Presentation on theme: "Fitness for work advice and certification"— Presentation transcript:
1Fitness for work advice and certification Dr Philip SawneyAOHNP(UK) Symposium13 May 2004
2Fitness for work advice & certification DWP’s roleOverview of current systemReform - Issues and challenges
3DWP and People of working age Minister for WorkJobcentre PlusHSC/EStrategy - To promote work as the best form of welfare whilst protecting the position of those in greatest needPolicy lead on: ‘statutory certification’; incapacity benefits; vocational rehabilitationWorking AgeSickness absence costs = £10 bn /year (CBI estimate);Expenditure on IB = £12 bn /year24% of GP consultations are work related
4Fitness for work - Statutory framework Medical evidence regulations - DWP guidanceForms Med 3; Med 5Social security regulationsNHS (GMS Contracts) regulations – including new GP contractDDA and H & S law
5Fitness for work medical advice – underlying principles Integral part of clinical management of patients of working ageStart from premise that return to work is optimal health outcomeRecognise the link between clinical care and the patient’s workAppropriate diagnosis and managementConsider alternatives to ‘unfit for work’Avoid unnecessary medicalisation of ‘absence’ from workSupport positive expectations re: working lives
6Health benefits of working generates self esteemreduces dependencyenhances social identityWork environments:develop social networksacquire, retain and develop skillsEvidence on mental health – overall healthier - importance of safe system of work
7Impact of being out of work: evidence Patients:Have reduced confidence and self esteemHave increased morbidity and mortality - particularly mental healthHave disability greater than underlying impairmentthe effects begin at weeks
8Med 3 Warning: this form may seriously damage your health In many ways Sick notes are like prescriptions – actions, consequences and side effects
9Fitness for work advice and certification “Absence from work attributed to a health condition, injury or disability”GP - patient axisIssue with quality of adviceKnowledge of workplaceShortfall in professional trainingLack of employer focusThe 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 absencethe physician certifies presence of illness/injury, advises on need to refrain from work and decides when patient is (fully) fit to return to workmanagement plays a very limited role in determining return to work but attempts to control abuse by demanding medical certification
10GP 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
11Employer’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“
12Employee (patient) views Non-medical factors strongly influence ‘fitness’ and capacity for workNeed 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
13The GP as ‘advocate’ Setting long term health beliefs and attitudes Need to consider the longer term effects of worklessness for the patientDistinguish between ‘own occupation’ [which GP certifies] and work in generalAdvocacy can be used as a barrier to communicationNeed to more positive expectations about patient’s working livesDifficult to balance needs of patient - manage expectationsNot offer a quick escape route from work; you need to see the end goal - aim for the best long term outcomeBe 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 existdon’t build your practice on the worst case experience (teachers with stress)
14Raising awareness Doctors Statutory guidance Desk aids DVD Website / Online learningProfessional meetingsDirect case related feedbackEmployersHSE guidance on absence managementNew website for employers
15Guidance, advice & training for doctors Guidance/advice: IB204 & Desk aidsIB204‘A Guide for RegisteredMedical Practitioners’Contains the rules & backgroundinformation about sicknesscertification & report writing forcertifying medical practitioners
18Reform of fitness for work advice and certification Need to balance:Patient AccessQuality of adviceCost/affordabilityContextNew NHS GP contract [‘quality targets’ ]Pathways to Work strategy – find an approach which better supports work retention / rehabilitationLegislation and structure of UK ‘benefits’ system (including Statutory Sick Pay)AccessPatients require access to professional advice on their fitness for work which is informed by a knowledge of their condition, including the diagnosis and treatment planPatients also want advice which they perceive will have their own best interests at heart rather than those of their employerQualityFitness for work advice provided by healthcare professionals with appropriate training, skills, and competencies in clinical management and occupational healthCostCurrent direct cost is largely marginal to the cost of the NHS provision of primary care services (though some observers, such as the BMA, would disagreeLittle direct administrative cost, including cost of procuring occupational health advice, to employers
19A new model ? Based on employer-employee axis Employee and management have the primary responsibility to initiate a timely return to workRole of healthcare professional confined to providing patient with factual information on restrictions or limitations arising from the diagnosed condition and other supporting advice as appropriateManagement control of sick leave is through workplace culture and timely return to work programs
20Reform difficult !Would require a different approach by all stakeholdersMajor training requirementFostering a greater awareness of rights and responsibilities including legal (eg DDA and Health & Safety Law)
21Take GPs out of the loop ?Primary care remains point of clinical care/advice to people of working ageRisk of setting up a dual system – supported by public fundingResource limitations not confined to GPs
22Helping patients return to work after illness or injury. VisionGeneral 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 planCommunicationRecognition of obstacles to a return to workKnowledge of support servicesActive management (rather than a passive ‘wait and see’ approach)A positive outlookA patient centred approachSickness certificationNeed to balance:Patient AccessQuality of adviceCost/affordability (& who pays!)New GP contractPathways to Work strategy – find an approach which better supports work retention / rehabilitationLegislation and structure of UK ‘benefits’ system (including SSP)para 6.48(v) of the new GP contractFurthering 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.
23Advice on fitness for work by other healthcare professionals ? Joint research:DWP [lead]Dept of HealthCabinet OfficeSteering group of key stakeholdersFieldwork in progressReport – 2004Issues = roles; training; workloadNo satisfactory alternative but many pilot schemes:Job Retention Pilots - earlier intervention to keep people in work (with adapatations)Pathways - earlier PCAPrivate Sector – pilots where GP is taken out of the loopEducation for employers and patients - EEF, Doctor Patient PartnershipOHSAS 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; andmanaging conflict.Other healthcare professionals may have:relevant specialist expertise andmore time than GPsbetter understanding of the requirements of the workplace.
24Sickness Certification - the future ? Need for excellence in medical care and support/encouragement for rehabilitationA more rounded view of advocacy re: advice and communication with employers and OHPsLikely to be a ‘mixed economy’ of specialist advice provisionDriver for change should be improved health and work outcomes for patientsThe 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 optionsLegal Frameworkincreasing the current 7 day period of ‘self certification’extending certification to other healthcare professionalsredesign of the statutory forms such as Med 3Administrationimproving training/management/audit of GP certification;improving rehabilitation support services available to patients of working age.
25www.dwp.gov.uk/medical More information Guides - IB 204, deskaids, Disability Handbookupdates and hot topicson-line training materialinformation about medical aspects of UK benefitsresearch / literature reviews