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Fitness for work advice and certification

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Presentation on theme: "Fitness for work advice and certification"— Presentation transcript:

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 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

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