1. Is your patient fit for work? Part 1 Stakeholders and standards Grant McMillan Hon Senior Clinical Lecturer Institute of Occupational and Environmental Health University of Birmingham Number 9 of a series of lectures and tutorials for medical undergraduates

2. HEALTH >>>> WORK >>>> HEALTH To ignore the two way interactions between work and health is to risk misdiagnosis, mismanagement and overall failure to do your best for your patients and society at large.

3. Learning points Stakeholders, assumptions and expectations Complexity of absence – role of health professional Usefulness of task-related health and fitness standards in matching people to employment Importance of ensuring that the patient and you agree that return to work is a planned outcome of treatment

4. Stakeholders in workers’ health Individual workers Community of workers Workers’ families Employers and shareholders Government and “society” Health professionals

5. Ground rules All stakeholders benefit from employees being fit and healthy. Employees need not be entirely fit and healthy for all stakeholders to benefit. Employees who are not entirely fit and healthy may still be employable. Employability may be enhanced by altering the work and/or workplace.

6. Absence is complex - not just about a health problem It is vital to have the right people dealing with the right issues Health related - assessment of fitness for roleHealth related - assessment of fitness for role Social/domestic such as debt, childcare, divorceSocial/domestic such as debt, childcare, divorce Work-related manager/employee relationshipsWork-related manager/employee relationships Reasonable adjustment of work and rehabilitationReasonable adjustment of work and rehabilitation

7. Stakeholders in workers’ health Individual workers Community of workers Workers’ families Employers and shareholders Government and “society” Health professionals

8. Absence is complex - not just about a health problem Health Professionals should focus on health issues and liaise with fellow stakeholders on other matters Health related - assessment of fitness for roleHealth related - assessment of fitness for role Social/domestic such as debt, childcare, divorceSocial/domestic such as debt, childcare, divorce Work-related manager/employee relationshipsWork-related manager/employee relationships Reasonable adjustment of work and rehabilitationReasonable adjustment of work and rehabilitation

9. Learning point 1 It is vital to have the right people dealing with the right issues

10. Matching people to employment – Assessment of fitness to work The purpose of a medical assessment for fitness to work is to determine that an individual is fit or unfit to perform the tasks involved effectively and without risk to their own health and safety and that of others. If found unfit, the assessment should define the limiting parameters so that a solution may be sought.

11. Medical certification of unfitness for work A “sick certificate” is a frequent routine request by patients to doctors. Doctors often see it as a worthless, time- wasting chore, yet offer little resistance lest they upset their relationship with the patient. Do they issue the certificate with little or no constructive thought?

12. Do some issue the certificate with little or no constructive thought? If so, why?

13. Do some issue the certificate with little or no constructive thought? Don’t they care?

14. Do some issue the certificate with little or no constructive thought. Perhaps, they don’t know what the patient does nor the demands that job imposes?

15. They issue the certificate with little or no constructive thought. Probably, they don’t know the employer’s attitudes to and arrangements for reduced health and fitness employees?

16. Hurdles faced by GPs and Secondary Care doctors They may not know: what the patient does, the demands of that work, the employer’s attitudes to and arrangements for reduced health and fitness employees?

17. Solutions? Employers should examine each job: Employers should examine each job: define the demands, hazards and risks define the demands, hazards and risks effect changes to maximise safety and minimise exclusion effect changes to maximise safety and minimise exclusion derive, publish and apply evidence – based standards of health and fitness derive, publish and apply evidence – based standards of health and fitness

18. Learning point 2 Published task-related health and fitness standards set by employers can be useful in matching people to jobs and determining whether workers are fit for work.

19. Fit for what? Fit for what? Three aspects of standards Safety Health Functionality

20. Safety-critical jobs road vehicle drivers pilots seafarers train drivers air traffic controllers

21. Driving as a safety-critical task vocational, non-vocational perceptual requirements cognitive requirements motor requirements stability, sudden change – epilepsy, hypoglycaemia,

22. Driving impairment medical condition treatment of condition fatigue – hours of work, time of day alcohol – limits and tolerability illicit and recreational drugs age – young:zest + inexperience – age:information processing impaired

23. Other safety-critical jobs Commercial diving Control room operators Emergency services Armed forces User of hazardous materials and equipment Food preparation Steel erector Medical personnel

24. Health-critical aspects of jobs Diabetes Epilepsy Back pain Skin disease Mental health Cardiac surgery

25. Function-critical General - fit to be present in the workplace do the job effectively and safely, without excess risk of harm to self or other. Specific - fit for special aspects of tasks eg printers, fabric matchers, fruit selectors having normal colour vision

26. Fit for what? Appreciation of Safety + Health + Function = Ability to decide on fitness for work, if you know the demands of the job

27. Fit for what? Appreciation of Safety + Health + Function = Ability to decide on fitness for work, if you know the standards for the job

28. Disability Discrimination Act Does the individual’s disability fall within the definition of the Act? What adjustments may be needed to accommodate the disabled individual in the workplace?

29. Employers should examine each job: define physical and mental demands define physical and mental demands define hazards and risks define hazards and risks maximise safety and minimise risk and exclusion of “disabled” maximise safety and minimise risk and exclusion of “disabled” derive, publish and apply evidence – based standards of health and fitnessderive, publish and apply evidence – based standards of health and fitness Learning point 3

30. Learning point 4 Importance of you and the patient agreeing that return to work is a planned outcome of treatment and agreeing on a plan to achieve that aim agreeing on a plan to achieve that aim

31. Forecast when will patient be sufficiently Safe + Healthy + Functional to agreed standards?

32. Consider and act on the most important psycho-social predictors for risk of long term incapacity

33. Low back pain AgeAge Pain intensity/functional disabilityPain intensity/functional disability Poor perception of general healthPoor perception of general health Psychological distress, depressionPsychological distress, depression Fear avoidanceFear avoidance CatastrophisingCatastrophising Pain behaviourPain behaviour Job satisfaction and worker disaffectionJob satisfaction and worker disaffection Duration of absence/incapacity Whether or not still employed Expectation about return to work

34. Is your patient fit for work? Grant McMillan Hon Senior Clinical Lecturer Thank you for your attention