Sickness CertificationSickness CertificationDavid StoutDavid Stout

AimsAims

Learn about Fit notesLearn about Fit notes

Introduce some ideas to help manage Introduce some ideas to help manage sickness in your surgerysickness in your surgery

ObjectivesObjectives

Learn how to fill in a fit noteLearn how to fill in a fit noteLearn the rules associated with fit notesLearn the rules associated with fit notesUnderstand the impact of worklessnessUnderstand the impact of worklessnessUnderstand your role in managing Understand your role in managing sicknesssicknessIntroduce some simple ways of assessing Introduce some simple ways of assessing fitness to workfitness to workIntroduce some ideas about how you can Introduce some ideas about how you can manage patients asking for time off workmanage patients asking for time off work

A simple consultation?A simple consultation?

What is your reaction when some requests a What is your reaction when some requests a sicknote? sicknote?

Think about the last few you have done Think about the last few you have done Were they easy to complete?Were they easy to complete? What sort of questions did you ask?What sort of questions did you ask? How good do you think you are at judging fitness to How good do you think you are at judging fitness to

work?work? What are the challenges in these consultations?What are the challenges in these consultations?

ChallengesChallenges

The management of less clear-cut medical The management of less clear-cut medical diagnosesdiagnosesCertification for common health problemsCertification for common health problemsThe pressure from patients to issue fit The pressure from patients to issue fit notesnotesFeeling uncomfortable when a decision Feeling uncomfortable when a decision has financial implications for the patienthas financial implications for the patient

Why does sickness Why does sickness matter?matter?

WorklessnessWorklessness

99% of patients return to work quickly but….

Work and Health – The Evidence Work and Health – The Evidence Common Health Problems Common Health Problems

66% of all sickness absence is due to 66% of all sickness absence is due to common health problems:common health problems:

Less severe mental health disordersLess severe mental health disorders Musculoskeletal disordersMusculoskeletal disorders Cardio respiratory disordersCardio respiratory disorders

Facts and figures Facts and figures (data 2008)(data 2008)

Based on figures before introduction of ESABased on figures before introduction of ESA On average, 1 million people report sick each week On average, 1 million people report sick each week

After 6 months, 3,000 of these are still not back at After 6 months, 3,000 of these are still not back at work work

Five years on, 2,500 of them will still be claiming Five years on, 2,500 of them will still be claiming Incapacity Benefit Incapacity Benefit

Over 2.7 million people claim Incapacity Benefit Over 2.7 million people claim Incapacity Benefit every year, which equates to 1 in 13 of the working every year, which equates to 1 in 13 of the working age populationage population

Length of absence is a riskLength of absence is a risk

Window of opportunity (1- 6 months)Window of opportunity (1- 6 months)

Worker off for 4 – 12 weeks: 10-40% Worker off for 4 – 12 weeks: 10-40% chance of being off work at one yearchance of being off work at one year

Worker off 6 - 12 months: 90% Worker off 6 - 12 months: 90% chance of never returning to any form chance of never returning to any form of work in the foreseeable future of work in the foreseeable future

Waddell and Burton

Risks and harm of being Risks and harm of being out of workout of work

Loss of fitnessLoss of fitness

Physical and mental deteriorationPhysical and mental deteriorationIncreased risk of poor healthIncreased risk of poor health x 2-3 x 2-3

Social exclusionSocial exclusion

PovertyPoverty

Waddell and Burton, 2006

Risk and harm – mental health risksRisk and harm – mental health risks

Psychological distress and depressionPsychological distress and depressionIncreased x 2-3Increased x 2-3

Increased suicide and mortalityIncreased suicide and mortality20% excess deaths20% excess deaths

Two-fifths of sickness absence in the UK is Two-fifths of sickness absence in the UK is caused by anxiety and depressioncaused by anxiety and depression

Families and workFamilies and work

Children in workless households: Children in workless households:

have a higher prevalence of recurrent have a higher prevalence of recurrent health conditions and lower well-beinghealth conditions and lower well-being

suffer higher rates of psychiatric suffer higher rates of psychiatric disordersdisorders

are more likely to experience are more likely to experience worklessness themselves during worklessness themselves during adult lifeadult life

Is Work good for your health and Is Work good for your health and wellbeing?wellbeing?

Strong evidence exists that unemployment is Strong evidence exists that unemployment is harmful to health. The unemployed have higher harmful to health. The unemployed have higher mortality, poorer general health, poorer mental mortality, poorer general health, poorer mental health and higher medical consultation, health and higher medical consultation, medication consumption, and hospital admission medication consumption, and hospital admission rates.rates.

(Waddell & Burton)(Waddell & Burton)

Is work good for your health and Is work good for your health and wellbeing?wellbeing?

Overall beneficial effects of work Overall beneficial effects of work outweigh the risksoutweigh the risks

Work can be therapeutic and can Work can be therapeutic and can reverse the adverse health effectsreverse the adverse health effects

Waddell and Burton

Shifting attitudes to Shifting attitudes to health & workhealth & work

Current:Current: Shift to:Shift to:

Work is a ‘risk’ and (potentially) Work is a ‘risk’ and (potentially) harmful to physical and mental harmful to physical and mental health.health.

Work is generally good for Work is generally good for physical and mental healthphysical and mental health

thereforetherefore andand

Sickness absence/certification Sickness absence/certification ‘protects’ the worker/patient ‘protects’ the worker/patient from workfrom work

Recognise the risks and harm of Recognise the risks and harm of long term worklessnesslong term worklessness

When does an illness When does an illness require time off work?require time off work?

AndAnd

How could I assess this?How could I assess this?

DiscussDiscuss

You could assess effect You could assess effect of health on workof health on work

SMARTIESSMARTIES

Fitness for work: health on workFitness for work: health on work

SStaminatamina MMobility: walking, bending, stoopingobility: walking, bending, stooping AAgility: dexterity, posture, co-ordinationgility: dexterity, posture, co-ordination RRational: mental state, moodational: mental state, mood TTreatment: side-effects, duration ofreatment: side-effects, duration of IIntellectual: cognitive abilitiesntellectual: cognitive abilities EEssential for job: food handlers, driving ssential for job: food handlers, driving SSensory aspects: safety – self and othersensory aspects: safety – self and others

You could assess effect You could assess effect of work on healthof work on health

DETTOLDETTOL

Fitness for work: work on healthFitness for work: work on health DDemands of the job: physical, intellectualemands of the job: physical, intellectual

EEnvironment: shop floor/office, risk factors nvironment: shop floor/office, risk factors (e.g. dusts, chemicals)(e.g. dusts, chemicals)

TTemporal: shift working, early startemporal: shift working, early start

TTravel: business travel – between sites, overseasravel: business travel – between sites, overseas

OOrganisational: lone-working, customersrganisational: lone-working, customers

LLayout: ergonomic aspects of workstation, work ayout: ergonomic aspects of workstation, work equipmentequipment

How can you help How can you help patients?patients?

Rehabilitation AimsRehabilitation Aims

Bio – psycho – social approachBio – psycho – social approach

Restore functionRestore function Restore confidenceRestore confidence Social integrationSocial integration

Key interventionsKey interventions

Early interventionEarly interventionCommunicate with line managerCommunicate with line managerRecognise what patient can do, rather Recognise what patient can do, rather than not dothan not doConsider simple alterations to support Consider simple alterations to support early returnearly return TOP TIP…..Go back part way through weekTOP TIP…..Go back part way through week

Integrating rehabilitation into the Integrating rehabilitation into the patient’s management planpatient’s management plan

Consider functional limitationsConsider functional limitationsReview effect of work on health and health Review effect of work on health and health on workon workConsider workplace, social and medical Consider workplace, social and medical factorsfactorsConsider what would support patient back Consider what would support patient back to full functionto full functionAppropriate advice, treatment and support Appropriate advice, treatment and support servicesservices

How might you do this in How might you do this in reality?reality?

What sort of consultation methods What sort of consultation methods will helpwill help

Changing BehaviourChanging Behaviour

Changing behaviourChanging behaviour

Ambivalence is common and normalAmbivalence is common and normal

Confrontational interviewing = resistanceConfrontational interviewing = resistance

Shift style - resistance diminishes, change talk Shift style - resistance diminishes, change talk increasesincreases

Collaboration, honour autonomyCollaboration, honour autonomy

Rollnick and Miller

MethodMethod

ImportanceImportance

ConfidenceConfidence

Importance + Confidence = ReadinessImportance + Confidence = Readiness

Rollnick and Miller

Importance and Importance and confidenceconfidence

““How important is it for you to get back to How important is it for you to get back to work?”work?”

““So how confident do you feel about getting So how confident do you feel about getting back to work?”back to work?”

Agenda setting- Agenda setting- device to hang a constructive device to hang a constructive consultation onto consultation onto

– “– “what might help increase…..”what might help increase…..” Rollnick and Miller

Support and resourcesSupport and resources

What's out there?What's out there?

Sources of supportSources of support

OH OH services in the workplaceservices in the workplace

Disability Employment AdvisersDisability Employment Advisers

Access to Work SchemeAccess to Work Scheme

Fit for work servicesFit for work services

Key messagesKey messages

Work is good for your health and Work is good for your health and well beingwell being

Effective negotiationEffective negotiation

Early interventionEarly intervention

Rehabilitation as part of the clinical Rehabilitation as part of the clinical management planmanagement plan

Fit notesFit notesThe nuts and bolts The nuts and bolts

Changes from the old daysChanges from the old days

Telephone consultation allowedTelephone consultation allowedRemoved option to say fit for workRemoved option to say fit for workNew option “may be fit for work….”New option “may be fit for work….”In the first 6 months limited to 3 month In the first 6 months limited to 3 month durationduration

Other stuffOther stuff

Only a Doctor to completeOnly a Doctor to completeRemains advice to your patientRemains advice to your patientComplete free of chargeComplete free of chargeNot until 7 days off workNot until 7 days off workIssued onIssued on Day you assessedDay you assessed A date after you assessed if reasonableA date after you assessed if reasonable Report from another doctorReport from another doctor

If you give adviceIf you give advice

The employer is not bound by itThe employer is not bound by it

If still unable to work does not have to If still unable to work does not have to return to see youreturn to see you

Mythical fit notesMythical fit notes

Diagnosis can still be vague if harmfulDiagnosis can still be vague if harmful

Some testing questionsSome testing questions

Some testing questionsSome testing questions

Am I legally liable if something goes wrong Am I legally liable if something goes wrong with the patient at their workplace?with the patient at their workplace?

Some testing questionsSome testing questions

Do I have to write a comment if I tick “may Do I have to write a comment if I tick “may be fit for work?be fit for work?

Some testing questionsSome testing questions

I still find employers wanting a “fitness for I still find employers wanting a “fitness for work” certificatework” certificate

Some testing questionsSome testing questions

Should hospital doctors be sending patients Should hospital doctors be sending patients to me for fit notes?to me for fit notes?

Some testing questionsSome testing questions

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

Some testing questionsSome testing questions

Can I put “bereavement” as a reason for Can I put “bereavement” as a reason for being unfit for workbeing unfit for work

Some testing questionsSome testing questions

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

Some testing questionsSome testing questions

Should I issue a fit note to someone who is Should I issue a fit note to someone who is at university?at university?

Other sickness certificationOther sickness certification

Holiday insuranceHoliday insurancePrivate sick notesPrivate sick notesFitness to travelFitness to travelGym notesGym notes

Fitness for work: prognosisFitness for work: prognosis

( see also OUP Handbook of General Practice)

Source: www.workingfit.com