Guidelines for a sustainable return to work with long COVID

Introduction

Several definitions of long coronavirus disease (COVID) have been used but as research is now defining the clinical issues, long COVID is best defined as ‘an infection-associated chronic condition that occurs after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and is present for at least 3 months as a continuous, relapsing and remitting, or progressive disease state that affects one or more organ systems’ [1]. or ‘the constellation of post-acute and long-term health effects caused by SARS-CoV-2 infection’ [2]

The virus infects through blood vessels and therefore can affect any part of the body. Whilst initial definitions such as NICE guidance [3] excluded organ damage it is now apparent that most people with long COVID have a combination of health problems affecting multiple parts of the body. Long COVID is therefore a syndrome that includes a wide variety of symptoms and presentations, all related to a past infection with COVID-19. Each patient is different; some may be profoundly affected, while for others, symptoms may have little or no impact on their day-to-day activities. Research studies have recently identified specific blood biomarkers that are associated with underlying types of LC subgroups but these tests cannot yet be used to guide treatment [4]. Currently, therefore, we need to use symptom-based assessments to guide different treatment or rehabilitation strategies rather than blood tests [1].

So it is important not to treat each recovering worker the same. As per usual occupational health (OH) practice, the effect of their health conditions on activities needs to be assessed against the requirements of their work and an assessment of fitness made.

Long COVID matters to employers, Occupational Health Practitioners and Workers due to the number of people affected simultaneously, and its effects on the economy [2,5,6]. It is disabling and causes long-term sickness absence. In individuals, it often results in prolonged and/or relapsing-remitting pictures.

People aged 35–65 years are most affected. In a study of people who self-classified as ‘inactive, not looking for work’, the prevalence of long COVID lasting beyond 12 weeks was 5·7%, confirming findings from studies showing that this condition is having a substantial effect on people’s ability to work in paid employment. Of the individuals who self-reported long COVID and provided a date, 71% had had symptoms for at least 1 year, 51% for at least 2 years and 31% for at least 3 years [7].

The nature of the underlying health problems in long COVID includes but is not limited to viral persistence, blood vessel inflammation, abnormal immune responses and disturbances of gut bacteria. In some cases, lymphopenia can lead to reactivation of other organisms (e.g. Epstein Barr virus, TB and others) [2,7].

Managers play a vital role in supporting workers back to work [8,9]. They are:

• often the first point of contact for the worker and a link to their team,

• best placed to help the worker feel valued and retain a sense of identity while dealing with a disabling long-term condition and

• able to put in place job modifications or work adjustments to enable workers to cope with both their job and their health on their return.

Benefits include retaining experienced workers, avoiding reputational risk, long-term productivity gain and preventing growing worklessness amongst over 1950s. Retaining skilled workers enhances the diversity of your workforce—and a workforce confident in their ability to work with health limitations [10]. Removing or reducing obstacles to return to work (RTW) helps staff retention and helps to avoid discrimination claims under the Equality Act 2010. Reasonable adjustments required by the Act will also help workers with long COVID perform their job well.

What we did

The Society of Occupational Medicine’s (SOM) long COVID Taskforce was formed in 2020 led by Professor Ewan Macdonald.

The Taskforce aims to address the issues of COVID and work from the point of view of all relevant stakeholders and comprises representatives from OH disciplines, vocational rehabilitation, sports and exercise Medicine, psychological health, workers with lived experience, employer organizations, union and governmental representatives, healthcare providers. The Taskforce expanded in 2024 to cover other long-term conditions, which similarly affect the ability to work, renamed ‘The Long-term Conditions Taskforce’.

We have published several guidance leaflets and linked webinars. These include the 2022 publication, ‘Long COVID and Return to Work, What Works?’ and, in early 2021, the production of two leaflets on how to assist people back to work with long COVID. In 2024, we updated the RTW Advice for Managers leaflet to take account of the subsequent accumulation of research and experience-based information, together with a one-page infographic. The ‘Managers’ leaflet was designed to provide a reference point for both managers and workers, and the details within it also provide detailed guidance for OH practitioners. This guidance is summarized below, and the full documents are available here:

Manager’s Guide

https://www.som.org.uk/sites/som.org.uk/files/SOM_Long_COVID_A_Managers_Guide_April_2024.pdf

Accompanying Infographic:

https://www.som.org.uk/sites/som.org.uk/files/SOM_Long_COVID_Infographic.pdf

Long Covid and Return to Work Myth Busters:

https://www.som.org.uk/sites/som.org.uk/files/SOM_Long_COVID_Myth_Buster_Final.pdf

For OH practitioners, the guidance should be read in conjunction with Long COVID and Return to Work What Works? [8] Clinicians need to understand the nature of the condition and be able to prevent progression where possible by attention to early treatment, prevention of inappropriate or excessive exertion in some situations, and prevention of reinfection [8,11].

Summary of Guidance

Certain suppositions run throughout the guidance: firstly, that managers should consider involving OH, Human Resources (HR) and union representatives where they exist at all stages; secondly that the ability of an employer to accommodate workers with long COVID depends on many factors such as size and resources.

A key aim is to address inequalities of healthcare provision through knowledge transfer (education).

We emphasize the concept of sustained RTW rather than only a RTW: in common with other long-term conditions, long COVID can have a relapsing-remitting pattern and it is important to prevent relapses. The key enablers of a sustained RTW in long COVID are (i) a prolonged phased return; (ii) a personalized, regularly reviewed flexible RTW plan and (iii) prevention of reinfection.

The guidance builds on decades of work on effective work rehabilitation for long-term conditions in general and long COVID in particular, and aims to provide a common language as laid out in the World Health Organisation guidelines [12] and rehabilitation of post-COVID-19 syndrome, World Physiotherapy Guidance on Safe Rehabilitation after Covid [13] and the work of Lunt and Burton [14,15].

Table 1 displays how Long COVID may be noticed in the workplace.

The guidance for managers is structured in five steps (full details in each step can be accessed online):

Step 1: Early—stay in touch while the worker is absent from work

• Stay in touch and agree how, ideally once a week. Early, supportive, and frequent contact is one of the most important things a manager can do to prevent work disability and achieve a successful RTW. Lack of contact from managers generally delays RTW.

• Advise them to seek medical assessment from their general practitioner (GP). Timely access to healthcare improves work ability [9,12].

• Give the worker permission to rest (essential for recovery after COVID-19 and can prevent long-term symptoms).

Step 2: Regular meetings

• Check if they have been able to access a doctor’s assessment for long COVID. Consider referral to OH.

• Medical clearance from GP or OH may be required where the job involves strenuous physical exertion, safety-critical tasks or if the person has pre-existing health conditions [17].

• Signpost to the access to work scheme. If you receive an access to work assessor’s report, please contact your Human Resources department to consider implementation. Look at the Health Adjustment Passport:

https://www.gov.uk/government/publications/health-adjustment-passport

• Manage the fall-out for the employee’s colleagues. The ‘IGLOO’ framework is a useful tool. This considers the Individual, the Group, the Leader, the Organizational and the Overarching contextual perspectives [18].

Step 3: Plan the RTW

• Remind the worker to take advice from their doctors or OH on anything they should and should not do regarding their health condition.

• Be flexible: the nature of the condition is prolonged, complicated and can fluctuate.

• TIMING OF RTW:

  • To help identify ‘readiness’ for work, a ‘work-like activity’ (e.g. reading duration) can be compared with work requirements [12].

  • To enable participation in daily activities, we suggest pacing (‘education and skills training on energy conservation techniques, including activity and energy management’) [12].

  • The person needs to be able to self-manage their energy at home before RTW.

  • When the illness is long, returning to work too soon or to a full workload can cause relapse, loss of confidence and work loss.

• Before RTW:

  • Do a workplace risk assessment of the worker’s duties.

  • If under health surveillance programme, inform the programme manager, as an earlier appointment may be required.

• Ask the worker to think about:

  • Obstacles to working—what they find difficult; what tasks can they do; what modifications are needed to do (part of) their job.

  • Solutions: what can be done to overcome the obstacles; develop and agree a Smart RTW Plan individually tailored to the identified obstacles- see Table 2.

    Table 2.

    Open in new tab

    Content of The ‘Smart’ RTW Plan

    The ‘Smart RTW Plan’ [14,15] should cover individual needs (not ‘wants’) and be agreed between worker and manager to cover: .
    Workers’ ideas on possible job modifications, based on identified obstacles to working Manager’s ideas on what is feasible Worker’s work priorities and employer’s core business needs
    Start date What the first day and week might involve
    Schedule for the first weeks Schedule for monitoring progress, with regular reviews. Agree other triggers for review.
    Who does what and when
    Getting to work—the commute
    Notes Flexibility is needed—long COVID can typically change or fluctuate over time. Consider sharing the Plan with OH, HR and relevant colleagues (for safety reasons).

    The ‘Smart RTW Plan’ [14,15] should cover individual needs (not ‘wants’) and be agreed between worker and manager to cover: .
    Workers’ ideas on possible job modifications, based on identified obstacles to working Manager’s ideas on what is feasible Worker’s work priorities and employer’s core business needs
    Start date What the first day and week might involve
    Schedule for the first weeks Schedule for monitoring progress, with regular reviews. Agree other triggers for review.
    Who does what and when
    Getting to work—the commute
    Notes Flexibility is needed—long COVID can typically change or fluctuate over time. Consider sharing the Plan with OH, HR and relevant colleagues (for safety reasons).

    Table 2.

    Open in new tab

    Content of The ‘Smart’ RTW Plan

    The ‘Smart RTW Plan’ [14,15] should cover individual needs (not ‘wants’) and be agreed between worker and manager to cover: .
    Workers’ ideas on possible job modifications, based on identified obstacles to working Manager’s ideas on what is feasible Worker’s work priorities and employer’s core business needs
    Start date What the first day and week might involve
    Schedule for the first weeks Schedule for monitoring progress, with regular reviews. Agree other triggers for review.
    Who does what and when
    Getting to work—the commute
    Notes Flexibility is needed—long COVID can typically change or fluctuate over time. Consider sharing the Plan with OH, HR and relevant colleagues (for safety reasons).

    The ‘Smart RTW Plan’ [14,15] should cover individual needs (not ‘wants’) and be agreed between worker and manager to cover: .
    Workers’ ideas on possible job modifications, based on identified obstacles to working Manager’s ideas on what is feasible Worker’s work priorities and employer’s core business needs
    Start date What the first day and week might involve
    Schedule for the first weeks Schedule for monitoring progress, with regular reviews. Agree other triggers for review.
    Who does what and when
    Getting to work—the commute
    Notes Flexibility is needed—long COVID can typically change or fluctuate over time. Consider sharing the Plan with OH, HR and relevant colleagues (for safety reasons).

Step 4: Support during the early days of the RTW

• Ensure the returning worker is updated on changes in the workplace.

• Give them permission to take things slowly at first. This helps readjustment to the workplace and avoids relapse.

• They may still be experiencing symptoms and need to take breaks.

• Review the Smart RTW Plan

Step 5: Regular review and ongoing support

• Review workload. Check they can manage their symptoms at work.

• Check if absence or modified work has implications for staff training, particularly in regulated professions

• Some people have ongoing symptoms, which mean they are unable to meet the requirements of the job—if so, it could be time to talk about a change of duties or redeployment. Seek advice from HR and OH.

The most effective workplace adjustments for achieving a safe and sustained RTW after COVID-19 are:

1. preventing reinfections at work,

2. a prolonged phased return (returning to work tasks and hours gradually),

3. an RTW Plan detailing the job adjustments, which consider day-to-day variations in symptoms and

4. not working beyond energy capacity as this can cause deterioration.

There are many workplace adjustments, which can make it easier to RTW, although the employer may not be able to accommodate every suggestion. More detail on possible adjustments for long COVID is listed in long COVID and RTW: what works

Obstacles to sustained work ability include ¹⁵.¹⁹:

• absence management systems where triggers are not adapted to those with long-term conditions, meaning people don’t take time off work when they’re unwell,

• attitudes of managers/colleagues: ‘I got over it, why can’t you?’,

• performance management, which may cause symptoms to worsen,

• a workload that prevents time to manage symptoms and

• management and HR consultations that exclude the employee and fail to take account of their needs

A helpful free resource from the Vocational Rehabilitation section of the NIHR ‘Locomotion study’ gives useful detailed advice on ‘preventing U-turns’ in RTW with long COVID, i.e. promoting a sustained RTW [19,20].

See Table 3 for how an effective phased return for Long COVID should look.

We would like to acknowledge the members of the SOM long-term conditions taskforce for their contribution to the guidance, especially Nick Pahl, Richard Williams, Jennifer Lunt, Jo Yarker including people with lived experience, Alison Twycross and Jenny Ceolta-Smith.

Competing interests

C.R.R. receive occasional honoraria for giving talks and webinars on long covid.

References