Certifying capacity for work

Professor Alex Collie, Chief Executive Officer, Institute for Safety Compensation and Recovery Research, Monash University

alex.collie@monash.edu / iscrr.com.au / @iscrr / @axcollie

Acknowledgments

• Professor Danielle Mazza, Dr Bianca Brijnath, Dr Rasa Ruseckaite, Dr Agnieszka Kosny, Ms Nabita Singh.

• Colleagues from the TAC, WorkSafe Victoria and the Health and Disability Strategy Group.

• The research presented was supported with funding and in-kind assistance by:– WorkSafe Victoria

– Transport Accident Commission

– Royal Australian College of General Practitioners

– Motor Accidents Insurance Commission of QLD

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Overview

• The link between work, health and productivity• Work injury in Australia• Why emphasise capacity for work?• What do we know about rates of sickness certification

for work-related conditions?• What are the barriers and facilitators to GP

engagement in certification and the RTW process?• The ‘fit note’ – has it worked? • What is next?

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At Work Off Work Possible Outcomes

Healthy & Productive Injured / Ill

Workers’ Compensation

“Hidden System” of sick leave, public health, income

protection, superannuation...

Back at work

Social Welfare

Disability

Retirement

Education / Re-training

Death

Work, Health and Productivity

Public Policy / Health Objectives

1. Preventing workers from becoming ill/injured and unproductive.

2. Helping injured/ill workers return to health and productivity while staying at work.

3. Helping injured/ill workers who leave the workplace to return to work.

4. Minimising the potential negative long-term outcomes of long term worklessness.

Poverty / Homelessness

1 2

3 4

1

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Inter-generational effects

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Work and Health – the evidence

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Work Injury in Australia, 2013/14

Work Injury in Australia

• Common work-related conditions (back pain, MSK, neck pain) are 3 of the 5 leading causes of disability (Global Burden of Disease Study, 2015).

• Among working age Australians, these conditions generate the greatest burden of disability.

• Estimated 532,000 work related injuries in 2013/14 (one per minute).

• Being off work can lead to:– changes in physical and mental health– reduced labour force productivity – impact on family and social relationships– reduced economic security of the worker– intergenerational effects

Cost of Work-Related Conditions

• $61.6 billion or 4.1% of Australian GDP (2012/13)• Average cost of a work-related accident = $116,600• Workers bear much of the cost, followed by community and employers

$4,400

$52,000

$19,100

Injury

Employer Worker Community

$9,600

$189,200

$24,800

Disease

Employer Worker Community

Safe Work Australia (2015). Cost of work-related injury and disease, 2012-13

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Why focus on GPs and certificates?

• GPs issue the majority of certificates

• GPs almost exclusively (~96% of cases) issue the first certificate

• The certificate is required for claim acceptance and ongoing benefit provision

• The certificate has potential to be a therapeutic tool as well as a procedural requirement

1 Dembe, A.E. et al. Am J Ind Med, 2003. 44(4) p 331-42

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Certification by numbers

• Most studies based on small clusters of GP practices.

• Few published research studies differentiate between rates of sick notes and fit notes.

• Lack of electronic population-based data capture has been a barrier to understanding.

Wynne-Jones et al (2009). Brit J Gen Practice

Rates of certification by gender in UK primary care (based on 14 GP practices).

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Certification by numbers (Victoria)

• Analyses of 124,424 initial medical certificates

• Issued by 9,750 GPs

• Between 1 Jan 2003 and 31 Dec 2010

• For accepted workers’ compensation claims

• State of Victoria

• We wanted to understand certification practices in detail.

• Victoria has state-wide electronic data capture on certificates for every accepted workers compensation claim.

Collie et al Med J Aust. 2013 Oct 7;199(7):480-3.

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Certification by numbers (Victoria)• 74.1% were issued as ‘unfit for work’ certificates

• 22.8% were issued as ‘alternate/modified duties’ certificates

• Proportion varies significantly by condition

Collie et al Med J Aust. 2013 Oct 7;199(7):480-3.

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Certification by numbers (Victoria)• Rates of unfit certificates have been reducing (A)

• Rates of alternate duties certificates have remained stable (B)

• Different patterns by injury / illness category

Ruseckaite R, Collie A et al. J Occup Rehabil. 2014 Sep;24(3):525-32.

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Certification by numbers (Victoria)• Regression analyses of factors associated with type of initial certificate

• Workers receiving ‘unfit for work’ certificates are more likely to:– Be older

– Have a work-related mental health condition

– Live rurally / remotely

– See a GP with a low to moderate caseload (13 to 49 claims)

• Workers receiving ‘alternate duties’ certificates are more likely to:– Be female

– Have a musculoskeletal disorder or back pain

– See a GP with a high caseload (>49 claims)

– Work for a medium, large or government employer

– Work in a managerial position

Ruseckaite R, Collie A et al. BMC Public Health. 2016 Apr 6;16(1):298

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Certification by numbers (Victoria)• A small proportion (13.2%) of GPs issue half of all certificates.

GP Group Claimants/GP GPs, N (%) Claims, N (%)

1 1 -13 (25pct) 6,824 (70%) 30,814 (24.8%)

2 14-26 (50pct) 1,638 (16.8%) 31,151 (25.1%)

3 27-48 (75pct) 917 (9.4%) 31,583 (25.4%)

4 49+ (100 pct) 369 (3.8%) 30,794 (24.8%)

Total 9,748 (100%) 124,342 (100%)

Mazza D, et al (in preparation)

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Factors affecting GP engagement in RTW

• Fit to Work Study (Victoria)• Qualitative interviews with four groups

– GPs (n=25)

– Injured workers (n=17)

– Employers (n=25)

– Insurance case managers (n=25)

• Study questions:– How do GPs, injured workers, employers, and compensation personnel

view the role of the GP in facilitating return to work?

– What are the reported barriers and enablers to GPs facilitating injured workers RTW?

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Qualitative study findings

• Certification is an administrative and clinical task underpinned by a host of social and systemic factors.

• Doctors consider certificates to be a method of communication.

• Case managers and employers consider certificates to be a therapeutic tool.

Mazza D, et al. BMC Fam Pract. 2015 Aug 15;16:100

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Qualitative study findings

• High rates of unfit for work certificates are in part due to:• GPs reliance only on injured workers feedback on capacity to work

• Poor communication between GPs, employers and compensation agents

• Lack of availability of alternative/modified duties

• Age and social circumstances of the injured worker and their family

• High degree of complexity in mental health claims

Mazza D, et al. BMC Fam Pract. 2015 Aug 15;16:100

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Qualitative study findings

• Significant barriers to GP engagement in managing injured workers:• High administrative burden on GPs from compensation system

• Low remuneration of time and effort

• Delayed payments

• Difficulty in referrals

• Conflicting medical opinions

• Lack of GP knowledge of workers compensation system

• Lack of continuity in engagement with insurers

Mazza D, et al. BMC Fam Pract. 2015 Aug 15;16:100 Brijnath B et alJ Occup Rehabil. 2014 Dec;24(4):766-76

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“They [insurance case managers] keep changing. And I have to ask, ‘Well why do these workers keep changing?’ Why is one patient who is in the system for a long time, constantly handed on to another worker who doesn’t know the patient, doesn't know their background? I might

have 15 years of knowledge of the patient ... I feel like we have continuity of care and the system doesn’t”

(GP25, m, 50yo, 25ye).

Compensation system barriers

Brijnath B et alJ Occup Rehabil. 2014 Dec;24(4):766-76

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• Mental health conditions = greater rate of unfit certificates (Wynne-Jones et al, 2009. Brit J Gen Practice)

• Risk factors for longer duration include older age, social deprivation, and presence of mild and severe mental disorders (Sheils et al, 2004. Brit J Gen Practice)

• Factors affecting GP attitudes = doctor-patient relationships, pressure on consultation time, limited knowledge about their patient’s workplace, and the administrative burden of dealing with the compensation system (Cohen et al, 2010 Occup Med; Kosny et al, 2006 J Occup Rehab)

Our results are consistent with evidence from European and North American studies

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Some potential GP focussed interventions

Factor Example Potential intervention/s

Medical certificate Recommending alternate duties may improve RTW outcomes.

Change to ‘fit notes’. GP specific guidelines for RTW.

GP knowledge of compensation system

Knowledgeable GPs aid worker recovery and system navigation.

GP focussed education and training on comp processes.

GP willingness to engage in comp system

Some GPs refuse or are unwilling to engage in comp cases. Creates barriers to access for workers.

Financial incentives. Minimise barriers to engagement (red tape).

GP knowledge of workers employment circumstances

Greater understanding = more likely to recommend alternate duties / RTW.

Third party acts as link b/w employer and GP (eg, OT, OR provider). GP specific guidelines for RTW.

GPs tend to focus on worker condition rather than RTW.

RTW not always/often focus of GP during worker consultation.

GP specific guidelines for RTW. Payment code for RTW consultation.

Strength of relationship with injured worker

GP can become patient advocate rather than RTW facilitator.

GP specific guidelines for RTW.

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Some recent efforts to change certification practices

• UK– Fit Note roll-out (from 2010)

– Fit for Work Service (from 2014)

• New Zealand– Better @ Work (2009 onwards)

• Victoria– Health Benefits of Safe Work Program (from 2013)

• ACT– Capital Health Network trial (from 2015)

• Queensland– New Certificate (April 2016)

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Has the ‘fit-note’ worked?

• Survey of GPs by UK Dept of Work and Pensions (2012)

66.3%

64.6%

60.5%

81.5%

60.8%

53.5%

48.2%

70.3%

0% 20% 40% 60% 80% 100%

Improved the quality of my discussionswith patients about return to work

Improved the advice I give to patientsabout their fitness for work

Increased the frequency with which Irecommend return to work as an aid to

patient recovery

Helped my patients make a phasedreturn to work (e.g. amended duties,

altered hours, workplace adaptations)

20102012

Courtesy Dame Carol Black

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Has the ‘fit-note’ worked?

• CBI – Absence and workplace health survey (2013)• UK employers views of fit note

Courtesy Dame Carol Black

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What other factors influence return to work?

Biological Social

Psychological

RTW

Family factors

Employer factors

Financial factors

Coping skills

Self-esteem

Motivation

Physical health

Disability

Genetic vulnerabilities

Relationships

Policy / Environmental factorsCo-morbidity

Age

Self-efficacy

Mental Health

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Putting it all together

RTW &Recovery

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Opportunities to improve certification

• Targeted education and training program focussing on how to certify for capacity rather than incapacity

• Video-based demonstrations with real patient scenarios

• Integration of the certificate into medical software• Demonstration of long term impact

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Vision: Improved GP performanceProf Danielle Mazza

• Develop tools to aid GPs to navigate the system:– Flow chart

– Education

– Practical guidance, tools and strategies

• Develop a suite of tools/resources and frameworks to help guide functional assessment (e.g. for persistent pain or mental health issues)

• Provide guidance for treatment options• Ensure the long-term sustainability of health provider

participation in the compensable injury landscape.

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New Project - National clinical guidelines for GPs on work-related mental health claims (2016-19)

• Key outcomes will be:– A clinical guideline to improve

GP management of patients with work-related mental health claims

– A guideline that is approved by the NHMRC and RACGP

– National dissemination of the guideline

– An evidence-based implementation plan to facilitate the translation of the guidelines into clinical practice.

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Can guidelines work?

• Sweden introduced diagnoses specific sickness certification guidelines nationally in October 2007.

• Survey of 4394 Swedish GPs in 2008 found that:– 76.2% reported using the guidelines

– 65.4% reported the guidelines had facilitated contacts with patients

– 43.5% reported the guidelines had facilitated contacts with social insurance officers

– 31.5% reported the guidelines as helping to develop competence

– 33.5% reported the guidelines as improving the quality of sickness certification consultations

Skaner et al. BMJ Open 2011.

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Take-home messages

• We know a lot now about rates of certification and factors that impact on GP certification practices.

• Emphasising fitness to work in certification is a positive step.

• Efforts to improve rates of fit to work certificates have not yet shown strong evidence of substantial impact. But we should keep trying.

• Return to work is a complex process involving multiple parties, many interactions and ‘events’.

• Changing certification practices is one opportunity among many for improving return to work outcomes.

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THANK YOU!

Contact Information:

alex.collie@monash.edu

(03) 9903 8610

www.iscrr.com.au

@iscrr / @axcollie