1. Fitness for work advice and certification
Dr Philip Sawney
AOHNP(UK) Symposium
13 May 2004

2. Fitness for work advice & certification
DWP’s role
Overview of current system
Reform - Issues and challenges

3. DWP and People of working age
Minister for Work
Jobcentre Plus
HSC/E
Strategy - To promote work as the best form of welfare whilst protecting the position of those in greatest need
Policy lead on: ‘statutory certification’; incapacity benefits; vocational rehabilitation
Working Age
Sickness absence costs = £10 bn /year (CBI estimate);
Expenditure on IB = £12 bn /year
24% of GP consultations are work related

4. Fitness for work - Statutory framework
Medical evidence regulations - DWP guidance
Forms Med 3; Med 5
Social security regulations
NHS (GMS Contracts) regulations – including new GP contract
DDA and H & S law

5. Fitness for work medical advice – underlying principles
Integral part of clinical management of patients of working age
Start from premise that return to work is optimal health outcome
Recognise the link between clinical care and the patient’s work
Appropriate diagnosis and management
Consider alternatives to ‘unfit for work’
Avoid unnecessary medicalisation of ‘absence’ from work
Support positive expectations re: working lives

6. Health benefits of working
generates self esteem
reduces dependency
enhances social identity
Work environments:
develop social networks
acquire, retain and develop skills
Evidence on mental health – overall healthier - importance of safe system of work

7. Impact of being out of work: evidence
Patients:
Have reduced confidence and self esteem
Have increased morbidity and mortality - particularly mental health
Have disability greater than underlying impairment
the effects begin at weeks

8. Med 3 Warning: this form may seriously damage your health
In many ways Sick notes are like prescriptions – actions, consequences and side effects

9. Fitness for work advice and certification
“Absence from work attributed to a health condition, injury or disability”
GP - patient axis
Issue with quality of advice
Knowledge of workplace
Shortfall in professional training
Lack of employer focus
The current UK model of medical certification is based broadly on the premise that:
the patient stops work when he/she feels illness or injury justifies absence
the physician certifies presence of illness/injury, advises on need to refrain from work and decides when patient is (fully) fit to return to work
management plays a very limited role in determining return to work but attempts to control abuse by demanding medical certification

10. GP views
“Poor understanding and training; many GPs are ambivalent about this work” - Hitchcock & Ritchie 2001
“Some dislike perceived ‘gatekeeper’ role and admit to poor practice” - Hussey et al BMJ 2004
“Area of work which creates confrontation with patients”
“GPs estimate that 30% of patients off sick could return to work” - Dr Foster April 04
“I have no interest whatsoever in long patients should be at work” – GP Bicester
“sick note responsibilities put GPs in an invidious position” – GP london
“sick notes are a waste of time…employers must deal with absenteeism” – GP Belfast
“GPs and sick notes: it is a rare pleasure to weild some power” GP Essex
“Getting a patient back to work is an integral part of their recovery”
“issuing sick notes is an essential part of our service…linked to clinical care” GP Norwich
“so what do we want – see a patient who is ill, not issue a sick note but expect someone else to do it ?” GP Bristol
“industry contributes much to this country and merits a reasonable service from the Govts primary care service in return” GP Stirlingshire

11. Employer’s views “GPs tend to see ‘work’ as harmful”
“GPs are overprotective of patients and distrustful of the motives of others”
“Need to end the so-called sicknote culture”
“Only 10% of employers think GPs provide effective support” IRS employment review - March 04 “

12. Employee (patient) views
Non-medical factors strongly influence ‘fitness’ and capacity for work
Need for timely access to professional advice from trusted source
“63% expect to turn to their GP for advice on fitness for work and rehabilitation” - ONS Omnibus Survey 2004

13. The GP as ‘advocate’ Setting long term health beliefs and attitudes
Need to consider the longer term effects of worklessness for the patient
Distinguish between ‘own occupation’ [which GP certifies] and work in general
Advocacy can be used as a barrier to communication
Need to more positive expectations about patient’s working lives
Difficult to balance needs of patient - manage expectations
Not offer a quick escape route from work; you need to see the end goal - aim for the best long term outcome
Be prepared to have a dialogue with the employer (there is a condition which is likely to impact on ability for work or require adjustments ) - positive messages - refer to specialists for expert advice; talk to expert occupational health practitioners where they exist
don’t build your practice on the worst case experience (teachers with stress)

14. Raising awareness Doctors Statutory guidance Desk aids DVD
Website / Online learning
Professional meetings
Direct case related feedback
Employers
HSE guidance on absence management
New website for employers

15. Guidance, advice & training for doctors
Guidance/advice: IB204 & Desk aids
IB204
‘A Guide for Registered
Medical Practitioners’
Contains the rules & background
information about sickness
certification & report writing for
certifying medical practitioners

16. Web site

17. Online learning

18. Reform of fitness for work advice and certification
Need to balance:
Patient Access
Quality of advice
Cost/affordability
Context
New NHS GP contract [‘quality targets’ ]
Pathways to Work strategy – find an approach which better supports work retention / rehabilitation
Legislation and structure of UK ‘benefits’ system (including Statutory Sick Pay)
Access
Patients require access to professional advice on their fitness for work which is informed by a knowledge of their condition, including the diagnosis and treatment plan
Patients also want advice which they perceive will have their own best interests at heart rather than those of their employer
Quality
Fitness for work advice provided by healthcare professionals with appropriate training, skills, and competencies in clinical management and occupational health
Cost
Current direct cost is largely marginal to the cost of the NHS provision of primary care services (though some observers, such as the BMA, would disagree
Little direct administrative cost, including cost of procuring occupational health advice, to employers

19. A new model ? Based on employer-employee axis
Employee and management have the primary responsibility to initiate a timely return to work
Role of healthcare professional confined to providing patient with factual information on restrictions or limitations arising from the diagnosed condition and other supporting advice as appropriate
Management control of sick leave is through workplace culture and timely return to work programs

20. Reform difficult !
Would require a different approach by all stakeholders
Major training requirement
Fostering a greater awareness of rights and responsibilities including legal (eg DDA and Health & Safety Law)

21. Take GPs out of the loop ?
Primary care remains point of clinical care/advice to people of working age
Risk of setting up a dual system – supported by public funding
Resource limitations not confined to GPs

22. Helping patients return to work after illness or injury.
Vision
General Practitioners, Hospital Specialists, Occupational Health specialists and Employers working together to facilitate optimal workplace rehabilitation for all ill or injured persons.
The key elements of a return to work plan
Communication
Recognition of obstacles to a return to work
Knowledge of support services
Active management (rather than a passive ‘wait and see’ approach)
A positive outlook
A patient centred approach
Sickness certification
Need to balance:
Patient Access
Quality of advice
Cost/affordability (& who pays!)
New GP contract
Pathways to Work strategy – find an approach which better supports work retention / rehabilitation
Legislation and structure of UK ‘benefits’ system (including SSP)
para 6.48(v) of the new GP contract
Furthering attempts to reduce certification work within general practice. National initiatives such as those established through the Cabinet Office will be implemented. Major local pilots in large companies and the NHS will be sought to evaluate the effectiveness of in-house occupational health services as an alternative to using general practice for certification. Should the pilots be successful the aim would be to allow the system to be refined so certification responsibility can be moved to occupational physicians and occupational health nurses, making significant progress towards national coverage by April 2006.

23. Advice on fitness for work by other healthcare professionals ?
Joint research:
DWP [lead]
Dept of Health
Cabinet Office
Steering group of key stakeholders
Fieldwork in progress
Report – 2004
Issues = roles; training; workload
No satisfactory alternative but many pilot schemes:
Job Retention Pilots - earlier intervention to keep people in work (with adapatations)
Pathways - earlier PCA
Private Sector – pilots where GP is taken out of the loop
Education for employers and patients - EEF, Doctor Patient Partnership
OHSAS first findings…
Generally speaking doctors acquire through their training and practice many of the basic skills required for this task:
making a diagnosis;
managing uncertainty;
rapid decision making; and
managing conflict.
Other healthcare professionals may have:
relevant specialist expertise and
more time than GPs
better understanding of the requirements of the workplace.

24. Sickness Certification - the future ?
Need for excellence in medical care and support/encouragement for rehabilitation
A more rounded view of advocacy re: advice and communication with employers and OHPs
Likely to be a ‘mixed economy’ of specialist advice provision
Driver for change should be improved health and work outcomes for patients
The broad consequence of the GPs’ unawareness of a rehabilitation role often leads to a passive or protective attitude that actually hinders the entire return to work process.
Other reform options
Legal Framework
increasing the current 7 day period of ‘self certification’
extending certification to other healthcare professionals
redesign of the statutory forms such as Med 3
Administration
improving training/management/audit of GP certification;
improving rehabilitation support services available to patients of working age.

25. www.dwp.gov.uk/medical More information
Guides - IB 204, deskaids, Disability Handbook
updates and hot topics
on-line training material
information about medical aspects of UK benefits
research / literature reviews