1. Sickness Certification
David Stout

2. Aims Learn about Fit notes
Introduce some ideas to help manage sickness in your surgery

3. Objectives Learn how to fill in a fit note
Learn the rules associated with fit notes
Understand the impact of worklessness
Understand your role in managing sickness
Introduce some simple ways of assessing fitness to work
Introduce some ideas about how you can manage patients asking for time off work

4. A simple consultation?
What is your reaction when some requests a sicknote?
Think about the last few you have done
Were they easy to complete?
What sort of questions did you ask?
How good do you think you are at judging fitness to work?
What are the challenges in these consultations?

5. Challenges The management of less clear-cut medical diagnoses
Certification for common health problems
The pressure from patients to issue fit notes
Feeling uncomfortable when a decision has financial implications for the patient

6. Why does sickness matter?

7. Worklessness
99% of patients return to work quickly but….

8. Work and Health – The Evidence Common Health Problems
66% of all sickness absence is due to common health problems:
Less severe mental health disorders
Musculoskeletal disorders
Cardio respiratory disorders
These are potentially remedial conditions 8

9. Facts and figures (data 2008)
Based on figures before introduction of ESA
On average, 1 million people report sick each week
After 6 months, 3,000 of these are still not back at work
Five years on, 2,500 of them will still be claiming Incapacity Benefit
Over 2.7 million people claim Incapacity Benefit every year, which equates to 1 in 13 of the working age population
So once you are of for 6 months returning to work becomes increasingly difficult independent off the reason fir the initial absence 9

10. Length of absence is a risk
Window of opportunity (1- 6 months)
Worker off for 4 – 12 weeks: 10-40% chance of being off work at one year
Worker off months: 90% chance of never returning to any form of work in the foreseeable future
Like any therapeutic interventions, sicknotes can produce side-effects and adverse reactions – use them with caution
Waddell and Burton 10

11. Risks and harm of being out of work
Loss of fitness
Physical and mental deterioration
Increased risk of poor health x 2-3
Social exclusion
Poverty
Waddell and Burton, 2006

12. Risk and harm – mental health risks
Psychological distress and depression
Increased x 2-3
Increased suicide and mortality
20% excess deaths
Two-fifths of sickness absence in the UK is caused by anxiety and depression

13. Families and work Children in workless households:
have a higher prevalence of recurrent health conditions and lower well-being
suffer higher rates of psychiatric disorders
are more likely to experience worklessness themselves during adult life

14. Fact about people being out of work
The risk of being out of work in the longer term is greater than the risk of other killer diseases such as coronary heart disease
Waddell & Aylward, 2005
Early intervention to help in returning to normal activity (including work) is crucial to prevent chronicity, dependency and job loss. 14

15. Is Work good for your health and wellbeing?
Strong evidence exists that unemployment is harmful to health. The unemployed have higher mortality, poorer general health, poorer mental health and higher medical consultation, medication consumption, and hospital admission rates.
(Waddell & Burton)

16. Is work good for your health and wellbeing?
Overall beneficial effects of work outweigh the risks
Work can be therapeutic and can reverse the adverse health effects
The component is intended to mitigate the negative implications for health and well-being of being “unemployed”, “retired” or “incapacitated
Effects of health on work: understanding the biopsychosocial model of disease and its importance in the work context
Waddell and Burton 16

17. Shifting attitudes to health & work
Current:
Shift to:
Work is a ‘risk’ and (potentially) harmful to physical and mental health.
Work is generally good for physical and mental health
therefore
and
Sickness absence/certification ‘protects’ the worker/patient from work
Recognise the risks and harm of long term worklessness
Big area for reform to increase the employment rate of sick and disabled people is incapacity benefits. Though not an end in itself
There are now around 2.7 million people claiming an incapacity benefit
Now have more than 3 times as many people on IB as JSA – stark contrast with the position in early 1980s where there were significantly more people unemployed.
In fact caseload has more than trebled since 1979.
Most of the increase (over 90%) took place before 1997.
Since that time we have seen a reduction in inflows to the benefit (by around one-third since 1997), reflecting greater economic stability and policy changes.
Problem is that outflows have fallen too – so we have seen a stabilising of the caseload.
Not the case that there is a hidden unemployment problem – which has been in the press recently - unemployment fallen MUCH faster than rise in IB caseload, employment is up (levels and rates). 17

18. When does an illness require time off work? And How could I assess this?
Discuss

19. You could assess effect of health on work
SMARTIES

20. Fitness for work: health on work
Stamina
Mobility: walking, bending, stooping
Agility: dexterity, posture, co-ordination
Rational: mental state, mood
Treatment: side-effects, duration of
Intellectual: cognitive abilities
Essential for job: food handlers, driving
Sensory aspects: safety – self and others
Look at what the patient needs clinically to get better.
Be positive - look at what patients can do, not what they can’t.
Ethical issues 20

21. You could assess effect of work on health
DETTOL

22. Fitness for work: work on health
Demands of the job: physical, intellectual
Environment: shop floor/office, risk factors
(e.g. dusts, chemicals)
Temporal: shift working, early start
Travel: business travel – between sites, overseas
Organisational: lone-working, customers
Layout: ergonomic aspects of workstation, work equipment
Asking about the patient’s job is essential information.
Early intervention to help in returning to normal activity (including work) is crucial to prevent chronicity, dependency and job loss. 22

23. How can you help patients?

24. Rehabilitation Aims Bio – psycho – social approach Restore function
Restore confidence
Social integration

25. Key interventions Early intervention Communicate with line manager
Recognise what patient can do, rather than not do
Consider simple alterations to support early return
TOP TIP…..Go back part way through week

26. Integrating rehabilitation into the patient’s management plan
Consider functional limitations
Review effect of work on health and health on work
Consider workplace, social and medical factors
Consider what would support patient back to full function
Appropriate advice, treatment and support services

27. How might you do this in reality?
What sort of consultation methods will help

28. Changing Behaviour

29. Changing behaviour Ambivalence is common and normal
Confrontational interviewing = resistance
Shift style - resistance diminishes, change talk increases
Collaboration, honour autonomy
Rollnick and Miller

30. Importance + Confidence = Readiness
Method
Importance
Confidence
Importance + Confidence = Readiness
Rollnick and Miller 30

31. Importance and confidence
“How important is it for you to get back to work?”
“So how confident do you feel about getting back to work?”
Agenda setting- device to hang a constructive consultation onto
– “what might help increase…..”
Rollnick and Miller

32. Support and resources
What's out there?

33. Sources of support OH services in the workplace
Disability Employment Advisers
Access to Work Scheme
Fit for work services
Ask patients if they have access to occupational health services – they can help.
DWP deskaids, IB204 guidance
The Health and Work Handbook
Government schemes – condition management programmes, disability employment advisers, Access to Work scheme
NHSplus evidence-based guideline on occupational health
HSE and Workplace Health Connect 33

34. Work is good for your health and well being
Key messages
Work is good for your health and well being
Effective negotiation
Early intervention
Rehabilitation as part of the clinical management plan 34

35. Fit notes
The nuts and bolts

36. Changes from the old days
Telephone consultation allowed
Removed option to say fit for work
New option “may be fit for work….”
In the first 6 months limited to 3 month duration

37. Other stuff Only a Doctor to complete Remains advice to your patient
Complete free of charge
Not until 7 days off work
Issued on
Day you assessed
A date after you assessed if reasonable
Report from another doctor

38. If you give advice The employer is not bound by it
If still unable to work does not have to return to see you
Mythical fit notes
Diagnosis can still be vague if harmful

39. Some testing questions

40. Some testing questions
Am I legally liable if something goes wrong with the patient at their workplace?

41. Some testing questions
Do I have to write a comment if I tick “may be fit for work?

42. Some testing questions
I still find employers wanting a “fitness for work” certificate

43. Some testing questions
Should hospital doctors be sending patients to me for fit notes?

44. Some testing questions
Do I need to issue a fit note “not fit for work” if the employer can not accommodate my suggestions?

45. Some testing questions
Can I put “bereavement” as a reason for being unfit for work

46. Some testing questions
Do I have to see / speak to a patient before issuing a fit note if they have seen a physiotherapist and been advised “no lifting and carrying for 2 weeks?”

47. Some testing questions
Should I issue a fit note to someone who is at university?

48. Other sickness certification
Holiday insurance
Private sick notes
Fitness to travel
Gym notes

49. Fitness for work: prognosis
Source:
( see also OUP Handbook of General Practice) 49