Manager confidence in supporting colleagues with long-term health conditions has fallen sharply in the United Kingdom, dropping from 70% in 2022 to 56% in 2026, according to research by vocational rehabilitation provider Working To Wellbeing (W2W). The decline coincides with a shift in NHS England's approach to mental health, ADHD and autism services that places new operational demands on the line managers who already report the least certainty about what good support looks like.

What the latest data shows about manager confidence

The W2W findings surface a capability gap visible from both sides of the management relationship. Just 53% of UK line managers say they feel confident supporting neurodivergent colleagues to thrive at work. Employees are less convinced: only 46% believe their line manager is equipped to do so. Read together, those figures do not describe a workforce of unwilling managers. They describe managers who are less certain about what competent support looks like, and employees who notice the difference.

The 14-point fall in long-term health confidence since 2022 carries retention implications that HR Directors will recognise. The Chartered Institute of Personnel and Development (CIPD), whose annual Reward Management and Health and Wellbeing at Work surveys track workforce sentiment across roughly 160,000 member organisations, has consistently found that perceived managerial support is among the stronger predictors of employee intention to stay. When people doubt that their manager can handle a health conversation, early disclosures that might have been resolved with a simple adjustment instead arrive on HR's desk later as attendance, performance or grievance cases.

The Fonagy review moves the starting point from diagnosis to need

Professor Peter Fonagy's review of NHS England's mental health, ADHD and autism services, published in October 2026, recommends that employers focus on an individual's specific day-to-day challenges rather than requiring a formal diagnosis before support is offered. In operational terms, this reframes the adjustment conversation: the question shifts from one about the nature of a condition to one about what is preventing this person from working effectively, and what practical change would help.

For many organisations that change is material. Diagnosis-led processes give managers a structured trigger: paperwork arrives, a referral follows, adjustments are agreed and documented. A needs-led model removes that trigger and asks managers to notice, ask and act earlier, often with incomplete clinical information and no assessment date to plan around. NHS England's own data shows that ADHD and autism assessment waiting times in many regions extend beyond two years, meaning that a diagnosis-first policy is, in practice, a policy of deferred support.

Dr Julie Denning, chartered health psychologist and managing director at Working To Wellbeing, links the survey results directly to the Fonagy review's direction of travel. She notes that the data reveals significant room for improvement in equipping line managers with the confidence and competence to spot and accommodate neurodivergent needs at an early stage, before needs escalate.

Where the legal and operational risk sits

Reasonable adjustments remain a statutory obligation. Under section 20 of the Equality Act 2010, employers in England, Scotland and Wales are required to make reasonable adjustments for disabled workers where a provision, criterion or practice places them at a substantial disadvantage compared to non-disabled colleagues. A needs-led approach does not replace that legal framework; it changes how early, and on what basis, organisations engage with it. ACAS (the Advisory, Conciliation and Arbitration Service), whose guidance on disability and mental health in the workplace is widely referenced in employment tribunal proceedings, advises that employers should not delay support pending a formal diagnosis where the employee's functional difficulties are already evident.

Four risk points stand out for HR and People leads:

• Inconsistency between managers. When adjustment decisions depend on individual manager confidence rather than a structured process, two employees with comparable needs can receive substantially different support. That inconsistency is difficult to defend if a decision is later challenged at an employment tribunal under the Equality Act 2010.
• Waiting for paperwork. Formal assessment routes remain slow. With the Fonagy review's direction of travel now on record, a position of withholding adjustments until diagnosis documentation arrives is becoming progressively harder to justify, both legally and reputationally.
• Undocumented informal agreements. Adjustments agreed without a written record leave no account of what was requested, what was considered and why. That gap offers neither the employee nor the organisation meaningful protection if the matter is later escalated to HR, ACAS or tribunal.
• Manager overload. Dr Denning is explicit that line managers already carry a heavy burden alongside core responsibilities, and that access to vocational rehabilitation support, for the manager and their neurodivergent direct reports alike, represents significant practical value.

Denning also cautions HR teams against interpreting low confidence as deliberate resistance. In her framing, employer reticence reflects anxiety about getting complex decisions wrong, rather than any intent to create barriers. That distinction matters for how organisations design their response: punitive capability frameworks are unlikely to shift confidence; structured support and specialist escalation routes are more likely to.

What HR teams can put in place now

Organisations that handle the transition from diagnosis-led to needs-led support effectively tend to remove the burden of unstructured clinical judgement from individual managers and replace it with process. The Health and Safety Executive (HSE), which oversees employer obligations on work-related stress and mental health risk, frames early intervention as a core component of risk management rather than a discretionary wellbeing measure. Steps worth evaluating at the people-team level include the following:

• A needs-led conversation guide. A short set of structured questions covering tasks, environment, communication preferences and scheduling, allowing managers to open a support conversation without requiring the employee to name a diagnosis or disclose clinical detail.
• A written adjustments record. Documentation of what was requested, what was agreed and when it will be reviewed. Records that travel with the employee, rather than residing with a specific line manager, survive team restructures and management changes.
• A defined escalation route. Clear points at which HR, occupational health or vocational rehabilitation specialists take over, so managers are not expected to handle complex clinical or legal questions alone. ACAS guidance on disability-related adjustments provides a useful reference framework for escalation criteria.
• Targeted manager training. Prioritise teams where absence data or adjustment request volumes are rising, and focus on the first conversation rather than comprehensive clinical knowledge. The ONS Annual Population Survey regularly shows higher rates of work-limiting health conditions in certain sectors and demographics; workforce analysis aligned to those datasets can direct training investment more precisely.
• Built-in review dates. Frame adjustments as time-limited trials with a scheduled check-in. Both parties are more willing to agree a measure when they know it can be refined.
• Dual-perspective measurement. Track manager self-assessed confidence alongside employees' view of whether their manager is equipped to support them. W2W's 53% versus 46% split illustrates that those two figures can diverge substantially, and the employee-side figure is the one more likely to predict disclosure behaviour and retention risk.

Reading the signal in your own employee data

Manager confidence is an internal metric, but its effects surface in channels HR already monitors. ONS data consistently shows that around one in five working-age adults in the UK lives with a long-term health condition; in a workforce of any size, the probability that neurodivergent or health-related support needs are present but undisclosed is high. Employees who feel unsupported record that view in engagement surveys, in exit conversations and in anonymous employer reviews, often well before a formal grievance reaches HR or ACAS.

The most informative early indicators tend to be specific: how frequently manager support, flexibility and workload feature in employee feedback; whether sentiment differs materially between teams; and whether adjustment-related concerns cluster in leavers' comments. Where those signals concentrate, manager capability is typically the operative variable, not the adequacy of written policy. Verified employee feedback gathered at scale, the kind wherewework compiles across real workplaces, shows whether an organisation's adjustment approach is experienced the way it reads in the staff handbook.

The Fonagy review does not ask line managers to function as clinicians. It asks organisations to respond earlier to what people need in order to work effectively. With manager confidence on long-term health conditions down to 56% from 70% four years ago, the practical question for HR is whether managers have the structure, specialist backup and documentation to do that consistently, before a dispute, an Employment Tribunal claim or a resignation makes the question unavoidable.