Health and Work in General Practice Dr Elfrieda Power

Patient perception of the role of GP’s 91% believe that GP’s should have a say on how long you should have off work due to ill health 61% believe that GP’s should advise you not to go to work 96% believe that GP’s should help you access treatment and therapy to help you manage at work

Worklessness “A state which includes not being in paid employment and not actively seeking employment” 66% of all sickness is due to minor self- limiting conditions 99% return to work quickly but..

Worklessness On average 1 million report sick each week After 6 months 3,000 are still not back at work Five years on 2,500 of them will be claiming Incapacity Benefit 2.7 million people claim IB each year which equate to 1 in 13 of the working age population Window of opportunity 1-6 months –Worker off for 4-12 wks % chance of being off work at 1 year –Worker off 6-12 months - 90% chance of never returning to work

Worklessness

Benefits of work For most adults of working age, there is strong evidence that work: –Promotes recovery and aids rehabilitation –Improves physical and mental health and well- being –Reduces social exclusion and poverty –The beneficial effects of work generally outweigh any risks of work

Benefits of work There is strong evidence that long periods out of work can cause or contribute to: –Higher consultation, medical consumption and hospital admission rates –2-3 times increased risk of poor health –2-3 times increased risk of mental health problems –20% excess mortality –Impact on children in workless households

Sickness certification is a major clinical intervention with potentially serious long-term consequences 2/3 sickness absence, long-term incapacity and ill- health recruitment is now due to ‘common health problems’ (mild-moderate mental health, musculoskeletal problems and cardio-respiratory problems) Much of this should be preventable Common health problems can often be accommodated at work, if necessary with appropriate adjustments Planning and supporting return to work, in partnership with patients, are important parts of clinical management

A Functional Assessment Diagnosis is not important Think about impact of health on work –HOW IS THIS AFFECTING YOU? Think about impact of work on health –WHAT DOES THAT INVOLVE? A fit note not a sick note –Combines MED3 and MED5 –A form of communication to employer –Should be advisory –NOT a legal document

Effects of work on health Demands of job –physical, intellectual Environment –shop-floor/office RF, dust, chemicals, noise etc Temporal –shiftwork, early start Travel –commute, between sites, overseas Organisational –lone working, customers Layout –ergonomic aspects, workstation and equipment

Effects of health on work Stamina –work fulltime, physical demands Mobility Mobility –Walking, bending, stooping Agility –Dexterity, posture, co-ordination Rational –Mental state, mood Treatment –Side effects, duration Intellectual –Cognitive abilities Essential for job –Food handlers, driving Sensory aspects –Safety, self and others

FIT NOTE Common workplace modifications: –Consider lowering patient targets –Suggest a workplace assessment –Need to change activity regularly –Altered pattern of work - shifts/tasks/content –Advise referral to an occupational physician –Reduced hours –Phased return –Training –Mobility and transport –Are you able to arrange physio? ENCOURAGE PATIENT TO KEEP IN TOUCH WITH WORK

The doctor who has the immediate care issues the fit notes, eg secondary care responsible if recent surgery etc. The doctor is not required to sign the patient back to work - they can go back when ever they feel ready If you think condition could be work related eg asbestosis, dermatitis - refer early to specialist Tribunals decide if someone has a disability so do not make that decision Consider return to work mid-week Avoid medicalising non-medical issues (eg stress) If work related issues write “patient states that there are factors related to work-based issues’ If bullying - empower patient to take to higher manager If employers ignore your suggestions - ask them to write to you and consult DWP website - EMPLOYERS RESPONSIBILITY A sick note is NOT a legal document - a form of communication between employee and employer Negatives of sick notes: Patient needs to be aware that legally they can legally be dismissed if they have too much time off work

Medically recognised diagnosis If tick, have to qualify Prognosis - refer to websites

Changing behavior Motivational interviewing –Shift style, remove ambivalence, empower individuals –“How important is it for you to get back to work? –“So how confident do you feel about getting back to work?” Grade 1-10 How would you approach this?

What if well and functioning? Please doc can I have a sick note? –“you’re putting me in a difficult situation - my role is to do a medical assessment but I can’t find anything wrong, you’re asking me to commit fraud” –“I you’re unhappy I suggest you d/w employer –“Evidence shows that it is better for your health to go back to work and that is what I believe is best for you, I would be doing a disservice if I signed the note”

Employment and Support Allowance ESA was developed to ensure that individuals would get the benefit and support they need to help them return to work, where possible. ESA is intended to be a combined benefit bringing together the rules from Incapacity Benefit (IB) and Income Support (IS). For both elements of ESA a person must have limited capacity for work. This is determined initially by a medical certificate from a GP (MED3) but then the Work Capability Assessment (WCA) which should be completed by week 13 of the claim.

ESA Assessment Phase –Lasts for up to 13 weeks. –During this phase the rate of benefit is based on Jobseekers Allowance (60.50/wk) although additional premiums may also be payable. –A Work Focus interview (WFI) takes place after 8 wks. Main phase –Starts once limited capacity for work has been established by meeting the WCA threshold. –A work related activity component becomes payable (24.00) conditional on complying with the work-related activity regime. This is paid in addition to the Assessment phase allowance (84.50/wk) equivalent to the long-term rate of Incapacity Benefit.

ESW Support Component –All cases are looked at by an approved HCP at the outset. –They identify individuals with the most severe limitations, will contact the GP/others for further evidence which may allow the individual to go straight to the support group without having to attend a WFI. –They do not to comply with work related activity regime and are entitled to an extra and disability premium (12.60) so total /wk.

Work Capability Assessment Assesses entitlement to ESA A medical assessment that has been developed to ensure it accurately reflects limited capability for work (ie looking at what they can and cannot do in a modern labour market and working envirnoment) Based on the effects of a persons condition, not the condition itself. Also a Work Focussed Health Related Assessment looking at the support a person may need. GP’s are an important part of the process - individuals may ask GP’s to provide info and this is taken into account

WCA Statistics 5%Assessed by the WCA as suitable for the ESA Support group 11%Suitable for ESA Work Related Activity Group 36%Assessed as fit for work 48%ESA before completing the assessment or the assessment is still in progress If a patient appeals the decision - GP should continue to write fit notes

Working for health website – Resources for GP’s – Occupational health adviceline for GPs – – Department of Work and Pensions – Practical advice on Recovery times – information/return-to- workwww.rcseng.ac.uk/patient information/return-to- work Work and Health leaflets –