple sclerosis at Merck
Serono’s Rome site. Another positive example is represented by the PROJOB initiative
launched by Associazione Italiana Malati di Cancro (Italian Association of Cancer
Patients, Relatives and Friends; AIMAC) in 2012. AIMAC professionals oer training
for HR managers, line managers and colleagues, consultancy for employers on legal
and contractual solutions for a better work-life balance and psychological support for
workers with chronic illness and those caring for ill relatives.
Research organisations focused on chronic illness seem to experience even lesser
chances of interaction with the industrial relations players. Indeed, these occasions
are largely limited to the collection of information required by research projects in
which researchers conduct interviews with managers and trade unionists or workers’
representatives; or, occasionally, to the workplace training programmes that some
such organisations, for example Fondazione IRCCS Istituto Neurologico Carlo Besta,
have developed on disability management.
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
107Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Regional and local public authorities and INAIL also interact with industrial relations
stakeholders. Aside from the involvement of the social partners in Consiglio di
Indirizzo e Vigilanza (INAIL’s Orientation and Oversight Committee; CIV),
11
an
important example is represented by the Memorandum of Understanding signed
in January 2020 by the Lazio regional directorate of INAIL on behalf of local trade
unions, employer organisations and several associations for disabled people. The
Memorandum concerns the use of INAIL funds for carrying out, with the support of
the public employment centre, return to work projects for disabled people involving
the breaking down of architectural barriers, the adaptation of workstations and
the organisation of training. Another case is provided by the project Insieme per il
Lavoro, resulting from a collaboration between the Municipality of Bologna and the
Archdiocese of Bologna, aimed at facilitating the job placement of people experiencing
social and economic vulnerability. The project was launched in 2017 and has developed
thanks to interaction with local trade unions and employer associations as well as with
a network of enterprises available to integrate such workers.
Even so, these important experiences seem quite rare in the Italian landscape and are
often focused on broad categories of disabled or disadvantaged workers which may
encompass, though do not specically refer to, people with chronic illness.
According to a director of the Ministry of Labour and Social Policies, trade unions
and employer associations are in steady and permanent dialogue with the legislator
concerning labour and industrial relations issues and, with specic regard to return to
work policy, have been consulted prior to the introduction of some legislative provisions.
However, the social partners oered us a quite dierent picture with most trade union
and employer representatives declaring that they were not involved in policy-making
on this issue.
3.3 Outcomes of social dialogue and collective bargaining with regard
to return to work policy at national and local levels
At national level, it does seem that social dialogue processes have resulted in the
introduction of legislative provisions seeking to facilitate the return to work; while
some important bipartite or multipartite social dialogue activities have been conducted
at regional or local level. On top of the aforementioned 2020 Memorandum signed in
Lazio, agreements were signed in July 2015 by the Municipality of Alessandria and local
trade union confederations; and in November 2011 by the Municipality of Pomezia, the
social consortium Coin and local trade unions. Both are aimed at the placement into
work of disabled people, thus extending potentially to people with chronic illness. A
local collective agreement was signed among social cooperatives in the area of Bologna
in April 2018 delivering information and consultation with workers’ representatives
concerning people ‘with functional limitations’ and the health and safety measures
being put in place in individual cooperatives; furthermore, it also focused on possible
11. This body is charged with dening the programmes, guidelines and strategic multi-year objectives of INAIL as
well as monitoring the proper management of the Institute’s economic resources.
Ilaria Armaroli, Maria Sole Ferrieri Caputi and Lorenzo Maria Pelusi
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations108
relocation opportunities to be implemented in conjunction with social consortia and
local cooperatives specically devoted to the workplace inclusion of disadvantaged
people. This process is coordinated and supported by a regional bilateral committee.
As regards national-level collective bargaining, most of the NCLAs signed by the
most representative trade unions (i.e. those aliated to the major confederations
Confederazione Generale Italiana del Lavoro, Confederazione Italiana Sindacati
Lavoratori and Unione Italiana del Lavoro) provide measures that ensure work
continuity for people aected by serious illnesses requiring periodic treatment.
Many NCLAs (such as those for the food industry, the electrical sector, professional
services rms, environmental services and social cooperatives), ensure that periods
of hospitalisation and absence related to the need for life-saving therapies and long-
term treatment are not considered in the calculation of when the protected period ends
for workers aected by certied chronic illnesses (including cancers, HIV, multiple
sclerosis and muscular dystrophy). Similarly, some NCLAs (such as those for the
banking sector, chemical and pharmaceutical sectors, glass industry, apparel industry
and stone materials) increase the length of the protected period, as far as 32-36 months,
for workers aected by chronic illness. Moreover, once the protected period is over,
NCLAs can provide ill workers with the possibility of beneting from unpaid leave of
absence that can last for four, six or twelve months depending on the sector.
Other agreements, such as the NCLA for the metalworking sector as well as that for retail,
specify that absences related to chronic illness are not a reason for wage reductions;
while the NCLA for the food industry grants workers aected by serious pathologies or
medical necessities the opportunity to obtain a severance payment in advance.
Clauses in other collective agreements concern working time such as the right to
change the employment relationship from full-time to part-time (conrming the rights
laid down in the law); paid time-o (also in compliance with Law No. 104/1992); other
forms of working time exibility (e.g. the banking sector agreement provides workers
aected by cancers and degenerative diseases with greater exibility on entry to and
exit from work); and the exclusion of chronically ill workers from certain work shifts
(e.g. on Sundays). The NCLA for the banking sector considers telework a suitable tool
to facilitate the return to work of disabled people.
Some NCLAs also establish funds supplementing the essential health provisions oered
by the public system and thus improving access to treatment for workers. These funds
are nanced out of the contributions paid by employers (and, in some cases, also by
workers) operating in the sectors concerned. These funds can oer the reimbursement
of expenses related to surgical operations, specialist examinations, diagnostic tests (in
the metalworking and food sectors), treatment and rehabilitative therapies for cancers
(in the banking sector) as well as medical consultancy and assistance (in the apparel
industry).
The sorts of measures set down in NCLAs are generally aimed at guaranteeing
job protection, economic support, work-care-life balance and enhanced access to
healthcare for workers aected by disabilities or chronic illness. Less attention,
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
109Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
however, is paid to the procedural and infrastructural elements (such as ad hoc
training activities for managers and workers’ representatives, targeted information
and consultation processes and guidelines for company-level bargaining on return to
work processes) whose use may potentially sustain the actual application of national-
level provisions that are indeed not always known and implemented at company
level. Relevant provisions in this sense can, however, be detected in the NCLAs in the
chemical and pharmaceutical and the banking sectors. Moreover, unlike local social
dialogue, NCLAs do not generally cast attention to active labour policies and tend
to concentrate on securing jobs and making them more sustainable for disabled or
sick workers rather than empowering workers themselves in the labour market. Only
the NCLA for agency workers (probably because of its cross-sectoral nature) seems
to acknowledge and sustain possible occupational transitions for disabled workers by
supporting vocational training and job placement paths for these workers.
3.4 The return to work process at company level and the involvement
of the social partners
3.4.1 Workers’ experiences with the return to work process
Considering the type of illness, our worker survey reveals that cancers are the ones
most often diagnosed while other frequent diseases with an impact on work include:
musculoskeletal disorders; chronic respiratory, cardiovascular and mental illnesses;
arthritis; and diabetes.
More than two in three workers are concerned about their return to work, most often
on the grounds that the employer might not be willing to adjust working conditions
to their post-illness situation. Workers also fear being left without support from the
employer if their subsequent productivity, concentration and work performance do not
fully meet the employer’s expectations. Other reasons for concern are the risk of being
required to return to work at full productivity right after treatment and without any
adjustment period, as well as the possible need to work long hours shortly after long-
term absence. Discrimination by colleagues and unequal nancial treatment, in the
sense that workers may not get bonuses due to their lowered productivity, constitute
additional grounds of concern.
With reference to workers’ actual return experiences, in a majority of cases the
initiative to return had been made by the workers themselves although almost one in
four identies that the triggering role here was played by the specialists treating them.
Indeed, the rst actor with whom workers discuss their return to work is their medical
specialist (38 per cent), followed by the general practitioner (29 per cent), the family (21
per cent) and trade unions to a lesser extent. It is thus no wonder that a crucial role in
facilitating the return to work is played by both the medical specialists and the family.
The role attributed to rehabilitation institutes, nurses and physiotherapists (considered
as crucial by 20 per cent of workers), as well as general practitioners and colleagues
(their role is important in combination with other actors for one in four workers), is also
relevant although less important is the contribution of NGOs or similar organisations
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Continuing at work. Long-term illness, return to work schemes and the role of industrial relations110
and trade unions or other employee representatives (60 per cent of workers deem them
to be unimportant).
With specic reference to the help provided by trade unions, almost half of workers
declare that they are not satised, although one in four are very pleased, receiving
the expected advice and support. More than eight in ten workers have not had the
wish to join trade unions as a means of better facilitating their return to work after
treatment, even though at least one trade union operates in most of the workplaces
where respondents are employed. Moreover, although the vast majority of workers
think that ‘the trade union should always be ready to address the health-related issues
of workers’ and that ‘support for the return to work should be an important element on
the negotiations agenda between trade unions and the employer’, only a small minority
declare that there have been actual negotiations between their employer and workers’
representatives about adjustments to their work tasks and responsibilities after the
return to work. Only one in four workers knows of other cases where a trade union
proved to be helpful in facilitating the return to work.
Neither are workers satised with the support received from their employer: more than
one in four are not satised at all and just 16 per cent report that they were very happy.
Turning to the specic characteristics of the return to work process, respondents are
equally divided between those who, after chronic illness, had returned to the same job
position and those who had not done so. The majority (57 per cent) receive either no
support or only limited help with regard to tasks or duties while, as for adjustments in
the work environment and in the type of employment, almost one-half are not provided
with any support. Similar results concern the opportunity to postpone deadlines
although less negative ndings emerge with reference to adjustments in daily working
time (oered, to an extensive or reasonable degree, to 34 per cent of workers), exible
working time solutions to facilitate medical examinations or treatments (extensive or
reasonable support for 43 per cent of workers) and the reassignment of some original
tasks and responsibilities (extensive or reasonable support for 39 per cent of workers).
However, at least two out of ve workers receive either no support or limited assistance
in all these areas.
3.4.2 Perspectives of HR, line managers and other relevant company actors
on return to work processes
The importance of regular contact with workers during absence is largely acknowledged
by HR and line managers. Indeed, despite them working mainly in large enterprises
with more than 250 employees, they are generally informed of the employee’s specic
chronic illness directly and there were relatively few cases of where they had instead
been informed by the employee’s own occupational physicians or the company’s medical
specialist. Regular contact with workers during absence are not always ensured through
formal channels (such as standard HR requests for medical updates) but sometimes
via informal phone calls and friendly conversations. On these occasions, workers are
generally notied of work-related issues and, albeit in fewer instances, also engaged in
decision-making and planning processes on work-related topics.
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
111Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
During sickness leave, three in four managers say they are forced to implement
important organisational measures generally implying a rearrangement of workow
and a redistribution of job tasks among other workers as well as, to a rather lesser
extent, the replacement of the sick worker. One in ten undergo nancial diculties.
It is thus no wonder that most (70 per cent) declare that they encourage processes for
the return to work during treatment. While dealing with workers on sick leave, HR
and line managers nd it useful to receive consultancy advice from an external expert
or campaigning and patient support organisation, as well as information or advice on
the specic chronic illness and proper adjustments which may be implemented in the
workplace. We pointed earlier to the important support given by private employment
agencies to companies, although managers frequently identify that this is missing,
along with legal advice on sickness leave and external counselling.
Managers report that return to work processes are generally initiated by workers
(56 per cent) or managers or employers (38 per cent) and anticipated either by a
thorough discussion or informal conversation between workers and managers, allowing
for a shared planning of specic return to work paths. A small majority of companies
provide workers with a phased return to work, even though this is largely not written in
any specic document or adaptable to individual situations. Return to work processes
tend therefore to take the form of ‘one size ts all’ solutions, indivisibly addressed to all
workers, and managed mostly by HR managers even though the role of line managers
and team supervisors is conceived as equally important. Meanwhile, less responsibility
is attributed to dedicated health and safety committees. The prevailing approach to
the return to work seems to be essentially reactive when facing a specic situation,
although there is a need for collaboration between HR managers and other business
departments as regards the adoption of a preventive and proactive attitude which could
result in the reconguration of workstations in such a way that they are suitable both
for healthy workers as well as disabled or sick ones.
In the large majority of cases, companies do cooperate with external stakeholders
when handling return to work situations. Indeed, such collaboration, as well as the
relationships between the managers and those employees aected by chronic illness,
are considered as pivotal in these processes and many respondents declare that both
aspects should be further improved.
As regards the content of return to work processes, adjustments to working duties are
perceived as relevant and, according to most, should be binding in law (74 per cent)
rather than simply subject to managerial discretion (53 per cent). One in four managers
think that individuals returning to work after chronic illness will not be able to perform
the same duties as before, while there is also evidence that HR and line managers
also believe that such workers are less committed to work. In this respect, the vast
majority think that ill workers are likely to be absent from work more often than their
colleagues (76 per cent). This, in turn, may be perceived as increasing the workload of
colleagues. Subsequently, adjustments to working time, work tasks or workload are
deemed necessary by the vast majority of respondents. In about half of cases, training
for employees returning to work after chronic illness is oered, although it is far less
common also to nd training initiatives targeted at other workers on how to deal
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Continuing at work. Long-term illness, return to work schemes and the role of industrial relations112
with colleagues returning to work (around 28 per cent). There is a level of support for
converting training from being merely an adaptive measure for upskilling or reskilling
a worker after a long period of absence into a more proactive process that gives value
to the new health conditions and personal skills developed by the worker as a result of
their illness.
These results are, however, sometimes at odds with the degree of satisfaction in these
elds perceived by workers. Workers’ experiences with the return to work process are
complex and, in the majority of cases, they do not see their companies as being prepared
to put in place the necessary adjustments required by their health condition. They also
perceive there to be a lack of coordination between companies and doctors during the
process. Moreover, workers underline the weak support received from companies and
trade unions during the process with specic reference to mentoring and guidance
practices. Given this context, it is no surprise that less than one-half of workers declare
that they felt welcome when they returned to the workplace.
Finally, we should not lose sight of the nding that a considerable share of managers
expect workers to return to their previous productivity level with no need for adjustment
(around one in three) or that about the same proportion had no clear opinion on this
point. Confusion around this issue potentially hints at the current denitions and
assessments of labour productivity being inadequate when it comes to workers aected
by chronic illness: these methodologies are rather abstract and standardised. More
particularly, there is no consideration of individuals’ health and mental conditions at
work and the various organisational and adjustment measures which should not be
neglected when assessing the work performance (and its sustainability) of people with
chronic illnesses in a given context (Tiraboschi 2015).
3.4.3 Experience of (and good practice in) facilitating the return to work at company level
and the role of industrial relations
Return to work policies for workers following chronic illness do not constitute a
prominent topic for company-level collective bargaining in Italy.
12
Indeed, although
managers nd it important to include a worker representative on the committee
addressing occupational health and safety, and that cooperation with workers’
representatives is widely considered to be helpful in increasing workers’ motivation
and improving the quality of relationships between workers and managers, regular
interaction with workers’ representatives does not always appear to be an attractive
option for HR and line managers. Interaction takes a long time and is less exible
than unilateral decision-making; it also entails the risk of additional requests being
made by the workers’ side. The result is that, when these issues are tackled in collective
agreements at company or workplace level, this mainly stems from where managers
are sensitive to workers’ problems and from a willingness to share commitment with
12. The scope of the analysis is represented by the ADAPT database of company-level collective agreements which
has gathered together approximately 3 000 collective agreements. The ndings from the database accord with
the views of workers in our survey in which 82 per cent of the latter say there are no negotiations between their
employer and trade union/employee representatives about adjustments in work tasks and responsibilities after
returning to work.
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
113Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
workers’ representatives. Another relevant prerequisite for negotiations over these
topics is constituted by an awareness among worker representatives of the issues at
stake and an inclination to deal actively with them.
By and large, not all the steps in a return to work process are formalised in a collective
agreement: there are some reasonable adjustments that may imply signicant
investments by the company in new technical facilities and equipment and that are
not included in collective agreements. Moreover, individual processes of return can be
managed by the social partners totally outside the regulatory framework of collective
agreements. For example, the relocation of a worker to dierent activities within a
social cooperative has not been written down in any agreement even though it has
been handled by both employer and trade union representatives. Consequently HR
and line managers tend to see that the most benecial results of the involvement of
workers’ representatives in this eld are not only binding collective agreements but also
training sessions organised for managers and workers’ representatives, information
leaets distributed to workers and inputs made from the labour side on how to improve
company return to work policies internally.
Employers occasionally do consult workers’ representatives, but they still prefer to
activate and implement return to work processes unilaterally, albeit sometimes in
collaboration with external experts and organisations. Important examples in this
sense are from the banking group Unicredit, which has organised awareness-raising
initiatives on disability (e.g. online courses, days dedicated to disability management,
focus groups, etc.) as well as training and professional mobility paths for deaf and blind
people (Stefanovichj 2017). In recent years, return to work initiatives have also been
promoted by the energy group Eni and AIMAC, with the participation of INPS, the
Sodalitas Foundation and l’Ordine Provinciale dei Consulenti del Lavoro (Provincial
Association of Labour Consultants) in Milan. Their project is entitled Una rete solidale
per attuare le norme a tutela dei lavoratori malati di cancro sui luoghi di lavoro
(Solidarity network to implement the norms protecting cancer patients in workplaces)
and is aimed at identifying regulatory solutions for Eni workers who have had various
cancers. The project also focuses on raising workers’ and managers’ awareness of these
problems so as to promote better job integration policies. The digital platform ‘Know
and Believe’, built in partnership with AIMAC and addressed to enterprises and health
funds for the organisation of awareness-raising campaigns, collaborative events, online
training courses and other initiatives to boost the prevention of cancer, is also worth
mentioning in this respect.
In addition to these activities carried out by companies mainly outside the sphere
of industrial relations, company-level collective bargaining can oer a normative
framework for HR managers and workers’ representatives when dealing with return
to work processes as it makes available organisational solutions and tools that can be
used in specic cases.
Among the dierent company-level collective agreements that do address this issue,
the most signicant clauses regard the increase in the length of the protected period
or a job retention guarantee being oered until the complete recovery of a worker
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Continuing at work. Long-term illness, return to work schemes and the role of industrial relations114
aected by cancer. Further norms that have been established in this way concern
work-life balance and, notably, the provision of unpaid sickness leave and additional
paid time-o to undergo medical examinations and treatment (sometimes reserved
explicitly to workers with chronic illnesses); and the possibility for certain categories
of worker (including disabled workers and ones experiencing chronic illness) to benet
from the unused time-o accrued to individual workers but voluntarily transferred to
a ‘Solidarity Working Time Account’ (introduced by Legislative Decree No. 151/2015
13
).
Other company-level solutions which have been collectively agreed as regards workers
with chronic illness include an exemption from working on weekends or on certain
shifts, priority access to remote work and the possibility to be transferred to sites closer
to home or allocated to dierent tasks where they are unt for their previous activities
(also in compliance with Legislative Decree No. 81/2008).
Specic attention is also paid to wage protection during periods of absence, particularly
in the form of the return to work at up to the full amount of the normal wage and the
guarantee of full performance-related pay (excepting the various days of absence from
work).
Other provisions, found somewhat less frequently in company-level collective
agreements, concern dedicated training courses for workers after long periods of
absence and campaigns for the promotion of healthy lifestyles, often in collaboration
with external experts and organisations. Welfare measures potentially targeted
at workers with chronic illness may also be encompassed by the direct provision or
reimbursement of expenses for medical examinations, tests and check-ups as well as
of contributions to health funds and for insurance policies against the risk of not being
able to support oneself or of developing serious illnesses (Tiraboschi 2019). By and
large, however, these solutions are primarily devoted to increasing access to healthcare
for workers from the perspective both of the prevention of serious diseases and their
proper treatment rather than the direct facilitation of return to work policies.
Finally, it is worth mentioning the experiences of those companies (largely
concentrated in the chemicals and pharmaceutical and the banking sectors) that have
established, via collective agreement, the professional gure of a ‘disability manager’
and/or joint labour-management observatories or committees on disability, entrusted
with the task of activating awareness-raising campaigns targeted at all workers and
the design of welfare, training and organisational solutions for the eective return
to work of disabled people. Following the setting-up of these roles and bodies, and
despite the term ‘disability’ being potentially misleading as it seems to exclude many
chronic illnesses, some companies have reached collective agreements regarding the
launch, in partnership with campaigning and patient support organisations, of specic
projects for the workplace inclusion of people aected by chronic illnesses at work (e.g.
the local partnership agreement signed by Merck Serono referred to in section 3.2).
Another example is the 2018 agreement signed by banking group Intesa San Paolo
13. Legislative Decree No. 151/2015 formally includes the possibility of workers transferring, on solidarity grounds,
unused time-o solely to workers who need to assist their sick children. However, collective bargaining has
expanded the scope of this measure.
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
115Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
which envisages a project for the inclusion of autistic workers, in collaboration with
a specialist association, as well as an alternative training path for mentally disabled
students. Funding for the initiatives at Intesa San Paolo comes from the sectoral bilateral
employment fund and the solidarity company account nanced by the employer and by
workers voluntarily giving up a small percentage of their salaries for this purpose.
4. Conclusions
The Italian legislation on chronic illness and labour rights generally does not attribute
functions and competences to industrial relations specialists, and the social partners
themselves argue that policy-making processes in respect of the return to work
provide rather poorly for their involvement. The legal framework on the return to work
after chronic illness in Italy is also signicantly fragmented and this compromises
local players’ thorough knowledge of it and their ability to implement it properly.
Furthermore both employers and social partners frequently lack this legal expertise
while being usually somewhat disinterested in these topics, preferring to focus their
action on more traditional issues.
It is thus no wonder that the role of collective bargaining in this area is rather limited,
being mainly focused on generalised responses to disability or chronic illness. Most
NCLAs, indeed, tend to provide workers who have chronic illnesses with employment
and wage security, a fair work-life balance and, thanks to supplementary health funds,
with better or additional healthcare services. Although the measures agreed in this eld
mainly relate to these social areas, some dierences can be detected across dierent
sectoral NCLAs as regards the scope and generosity of these solutions and their main
targets (e.g. either disabled workers, workers with chronic illness, workers aected by
cancers and degenerative diseases, workers in need of life-saving therapies, etc.). In
particular it has been reported that there is a lack, across dierent NCLAs, of clear
and homogeneous denitions of the worker categories which are intended to be the
beneciaries of return to work measures and other forms of protection (Osservatorio
AISM 2017). This has led to great confusion in their application and, consequently, to
the risk of unequal treatment across companies and economic sectors.
It is in the light of these considerations that we can agree with and further advance
AISM’s suggestion that the social partners overcome the disparities in protection
standards caused by the varying beneciaries identied in dierent NCLAs and extend
the rights and prerogatives to more comprehensive and less compartmentalised worker
categories (Osservatorio AISM 2017). The potential wide and generalising eect of this
approach must not, however, overlook the specic characteristics of each condition and
the particular needs of every single person with chronic illness, in respect of whom
each return to work plan needs to tailor its measures carefully.
With reference to decentralised industrial relations, it is worth pointing out that local
and company-level bargaining on the return to work after chronic illness is largely
underdeveloped and reliant on the mutual willingness of individual trade unions,
employer representatives and managers. As a consequence, when it does take place,
Ilaria Armaroli, Maria Sole Ferrieri Caputi and Lorenzo Maria Pelusi
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations116
company-level bargaining is essentially limited to large and well-structured companies
(generally equipped with the necessary nancial and technical resources to address
return to work processes), that are mainly concentrated in specic sectors such as the
chemical and pharmaceutical, energy and banking sectors.
As observed from the sectoral level, collective company-level solutions are usually aimed
at providing workers with protection within their existing employment relationship
and do not support, nor cover, any possible employment transitions. In contrast, active
labour market policies and return to work programmes are found to be more frequently
designed and implemented at regional level, where the social partners often engage
with other relevant stakeholders in joint initiatives and projects. At company level,
employers and workers’ representatives may sometimes be found to cooperate with
each other in return to work processes even outside the framework of formal collective
agreements. As a result, the processes of return for workers experiencing chronic
illness in Italy still seem to be largely managed on an informal and individual basis. In
companies, these processes are mostly addressed unilaterally by company managers
– at best, with the support of a few external experts – whilst the involvement of
workers’ representatives is quite rare. This situation is likely to jeopardise worker voice
in return to work processes, thus explaining the already-polarised views of workers
on the amount of support received from their employers. The situation also explains
surveyed workers’ largely negative perceptions on workplace adaptations after long-
term absence and the role of labour representatives in these dynamics.
In partial contribution to the prevailing informality of the management of these
issues, as well as the lack of a homogeneous, widespread commitment among the social
partners to return to work processes, is the absence of any form of coordination and
promotion starting from national industrial relations levels. Exceptions can be found
in the NCLAs for the chemical and pharmaceutical and the banking sectors, where
trade unions and employer associations have emphasised certain procedural aspects
(e.g. ad hoc training activities for managers and worker representatives and targeted
information and consultation rights), enabling local negotiating parties to put in place
informed and site-specic solutions. Moreover, these NCLAs have sought to enhance
the role of a national bilateral observatory in promoting and coordinating active labour
market projects at local level, as well as encouraging companies to adopt disability
management plans. It is thus not by chance that the most relevant collective return
to work solutions have been implemented in companies operating in these sectors.
However, both these agreements suer from the lack of a clear provision of a monitoring
system aimed at checking the implementation in practice of the suggested measures.
In the light of these ndings, it is desirable that the social partners at national level take
action to foster the role of local actors on this topic and improve their competencies at doing
so. Successful results can be achieved especially when social partners collaborate with
research institutes, campaigning and patient support organisations, public institutions
and other relevant stakeholders in this eld. However, these interactions, which are all
the more important in this area given the multidimensionality of the issue (aecting the
worker primarily as a person and a member of a family and a social community), seem
limited to certain contexts and situations stemming from the availability and interest of
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
117Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
particular individuals. Major eorts should thus be oriented towards deepening social
partner knowledge of the existing legal framework, strengthening multi-stakeholder
cooperation and coordination across dierent levels and promoting a preventive and
proactive approach to the return to work. This ought to have been done prior to the
emergence of a critical health situation, and not in response to one, by redesigning work
environments to make them more inclusive and sustainable for all and by rethinking
notions of productivity, work performance, task fullment and suitability for work, inter
alia, concerning their more appropriate adaptation to the needs of workers experiencing
chronic illness (Tiraboschi 2015). This is even more urgent considering that workers
undergoing a return to work are largely worried about not being able to keep up
their usual levels of productivity and performance, and that a considerable portion of
managers expect workers to be back at their previous pace with no adjustments.
Ultimately, as collective agreements mainly provide protections for workers within
their existing employment relationship, greater attention should be paid by the social
partners to the periods of transition (such as periods of absence from work due to
treatment and periods of transition to a dierent job), within which workers may feel
lost and in need of the external support which, today, is largely being sourced from
relatives, physicians, colleagues and professionals from campaigning and patient
support organisations. It is in this area that, given the many personal changes and
events (e.g. disease, maternity, caregiving, etc.) which potentially have an impact on
individuals’ careers, the maturity, innovativeness and readiness of industrial relations
actors and institutions will be measured.
References
Bono R. (2020) La giurisprudenza nazionale a tutela del lavoratore disabile tra divieti di
discriminazioni e obbligo di soluzioni ragionevoli, in Del Punta R., Gottardi D., Nunin R. and
Tiraboschi M. (eds.) Salute e benessere dei lavoratori: profili giuslavoristici e di relazioni
industriali, Bergamo, ADAPT University Press, 67-81.
Caprile M., Riobóo I. Welz C. and Rodríguez R. (2017) Mapping varieties of industrial relations:
Eurofound’s analytical framework applied, Luxembourg, Publications Oce of the European
Union. https://www.eurofound.europa.eu/sites/default/files/ef_publication/field_ef_
document/ef1755en.pdf
Carfì A., Bernabei R. and Landi F. (2020) Persistent symptoms in patients aer acute COVID-19,
JAMA, 324 (6), 603-605.
Colombo S. and Regalia I. (2016) Changing joint regulation and labour market policy in Italy
during the crisis: On the edge of a paradigm shi?, European Journal of Industrial Relations,
22 (3), 295-309.
CNEL (2019) 10° Report periodico dei Contratti Collettivi Nazionali di Lavoro vigenti depositati
nell’Archivio CNEL. http://www.bollettinoadapt.it/wp-content/uploads/2020/02/Decimo_
report_CCNL_vigenti_dicembre_2019.pdf
EuroHealthNet (2017) Joint statement on ‘improving the employment of people with chronic
diseases in Europe, Framing paper. https://bit.ly/3xu323X
Fernández Martínez S. (2017) L’evoluzione del concetto giuridico di disabilità: verso un’inclusione
delle malattie croniche?, Diritto delle Relazioni Industriali, 27 (1), 74-97.
Ilaria Armaroli, Maria Sole Ferrieri Caputi and Lorenzo Maria Pelusi
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations118
ISTAT (2019) Sanità e salute, in Annuario statistico italiano 2019, Roma, Istituto nazionale di
statistica, 121-160. https://www.istat.it/it/files//2019/12/C04.pdf
Istituto Piepoli (2008) Quel brutto male: il vissuto sociale del cancro RAPPORTO 286-2007,
Milano, Istituto Piepoli. https://dg4fet0kj3gdo.cloudfront.net/download/allegati/Quel_
brutto_male.pdf
La Stampa (2011) Gli ammalati di cancro vogliono continuare a lavorare, La Stampa, 17 May
2011. https://www.lastampa.it/salute/2011/05/17/news/gli-ammalati-di-cancro-vogliono-
continuare-a-lavorare-1.36961494
Leonardi S. (2017) Trade unions and collective bargaining in Italy during the crisis, in Lehndor
S., Dribbush H., Schulten T. (eds.) Rough waters: European trade unions in a time of crises,
Brussels, ETUI, 83-107.
Leonardi S., Ambra M. C. and Ciarini A. (2017) Italian collective bargaining at a turning point,
Working Paper “Massimo d’Antona’ INT 139, Catania, Centre for the Study of European Labour
Law ‘Massimo D’Antona, University of Catania. https://bit.ly/3k7Onrk
OECD (2009) Sickness, disability and work keeping on track in the economic downturn, Paris,
OECD Publishing. http://www.oecd.org/employment/emp/42699911.pdf
Osservatorio AISM (2017) Sclerosi multipla, gravi patologie, disabilità: analisi della contrattazione
collettiva nazionale, Genova, Associazione Italiana Sclerosi Multipla. https://allegati.aism.it/
manager/UploadFile/2/20171215_723.pdf
Stefanovichj S. (ed.) (2017) Disability management, welfare e permessi solidali: analisi di casi
aziendali e contrattuali che arontano la sfida della disabilità e gravi patologie, Roma,
Edizioni Lavoro.
Tiraboschi M. (2019) Welfare for people. Secondo rapporto su ill welfare occupazionale e
aziendale in Italia, Bergamo, Adapt University Press.
Tiraboschi M. (2015) The new frontiers of welfare systems: the employability, employment and
protection of people with chronic diseases, E-Journal of International and Comparative Labour
Studies, 4 (2). http://ejcls.adapt.it/index.php/ejcls_adapt/article/view/283/384
Università Cattolica Sacro Cuore, Istituto Sanità Pubblica (2020) Rapporto Osservasalute 2019.
Stato di salute e qualità dell’assistenza nelle regioni italiane.
https://www.osservatoriosullasalute.it/osservasalute/rapporto-osservasalute-2019
Vargas Llave O., Weber T. and Vanderleyden J., (2019) How to respond to chronic health problems
in the workplace, Luxembourg, Publications Oce of the European Union.
https://www.eurofound.europa.eu/publications/policy-brief/2019/how-to-respond-to-
chronic-health-problems-in-the-workplace
All links were checked on 07.06.2021.
Overcoming the voluntarist and irregular approach of Italian social partners to the return to work
119Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Database and datasets
Eurostat, People having a long-standing illness or health problem, by sex, age and labour
status [hlth_silc_04]. http://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=hlth_
silc_04&lang=en [Accessed 30.12.2020].
Istat, Aspetti della vita quotidiana: Stato di salute – età dettaglio. http://dati.istat.it/Index.
aspx?QueryId=15448# [Accessed 30.12.2020].
Istat, Aspetti della vita quotidiana: Stato di salute – posizione nella professione. http://dati.istat.
it/Index.aspx?QueryId=15448# [Accessed 30.12.2020].
OECD.Stat, Collective bargaining coverage. https://stats.oecd.org/Index.aspx?DataSetCode=CBC
[Accessed 03.06.2020].
OECD.Stat, Trade union density. https://stats.oecd.org/Index.aspx?DataSetCode=TUD [Accessed
03.06.2020].
121Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Chapter 6
Missing a framework for returning to work:
the role of the social partners in Romania
Adela Elena Popa, Felicia Morândău, Radu-Ioan Popa and Mihai Stelian Rusu
1. Introduction
Population ageing and the increasing prevalence of chronic illness constitute demograph-
ic developments which are inuencing labour markets across the European Union with
a likely higher impact on those countries, such as Romania, where welfare and health-
care systems are already challenged. The Romanian case is interesting as it has a specic
prole among other countries in Europe: poorer labour market and health indicators
compared to the EU average and a weak and ineective trade union movement. We detail
these three aspects below; for a more detailed presentation, see Popa et al. 2021).
First, labour market indicators have improved in the last few years, but there remain
ongoing diculties. After the employment rate reached its lowest point of 63.5 per cent
of the working age population in 2009, it increased slowly but steadily to 66.7 per cent
in 2019 (Eurostat and Trading Economics 2020). Despite this upward trend, Romania
is still slightly below the mean employment rate for the EU-27 (73.1 per cent in 2019).
Moreover the duration of working life in Romania was 35.9 years in 2019, below the
EU-28 average of 36.4 (Eurostat 2020), while the activity rate (the labour force as a
percentage of the country’s total population) was, at 72.3 per cent in 2017 (European
Commission 2019), also behind that of the EU-28. The unemployment rate reached
its lowest level in December 2018 (3.8 per cent), while the long-term unemployment
rate (those unemployed for more than 12 months) is low compared to other European
countries – 1.6 per cent in 2019 (Eurostat and Trading Economics 2019). However,
a good share of this category either remain unemployed (73.2 per cent) or become
inactive (13.2 per cent).
Second, the healthcare system in Romania has, since 2017, been based on social and
health insurance contributions paid by the employed population out of their salaries.
Before 2017, such contributions were shared equally with the employer. The state pays
the contributions for several vulnerable social categories (the unemployed, pensioners
with low retirement incomes, people receiving social benets) while coverage for other
categories (including disabled people and those with chronic illness) is provided out
of the contributions of employed people. Despite the neoliberal policies which have
been implemented in the healthcare system during the last decade, it remains both
chronically undernanced – 4.7 per cent of GDP went on health expenditure in 2018
(Eurostat 2018b) – and centralised. Romania also has problems with healthcare
outcomes (high infant deaths, low cancer survival rates, a high number of deaths before
age 65) and it faces problems in prevention and the range and reach of the healthcare
services provided (Björnberg and Phang 2019).
Adela Elena Popa, Felicia Morândău, Radu-Ioan Popa and Mihai Stelian Rusu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations122
The main cause of morbidity and mortality in Romania is represented by cardiovascular
diseases. The mortality rate from ischaemic heart disease is three times higher than
the EU average (OECD/European Observatory on Health Systems and Policies 2019).
Another relevant, although indirect, indicator of the prevalence of chronic illness in
Romania is given by hospital discharge rates. Romania is discharging patients with
diseases of the circulatory system, which are among the most prevalent chronic
illnesses in the country (Eurostat 2018a), at an increasing rate and here it ranks eighth
among EU countries. Romania has a standardised death rate around 2.5 times higher
than the EU average (Eurostat 2017). Cancer is the second cause of morbidity and
mortality, with lung cancer being the most frequent cause of death in this category
(National Institute of Statistics 2020).
Furthermore, around 46 per cent of people beyond the age of 65 suer from at least one
chronic illness, women being more aected than men. It is additionally estimated that
more than 3 per cent of the country’s population suers from one form or another of
rheumatic disorder with the active population being signicantly aected. More than
half of absenteeism in the workplace and around 60 per cent of permanent incapacity
for work are caused by musculoskeletal diseases in Romania (Dorobantu 2018). Thus,
besides the pressure on the healthcare system, such diseases are having an important
socioeconomic impact upon the labour market and the welfare state.
In the last year, the Covid-19 pandemic represented an extra burden for all workers
including those with chronic illnesses. In January 2021 the number of Covid-19
cases diagnosed since the beginning of the pandemic stood at 728 743 among which
there were 674 594 cured cases while 106 196 people had been immunised through
vaccine (Covid-19. Date la zi 2021). The peak number of cases was in November 2020
(around 10 000 a day). No ocial data is currently available in Romania regarding the
return to work after Covid-19 or about its longlasting health eects which can lead to
further absence from the labour market. Even though some employer associations and
federations of trade unions are involved in making sure that preventive measures are
taken in the workplace or in advocating the benets of teleworking, there is no data
available which allows us to draw conclusions on their impact.
Third, the type of industrial relations system in Romania may be described as central
and eastern European neoliberal and decentralised (Bechter et al. 2012; Bohle and
Greskovits 2012). Traditionally Romania had a strong trade union movement and
a coordinated system of collective bargaining until the reform of social dialogue
legislation in 2011. This legislation changed how trade unions were established and
how they functioned. The result has been a decrease in collective bargaining from
100 per cent (in 2010) to around 35 per cent (Stoiciu 2016), a gure which contemporary
sources also support (ETUI 2020). According to the same data source, the trade union
membership rate is 33 per cent but the numbers vary depending on the source. At
present, social dialogue is weak and largely ineective as responsibility for bargaining
is placed at company level and actors in the companies have not fully assumed their
role. Of all the issues addressed by trade unions, their inuence on health issues is
rather limited.
Missing a framework for returning to work: the role of the social partners in Romania
123Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
The rest of the chapter is structured as follows: section 2 describes the Romanian policy
framework for the return to work after chronic illness; section 3 provides analysis
regarding the involvement of the social partners in the return to work at national level;
section 4 analyses the same issues at company level; and section 5 provides concluding
remarks.
2. The policy framework on the return to work in Romania
This section summarises the policy framework for sickness, invalidity and the return
to work in Romania.
1
Data were collected initially by desk research and then compared
with information from individual interviews with health and social security experts.
Of the four groups of countries described by Belin et al. (2016), Romania belongs to
the third group with an ad hoc approach, i.e. not planned and supervised but usually
determined on a case-by-case basis. The main target groups are disabled workers and
those with occupational conditions or injuries and, in respect of some provisions,
workers with chronic illnesses. Few actors are formally mentioned as having a role in
the return to work and there are no statutory programmes for it.
2.1 The sickness and invalidity system in Romania
The Romanian social security system is based on social insurance (which pays for
invalidity benet) and health insurance (which pays for sickness leave). Dierent
government departments formulate the criteria and supervise the requirements for
sickness leave and invalidity benet: Ministerul Sănătăţii (Ministry of Health) is
responsible for the sickness leave provisions, named temporary work incapacity in
Romanian law, while Ministerul Muncii și Protecției Sociale (Ministry of Labour and
Social Protection; MMPS) is responsible for invalidity benet, disability benet (since
2019) and other related payments. The provisions for sickness absence and invalidity
are established in law and thus the system is rather centralised with the state having
the key role while other actors, including employers, trade unions and employer
associations, make a less signicant contribution to how these systems function and
how policies are shaped.
Dierent measures are established for accidents at work and occupational diseases
compared to diseases not related to the workplace.
2.1.1 Sickness leave provisions
All workers are eligible for temporary work incapacity on a conditional basis, i.e. if
they are insured by the public social insurance system, have a contribution record of
1. The analysis here focuses on several pieces of legislation: Law 19/2000 (public pension system); Law 263/2010
(the unitary system of public pensions); Emergency Ordinance 158/2005 (temporary work incapacity and social
security); the Labour Code (53/2003); Government Decision 355/2007 (employee health monitoring); Law
448/2006 (protection and promotion of the rights of disabled people); Law 319/2006 (security and health at the
workplace); and Government Ordinance 137/2000 (preventing and sanctioning all forms of discrimination).
Adela Elena Popa, Felicia Morândău, Radu-Ioan Popa and Mihai Stelian Rusu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations124
at least one month and can provide a medical certicate. The duration of incapacity is
a maximum of 183 days (six months) in one year and workers cannot be red during
this period. After an initial period of 90 days, the period of incapacity can be extended
up to the 183-day limit with the approval of an expert social security physician. For
several specic diseases (such as tuberculosis, some cardiovascular diseases, AIDS
and cancer), the duration can be longer than six months.
Temporary work allowance is generally paid by the employer for the rst ve days of
sickness leave and then out of the public social insurance budget (Fondul Naţional Unic
de Asigurări Sociale de Sănătate; National Fund for Social Health Insurance; FNUASS)
until the end of the period of incapacity. Generally the level of benet is 75 per cent of
average monthly income earned in the six months prior to the month when the illness
occurred; however, it is 100 per cent when the illness occurred through an accident at
work or an occupational disease or if the illness is tuberculosis, HIV/AIDS or cancer.
The timing of the considerations about the return to work is the end of the period of
sickness leave. The sole early intervention is an obligation on workers with sickness
leave longer than 90 days to follow a medical rehabilitation programme which is set
out in the following sections. The return to work is usually done informally, it is not
planned and is rarely phased (part-time work then full-time work). When resuming
work, the occupational physician must give an assessment but is not really involved in
the return to work process.
2.1.2 Invalidity benefit provisions
Workers who are assessed as having lost more than one-half of their work capacity
due to accidents at work or occupational diseases, tumours, HIV/AIDS, schizophrenia
or accidents and diseases not related to work can apply for invalidity benet provided
they have completed the required contribution period (also related to the age of the
worker). There are three degrees of invalidity. The rst degree means a total loss of
work capacity and self-care ability; the second degree represents a total loss of work
capacity while preserving self-care capacity; and the third degree represents the loss
of at least half of work capacity (the worker can work corresponding to a maximum
of one-half of normal working time). The assessment of work capacity is carried out
by expert social insurance physicians from Casa Națională de Pensii Publice (the
National House of Pensions; CNPP) which is a part of MMPS. Invalidity benet, which
is paid by CNPP, can be extended up to retirement but every 1-3 years the person is
reassessed by an expert social insurance physician. Several situations may halt benet
payment. The contributors to this fund are salaried workers, employers and the self-
employed. Invalidity benet can vary as it is calculated based on gross salary and the
contribution period.
During the period of invalidity, beneciaries must follow a medical rehabilitation
programme recommended by the expert social insurance physician; benet will be
stopped if the beneciary does not comply. After the invalidity benet ends, the worker
must usually nd another job. Here, too, the occupational physician must give an
assessment but is not really involved in the return to work process.
Missing a framework for returning to work: the role of the social partners in Romania
125Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
2.2 Policies on the return to work in Romania
The Romanian legislation thus makes several stipulations for sick leave and invalidity
which are indirectly related to the return to work. In addition, there are other
provisions which can also be indirectly related to this issue. These provisions are
general, indicating broad principles rather than specic actions designed to facilitate
the return to work. No specic measure, procedure or intervention is provided by law
after the period of sickness leave ends and the return to work is not specically planned
although employers may allow a worker to resume work on a part-time schedule
initially (depending on the type of job). Specic roles in the return to work process are,
however, allocated to the treating physician, the employer, the occupational physician
and the local public employment agency. No other actors have a role, while that of the
employer is marginal. Furthermore no active labour market policies targeting workers
who have been on sickness leave are in place.
2.2.1 Sickness leave
No specic procedure in respect of the return to work which involves either the employer
or an occupational physician is set down for this period. However, there are several
stipulations regarding the recovery of work capacity which must be followed during
the period of leave. Thus, to achieve the recovery of work capacity, workers who are
on sickness leave for more than 90 days can benet from medical and spa treatment
of 15-21 days for recuperation, following an individual plan provided by the treating
physician and approved by the expert social security physician. Individual medical
rehabilitation plans are phased and mandatory and paid by FNUASS.
2.2.2 Resuming work
Workers who return to work after sickness leave of more than three months, or
who change jobs, must obtain a medical certicate (t note) from the occupational
physician. The t note can have four outcomes: able to work; conditionally able to work;
temporarily unable to work; and permanently unable to work. Based on the t note,
measures for work adaptation can be established by the employer.
If a worker lacks work capacity (validated by the expert social security physician), the
employer has to oer another role compatible with the skills and/or work capacity of
the worker. The worker has three days in which to inform the employer whether or
not the new role is accepted. If the employer does not have vacant positions to oer,
the employer must refer the worker to the local employment agency which will oer
guidance on obtaining a new job according to the worker’s skills and capacity. The
employer can dismiss the worker only if that person does not respond in three days to
the proposal of an alternative role or only after referral to the local employment agency.
If dismissed in this situation, the worker may receive compensation according to the
individual work contract or the collective labour contract.
Adela Elena Popa, Felicia Morândău, Radu-Ioan Popa and Mihai Stelian Rusu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations126
2.2.3 Provisions for disabled people
Some workers who have chronic illnesses have a disability certicate issued by
Serviciul de Evaluare Complexa a Persoanelor Adulte cu Dizabilitati (Authority for
the Complex Assessment of Disabled Adults; SECPAD) which is also part of MMPS.
There are several provisions for people with such a certicate if they want to (re-)
integrate into work. Public authorities have the obligation to establish and maintain
sheltered units and sheltered jobs and to initiate measures to incentivise employers
to hire and maintain disabled people in work. Public authorities must also oer social
services and counselling for disabled people and their families as well as for employers.
Employers with at least 50 employees have the obligation to hire disabled workers (a
minimum of 4 per cent of the total number of employees) but alternative options are
available for employers who cannot meet this requirement. Employers who hire disabled
workers may benet scally in many ways, including the deduction of their expenditure
on workplace adaptation and in respect of vocational rehabilitation and guidance.
Disabled workers have the right to benet from reasonable accommodation in the
workplace, counselling and work mediation, the possibility to work fewer than eight
hours daily (on advice from SECPAD) and exemption from payroll taxes. Employers
have the obligation to adapt the workplace according to the needs of ‘groups sensitive
to risks’ as set out in the law.
Other general provisions include the outlawing of discrimination based on chronic
non-communicable diseases in the workplace and the concept of special medical
supervision which refers to the assessment of the work capacity of workers with chronic
illness carried out by occupational physicians.
3. Involvement of the social partners in shaping return to work
policies at national level
This section presents ndings from our survey of the social partners, the roundtable
discussion, two separate discussion groups with employers and with trade unions and
from interviews with national stakeholders.
3.1 Actors and stakeholders in return to work policies
A major characteristic of the Romanian policy-making system is its centralised nature.
In the context of the return to work, the state plays the main role while the involvement
of the social partners and other stakeholders is rather limited. Traditionally, and even
more so since 2011, the practice of social dialogue in Romania has been weak.
At national level, tripartite social dialogue is coordinated through institutional
structures. At government level, Consiliul Național Tripartit pentru Dialog Social
(the National Tripartite Social Dialogue Council) is composed of members of trade
Missing a framework for returning to work: the role of the social partners in Romania
127Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
unions and employer associations and members of the government (Ministerul Muncii
și Protecției Sociale 2020). The technical secretariat role is carried out by Comisia de
Dialog Social (Social Dialogue Commission) which functions within MMPS. Also at
national level there are consultations between the government and Consiliul Economic
şi Social (the Economic and Social Council), a civic dialogue body composed of civil
society representatives.
Besides these actors, there are ve trade union confederations with representation at
national level and with a more signicant membership density in industry (75-85 per
cent) than in public administration (30 per cent) (ETUI 2020). Since 2011 collective
agreements are no longer negotiated at national level, only at industry or sector level,
company level or for groups of companies. Negotiations are regulated by the law on the
social dialogue under which only trade unions (and employer associations) that represent
at least 7 per cent of employees (10 per cent of employers) in a sector of activity can
negotiate at that level. When it comes to the company level, only one trade union can be
representative of employee interests. In companies with more than 20 employees and
no trade union, employee representatives can be elected (ETUI 2020). All companies
with more than 10 employees should elect health and safety representatives, although
their responsibilities are rather general in maintaining workplace health and safety.
Concerning to whom companies turn when they need information on health and
safety, Romanian companies turn mostly to labour inspectorates (in 82 per cent of
organisations) and much less to employer associations (27 per cent) or to trade unions
(11 per cent) (Irastorza et al. 2016).
Since the 2011 reform of the social dialogue (Law 62/2011), social dialogue has been
weak and ineective. According to the results of our research study the provisions of
Law 62/2011 are very restrictive as regards trade unions while favouring employers. The
number of collective agreements negotiated at company level has dropped signicantly
and social dialogue has been reduced to focus only on a few points based on the minimal
requirements of the labour code. Trade unions have been dealing mostly with nancial
issues and working conditions while health and safety issues, including the return to
work, remain under-regulated.
Another institutional actor is Agenția Națională pentru Ocuparea Forței de Muncă
(Public Employment Agency; ANOFM), alongside its regional agencies, but it deals
mostly with unemployed people in good health and has only a formal and marginal
role regarding workers returning to work after sickness or disability.
Civil society is also characterised by having little involvement in shaping return to work
policies. For example, among the 135 associations and 33 foundations active in the eld
of cancer, only nine associations and one foundation are engaged in explicit activity
facilitating work reintegration (Popa et al. 2016). Some initiatives could be undertaken
by researchers active in this eld as a result of the projects they carry out, but
communication with the upper political layer is usually limited as there are no formal
bottom-up ways to propose policies, or changes in policy, and public consultations are
rarely organised as well as ineective and usually non-transparent when they are.
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Continuing at work. Long-term illness, return to work schemes and the role of industrial relations128
Discussions with stakeholders conrm that they are not directly involved in shaping
policy at national level on the return to work following chronic illness. Employer
participants in these discussions agree that the state (as the most important actor),
employers (especially HR departments) and workers should all be involved more while
some stress that specialist physicians should have greater involvement. Trade unions
are only marginally involved and their involvement is usually restricted to nancial
issues. For their part, trade union participants also agree that the state is the most
important actor, followed by trade unions, employers and the College of Physicians.
Even so, all the participants see themselves as passive actors regarding their inuence
in shaping policies, acknowledging that they merely act within the context of the law.
Here, a lack of initiative in shaping policy is explainable by a lack of mechanisms which
strengthen cooperation between the political actors and stakeholders at lower levels.
Half the social partners agree that, although marked by obstacles, cooperation between
them and other stakeholders (government, members of labour market institutions,
medical organisations, rehabilitation centres, NGOs, psychologists, therapists and other
professionals) is vital in facilitating policy creation and implementation concerning the
return to work.
3.2 Views and level of involvement of industrial relations actors in return
to work policies
Seven Romanian social partner organisations participated in the research (including
three employer associations and three trade unions), all involved in tripartite national
social dialogue. Here, we supplement the responses with data from the roundtable
discussion, stakeholder discussion groups and interviews with the social partners.
3.2.1 Social partners’ perceptions of EU-level return to work policies
Over half arm that their organisations participate in EU-level social dialogue
structures and that they have knowledge of EU-level policies supporting the return to
work following chronic illness. Most trade union representatives agree that the agenda
in this eld should be part of an EU strategy and that the EU-level agenda should be
more energised on this issue to the point of making binding recommendations for
member states. Others also disagree with the idea that the EU-level agenda addresses
policies appropriately and that no changes are needed, as well as that the return to
work should feature more highly on the agenda of EU-level social dialogue. EU-level
policies on the return to work should serve as the basis of a framework for national
policies; while cooperation at EU level is considered both necessary and relevant.
3.2.2 Social partners’ perceptions of national return to work policies
The main problem in Romania appears not to be the absence of an elaborate policy
framework but the lack of proper implementation and enforcement, although almost all
respondents agree that trade unions and employer associations should be more active
in addressing the policy-making process in this area. Most respondents say they know
Missing a framework for returning to work: the role of the social partners in Romania
129Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
of the existence of national policies and measures in this area, even though Directive
2000/78/EC establishing a general framework for equal treatment in employment and
occupation is not a well-known measure, while two-thirds know of specic measures
facilitating the implementation of return to work policies.
The majority are occasionally involved and consulted in policy-making on the return
to work yet respondents do strive for more active participation. Half of those involved
assert that they take the initiative on the issue with the other half acknowledging that
the initiative is driven by external factors (such as at national or EU level). Participants
identify two important barriers to their involvement in shaping policy: governments
who disregard their initiatives; and not being recognised as a relevant partner for
policy-making in the area.
One-third have occasional involvement in policy implementation while the rest have
limited, ad hoc or marginal involvement. The cause of this lower level of involvement
in policy implementation is the lack of a national strategy or legislative framework
to facilitate engagement. Half monitor how return to work policy is implemented at
company level while one-third monitor it at national level.
As highlighted in part by our own previous research (Popa and Popa 2019), participants
in the stakeholder discussion groups identify several positive aspects of the current
legislation on sickness leave, invalidity and the return to work. These include the labour
code (considered as a good policy); sickness leave being generous and fully-paid in respect
of some illnesses; the impossibility of dismissing a worker during sickness leave; and
the stipulations on occupational diseases (some of them being chronic illnesses). On the
negative side, participants highlighted the insucient regulation of the phased return to
work and working time exibility; the non-existent counselling services; the insuciency
of rehabilitation services and the low degree of their accessibility; that sickness leave is
granted only on a month-by-month basis, thus challenging the employer’s need to make
long-term replacement plans; and the lack of facilities to help employers accommodate
an employee’s return after chronic illness since the system is sanctions-based.
In sum, the stakeholders are rather poorly involved in policy-making. They lack the
proper means to participate and have somewhat withdrawn from this process in the
context of the state being deemed to have the most signicant responsibility. On the
other hand, the social partners agree that the policy stipulations that are in place in
this area are not specic enough. Here, they mention the need for a legal framework,
reecting EU-level strategy, with clear procedures for employers and other stakeholders
supporting the return process. The social partners agree they should be more active
but consider their power of inuence to be limited.
3.2.3 Social partners’ perceptions of the role of national industrial relations
in returning to work
The social partners are involved mostly in activities related to collective bargaining
and less so in raising workers’ awareness of their rights, lobbying public institutions
and providing assistance to individual workers.
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Continuing at work. Long-term illness, return to work schemes and the role of industrial relations130
All stakeholders consider that the trade union role could extend to negotiations on
health funds and bonuses for workers with chronic illness. Industrial relations are
judged as important in the return to work; yet the framework within which the actors
could function eectively is missing. Stakeholders also agree on the importance of all
the social partners, at all levels, in shaping and implementing policy through social
dialogue. However, they see the main objective of their involvement in the context of
improving the policy proposals of MMPS, as the main actor.
3.3 Outcomes of social dialogue regarding return to work policies
Our ndings suggest that, overall, the outcomes of social dialogue on the return to
work are poor. Interviews with various stakeholders pointed to the presence of little
cooperation with industrial relations actors. Where such cooperation does exist, it is
mostly with trade unions although, even then, it is only limited. An individual (tailored)
approach at company level is considered more useful and using collective bargaining is
common practice. An example was oered in which the trade union had negotiated that
a worker would receive a lump sum of two years’ salary before being made redundant
following the loss of work capacity. More often, however, trade unions help employees
nancially with their treatment and oer informal support and encouragement for the
return to work.
3.4 Views on the potential for action on the return to work and
the contribution of the industrial relations actors
The very few examples of best practice which the social partners were able to oer
concerning return to work policies were rather abstract. Several measures were
proposed as a means of improving social dialogue co-operation: to elaborate better
legislation; to oer scal advantages for employers supporting an appropriate
environment for employees with chronic illnesses; to include return to work on
the collective bargaining agenda; and to build a culture at company level based on
the argument that organisations with good performance take care of their human
resources.
Our evidence conrms that current approaches are based on informal action and the
employer’s willingness and good intentions, similar to the ndings of other studies
(Tiedtke et al. 2012; Stepanikova et al. 2016). There is, however, a need for clear
strategy and procedures from national legislative level to company level. Here, our
interview participants make two notable suggestions. The rst is to change the law to
include an option to allow a phased return to work of 2-4 hours (at present, if a worker
wants to return to work for 4 hours, sick leave is suspended). The second is to introduce
a reintegration incentive (a nancial incentive for those who go back to work earlier).
Both suggestions are similar to those that apply to maternity leave. Another important
recommendation is to establish an agency, or at least a virtual platform, where workers
could access all services needed for the return to work in one place – rehabilitation,
counselling, legal advice and medical advice. Such a service could function as a ‘safety
Missing a framework for returning to work: the role of the social partners in Romania
131Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
net’ for people who fall between the dierent systems (i.e. medical, employment and
social security).
Participants also identify that employer associations should have a more active role
in the return to work and there should be training for employers and employees in
raising awareness about health, disease prevention and work-related issues. Another
suggestion is to give small companies special attention and support in that they might
have other priorities because of the high burden of legal obligations and taxes.
Based on the level of cooperation between trade unions and employer associations,
one participant advanced the view that trade union representatives are less involved
and less open to cooperation and dialogue since their expectations had developed
exclusively around possible benets and ready-to-go solutions rather than in active
participation. Instead, cooperation with employee representatives was better as they
engaged more actively in negotiation with employers and were less conictual and
more exible than trade union representatives.
2
Stakeholders nevertheless stress that trade unions and employers should play an active
role in improving rehabilitation and the return to work. Here, cooperation between the
occupational physician and the HR specialist is considered essential if the return is to
be successful. One expert social insurance physician explained that most workers on
long-term sickness leave following chronic illness preferred to go for retirement even if
they still had some capacity for work. In his opinion, this preference could be explained
via the lack of available counselling and vocational support and a lack of support from
the employer as well as through the inexibility of the provisions for part-time work.
Instead, the return to work for those with a low level of employability (workers with only
half of their work capacity left, i.e. the third degree of invalidity) could be facilitated by
cooperation between three actors: ANOFM; occupational physicians; and the expert
social security physicians. There is, additionally, a lack of cooperation between the
expert social insurance physicians and social workers even though this is essential for
an accurate assessment of work capacity. Capacity is therefore evaluated based only on
medical documents and patient declarations and not on a social investigation carried
out by a social worker within the patient’s own environment, which can negatively
inuence the correct assessment. Another suggestion is that there could be nancial
incentives for employers to hire workers with reduced work capacity following chronic
illness, perhaps akin to the incentives for taking on unemployed people.
Stakeholders agree that the greater involvement of ANOFM is necessary although
the Agency itself points out that each career counsellor usually works with 3 000
unemployed people and that the serious shortage of career counsellors is responsible
for their low involvement in return to work issues. ANOFM has no targeted programmes
for workers with chronic illness looking for job reorientation.
2. Trade union and employee representatives are distinct entities in the Romanian social dialogue law.
In organisations which do not have a trade union, employees can elect a representative who has the same rights
as the trade union representative.
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Continuing at work. Long-term illness, return to work schemes and the role of industrial relations132
4. The return to work process at company level and
the involvement of the social partners
Following this analysis, we turn next to information describing the current situation
concerning the company-level return to work process and the involvement of the social
partners.
4.1 Workers’ experiences with return to work at company level
The most prevalent diseases reported to us by Romanian workers are cancers (61.1
per cent) followed at some distance by cardiovascular disease, musculoskeletal disease
and diabetes.
3
A majority say they had been concerned about their return to work, the
biggest concern being that nobody would oer support followed by the fear of being
left without any support from the employer. Otherwise, workers are concerned about
pay gaps, worry that they need to return at full productivity right after treatment and
that their employer would not be willing to adjust working conditions to their capacity
for work.
Workers see the most important actors in oering support for their return to work as
the HR department, the team leader or line manager and the head of the company while
less frequent responses concern the external psychologist or occupational therapist,
rehabilitation institutes and the trade union. Almost half of workers state that they
were not at all, or only partly, satised with the help and support they received from
the employer while just over half were not at all, or only partly, satised with the help
and support oered by trade unions.
Studies have shown that keeping in contact with manager and colleagues is important
for a successful return to work (McKay et al. 2013; Isaksson et al. 2016). Four out of
ve workers in our sample were in touch with their colleagues during treatment while
40 per cent were in touch with their direct manager and 20 per cent with the head of
the company or HR department. Only a small share of respondents say they kept in
touch with their trade union representative. The initiative on returning to work seems
not to be work-driven since most workers say it was their personal initiative followed
by that of the specialist treating their disease and then their family or the head of the
company.
Workers most often see the family as playing the most crucial role in enabling their
return to work followed by the specialist physician and work colleagues. At the other
end of the scale, workers do not consider that NGOs, rehabilitation centres or nurses or
their trade union representative play an important role in this area.
High percentages of workers receive no support in making adjustments to their work
contract (63 per cent), in postponing deadlines, in making changes to daily working
3. For more details, see the Romanian country report on the REWIR project website: https://www.celsi.sk/en/
projects/detail/64/
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133Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
time or in sharing tasks and responsibilities with colleagues. On the other hand, they
were more likely to receive reasonable and extensive support in the work environment
mostly in the form of time being made exible to allow for medical appointments.
4.2 Perspectives of HR representatives, line managers and other relevant
company actors in the return to work process at company level
Regarding the consequences that a worker’s absence has on the company, two-thirds of
managers would choose not to replace the worker but to rearrange workow and divide
tasks between other employees. Slightly more than one in ve thought that there would
actually be no signicant eect on the organisation.
In terms of the resources needed to support workers on sickness leave, managers value
external counselling from doctors and therapists; being able to obtain information
and advice on the types of chronic illness; external counselling and cooperation with
dedicated professional and/or campaigning and patient support organisations; and
information on adjusting the workplace and workstations in general.
Company representatives disagree that individuals returning to work after chronic
illness are unable to perform their duties as before or that workers will be less
committed to work. Quite a large percentage agree, however, that a worker returning
to work with reduced duties would increase the workload of colleagues while more
than half agreed that a worker with chronic illness is likely to be absent from work
more often than other workers. Even so, strong majorities agree that a worker should
be entitled to adjustments to working duties (in terms of working time and workload)
either at the organisation’s discretion (63 per cent) or in terms of legal entitlement (68
per cent). A slim majority agree that workers should have the right to a phased return to
work on full pay; two-thirds think it important to stay in touch with the worker during
absence; and a small majority believe that returning to work during treatment helps
with the return to normality and is encouraged in their organisation.
The return to work process is managed mostly by HR and, in a small number of cases,
by the line manager or team leader or by general management. Respondents viewed
this situation as adequate but one-third favoured the idea that, besides HR and line or
team managers, a dedicated health and safety committee should manage this process.
Company representatives tend to report that there is no dened adjustment plan
available for each employee returning after a long illness and neither is there a
common standard procedure for managing the return to work nor an ad hoc and
exible adjustment plan. Companies do, however, cooperate with other external
organisations (for example, the occupational health service) when managing return to
work situations. One key participant with extensive experience regarding the return to
work after occupational diseases and accidents at work, gained from participating in
organisational health and safety committees, stated that some employers do refuse to
make necessary adjustments in order to avoid creating precedents for other employees.
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Continuing at work. Long-term illness, return to work schemes and the role of industrial relations134
When asked what would improve the return process in their organisation, most point
to better interpersonal relations between managers and workers returning from long-
term sickness leave, the organisation’s own policies being more progressive, legislative
and institutional support coming into existence and clearer paths to cooperation with
external stakeholders.
A majority of company respondents indicate that there is a trade union or other form of
employee representation in their organisation. However, the return to work is addressed
by fewer than one in ve collective agreements although around one in three managers
think that this is a suitable matter to be addressed in a collective agreement. In more
than two-thirds of companies, over half of employees are unionised, yet only one in
ve company respondents agree that there is regular interaction between managers
and trade unions on return to work issues. In a clear majority of companies, however,
a trade union representative is part of the committee addressing occupational health
and safety, with managers agreeing that this is important.
4.3 Interactions between employers and employees in facilitating
the return to work
The experience of returning workers and their interaction with their employer is no
better than neutral and, in some cases, draws a rather negative picture. The shares of
workers agreeing, disagreeing or being neutral to the statement that they felt welcome
at their workplace are almost equal (around 30 per cent in each case). Regarding how
well-prepared the employer was to accommodate the worker, more than two in ve
either disagree or are neutral. Most do not receive extensive mentoring or guidance
from their employer and an even higher proportion (some two-thirds) do not receive
mentoring or guidance from the trade union. Half do not consider their return to have
been a process that had been well-coordinated between the company and their doctors.
Three-quarters, however, are able to return to the same job position.
Regarding their return to work experience, when prompted by an open question,
workers tend to describe negative or mildly negative experiences. Some of the more
negative experiences are as follows:
‘I had a horrible experience [at] my former job, so I had to look for another.’
‘My employer, which is a public one, did not care about my disease, so after my
return I have worked as much as the other employees. Nowadays, with Covid-19,
my employer abuses and discriminates against me after I had the audacity to say
that he was endangering my life and exposing me to this virus.’
‘I did not receive [the] salary rise that all the other colleagues received. They [i.e.
the employer] said to me that I [had] lost this opportunity.’
‘I did not have the opportunity to return to the same position. They totally refused
this.’
Among the more mildly negative experiences were returning to work but having to deal
with extreme fatigue and exhaustion; returning to work without being physically t
Missing a framework for returning to work: the role of the social partners in Romania
135Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
simply because the sickness leave period had expired; and returning to work without
receiving any form of support.
Turning to the perspective of managers, a considerable share do have contact with
workers absent on sickness leave (regular or irregular) and only a small percentage
has no such contact. During absences, most managers say they keep workers informed
of work-related issues or involve them in these (such as asking for opinion, advice,
involvement in planning and in decision-making, etc.)
Romanian companies do not usually have common standard procedures for the return
to work but do plan to introduce them. The most common practice is cooperation
with external organisations such as public employment agencies and occupational
physicians. A lack of company-level procedures for the return to work is compensated
by other ways of facilitating the workplace reintegration of workers following
chronic illness. Thus, a majority of managers discuss the return with the worker in
a meeting which is usually informal. Company-level actors also report that they oer
adjustments, mostly as regards work tasks and workload, although less than one-half
oer adjustments in working time. Half do oer adaptations of the workplace but only
around one in three oer training to workers as well as to colleagues to prepare for the
worker’s return. These results support the ndings from another study carried out on
Romanian employers (Popa et al. 2020).
Managers acknowledge that the most dicult workers to accommodate back into
work are those with mental health illnesses (including alcohol and drug addictions
and depression), some citing stories of return to work failures for workers with mental
health disorders who were prone to violent behaviour. They tend to agree, however, that
managers in general have to make a shift from being too focused on what returning
workers cannot do in the company to focusing on what they can do.
In terms of good practice, managers point to maintaining contact with employees
during sickness leave, being aware of employees’ real needs, encouraging the return
to work by letting workers know they are valued and adjusting working conditions.
Other good practices are represented by the prevention of dismissal during workers’
sickness leave, the obligation to keep jobs open until they come back, a generous period
of fully-paid sick leave in respect of some illnesses and good legislation on occupational
diseases.
At the same time, an important deciency in the legislation, which was the subject
of intense discussion by our employer representatives, is the situation in which an
employer cannot provide a new or adjusted job position for a worker who has received
a ‘conditionally able to work’ assessment from an occupational physician. In such
a case, the employer is legally required to refer the worker to the local employment
agency before dismissing them. The problem here is that there are workers who have
lost their jobs and are no longer patients but are too young to retire. Scarce and over-
long vocational rehabilitation programmes subsequently block them from the timely
acquisition of new skills for a new job. Many of the employers we spoke to had such
workers and it was a matter of regret to them that they could not nd viable solutions.
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Continuing at work. Long-term illness, return to work schemes and the role of industrial relations136
4.4 Views on the potential for social dialogue to support the creation and
implementation of return to work policies at company level
Over three-quarters of workers say they had not given thought to joining a trade union
after a recent diagnosis in order to support or facilitate their return to work after
treatment, although in half of the cases there was no trade union or any other form of
employee representation in the workplace. Furthermore, the overwhelming majority of
workers say that no negotiations took place between their employer and trade union or
employee representatives about adjusting their work tasks and responsibilities.
Looking at the role of trade unions in this process, most workers agree that trade
unions should address health-related issues and that the return to work should be on
the trade union agenda. Overall, the views about social partners are mixed in that most
workers think this issue should be addressed through binding agreements with the
employer, yet slightly more than one-half consider that trade unions are not powerful
enough to facilitate the return to work. Moreover, most are not aware of other cases in
which a trade union proved to be helpful in facilitating a return to work.
At company level and regarding what possible benecial outcomes could result from
cooperation with trade unions, company representatives highlight the following
elements: the inclusion of specic provisions in binding collective agreements;
training sessions for managers and team leaders directly exposed to interaction with
workers with chronic illnesses; input from employee representatives on internal
policies; informal agreement on the role of employee representatives in supporting the
management of the return to work process; trade union involvement on the health and
safety committee; training sessions for unions and employee representatives on issues
connected with the return to work; and being able to have individual consultations
between workers and trade unions.
The most prevalent opinion at stakeholder level is that general legislation on the return
to work is available, and capable of serving as a framework, but that it lacks specic
recommendations for organisations actually facilitating returns. This opinion, coupled
with the perception that the legislation is too general, indicates an important need of
Romanian organisations – to have more specic policy recommendations with which
to approach workers with chronic illnesses. Managers thus argue that the current
legislation needs to be revised. Some participants gave examples of initiatives in
connection with other areas than the return to work (for example, those related to
maternity leave) through which they had tried to ll the gaps in the legislation. They
suggested that such initiatives could be disseminated as examples of good practice and,
later, generalised through state programmes.
Consistent with this, a large share of respondents in the company survey would welcome
more specic provisions in law to guide the approach to the return to work at company
level. For example, around one-quarter wish for more exible legislation that would leave
greater space for company-level decisions. However, none of the responding managers
here would opt for legislation which stipulated binding regulations for the return to work
and only a small group considered any change in the current legislation to be necessary.
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137Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
5. Discussion of research findings and conclusions
The main results from analysing the data converge towards the idea that returning to
work is an issue insuciently regulated by law and which does not generate sucient
involvement by stakeholders. Romania has a general policy framework on sickness
leave, invalidity and disability, mostly concerning benets and conditionality of access,
but, turning to the social dialogue, it is evident that the state has the most substantial
role with employers and trade unions occupying only rather minor ones.
The relevant policy framework for sickness leave, invalidity and disability provides
only general guidelines mostly in relation to benets, eligibility and period of
entitlement. The policy does not contain specic measures or interventions for making
the return to work easier when the sickness leave or invalidity period is over, although
some provisions do concern and facilitate this to some extent (e.g. the provisions on
rehabilitation targeting the recovery of work capacity). The social security system is
based on social insurance and health insurance and is coordinated by two ministries
and several lower-level agencies and services. Several pieces of law regulate these issues
and the process of applying for benets is characterised by a considerable amount of
bureaucracy. One positive aspect of the legislation, however, is a generous period of
fully-paid sickness leave.
Overall, the return process after sickness leave or invalidity is not planned, rarely
phased and entails formal obligations for the specialist physician, the occupational
physician and the local public employment agency, but only a marginal role for the
employer. No active labour market policies specically targeting the return to work
after chronic illness are in place; and the existing law provides only general stipulations
for resuming work.
Institutional actors at state level play the most important role in the return to work
process. Based on our research data, the social partners are not currently involved
in this to their full potential and see themselves as rather passive players, especially
in terms of shaping policy, tending also to be content with the situation that the state
should be the main actor.
Romania does not have a dedicated return to work policy in the case of chronic
illness, but more than half the social partners in our sample evaluated the policy
framework as being suciently well elaborated but lacking in proper implementation
and enforcement. They agree that the EU-level strategy should be reected in this
framework and that there is a lot of work ahead on policy implementation. Even so,
trade unions and employer associations feel that they do not have sucient power
or instruments to shape policy. Our ndings also highlight that the preferred way of
approaching the return to work entails a more focused legislation which should also be
exible and give space for companies to implement tailored measures and initiatives
for the workers aected.
All agree that trade unions and employee representatives should make an important
contribution to the return to work. At present, however, there is little involvement of
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Continuing at work. Long-term illness, return to work schemes and the role of industrial relations138
trade unions, alongside reduced cooperation with other industrial relations actors,
while the level of involvement that they do have tends to be limited to negotiating
nancially worthwhile outcomes for workers in dicult situations. Participants agree
that employee representatives and trade unions could become more active opinion
makers that could raise awareness of the issues related to the return to work process.
Workers have rather negative experiences of returning to work and they express
dissatisfaction with the level of support they receive from both employer and trade
unions. This support can be described as inconsistent, as other studies also highlight
(Mak et al. 2014; Robinson et al. 2015). Most keep in contact with their colleagues at
work but less do so with their direct or general manager. Workers’ families and their
physicians are the two key actors oering support and inuencing the success of their
return. In terms of adjustments, they report receiving reasonable and extensive support
mostly in terms of the exibilisation of working time as well as some adjustments
regarding the working environment and in their tasks and duties. However, their open
feedback regarding their experience is largely negative, disclosing a continuum of
adverse situations from indierence and lack of support to discrimination and abuse.
In conclusion, other than for the government and its subordinate institutions (ANOFM,
the regional work inspectorates and the regional CNPP oces), the other actors (trade
unions, employers and NGOs) believe that they have a passive role in the return to work
and that not much can be done to change this situation. Their ideas for improvement
relate more to the state and the legislation and less to their own potential involvement.
The best way to improve occupational reintegration following chronic illness would
indeed be to have specic legislation with dened roles, steps and outcomes. However,
even in the absence of such legislation there are ways to move things forward.
First, the role of trade unions and employer associations is essential as they can be the
‘voice’ of workers with chronic illnesses and of their employers. Thus, one opportunity
for change regards the constant eorts of trade unions and employer associations
to raise awareness of return to work issues, even when a change in policy is not
immediately forthcoming.
Second, a possible improvement for these workers could be accomplished by including
return to work issues in collective agreements negotiated at company level. Yet, as
trade union participants told us, only about a third of Romanian companies now have
collective agreements and, among these, only approximately 5 per cent are negotiated
in the company, the rest having a simulacrum of a collective agreement which is usually
very brief. This situation is a consequence of the social dialogue reform in 2011 which
dramatically decreased collective bargaining in Romania.
Third, the interactions between employers and trade unions and employee represent-
atives could be intensied; currently there is little consultation with them on issues
related to the return to work. Workers with chronic health conditions mostly trust
their employers to oer support for their return to work but they do expect greater
involvement from the trade unions.
Missing a framework for returning to work: the role of the social partners in Romania
139Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Fourth, opportunities for policy change in this area might also develop from initiatives
of researchers in the eld who can indicate, based on their studies, the most eective
ways of bringing about improvement. In Romania, studies in this area have started to
accumulate only recently. It is essential for these studies to continue in order to gain
knowledge about the return to work in specic policy and social contexts and to ensure
that policy-making is informed by an evidence base.
References
Bechter B., Brandl B. and Meardi G. (2012) Sectors or countries? Typologies and levels of analysis
in comparative industrial relations, European Journal of Industrial Relations, 18 (3), 185–202.
Belin A., Dupont C., Oulès L., Kuipers Y. and Fries-Tersch E. (2016) Rehabilitation and return
to work: analysis report on EU and Member States policies, strategies and programmes.
Luxembourg, Publications Oce of the European Union. https://osha.europa.eu/en/tools-
and-publications/publications/rehabilitation-and-return-work-analysis-eu-and-member-state/
view
Björnberg A. and Phang A.Y. (2019) Euro Health Consumer Index. 2018 Report, Marseillan, Health
Consumer Powerhouse Ltd. https://healthpowerhouse.com/media/EHCI-2018/EHCI-2018-
report.pdf
Bohle D. and Greskovits B. (2012) Capitalist diversity on Europe’s periphery, Ithaca, Cornell
University Press.
Covid-19 Date la zi (2021) COVID-19: Date La Zi. https://datelazi.ro
Dorobantu M. (2018) Bolile reumatice și musculo-scheletale, responsabile pentru 60% din rata
incapacităţii permanente de muncă, Raportul de garda.ro. https://raportuldegarda.ro/articol/
boli-reumatice-musculo-scheletale-incapacitate-permanenta-munca/
ETUI (2020) National Industrial Relations. Romania - Key facts. https://www.worker-participation.
eu/National-Industrial-Relations/Countries/Romania
European Commission (2019) Commission sta working document. Country report Romania
2019. - Including an in-depth review on the prevention and correction of macroeconomic
imbalances Accompanying the document. Communication from the Commission to the
European Parliament, the European Council, the Council, the European Central Bank and the
Eurogroup. 2019 European Semester: assessment of progress on structural reforms, prevention
and correction of macroeconomic imbalances, and results of in-depth reviews under Regulation
(EU) No 1176/2011. SWD (2019) 1022 Final, Brussels, 27 February 2019.
https://ec.europa.eu/info/sites/info/files/file_import/2019-european-semester-country-
report-romania_en.pdf
Eurostat (2017) Causes of death - standardised death rate by NUTS 2 region of residence
(HLTH_CD_ASDR2). https://ec.europa.eu/eurostat/databrowser/view/HLTH_CD_ASDR2__
custom_469008/default/table?lang=en
Eurostat (2018a) Cardiovascular diseases statistics. (hlth_co_disch2). https://ec.europa.eu/
eurostat/statistics-explained/index.php?title=Cardiovascular_diseases_statistics
Eurostat (2018b) Government expenditure by function - COFOG. https://ec.europa.eu/eurostat/
statistics-explained/index.php/Government_expenditure_by_function_%E2%80%93_COFOG
Adela Elena Popa, Felicia Morândău, Radu-Ioan Popa and Mihai Stelian Rusu
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations140
Eurostat (2020) Duration of working life on the rise. https://ec.europa.eu/eurostat/web/
products-eurostat-news/-/DDN-20200608-1
Eurostat and Trading Economics (2019) Romania long term unemployment rate 1997-2019 Data.
https://tradingeconomics.com/romania/long-term-unemployment-rate
Eurostat and Trading Economics (2020) Romania employment rate | 1996-2020 Data |
2021-2023 Forecast | Historical | Chart. https://tradingeconomics.com/romania/
employment-rate
Irastorza X., Milczarek M. and Cockburn W. (2016) Second European survey of enterprises
on new and emerging risks (ESENER-2). Overview report: managing safety and health at
work, Luxembourg, Publications Oce of the European Union. https://osha.europa.eu/en/
publications/second-european-survey-enterprises-new-and-emerging-risks-esener-2-overview-
report
Isaksson J., Wilms T., Laurell G., Fransson P. and Tiblom Ehrsson Y. (2016) Meaning of work and the
process of returning aer head and neck cancer, Supportive care in cancer, 24 (1), 205–213.
Mak A.K.Y., Chaidaroon S., Fan G. and Thalib F. (2014) Unintended consequences: the social
context of cancer survivors and work, Journal of Cancer Survivorship, 8 (2), 269–281.
McKay G., Knott V. and Delfabbro P. (2013) Return to work and cancer: the Australian experience,
Journal of Occupational Rehabilitation, 23 (1), 93–105.
Ministerul Muncii și Protecției Sociale (2020) Dialogul Social Tripartit. http://dialogsocial.gov.ro/
wp-content/uploads/2019/02/Dialogul-social-tripartit.pdf
National Institute of Statistics (2020) Death by causes in Romania. http://statistici.insse.ro:8077/
tempo-online/#/pages/tables/insse-table
OECD and European Observatory on Health Systems and Policies (2019) State of Health in the EU,
Romania Country Health Profile 2019, Paris, OECD Publishing; Brussels, European Observatory
on Health Systems and Policies. https://ec.europa.eu/health/sites/health/files/state/
docs/2019_chp_romania_romanian.pdf
Popa A.E. and Popa R.-I. (2019) Working as a cancer survivor in Romania: an overview of the
statutory policies for return to work, Disability and Rehabilitation, 45 (19), 1-8.
Popa A.E., Morândău F., Popa R.I., Rusu M.S. (2021) Shaping return to work policy: the role of
industrial relations at national and company level. Country report for Romania. REWIR Working
paper. https://www.celsi.sk/media/datasource/National_Report-Romania-merged.pdf
Popa A.E., Morândău F., Popa R.I., Rusu M.S. and Sidor A. (2020) Supporting the return to
work aer cancer in Romania: exploring employers’ perspectives, Journal of Occupational
Rehabilitation, 30 (1), 59-71.
Popa A. E., Vlase I. and Morândău F. (2016) Nongovernment sector fighting cancer in Romania,
Journal of Community Positive Practices, 16 (2), 39-55.
Robinson L., Kocum L., Loughlin C., Bryson L. and Dimo J.K. (2015) I wanted you to know: breast
cancer survivors’ control of workplace communication about cancer, Journal of Occupational
Health Psychology, 20 (4), 446-456.
Stepanikova I., Powroznik K., Cook K.S., Tierney D.K. and Laport G.G. (2016) Exploring long-
term cancer survivors’ experiences in the career and financial domains: interviews with
hematopoietic stem cell transplantation recipients, Journal of Psychosocial Oncology, 34 (1-2),
2-27.
Stoiciu V. (2016) Romania’s trade unions at the crossroads: challenged by legislative reforms,
economic crises and a power-loss of 60 per cent, Berlin, Friedrich-Ebert-Stiung.
Missing a framework for returning to work: the role of the social partners in Romania
141Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Tiedtke C., Donceel P., Knops L., Désiron H. Dierckx de Casterlé B. and de Rijk A. (2012)
Supporting return-to-work in the face oflegislation: stakeholders’ experiences with return-to-
work aer breast cancer in Belgium’, Journal of Occupational Rehabilitation, 22 (2), 241-251.
All links were checked on 07.06.2021.
143Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Chapter 7
Return to work practice in Slovakia: matching best
practice with the scope of social partner activity
Barbora Holubová, Marta Kahancová, Mária Sedláková and Adam Šumichrast
1. Introduction
The labour market integration of disabled people has received increasing policy attention
not only at EU level but also in particular EU member states, including Slovakia. In the
context of labour shortages prior to the Covid-19 crisis, measures pertaining to a longer
working life and quick (re)integration into work have become increasingly important.
There are, of course, several contextual issues surrounding these policy debates.
Slovakia’s ‘Country Health Prole 2019’ (OECD 2019) summarises that life expectancy
in Slovakia has increased but that, at 77.3 years, it still remains among the lowest
in the EU, where average life expectancy stood at 80.9 years in 2019. We should
remember that, although life expectancy has increased, about 40 per cent of people
aged 65 still report having at least one chronic disease. In general, access to healthcare
in Slovakia has attained a decent level at which only 2.4 per cent of the population
reported unmet medical needs in 2017 – the remaining percentage is likely to be
related to ethnic divides and regional inequalities and not directly to chronic illness.
Meanwhile the OECD’s data on public spending due to incapacity show that Slovakia
spent 1.86 per cent of its GDP in 2015 on disability cash benets (payments made in
respect of complete or partial inability to participate gainfully in the labour market
due to disability). This is close to the OECD average, but signicantly less than those
countries which are spending more than 3 per cent of their GDP on this type of benet
(e.g. the Netherlands, Finland, Sweden and Norway).
After Slovakia’s political and constitutional crisis in 1998, the employment rate
rose from a nadir of 56.3 per cent in 2000 and saw continual growth in the years
after 2014 to reach the EU average of 68.4 per cent in 2019.
1
At the same time, the
employment rate of people with health conditions stood at just 16.6 per cent in 2015
(Ondrušová et al. 2017). Among the reported reasons for absence from work since
2006, the percentages of people citing chronic illness and disability as the main cause
have oscillated between 7 per cent and 45 per cent.
2
Most of the policy attention has
targeted people with formally-attained disability status, but there is a pool of people
of working age who have faced chronic illness and long-term absence from work who
do not have this status. In the context of pre Covid-19 labour shortages in the Slovak
1. Eurostat: Employment and activity by sex and age - annual data; online data code: LFSI_EMP_A;
https://ec.europa.eu/eurostat/databrowser/view/LFSI_EMP_A__custom_697052/default/table?lang=en
2. Eurostat, Absence from work by main reason, sex and age group - quarterly data[lfsi_abs_q];
https://data.europa.eu/data/datasets/hvwzmlvgj18dxi5l5baaw?locale=en
Barbora Holubová, Marta Kahancová, Mária Sedláková and Adam Šumichrast
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations144
labour market, the return to work of this group of people has become more important
than ever before.
Research into the labour market integration of disabled people in Slovakia is, overall,
rather scarce but the return to work after, or with, chronic illness of people who do
not have formal disability status has been even less studied. The return to work is a
complex process requiring the interaction of various stakeholders at various levels
of policy-making and implementation, including workers and employers but also
rehabilitation centres, health professionals, workers’ representatives, the higher-level
social partners as well as policy-makers. Policy areas which have an eect on the return
to work encompass sickness, disability and employment. Despite the relevance in a
labour market perspective of the return to work of people experiencing chronic illness,
little is therefore known about how this process has evolved in Slovakia and how the
distinct actors can play a facilitating role therein.
With this aim in mind, the chapter aims to identify (a) the role that is played by the
industrial relations actors in shaping return to work policies and facilitating the returns
process at workplace level; and (b) the opportunities and challenges which exist for
strengthening social dialogue and industrial relations in Slovakia through greater
involvement of the social partners in return to work policy and implementation. The
analysis of these questions is set in the context both of Slovakia’s healthcare system
and its structures of industrial relations.
From an industrial relations perspective, Slovakia is an interesting case because it has
a stable structure of bargaining partners and a detailed legislative system supporting
their roles in collective bargaining, yet there is little vertical coordination between
bargaining at the sectoral and the company levels (Kahancová et al. 2019). In the past
30 years of its post-socialist history, Slovakia’s industrial relations has evolved into an
embedded neoliberal system (Bohle and Greskovits 2012), with a key feature being a
trade-o between trade union access to policy-making in the early 1990s and social
peace (Bohle and Greskovits 2012). In turn, trade unions have formally gained access
to tripartism although their membership has gradually declined. In response, unions
are increasingly seeking new opportunities to strengthen their voice both at national
and at workplace levels. It is thus interesting to explore the extent to which the return
to work, a topic with outreach to both these levels and which closely concerns working
conditions, yields opportunities for union involvement and bargaining.
Several original sources of data have been used for the analysis, including roundtable
discussions and face-to-face interviews with relevant national stakeholders from
government agencies, campaigning and patient support organisations, trade unions
and employer associations. Moreover, online surveys have also been launched to collect
responses from workers and managers; however, response rates were signicantly
inuenced by the Covid-19 pandemic and the related economic and employment
protection measures.
The remainder of this chapter is structured as follows. Section 2 introduces the
policy framework for return to work policies in Slovakia while section 3 analyses the
Return to work practice in Slovakia: matching best practice with the scope of social partner activity
145Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
involvement of the social partners in shaping these policies and their implementation
at national level. Section 4 focuses on the company level and analyses the views of
managers and workers while Section 5 summarises the main ndings, responds to
the research questions and formulates several policy recommendations related to the
policy agenda.
2. Policy frameworks on the return to work in Slovakia
Slovakia is among those countries with a limited framework for the return to work in
which rehabilitation support essentially exists only for people with formal disability
status and where government bodies are the main actors in terms of policy formulation.
There are two basic categories in the Slovak system as regards the workplace integration
of people experiencing health-related disadvantages: recipients of invalidity benet;
and severely disabled people. A person receiving invalidity benet must not be
recognised as severely disabled and vice versa.
Invalidity benet is backed by disability insurance and its acquisition is overseen by
Sociálna poisťovňa (Social Insurance Agency; SP) based on a medical assessment. The
purpose of the benet, which is called an invalidity pension in Slovakia, is to provide
the insured person with an income in the case of a decline in the ability to perform
work activity because of the insured person’s long-term unfavourable health condition.
The following categories of worker are eligible for invalidity pension:
(i) disabled people;
(ii) those who have acquired the requisite number of years of pension insurance
(which is determined by age); and
(iii) those who, on the day of their invalidity, did not meet the conditions for entitlement
to a retirement pension or who have not been granted an early retirement pension.
The origin and duration of the disability are assessed in line with the benet procedure
by a social insurance physician. The calculation of the amount of the disability pension
is complex and depends on the period of pension insurance which the insured person
had acquired on the day of becoming entitled to invalidity pension. Subsequently, the
‘accrued period’ is the period from the origin of the right to an invalidity pension to the
day of reaching retirement age.
While the receipt of invalidity benet encapsulates the view that the person receiving
it has reduced work capacity, severe disability is seen as the reduced ability to lead an
active life which does not necessarily imply a reduced capacity for work. Thus, unlike
a person in receipt of invalidity benet, someone who is severely disabled does not
receive wage compensation from SP but a benet to compensate for the social impact
of the health disadvantage.
In the absence of specic return to work policies in Slovakia, people with chronic
illnesses are supported only by the sickness benet system. Sickness benet must be
Barbora Holubová, Marta Kahancová, Mária Sedláková and Adam Šumichrast
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations146
provided to an insured person who has been recognised as temporarily incapacitated
from work as a result of sickness or an accident or who is obliged to respect a quarantine
measure (hereinafter ‘temporary work incapacity’). The following categories are
eligible for sickness benet:
(i) employees;
(ii) self-employed people with compulsory sickness insurance;
(iii) people with voluntary sickness insurance; and
(iv) people who have become temporarily incapacitated after the termination of
sickness insurance within the protected period.
Sickness benet is paid by the employer for the rst ten days and then by the public
budget (via social insurance) until the end of temporary work incapacity. From the rst
to the third day, the benet is 25 per cent of the daily assessment basis; from the fourth
to the tenth day it is 55 per cent of it (this may dier as a result of collective bargaining
and it can go up to 80 per cent). After ten days the level is calculated as 55 per cent of
the daily assessment basis. The maximum duration of temporary work incapacity is set
at 52 weeks. The expiry of this period does not lead to the termination of temporary
work incapacity status where this can be justied by the individual’s state of health
continuing to be unfavourable. It does mean, however, that the insured individual is no
longer entitled to sickness benet.
We have said already that there are no coherent and detailed return to work policies
in Slovakia and neither, consequently, is there much of a focus on people returning to
work after long-term sickness or who are seeking reintegration into the labour market.
It is not only this, however. It is also the case that Slovakia does not have any denition
of these categories of people and we do not even know their number. Furthermore there
are no studies that concentrate on this group. However, it is worth mentioning one
measure in particular as well as some more general legal provisions of the Labour Code
which may be supportive of a return to work process.
This measure is vocational rehabilitation (Act on Social Insurance § 95). This is
a benet that can be provided by accident insurance and is intended to support the
worker’s eorts in returning to work and with social reintegration. There is no legal
right to rehabilitation, but it may be provided after an assessment of the medical tness
of an injured worker who, because of an accident at work or an occupational disease,
has experienced a decline in work capacity. This is carried out by a medical assessor
from social insurance and is made in particular view of the possibility of getting the
injured worker back to work. The maximum duration of vocational rehabilitation is
six months. In justied cases – in which it can be assumed that the injured worker
will acquire the ability to work at his or her previous level of activity – benet can be
extended by another six months. The problem is, however, that this tool is little used
and that some people appear to be ashamed to seek it; while counselling on the issue
is also insucient.
There are three legal stipulations in the Labour Code that are relevant in a return to
work context. The rst is the job guarantee provided under Labour Code § 157 – when a
Return to work practice in Slovakia: matching best practice with the scope of social partner activity
147Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
worker returns after temporary work incapacity, the employer is obliged to assign him
or her back to the original work they were undertaking and to their original workplace.
Where such reassignment is not possible, the employer is obliged to assign the worker
to dierent work which corresponds to the contract of employment.
The second stipulation, under Labour Code § 64, is a prohibition on notice which
guarantees that the worker cannot be red during the period of temporary work
incapacity (sickness leave). There is also a general provision in § 2 of the Anti-
discrimination Act which states that ‘[a]dherence to the principle of equal treatment
shall lay in the prohibition of discrimination on the grounds of sex, religion or belief,
race, nationality or ethnic origin, disability…’ and that (in § 7):
‘In order to apply the principle of equal treatment employers shall take appropriate
measures to enable a person with a disability to have access to employment, to
work of a certain type, to promotion or access to vocational training; except if
the adoption of such measures would impose a disproportionate burden on the
employer.’
The third stipulation refers to job assignment (§ 55). This obliges the employer to
reassign the worker to another job if, because of a medical condition, he or she has
lost the long-term ability to continue carrying out the previous work, if he or she is
not allowed to do so due to an occupational disease or if he or she has reached the
maximum permissible exposure at the workplace determined by a decision of the
competent public health authority. The medical report must show that the worker has
lost the ability to continue to perform the work done to date; such an opinion could
be issued by a physician, specialist doctor or a medical facility. Where such a medical
report has been issued, the worker must submit this to the employer and request a
transfer to another job.
We should also note that some collective agreements do exist that partially stipulate
provisions on the return to work. Some establish an employer’s obligation to the worker
in the form of nancial compensation if he or she develops an occupational disease or
work-related injury or receives a one-o nancial sum during long-term incapacity for
work due to health problems. Workers with an occupational disease are sometimes,
based on a provision in the collective agreement, protected against the termination
of employment in the event of organisational change.
3
Furthermore some large
companies, such as Volkswagen Slovakia, have developed internal policies that seek to
take preventive action so that people do not end up being absent due to sickness.
The increased labour market protections available for people with health conditions
is presented as a blanket statement in several strategic documents that set out the
reasons and tools to support the work integration of vulnerable people. Several laws,
allowances and measures help such people integrate into the labour market and, in
respect of this, there exists a number of stipulations including increased labour law
3. In this context, it is notable that the employer has a general legal obligation to ensure health and safety at work
and that this has a preventive aspect concerning the emergence of various occupational diseases and injuries.
Barbora Holubová, Marta Kahancová, Mária Sedláková and Adam Šumichrast
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations148
protection, active labour market policies, mandatory quotas for the employment
of people with disabilities and vocational guidance services. There are, in addition,
sheltered workshops and, since 2018, social enterprises for work integration as well
as several NGOs dealing with this issue. However, where someone returns to work
following a chronic illness that did not lead to the acquisition of formal disability
status, sickness leave is the basic tool and there are almost no other options (measures,
procedures or interventions) available in the Slovak legislation to help these people get
back to work.
Therefore we conclude that, generally, the legislative framework on the return to work
is limited in Slovakia. Currently the actual returns process is largely discretionary,
resulting from the interaction between the relevant actors and company-level policies,
and lacking a strict anchoring in dedicated legislation.
3. Involvement of the social partners in shaping return
to work policy at national level
As summarised earlier, the existence of return to work policies, measures and policy
implementation is tied up with people having formal disability status or decreased work
capacity. This connection is rmly embedded in the perceptions of the social partners
and other stakeholders, e.g. campaigning and patient support organisations supporting
disabled people. Policies on the return to work therefore rarely relate to people with or
after chronic illness in the absence of formal disability status or eligibility for invalidity
benet.
This perception of the return to work concept needs to be kept strongly in mind and
provides the backdrop to our analysis which exploits three sources of data: a survey
of the social partners
4
and interviews and roundtable discussions with stakeholders.
3.1 Key actors in return to work policy
Government bodies are the main actors in terms of the formulation of policies on the
return to work. Ministerstvo práce, sociálnych vecí a rodiny (the Ministry of Labour,
Social Aairs and Family) designs the legislative framework and determines the
conditions applying to work assistance for disabled people and other supportive measures.
The creation of return to work policies and the monitoring of their implementation is the
job of a specialist department in the ministry. An important role is also attributed to
Ústredie práce, sociálnych vecí a rodiny (Central Oce of Labour, Social Aairs and
Family; ÚPSVaR), the central labour market authority in Slovakia. This is an umbrella
labour market organisation with a broad regional structure of 46 local labour oces
which manage a database of jobseekers, including jobseekers with reduced work capacity.
4. The sample used for the analysis is rather small; therefore the ndings need to be taken as indicative rather than
representative of the opinions of the social partners in Slovakia. More details can be found here: https://www.
celsi.sk/en/projects/detail/64/
Return to work practice in Slovakia: matching best practice with the scope of social partner activity
149Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Return to work is not a key issue that ranks high on the trade union agenda. This is
more the result of a lack of resource and a shortage of expertise than any absence of
a willingness to be more active. On the employer side, associations act based on the
demands of their members which are not interested in greater activity on the issue of
the return to work.
Other relevant actors are the health insurance agencies which possess the most detailed
evidence of people experiencing chronic illness and disability. Agentúry podporovaného
zamestnávania (the Supported Employment Agencies) and occupational health
physicians are additional actors with the potential to inuence return to work policies.
Campaigning and patient support organisations perceive their contribution as indirect
in the sense that they provide personal support services (targeting courage and self-
condence) so that such workers can be better integrated into the work process.
3.2 Views and level of involvement of industrial relations actors
The social partners perceive EU-level return to work policies as relevant and
call for greater action, citing that EU-level social dialogue should adopt binding
recommendations for the member states in this area. Despite this, more than half are
not aware of any EU-level policies that support the return to work for workers after
treatment for chronic illness.
In contrast to the low awareness of EU-level policies, the social partners are conscious
of national policies and measures in this area. They believe that Slovakia has, in general,
an elaborate policy framework and that it properly implements and enforces return to
work practices. As established earlier, however, these are predominantly associated
with disability and are not ones comprehending the return of workers after treatment
for chronic illness. Indeed, our interviewees among the social partners conrm that a
standardised policy on the return to work following chronic illness is absent at national
level.
Consequently the involvement of the social partners in shaping return to work policies
after chronic illness is limited. Research shows that they are currently working on, or
actively involved in, neither policy creation nor its implementation.
This low commitment to being more involved in policy direction is supported by a
relatively high level of satisfaction with the current extent of their involvement.
Employ er associations are more satised with this than are trade unions which
acknowledge that they should be more active in this area. However, the involvement
of the social partners here is mostly conditioned by external factors, i.e. the national
government’s priorities or agenda in national social dialogue. Moreover, the reasons
for non-involvement relate to the internal organisational structures of the social
partner organisations: the social partners do not consider involvement in return to
work policy-making as a key priority on their agendas and, therefore, are not actively
taking initiatives to increase their participation in policy development.
Barbora Holubová, Marta Kahancová, Mária Sedláková and Adam Šumichrast
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Considering policy implementation, most social partners have an awareness of specic
measures that facilitate the application of return to work policies and are actively
involved at this stage, more at company level and using an informal, case-by-case
approach. This is conditioned by the presence of a committed representative of trade
unions or employer associations within the company who is actively engaged in policy
implementation on the issue.
Trade unions are mostly involved in collective bargaining and providing individual
assistance to workers (e.g. by assisting them with the bureaucratic procedures of
applying for benets or helping them voice their problems to the employer). The type of
collective bargaining related to the return to work that trade unions have been involved
in has occurred solely at national level.
The employer association is in a position to submit various proposals concerning
return to work policies, and to get these on the agenda, since it is a member of the
national tripartite council. However, it is basically against any regulation, including
on the return to work, and does not see any demand coming from its members. On the
other hand, it does welcome any measure which supports the exibilisation of work
which might also be relevant to people returning to work after a long illness or with a
disability. It sees employers’ views on return to work policies not only as an economic
matter but also as a matter of social responsibility:
‘We as employers want to act like those who are not only interested in prot but
want to be perceived by the public as those who are also interested in people who
are not at their best in terms of the ability to work.’
3.3 The nature of interactions between industrial relations actors and
other stakeholders in return to work policy
Most social partners evaluate the degree of cooperation between stakeholders (trade
unions, employer associations, government, labour market institutions, medical
organisations, rehabilitation centres and NGOs) as potentially important in facilitating
a sustainable and feasible return to work policy framework, but they do see obstacles in
it. However, the majority repeatedly conrm that there is a lack of cooperation in terms
of return to work policy-making and implementation. The social partners generally
agree that more intensive interaction between stakeholders is essential and also
that trade unions and employer associations should both be more active in return to
work policy implementation at national level. At the moment, cooperation works only
partially and between some actors, but an overall umbrella mechanism at national level
is also missing. For example, attempts to initiate systemic cooperation to promote the
enforcement of the UN Convention on the Rights of Persons with Disabilities, which
would bring together all relevant actors, failed due to insucient political support.
Some campaigning and patient support organisations express strong dissatisfaction
with the amount of cooperation with employment oces as well as with their
unwillingness to assist the return to work in individual cases. Meanwhile government
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151Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
bodies claim that they do cooperate with trade unions at sectoral or company level
where a trade union organisation has been established.
The most relevant platform for cooperation is the Committee for Disabled People
which joins representatives of government and public regional administrations with
campaigning and patient support organisations. This Committee is the place to discuss
urgent problems and to initiate or prevent a change in the legislation that might
damage the interests of disabled people. The Committee also consults on particular
cases of alleged discrimination against disabled people and drafts recommendations
for improvement although it only rarely proposes policy documents, focusing more on
various initiatives. Trade unions and employer associations are either not present on
the Committee or are present but not active.
Other platforms for cooperation are the employment committees which operate in the
state employment oces which are spread widely throughout the regions. Trade unions
and employer representatives are involved in these committees and they do discuss
the employment of someone with reduced work capacity or with formal disability
status. The committees seek to place such a person either in a particular company or in
sheltered workshops or workplaces.
5
This lack of cooperation between all the relevant actors results in the absence of
any acknowledgement of the problems as well as a lack of development of the skills
associated with how to treat a person returning to work following chronic illness. The
need here for a change of approach by the social partners was expressed to us by one
representative of a patient support organisation:
‘I would be interested in the trade unions’ response to the extent to which they
have mapped the problems of people who nd themselves in a chronic disease
situation and what they do for them. The people themselves who are to return to
work solve many issues, but they will certainly not come to the trade union with a
solution. So, instead, proactive detection is needed.’
3.4 Outcomes of social dialogue with regard to return to work policy
Stakeholders consider that incorporating return to work measures into collective
agreements might be dicult. Nevertheless social dialogue resulting in specic
agreements could be a useful tool for making return to work policy more visible and in
terms of raising awareness. There are doubts that it would solve particular cases, but it
could be used as a ‘reminder’ to boost sensitivity towards the people concerned.
5. A sheltered workshop is a workplace where there is more than one job established for a disabled person and
where at least 50 per cent of workers are disabled. A sheltered workplace is a workplace where a job for a person
with a disability has been established but which is not a sheltered workshop. A workplace where a disabled
citizen carries out a self-employed activity is also considered a sheltered workplace. A sheltered workplace can
also be set up in the household of a disabled person.
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State administration representatives consider that policy guidelines on the return to
work are necessary and report that the social partners are, for the most part, involved
in commenting on the legislation which has already been drafted. ÚPSVaR could
not, however, comment on the state of social dialogue in the return to work area: it
is a subordinate agency and acts strictly in terms of the implementation of current
legislative measures. It does not possess competencies in social dialogue and cooperates
with employers only as far as supporting them in the employment of disabled people.
Trade union representatives challenge the feasibility of a general procedure for
social dialogue at national level and warn against unnecessary bureaucracy and
impracticalities. Even if a return to work process was anchored in a collective agreement
at national level, it would be challenging to implement and oversee. Here, they regard
an individual approach at company level to be more useful. Employee representatives
at company level similarly prefer an individual, informal approach in specic cases
without any anchoring in social dialogue practice at national level. This is in line with
ndings that the return to work agenda is currently outside the scope of trade union
activities which are focused on sectoral and company-level collective bargaining,
monitoring processes and in providing assistance to individual workers.
3.5 Views on the future potential for action on return to work and
the contribution of industrial relations actors
For some trade union representatives, collective agreements at sectoral or company
level are seen as potential and practical tools for extending obligations to employers.
NGOs and charities, despite not having experience with collective bargaining, also see
an opportunity for social dialogue to include supportive measures for disabled people
(or who have chronic illness) at company level. At the same time, there is room to
seek improvement in the involvement of labour inspectorates in return to work cases
following an accident at work; stakeholders identify that the inspectorates should
not just act as an enforcement body but should also provide preventive advice and
counselling for disabled people.
Stakeholders also highlight a need for greater exibility in employment services and
better information on vocational training for disabled people and those experiencing
chronic illness before entering the labour market. Trade unions need similarly to
be better informed about the particular contribution they can make as well as more
available for people seeking to return to work.
There is also room for improvements in the legislation. The law on sickness insurance
allows only 52 weeks of paid sickness leave and, after one year of this, people have to
be granted disability status. Furthermore it is acknowledged that there is space for
campaigning and patient support organisations to campaign for people in general to
accept illness and to avoid shaming and stigmatising disabled people or those with
illnesses.
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153Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
To sum up, the involvement of the social partners in shaping and implementing return
to work policies is limited. One contributory factor here is that the policy framework
does not comprehend people returning to work following chronic illness. The absence
of a proper policy framework does, however, provide space for an informal and
individualised approach by the social partners in terms of their capabilities of providing
support in this area. All the actors expect improvements in cooperation and are open
to their more systematic involvement in this area, in particular as part of workforce
diversity management in the case of employers and as part of collective bargaining in
the case of trade unions.
4. The return to work process at company level and
the involvement of the social partners
This section focuses on experiences with return to work at company level, i.e. the
experiences of workers and managers based on the data and information gathered
from our primary research activity.
4.1 Workers’ experiences with the return to work process at company level
Regarding individual experiences of returning to work, it is important to note that
the number of responses to the survey was quite low and to consider the following
statements with a degree of caution.
The most prevalent type of disease in our sample of workers was cancer, followed by
cardiovascular disease and musculoskeletal diseases while the rest identied other
types of illness or a combination of several. The prevalence of particular illnesses in
our sample corresponds to data from the general population according to which the
most frequent causes of the hospitalisation of patients in 2018 were circulatory system
diseases, digestive system diseases and cancer (NCZI 2018).
Most respondents state that they were not concerned about their return to work. Those
who were concerned expressed that were most commonly afraid of the need to jump in
at full productivity right after treatment without an adjustment period. Other concerns
related to the fear of a lack of support at the workplace and nancial discrimination, as
well as having no support from the employer and the pressure to work long hours right
after recent treatment.
Almost all workers with a prevailing diagnosis intend to return to their current job
after treatment and nearly half plan to continue working during treatment, if possible.
Most also have an arrangement with their current employer to return to the same
work position after treatment and, among those respondents who had already been
through the return to work process, more than two-thirds did indeed return to the
same position.
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A direct team leader or line manager is considered to be the most important person
in terms of supporting an individual worker’s return, followed by the HR department.
Some respondents also mention campaigning and patient support organisations as
important in helping to facilitate the return to work. The direct team leader or line
manager was likewise listed as the go-to contact in easing the return process in terms
of making adjustments to working time, exposure to stress, physical well-being at
work and similar aspects, although a smaller number of workers would turn to the
company’s HR department for help.
During treatment, the people at the workplace with whom respondents are most often
in touch are their colleagues and, to a lesser extent, their direct manager. A small share
identify that they were not in contact with anyone from their workplace during their
sickness leave. Most of the time, respondents return to work on their own initiative,
but some had also returned after medical approval, either based on advice from their
general practitioner or a specialist treating their illness. Medical sta (specialists as
well as the general practitioner) were also among the rst to discuss an individual’s
return to work.
Nearly half of the workers who responded to the question say that had not felt particular-
ly welcome after they had returned to work. Moreover, more than half do not feel that
the company was well prepared in terms of making the necessary accommodations
as a result of their health condition. In addition, nearly two-thirds say they had not
received extensive mentoring and guidance from either their company or employer or
the trade union/employee representatives upon their return while the return to work
does not seem to have been a process that was particularly well-coordinated between
the company and their doctors.
Of all the categories of potential work adjustments, the majority receive no, or only
very limited, support in respect of the health conditions they experience due to chronic
illness. Where reasonable or extensive support was received, this was mostly in
connection with being exible about time, the sharing of tasks with colleagues and the
postponement of some deadlines.
Workers’ families and the specialists treating illness play a crucial role in the returns
process while the role of the employer in this respect is not considered very important
and support from work colleagues or friends is also seen as limited. The vast majority
identify that NGOs, organisations for rehabilitation and trade union/employee
representatives do not play an important role in their process of returning to work.
Several respondents shared their individual experiences and suggestions for changes
to the system. One respondent with cancer suggested increasing the limits on paid
visits to the doctor (‘sick days’), due to their increased frequency relating to the nature
of their illness. Another pointed out that each experience with the return to work is
dierent, inuenced by company, supervisor and many other factors. Indeed, several
identify the signicance of a sector-specic approach: in their experience, sectors such
as IT, which regularly has a shortage of workers, appears to have the ability to involve
workers with health conditions (after or during sickness leave) more easily than others
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155Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
due to the nature of IT work. While computer-based work allows for greater exibility,
workers can, for instance, perform smaller tasks or work from home.
Nevertheless, some experiences of workers were rather negative:
‘After returning to work, one seems to be sitting on an express train. Everyone
expects that I will manage the whole amount of work. Nobody talks about
surviving the diagnosis and the limitations resulting from it. My work pace is
monitored and occasionally corrected by my husband or I try to refuse the work
that exceeds normal working hours. I have problems with being on time. I refuse
to work unpaid overtime and take my work home for the night.’
‘After returning to work, I was under pressure from my superiors and colleagues
to quit my job and be replaced with a healthy worker.’
It is clear that unions have only limited opportunities to support workers. Of those
respondents who discussed their sickness leave with trade union representatives, only
one in ve conrm a supportive response in terms of the help and support oered
to them while an equal proportion report no help or support being oered during
sickness leave. Our sample was split into equal groups of unionised and non-unionised
workers, but the majority have trade union or employee representatives present in their
workplace. Of those respondents who were not union members, most had not thought
about joining the trade union in order to support or facilitate the process of their
return to work. This conrms that workers do not consider trade unions and employee
representatives to be important actors in the return to work.
4.2 Perspectives of HR, line managers and other relevant company actors
on the return to work process at company level
Investigating how employee absence due to a long-term medical condition aects the
organisation, the vast majority of managers state that the employee is not replaced in
the rst instance but that the workow is rearranged and job tasks divided between
other employees. Notably, a small share of managers pinpoint that there is no signicant
eect on the organisation.
Managers consider that legal advice regarding sickness absence plays a supportive role
in helping them deal with workers absent on sickness leave. The same is true of external
counselling, e.g. from doctors and therapists as well as cooperation with dedicated
professional associations and/or campaigning and patient support organisations, such
as the League against Cancer. On the other hand, managers also reveal that all the
resources that might be potentially supportive in dealing with workers on sickness
absence are all equally missing: legal advice regarding sick leave; information on
nancial strategies in dealing with sickness related absence and external counselling.
Managers mostly agree that a worker should be entitled to an adjustment of their working
duties at the organisation’s discretion and that it is crucial to stay in touch with the
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worker during the period of absence. At the same time, managers mainly disagree that
a worker is less committed to work after being diagnosed with a chronic illness. They
would not, however, recommend more time-o than the current legislation stipulates.
A majority of managers state that there is trade union or employee representation in the
organisation. Even so, company-level collective agreements do not address the return
to work. Instead, practices that would best apply to the organisation are: interaction
between management and unions regarding return to work policy and practice, as long
as this is ad hoc and not regular; and the inclusion of a worker representative on the
committee addressed to occupational health and safety. The barriers that managers
see in terms of cooperating with trade unions and other employee representatives in
facilitating the return to work is that the management of, and responsibility for, the return
to work process may become unclear. At the same time, the most prevalent outcomes
that they nd benecial as regards engaging with unions/employee representatives
on the return to work are training sessions for managers and team leaders directly
exposed to interaction with workers with chronic conditions; and training sessions for
the union and/or employee representatives who are likewise involved.
4.3 Interaction between employer and employee in facilitating
the return to work
4.3.1 Workers’ perspectives
Workers feel that their employers were generally supportive after they had announced
the need to take sickness leave but, at the same time, did not feel that their employers
oered any help or support during their absence. In practice, neither did they benet
from any mentoring or coordination of experience between the company and their
doctors.
The level of satisfaction with the help and support received from employers and trade
unions at company level shows variance. Most are satised with both employers and
unions, but more than one-third express strong dissatisfaction with the support and
help (or lack thereof) from trade unions. Furthermore over two-thirds state that there
were no negotiations between their employer and trade union/employee representatives
about adjustments to their work tasks and responsibilities after the return to work.
4.3.2 Managers’ perspectives
A majority of managers describe the type of interactions with workers during sickness
leave as irregular and mostly informal. The responses here suggest that workers on
sickness leave receive no updates on work-related issues during their period of leave:
managers admit that, during a worker’s sickness absence, they neither keep the worker
informed about work-related issues nor involve him or her in work-related matters (such
as asking for that person’s opinion, advice or involvement in planning or in decisions).
According to managers, the return to work is indeed, in line with the responses of
workers presented above, initiated mostly by workers themselves.
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157Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Regarding return to work procedures that might be available at company level, a few
admit that either there are no specic procedures or that they do not know about them.
If any return to work procedure is available, then there is the possibility of a phased
return to the organisation and/or that the organisation might cooperate in this respect
with other external parties, e.g. the occupational health service.
Corresponding to previous ndings, the type of support most frequently oered to
an employee returning to work is the availability of informal procedures. Another
relatively common support is that, before the worker’s return, there is a thorough
discussion to plan the return process. However, it seems that managers also expect the
worker to be back to regular productivity upon returning to work without the need for
adjustments.
In the context of the lack of a formalised policy on the return to work at national level
beyond disability policies, companies deal with the return to work of their workers
individually and behind closed doors. HR departments deal with an individual’s return
on a case-by-case basis and, most probably, there are no formalised processes or policies
at company level. Nevertheless, several good practices and experiences are apparent
from our research. For example, in a large automotive manufacturer, trade unions are
part of a health and safety committee that treats every return case individually. In
another smaller workplace, the informal nature of the interaction between manager
and workers had smoothed the return process, as did the level of engagement during
the period of sickness leave itself and the need to cope with the employer’s various
bureaucratic obstacles in order to adjust the workspace to t the returning worker.
Asking managers about how to improve the return to work process in their organisation
revealed that most see the need for better cooperation with external stakeholders,
e.g. medical doctors, therapists and campaigning and patient support organisations.
Another suggestion for improvement is the demand for better organisation-wide
policies and activities. Finally, managers would welcome more specic provisions in
the legislation on the return to work to guide the organisational approach, as well as
the legislation itself becoming more exible, leaving more space for company-level
management decisions on return to work issues.
4.4 Views on the future potential for social dialogue to support
the development and implementation of return to work policies
at company level
Nearly nine out of ten workers are unaware of cases in which a trade union had proved
helpful in the facilitation of a return to work. Workers’ lack of awareness of trade union
work, together with their opinion that trade unions should always be ready to address
the health-related issues of workers and that support for the return to work should be
an element of negotiations between trade unions and the employer, identies that there
is major potential for social dialogue to act as a tool to address return to work processes.
Signicant issues remain, however: for example, one-third of workers perceive trade
unions to be insuciently powerful to facilitate the return to work in Slovakia while
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a quarter are unsure whether the preferred form of support should be to seek binding
agreements with employers.
From the employer perspective, although based on a small number of responses,
managers prefer to look to training sessions for team leaders who are directly exposed
to interaction with workers experiencing chronic conditions. According to managers,
the legislation is too general in terms of managing returns to work following chronic
illness and thus does not oer sucient support to companies. Furthermore the
legislation has other shortcomings in that it is unclear and creates further burdens,
and is thus not particularly helpful.
Overall, the following can be summarised about the return to work process at company
level. Employees receive only limited support from their employer in the process of
returning to work following chronic illness. The majority return to work on their own
initiative and most receive support neither from the employer nor the trade unions at
the workplace. Employers, on the other hand, deal with returns to work on an individual
basis and without formal rules within the organisation. Managers expect employees
to have the same productivity level as before and the availability of adjustments to
working conditions is limited.
5. Discussion of research findings and conclusion
In terms of the legislative framework, the legislation in Slovakia is biased towards
those people with chronic conditions who acquire formal disability status or who are
entitled to invalidity benet from the state. The vast majority of policies, as well as the
policy implementation experience, focuses on this subgroup, leaving those undergoing
return to work processes, but without formal disability status, subject to the individual
discretion of employers and general sickness benet policies.
The actors involved in policy-making and implementation relevant to the return to
work (and including disability policies) include stakeholders at state level and the social
partners as well as NGOs, charities and campaigning and patient support organisations.
Among these, return to work policies are identied as among the ‘core business’ of
specialised government and employment oces, patient support organisations, NGOs
and charities.
For both trade unions and employer organisations, return to work policies are secondary
or even marginal as regards their current agendas. Awareness of EU-level policies on
the return to work remains low among the Slovak social partners although they do
support more active EU-level policies promoting the return to work in member states.
At the same time, some maintain that return to work policies should be addressed
exclusively at national level due to the diversity in European policy frameworks and
industrial relations systems.
In contrast, the social partners are well aware of national return to work policies
(where these are related to formal disability status) but are not actively involved in
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159Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
policy design as this is not a core priority for their organisations. It is also clear that the
social partners lack a coherent national strategy towards the return to work of people
following chronic illness. Despite lacking a dedicated framework for national return to
work policies which extends beyond disability, most of the social partners think that
Slovakia has an elaborate policy framework and properly implements and even enforces
practices on the return to work. Regarding policy-making and implementation in this
area, employer associations perceive their involvement as sucient although there is a
demand for more active involvement among the trade unions.
At national level, return to work policies are not a priority for trade unions due to low
capacity and a priority focus on other, broader, interests of workers. Nevertheless
trade unions are involved in commenting and consulting on the relevant legislation
and provide legal consultation for their members, when needed. Besides this, trade
unions are mostly engaged in providing individual assistance to individual workers
at company level, something that is viewed as more benecial than unions supporting
an agenda on the return to work in national-level social dialogue. On the other hand,
social dialogue could, where it results in specic agreements, be a valuable tool to make
policy on the return to work more visible and to raise awareness among all stakeholders
on the potential role that trade unions could play in the return to work process.
Employer associations at the highest level, as regular members of the national
tripartite council, can submit various proposals for the amendment of return to work
policy. Nevertheless, they do not perceive any demand from their membership base for
such activity. Even though the return to work theme is perceived by employers both
as an economic issue and as a matter of social responsibility, employers resist stricter
regulation and call for greater work exibilisation in general and for the return to work
agenda to be addressed individually at workplace level.
Despite such obstacles, the social partners do see opportunities for their greater
involvement in this policy area. Most evaluate the level of cooperation between trade
unions, employer associations, government, labour market institutions, medical
organisations, rehabilitation centres and NGOs as potentially important in terms
of facilitating a sustainable and feasible policy framework on the return to work.
Furthermore there is general interest in increasing the participation of the social
partners both in policy design and implementation. Suggestions for improving the role
of social dialogue include a better integration of the return to work agenda in collective
bargaining, more systematic data collection and reform of the present system and of
the quotas for employers to employ disabled workers.
All stakeholders agree that cooperation between the various types of actor is, however,
lacking and that there is room for improvement. Cooperation could be extended to
involve other stakeholders too, such as labour inspectorates or employment promotion
agencies, rehabilitation centres and others. At the same time, the level of cooperation
that does prevail needs to be intensied and to become a platform for the specic
discussion of topics related to the return to work.
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Collective bargaining and collective agreements at sectoral or company level are seen
as potential practical tools to stipulate obligations for employers in terms of return
to work policies. There is also room for the legislative improvement of the present
disability policy and its implementation procedure. This includes, for example, an
amendment to the legislation on sheltered workplaces for disabled people. While the
current allocation to sheltered workplaces does not facilitate an easy transition into
regular jobs, a legislative amendment should aim to revisit the role of a sheltered labour
market for people with health conditions, In particular, it should propose a mechanism
for cooperation between employers and other stakeholders, including unions and
NGOs, supporting labour market integration to facilitate an easier and more direct
return to regular jobs instead of sheltered ones.
At company level, workers undergoing a return to work process are mostly fearful
of a lacking transition period and that they would be expected to resume working at
immediate full productivity. Lived experience indeed shows that this is the case on the
part of most employers in the absence of a national-level policy on the return to work and
since most employers do not normally have even a company-level policy stipulating the
exact process that should be followed. In the few cases where concessions are granted,
these refer to exible time arrangements and task sharing with other colleagues. For
the most part, no specic return to work procedures are available at company level and,
even where they are, managers have little awareness of them. Neither are workers aware
of the potential role for trade unions in facilitating their return. Nevertheless several
examples of good practice may be identied at company level where employers have
successfully managed to integrate workers with health conditions and/or disabilities.
Despite being in touch with colleagues, and occasionally with their line manager, during
their treatment, most respondents feel only ambivalently welcome at their workplace
after they return. Managers also acknowledge that interactions with workers during
their period of sickness leave are irregular and informal. A majority of workers do not
think that the company is suciently well prepared to accommodate the necessary
adjustments required by their health condition. Where adjustments are made, this
is mainly in connection with time exibility, task sharing with colleagues and the
postponement of some deadlines.
There is a variation in the level of satisfaction of workers with the help and support
they receive from employers and trade unions at company level. Most are satised, but
one-third express strong dissatisfaction with the support and help they received from
trade unions. Overall, the role of trade union/employee representatives is not perceived
as an important one in the process of their returning to work. This might, however, be
inuenced by the relevant respondents not consulting with employee representatives on
their need for a long-term period of absence. Furthermore most workers are unaware of
cases in which a trade union had proved helpful in terms of facilitating a return to work.
Despite some workers regarding trade unions as insuciently powerful in this respect,
they still expected that trade unions would always be ready to address the health-
related issues of workers. Workers support the notion that the return to work should
be an element of negotiation between trade unions and employers. These opinions, too,
highlight the potential for social dialogue as a tool to address return to work processes.
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161Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Research into the return to work in Slovakia shows that there is a missing link
between EU-wide strategic concepts, their integration into national policies (which are
currently restricted to people formally recognised as disabled) and their subsequent
implementation in practice at company level. Companies lack policies on workforce
diversity and there is an insucient elaboration of the concepts of an ageing workforce,
tness for work and the overall concept of workforce diversity, extending to workers
with health conditions. The connection between EU, national and company-level use
of such concepts is currently limited. Better interconnection could be facilitated via
the European Semester but also via a better articulation of social partners’ interests as
regards their own EU-level organisations and social dialogue committees.
Our policy recommendations refer to roles, strategies and particular actors at various
levels where return to work policies and their implementation need attention, as well
as in terms of a conceptual understanding of the return to work.
First, the study points to the need for more systematic data collection on people with
chronic conditions and their working life trajectories. This is currently lacking and
thus complicates policy-making and the implementation of return to work policies.
Second, return to work policy should, conceptually, clearly distinguish between people
with and without formal disability status. The focus is currently the former and a
dedicated policy mix for the latter group is almost non-existent.
Third, given the need for more eective policy implementation on the return to work,
closer cooperation between stakeholders is desirable in terms of discussions among
expert groups but also in connection with practical steps. The latter should encompass
a more coordinated management of the return to work process at national level (e.g.
integrating this agenda into a single umbrella organisation rather than decentralising
it across various stakeholders that lack cooperation).
Fourth, the greater involvement of trade unions is called for at each of the national,
sectoral and company levels. At national level, unions could build on their priority of
workforce protection, which is shared by state stakeholders, while opportunities for
including return to work provisions in collective bargaining at sectoral and company
levels may be explored.
Fifth, at company level, and despite employers’ longstanding preference for addressing
the return to work on an individual basis, a more systematic approach would be welcome
by workers actually undergoing a return to work. This would add to the transparency of
employment policies as well as assisting their interaction with national-level policies.
Trade union involvement in framing diversity policies at company level more broadly,
but also in including stipulations on the return to work, also constitute areas for further
exploration and analysis.
Finally, the study has identied a gap between relevant EU-level policies (not only in
the narrow sense of the return to work but in the broader sense of an ageing population,
tness for work issues and the labour productivity debate), national-level policies and
Barbora Holubová, Marta Kahancová, Mária Sedláková and Adam Šumichrast
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations162
the decentralised implementation level. The comparative experience of various EU
member states is essential as a means of facilitating better articulation between these
levels to address return to work policies within the EU from a multi-level governance
perspective.
References
Bohle D. and Greskovits B. (2012) Capitalist diversity on Europe’s periphery, Ithaca, Cornell
University Press.
Kahancová M., Martišková M. and Szüdi G. (2019) Enhancing the eectiveness of social dialogue
articulation in Europe (EESDA), National report: Slovakia, Research Report 29, Bratislava,
Central European Labour Studies Institute.
NCZI (2018) Health Statistics Yearbook of the Slovak Republic. http://www.nczisk.sk/en/Pages/
default.aspx
OECD (2019) Slovakia country health profile 2019, state of health in the EU, Paris, OECD
Publishing.
Ondrušová D., Kešelová D. and Repková K. (2017) Akčný plán prechodu z chránených dielní na
zamestnávanie osôb so zdravotným postihnutím na otvorenom trhu práce [Action plan for the
transformation from sheltered employment to the employment of disabled people in the open
labour market]. Bratislava, Institute for Labour and Family Research.
All links were checked on 04.06.2021.
163Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Conclusions
Return to work after chronic illness and the way ahead
Mehtap Akgüç
1. Why does the return to work following chronic illness matter?
Demographic developments including ageing and, simultaneously, declining birth
rates, resulting in a shrinking workforce, coupled with an increasing prevalence
of chronic illness among all age groups – but particularly for older workers – imply
that more people of working age are expected to face health problems at some point
during their career. Meanwhile, chronic illnesses, usually characterised by a long-term
nature and slow progression regardless of whether or not there is a cure, constitute
the main reasons for absence from work, as well as presenteeism at work, and could
be a precursor for early exit from the labour market. In addition to the eects on
health and the personal and professional setbacks to the person at the centre (as well
as the indirect costs for caregivers), chronic illness and the related issue of long-term
absence from work also pose challenges to employers regarding the continuity of work
due to missed workdays or productivity losses. Costs can reach signicant amounts
when aggregated; for example, while the direct costs of work-related cancer in terms
of healthcare and productivity losses can vary between €4-7 billion, the indirect costs
can reach nearly €334 billion annually.
1
Furthermore, soaring sickness and disability
benets in many countries, in the face of a declining workforce, is putting further
strain on the sustainability of social protection systems in Europe.
For all these reasons and more, the return to work and the occupational reintegration
of individuals with chronic illness has become an important element of various policy
areas ranging from employment to health and safety policies and to ones focused on
social inclusion. Moreover, in addition to addressing the specic challenges faced by
individuals with limiting health conditions, their reintegration into work is part of a
wider European policy agenda promoting not only a healthier Europe, with active and
healthy ageing involving longer working lives, but also establishing inclusive European
societies in which various strategies aim at reducing the risk of the marginalisation and
poverty of vulnerable individuals, as well as discrimination against them.
In this context, given the importance of the social partners in representing the
interests of workers and employers and striking a balance between the two sides in the
workplace, the role of industrial relations structures and actors comes to the fore in
terms of how far they remain relevant in addressing and facilitating the return to work
of individuals following chronic illness. This has been the core task of the book which
looks at this issue from several distinct angles.
1. https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:52017DC0012&from=EN (page 4).
Mehtap Akgüç
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations164
In particular, various chapters provide a detailed picture of return to work policies
and experiences from multiple governance stages, including EU, national and company
levels and with a particular focus on the industrial relations actors, and zoom into
the perspectives of workers going through return to work or reintegration processes
following chronic illness. Six countries – Belgium, Estonia, Ireland, Italy, Romania and
Slovakia – are analysed in depth to understand how the return to work is implemented
and perceived by national stakeholders, social partners, managers and workers. The
evidence base used for the analyses relies on mixed methodologies combining both
qualitative approaches, drawing on an overview of the existing academic and policy
literature, and quantitative ones exploring primary data collected in a number of
online surveys and interviews and at various stakeholder events.
2. EU-level approach to the return to work
The overall analysis suggests that EU-level initiatives and industrial relations actions
have, so far, been limited in the specic context of the return to work following chronic
illness. This is partly due to the subsidiarity principle as employment and social policies
remain a national competence. Nevertheless, a number of actions and strategies from
a range of policy elds have been put forward and these have some relevance for the
return to work and reintegration of individuals experiencing chronic illness. From a
health and safety perspective, while EU policies have mainly focused on the prevention
of occupational accidents and work-related diseases, the importance of chronic illness
is increasingly acknowledged in the face of its rising prevalence in Europe. However,
chronic illness is still frequently subsumed within the disability framework.
At least three recent EU initiatives are worth mentioning with a clear relevance for
the return to work. The rst is the recently-released Strategy for the Rights of Persons
with Disabilities, which specically refers to the workplace rehabilitation of workers
with chronic illness. The second is the EU ‘Beating Cancer’ Plan that also addresses the
return to work of individuals experiencing cancer. Last but not least, the new Strategic
Framework on Health and Safety at Work for 2021-2027 has also a role to play in the
return to work context.
As regards the involvement of the EU-level social partners in the return to work,
the analysis points to limited action at this point. However, the social partners here
consider the issue to be highly relevant, even if it is not as yet much on their agenda.
It was also largely acknowledged that, in this context, EU-level action could be more
appropriate for raising awareness and organising information campaigns as well as
supporting national members with more practical guidance on facilitating the return to
work at national, sectoral or company levels where more specic actions can be taken.
Conclusions – Return to work after chronic illness and the way ahead
165Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
3. Approaches to and experiences with the return to work
in six member states
In most of the countries studied, the existing national policies and legislative framework
do not specically or suciently address the return to work and reintegration of
individuals with chronic illness; the target is rather those individuals who have
disability status, the extent of which is assessed and certied by medical authorities.
Individuals with chronic illness usually fall under a certain category of disability status
when it is established that their illness has caused a partial or complete loss of work
capacity.
Considering the overall policies and approaches to the return to work based on the
national analyses, some commonalities may be observed. It emerges that, in most
of the countries, other than Belgium which has an elaborate framework for the
reintegration to work of people with non-occupational illnesses, there is no specic
national policy framework addressing reintegration. Most of the time national polices
consist of general sickness leave or disability provisions and quite often constitute a
rather fragmented approach to the return to work in which the state usually takes the
leading role in policy creation. Consultation and collaboration – let alone co-design –
with the social partners or other stakeholders on the return to work or related policies
remains limited and the scope for interactions between various actors depends on
national legislative structures and industrial relations traditions. At the same time,
the return to work lies at the intersection of several policy domains – employment,
occupational health and safety, social inclusion and disability – and, as such, policy
design and then implementation involve dierent stakeholders whose priorities might
diverge. This might also complicate the coordination of policy-making on the return
to work.
In some cases, the existing law accords specic roles to the social partners or other
relevant stakeholders to take part in policy-making (e.g. Belgium) while in others
consultations are organised in an ad hoc or voluntary manner (e.g. Ireland), if at
all (e.g. Estonia or Romania). In Italy, the legal framework on the return to work is
somewhat disconnected and often the social partners lack the legal expertise properly
to implement the legislation at local levels. A similar situation arises in Ireland, which
has a disjointed and complex benet-setting system that is hard to navigate for workers,
especially when dealing with chronic illness.
It also emerges that ‘one size ts all’ kinds of solutions do not work well in the context
of returning to work after or with chronic illness because of sectoral, company and
individual specicities that necessitate a more tailored approach on a case-by-case
basis. For example, in Slovakia individual assistance to workers at company level is
provided by trade unions to facilitate the return to work in the absence of focused and
targeted policies. The presence of decentralised and informal channels for dealing
with the issue is also common in some countries (e.g. Ireland and Italy). In Romania,
the existing law only provides general stipulations as regards work reintegration and
no specic measures or interventions exist for easing the return to work, despite a
generous duration of fully-paid sickness leave.
Mehtap Akgüç
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations166
The type of disease also matters as workplace or workload adjustments and the
needs of individuals with musculoskeletal disorders may well dier from those of
individuals with mental health conditions or cancer. In this respect, campaigning and
patient support organisations or other relevant NGOs are also considered key actors
as they have deeper knowledge on the specicities of particular illnesses and patient
experiences and can inform policy-makers and the social partners on the precise needs
and priorities of individual workers.
All in all, it is acknowledged that the return to work with chronic illness is a complex
subject involving a multitude of actors and stakeholders each of whom might have a
specic role to contribute in the facilitation of the overall process.
4. The role of the social partners in the return to work
The overall ndings reveal mixed results as regards the role and involvement of the
social partners in return to work policies and processes. On the one hand, while they
nd it relevant, the return to work is not yet a pressing issue for them and hence it is not
surprising that their involvement in such issues is limited.
In Estonia, given low union density coupled with weak sectoral social dialogue, neither
trade unions nor employer organisations have taken much initiative in return to work
matters. In Romania, there is reduced involvement and collaboration, focusing mainly
on nancial benets for workers, among the industrial relations actors but their role in
raising awareness is also acknowledged. In Italy, regional and company-level collective
bargaining on this issue is largely underdeveloped, relying mainly on the mutual
willingness of trade unions, employer representatives and managers; when it happens,
it is limited to large companies in specic sectors. Ireland’s new-traditional social
partnership ended following the recent nancial crisis in 2009 and, since then, social
dialogue has been weakened generally; nevertheless, the high-level social partners
were able to make their input into policy development at national level regarding the
employment strategy for people with disabilities. In Slovakia, the return to work is not
a key topic on the trade union agenda but this is due to low capacity and a shortage of
expertise rather than any lack of willingness to be more active in the eld.
In contrast to the other countries, the social partners in Belgium have played a key
and multifaceted role in the development of a recent dedicated return to work policy
framework via the social dialogue. This is in the context of a deeply-established
industrial relations setting with high rates of unionisation and collective bargaining
coverage. Despite the unforeseen contract termination outcomes (so-called medical
force majeure) implicit in the framework, the intensive and high level of interaction
between government and social partners during the policy design process has put
Belgium at the top of the list of the countries studied in this book where the social
partners have made an important dierence in the return to work.
Conclusions – Return to work after chronic illness and the way ahead
167Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
5. Workers’ perspectives and experiences during the return
to work
It appears that one of the main challenges for workers in the return to work is a fear
of returning without having the right support during the process. Partly this is due to
the lack of necessary adaptations in the workplace or other types of (e.g. psychological)
support following return. Here, a big part of the responsibility falls on employers who
are either too concerned about the costs of adjustments or truly lack the capacity or
knowledge to implement existing laws giving certain rights to workers. In either case,
it emerges that more education and better informed employers would be more able to
understand what their role is in this process and what reasonable accommodations can
be made to assist workers.
As regards perspectives on trade unions, workers’ rather underwhelming actual
experiences during their return to work could possibly be due to workers having very
high expectations of what trade unions are able to do for them in this scenario and,
perhaps, because workers might consider their trade union representative simply as
a means to realise gains on their behalf behind the scenes. A shift in mindsets might
be necessary here as more could be achieved. At the same time, trade unions seem
to struggle to reach such workers because of the individualised nature of the context
of illness and because of privacy concerns, making situations harder to collectivise.
Nevertheless trade unions should continue to be proactive by informing workers about
their rights and raise awareness about the issues, possibly also by joining forces with
other campaigning and patient support organisations.
The other major issue is what the experience of chronic illness makes workers think
about going back to work. It is possible that dealing with a chronic illness makes workers
realise their vulnerabilities and rethink the importance of time (and life) and thus it
can lead to a desire to ‘slow down’. This is where policy campaigns to make working
lives longer give an uncomfortable message by incentivising workers back to work in
the context of the requirement for labour to sustain social security systems. At the
same time, working after chronic illness can also be part of the rehabilitation process
as it can make workers feel valued despite their vulnerabilities or reduced capacity.
6. Return to work in the Covid-19 context
Here, there are several countervailing eects in play. While the pandemic has
added further complications to the return to work process, it might also oer ample
opportunities with which to facilitate it.
On the one hand, because of overwhelmed and reduced healthcare services in hospitals
during lockdowns, as well as the likely avoidance of medical centres by individuals
due to a fear of virus propagation, the pandemic may have delayed the early detection
as well as treatment of chronic diseases such as cancer that would otherwise have
been monitored and caught. Moreover, recent studies hint at the long-term impacts of
Covid-19 on individuals already experiencing chronic conditions and who are at mild to
Mehtap Akgüç
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations168
high risk should they catch Covid-19 (we refer here to Long Covid; for more on this, see
the Introduction). Limited social (and professional) contact due to lockdown measures
can also extend the recovery process and the reintegration to work of individuals with
chronic illness. The pandemic, therefore, might have further compromised the return
to work process of individuals with chronic conditions.
On the other hand, mandatory teleworking in certain jobs, where this is possible, and
the exibility that this entails might well oer new possibilities to individuals with
chronic conditions in the sense of being able to perform their work from home. Prior to
the pandemic, it might have been harder to negotiate this with employers.
In some cases, the pandemic context can also oer the opportunity to rethink existing
social security and social protection systems and to consider adapting them to the new
context generated by Covid-19. Ireland is a case in point: up to now, there has not been
a statutory sickness pay scheme in place in the country but the government has been
considering introducing related reforms in a reection of the devastating health, social
and economic circumstances created by the pandemic.
7. Policy considerations and the way forward
Considering the overall involvement and perspectives of the various stakeholders across
the dierent countries analysed, a number of policy considerations come forward.
First and foremost, there is a need to promote a proactive approach to the return
to work in which workers are accompanied through eective and transparent
communication of policies and procedures which, in turn, help them better navigate
what appears to be an already complex process. The overall approach should also take
into account the specic needs and priorities of workers, depending on the illness,
while accordingly thorough discussions on workload and workplace adjustment,
matching the requirements of the reasonable accommodation regulations, would be
highly benecial in facilitating a successful return to work. It would also be helpful if
the EU’s reasonable accommodation legislation, which currently addresses the needs
of disabled workers, could be formally extended to cover workers who are chronically
ill. Employers, particularly managers in small and medium enterprises, should also be
guided and informed along the way.
Despite the currently limited involvement of the social partners in return to work
issues, it is largely believed and expected that eective social dialogue can help to
design and facilitate return to work and reintegration policies. As the voice of workers,
there is also the important role and responsibility of trade unions to raise awareness on
the issues and accompany workers at all levels. However, this requires a deepening of
the knowledge of the social partners on the existing legal framework, a strengthening
of multi-stakeholder cooperation and coordination across dierent layers of policy-
making and implementation, and an intensication of interactions between the social
partners as a means of discussion and exchange on particular aspects of the return to
work.
Conclusions – Return to work after chronic illness and the way ahead
169Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
There are also challenges in tackling the return to work through social dialogue because
of the private and sensitive nature of the context of illness and since workers away from
the workplace as a result of sickness leave are actually on the margins of social dialogue
procedures. This is where trade union representatives could play a more proactive role
in accompanying and engaging with workers while respecting sickness and recovery
periods. Overall, however, experience from the countries studied suggests that having
a broad national framework enforcing basic rights and requirements, complemented
by a tailored company-level approach, could actually work rather well. In particular,
sectoral specicities and company-level characteristics are likely to play an important
role in a better targeting of the return to work process. A further possibility could be to
push for collective agreements at company level.
It also appears that, once the recovery or recuperation period is over and workers are
ready to think about going back to work, the process of return needs to be handled
quite ‘gently’ in a way that allows workers to come back in a gradual and progressive
manner – be it in terms of work time and tasks or level of responsibility. Flexibility is
also important in cases where individualised accommodations might be necessary, as
long as the exible approach follows from agreed principles (or ones accorded by law)
around job security, income security and so on. It is well worth giving these sorts of
issues formal consideration either in existing dialogue processes and/or in terms of
how legislation responds to the concerns of both workers and employers in this area.
At EU level, the key role continues to lie in awareness-raising on return to work issues
as well as providing information and practical guidelines to be transmitted to national,
sectoral and company levels. The potential development of a European charter on the
return to work, where all relevant information could be gathered, is an option. Another
avenue is to incorporate the issue into the European Semester process in which member
states would closely monitor the employment and social inclusion of individuals with
chronic illness. The social partners could also more proactively participate in this
process.
Finally, further multidisciplinary collaborations will be of help in increasing
knowledge and expertise on the return to work after or with chronic illness. Such
collaborations would allow the exchange of best practice and inform policy-making.
Deeper cooperation between the social partners and campaigning and patient support
organisations could be especially enriching for both sides. Furthermore increased
eorts to collect harmonised data on the return to work and chronic illness will also
be needed to allow a proper measurement of the scale of the issues so that informed
decisions may be made about them in the future.
171Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
List of abbreviations
AIMAC Associazione Italiana Malati di Cancro (Italian Association of Cancer Patients,
Relatives and Friends)
AISM Associazione Italiana Sclerosi Multipla (Italian Multiple Sclerosis Association)
ANOFM Agenția Națională pentru Ocuparea Forței de Muncă (Public Employment
Agency) (Romania)
CEE Central and eastern Europe
CES Comprehensive Employment Strategy (Ireland)
CIPD Chartered Institute of Personnel Development (Ireland, UK)
CIV Consiglio di Indirizzo e Vigilanza (Orientation and Oversight Committee of
INAIL) (Italy)
CNPP Casa Națională de Pensii Publice (National House of Pensions) (Romania)
CNT/NA Conseil National du Travail/Nationale Arbeidsraad (National Labour Council)
(Belgium)
EAKL Eesti Ametiühingute Keskliit (Estonian Trade Union Confederation)
EH Eesti Haigekassa (Estonian Health Insurance Fund)
ET Eesti Töötukassa (Estonian Unemployment Insurance Fund)
ETK Eesti Tööandjate Keskliit (Estonian Employers’ Confederation)
ETUC European Trade Union Confederation
EU European Union
Eurofound European Foundation for the Improvement of Living and Working Conditions
EU-OSHA European Agency for Safety and Health at Work
FEDRIS Agence fédérale des risques professionnels/Federaal agentschap voor
beroepsrisico’s (Federal Agency for Occupational Risks) (Belgium)
FNUASS Fondul Naţional Unic de Asigurări Sociale de Sănătate (National Fund for Social
Health Insurance) (Romania)
GDP Gross Domestic Product
GDPR General Data Protection Regulation
HR Human Resources
HSE Health Service Executive (Ireland)
IBEC Irish Business and Employers Confederation
ICTU Irish Congress of Trade Unions
ILO International Labour Organization
INAIL Istituto Nazionale per l’Assicurazione contro gli Infortuni sul Lavoro
(National Institute for Insurance against Accidents at Work) (Italy)
INAMI/RIZIV Institut national d’assurance maladie-invalidité/Rijksinstituut voor ziekte- en
invaliditeitsverzekering (National Institute for Health and Disability Insurance)
(Belgium)
INPS Istituto Nazionale Previdenza Sociale (National Institute for Social Security)
(Italy)
MMPS Ministerul Muncii și Protecției Sociale (Ministry of Labour and Social Protection)
(Romania)
MSD Musculoskeletal Disorder
NCLA National collective labour agreement(s)
NGO Non-governmental Organisation
List of abbreviations
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations172
OECD Organisation for Economic Cooperation and Development
SECPAD Serviciul de Evaluare Complexa a Persoanelor Adulte cu Dizabilitati (Authority
for the Complex Assessment of Disabled Adults) (Romania)
SME Small and medium-sized enterprise
SP Sociálna poisťovňa (Social Insurance Agency) (Slovakia)
UN United Nations
ÚPSVaR Ústredie práce, sociálnych vecí a rodiny (Central Oce of Labour, Social Aairs
and Family) (Slovakia)
WHO World Health Organization
173Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
List of contributors
Mehtap Akgüç is Senior Researcher in the Economic, Employment and Social Policies
Unit of the Research Department of the European Trade Union Institute. She is also
a research aliate at IZA (Institute of Labor Economics). Her main research interests
include various topics related to labour markets and policies including inequalities,
migration and mobility, platform work, the green and the circular economy, industrial
relations and economic development. She has a PhD in empirical labour economics
from the Toulouse School of Economics in France.
Ziv Amir was Honorary Professor at the University of Salford, UK (until October
2019). He is a social scientist with a particular interest in the association between
health and work, mainly in exploring the role of employers in supporting employees
aected by cancer to maintain their employment.
Ilaria Armaroli is Research Fellow at ADAPT. She received a PhD in human capital
formation and labour relations at the University of Bergamo (Italy). Her research focus
is related to industrial relations, collective bargaining and employee voice both at
national and international level.
Maria Sole Ferrieri Caputi is Junior Research Fellow at ADAPT and a PhD student
in human capital formation and labour relations at the University of Bergamo (Italy).
Her research focus is related to local and company welfare and diversity management
at the workplace.
Paula Franklin is Senior Researcher at the ETUI whose work explores the
intersections of employment and working conditions, health and gender. She holds an
Honorary Researcher position at Newcastle University’s Population Health Sciences
Institute and has acted as an independent expert for the World Health Organization on
health equity and for the European Commission on gender and health.
Tish Gibbons is Head of SIPTU College, Ireland’s only full-time trade union college.
Her research interests include collective bargaining, trade union organisation, labour
history and employment law.
Margaret Heernan is Associate Professor in human resource management at
Dublin City University. Her research interests include employee well-being, strategic
human resource management and organisational justice.
Eugene Hickland is Assistant Professor of employment relations and HRM at Dublin
City University. His research interests include industrial democracy, employment
regulation, employee voice, trade union organisation and workplace innovation.
Barbora Holubová is Researcher at the Central European Labour Studies Institute
(CELSI) in Bratislava. Her research area is the labour market, social policies, gender
inequalities and comparative policy analysis.
List of contributors
Continuing at work. Long-term illness, return to work schemes and the role of industrial relations174
Marta Kahancová is Senior Researcher, Founder and Managing Director at the
Central European Labour Studies Institute in Bratislava, Slovakia. Her research
interests focus on industrial relations, trade union strategies in central and eastern
Europe, precarious work, undeclared work and working conditions in the care sector.
Felicia Morândău is Lecturer at Lucian Blaga University of Sibiu, Romania. Her
research interests include topics from the area of the sociology of the family and the
sociology of education. In recent years she has been involved in research on returning
to work after cancer in Romania.
Lorenzo Maria Pelusi was Research Fellow at ADAPT and at the University of
Modena and Reggio Emilia (Italy). He received a PhD in human capital formation and
labour relations at the University of Bergamo (Italy). His research focus was related to
occupational health and safety.
Adela Elena Popa is Associate Professor at Lucian Blaga University of Sibiu, Romania.
Her previous research deals with health policy and the return to work after cancer.
Radu-Ioan Popa is Senior Lecturer at Lucian Blaga University of Sibiu, Romania
and Honorary Fellow at Munich University of Applied Sciences, Germany. With a PhD
in psychology, his main research focuses on human resources management and work
pathology.
Triin Roosalu is Associate Professor of sociology at the Institute of International
and Social Studies, Tallinn University. She has explored social inequalities in care,
work and lifelong learning throughout her academic career. Her most recent research
into working conditions, organisational practices and industrial relations includes
discussing gender gaps in pay and promotion.
Mihai Stelian Rusu is Lecturer in sociology at Lucian Blaga University of Sibiu,
Romania. His work deals with the politics of memory and death in postsocialist
Romania.
Mária Sedláková worked as Researcher at the Central European Labour Studies
Institute (CELSI) at the time of writing and has since joined the International Labour
Organization as Technical Research Ocer. Her research focuses on collective
bargaining and social dialogue, non-standard and new forms of employment and
labour market policies and institutions.
Adam Šumichrast is a doctoral candidate at the Institute of History of Masaryk
University, specialising in comparative labour and social history, and also a junior
researcher at the Central European Labour Studies Institute. He is interested in
researching industrial unrest and collective action, including during the present and
especially in Slovakia and Czechia.
List of contributors
175Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Marti Taru is Researcher at the Institute of International and Social Studies, Tallinn
University, and has dedicated his research career to understanding youth and work
patterns across Europe. He is currently working towards completing his PhD thesis on
the role of European Youth Guarantee in supporting the transition to the labour market
of vulnerable young people.
Aurora Trif is Associate Professor in international employment relations at
Dublin City University Business School. Her research interests include comparative
employment relations in eastern Europe, precarious work, trade union innovation,
collective bargaining and workplace partnership.
Nina Lopez Uroz is Research Assistant at the Centre for European Policy Studies
in Brussels and incoming PhD candidate at the European University Institute. Her
research interests include labour market and social policies, industrial relations and
political economy.
Leonie Westho is a DPhil researcher at Nueld College, University of Oxford, and
an Associate Researcher at the Centre for European Policy Studies, Brussels.
177Continuing at work. Long-term illness, return to work schemes and the role of industrial relations
Acknowledgements
First of all, I would like to thank all the contributing authors for their collaboration in
the joint eort to compile this book, which is on the major topic of returning to work
after chronic illness especially in the context of the recent pandemic. This has been a
tremendously enriching experience for me.
I would also like to thank Philippe Pochet, Nicola Countouris and Sotiria Theodoro-
poulou who have supported my engagement with this book right from the beginning,
quickly after I joined the ETUI.
I am grateful to the language editor, Calvin Allen, as well as the team in the ETUI’s
Documentary Centre and the ETUI editorial team who have been extremely patient
and professional throughout the editing and layout process. Mehmet Koksal has been
particularly supportive prioritising publication during what has been a hectic period of
work.
The majority of the chapters that you read in this book – particularly those on the
European approach to the return to work and the country-specic ones – are related
to the research project ‘Negotiating Return to Work in the Age of Demographic Change
through Industrial Relations’, funded by the European Commission between 2019-2021
(REWIR Project No. VS/2019/0075). However, all the chapters have been written
independently of that project’s deliverables and have been subject to peer review as well
as language editing, making them distinct and discrete contributions to the literature
on the return to work.
Finally we are sad to record the passing in August 2020 of Dr. Lorenzo Maria Pelusi who
co-wrote the chapter ‘Over-expectation and underprovision: overcoming the voluntarist
and irregular approach of Italian social partners to the return to work’. His colleagues
have devoted this chapter to him and I would like to extend that by dedicating the wider
volume to his memory.
Mehtap Akgüç, Editor
D/2021/10.574/21
ISBN 978-2-87452-608-4
European
Trade Union Institute
Bd du Roi Albert II, 5
1210 Brussels
Belgium
+32 (0)2 224 04 70
www.etui.org
Continuing at work
Long-term illness, return to work schemes
and the role of industrial relations
Edited by Mehtap Akgüç
This book focuses on the role of industrial relations structures and related actors in terms of how
far they remain relevant in addressing and facilitating the return to work of individuals following
chronic illness.
While the demographic transition and the transformation of labour markets call for longer
working lives and policies on active ageing, the prevalence of chronic health conditions has also
increased in ageing societies. This exacerbates issues connected with shrinking workforces and
the sustainability of social security systems. Concerns have also been raised about managing the
return to work of workers with chronic illness or disabilities, challenging the inclusive workplace
and other related social or labour market policies. The Covid-19 pandemic has additionally
affected the return to work process in multiple ways, making the issue ever more important in
the current public health context.
The chapters display a detailed picture of return to work processes alongside existing legal and
policy frameworks and experiences from multiple governance stages (EU, national and company
levels) and provide overview perspectives from distinct angles. Six countries – Belgium, Estonia,
Ireland, Italy, Romania and Slovakia – are analysed in depth to understand how the return to work
is implemented and perceived by national stakeholders, social partners, managers and workers.
The key message emerging from the analysis is that the return to work following chronic illness
is a complex subject involving a multitude of actors and stakeholders each of whom might have
a specific role to contribute to (the facilitation of) the overall process.
Continuing at work
Edited by Mehtap Akgüç
