A recent gathering in Wales brought together GPs and occupational health teams to discuss the impact of fitness-for-work statements on sickness absence at various organisations. Occupational health practitioners provide their feedback on the event.
It has been more than two years since the medical Statement of Fitness for Work was introduced. Published articles have warned that fit notes have made no difference to sickness absence (Chamberlain, 2012) and that if employers want the fit note to work, they need to take more initiative when it comes to making contact with GPs (Paton, 2012).
To celebrate the second anniversary of the Statement of Fitness for Work, a number of local GPs were invited to meet OH practitioners from the North-West Wales public sector. The areas represented are a main source of employment for all people living in North-West Wales, namely: Betsi Cadwaladr University Health Board (BCU), Bangor University and Gwynedd Council.
The purpose was to highlight employer health-at-work programmes and discuss the impact of fitness-for-work medical statements, so that any operational problems arising from the use of them could be discussed. HR officers were also in attendance.
Gwynedd Council occupational health service
Gwynedd Council's occupational health service (OHS) was recognised in March last year with a gold-level award from the Welsh Government's Corporate Health Standard. The council has a robust sickness absence policy in place and managers are aware of the OHS's role in improving health and wellbeing, either reactively when conducting sickness absence consultations or through health-promotion activities. To support health at work, employees of Gwynedd Council benefit from early access to services such as physiotherapy and counselling. Any staff member who is absent from work due to a musculoskeletal disorder (MSD) or stress/mental health issue is referred to OH on their first day of absence.
The OHS works closely with the musculoskeletal health adviser who works within the "back care team", which has contributed to a reduction in sickness absence due to MSDs over the past two years.
Another development within the council has been "Care Call", where employees on their first day of absence receive a phone call from one of the OHS nurses. The nurse provides the member of staff with advice to support their recovery and obtains their consent to let the employee's line manager know what is wrong and the health advice that has been given. The scheme has also been introduced within the "Home Care Service".
Meetings between OH and GPs have helped GPs' understanding of both the assistance available to staff and the role that OH services undertake in the council. Concerns and questions about the fitness-for-work process were also raised.
Betsi Cadwaladr University Health Board
BCU is one of the largest employers in North Wales, and supporting the health and wellbeing of the workforce is crucial to the delivery of excellent patient care. Many of the recommendations cited in the Department for Work and Pensions guidance on the fit note are already in place within the organisation.
Conversations between the employee, OH and the wellbeing department take place on how a return to work will be managed. Advice is given to the manager on adjusted duties, phased return and flexible working, taking into consideration the patient's fitness standards and work area.
Meetings between OH and GPs have helped GPs' understanding of both the assistance available to staff and the role that OH services undertake."
BCU has also introduced a service providing support to employees prior to the requirements for a fitness-to-work certificate after seven days' sickness absence.
The Health and Safety Executive (HSE) suggests that early intervention is the key to increasing the chances of an employee making a full recovery and a speedy return to work (HSE, 2004). With this in mind, OH and the wellbeing department introduced "CARE" (Confidential Advice Relating to Employees). CARE offers early support and advice for employees from day one of sickness absence or if they are experiencing health or social difficulties while at work.
The causes of sickness absence in the workforce can range from common health conditions through to personal and social reasons, such as financial or relationship problems, which also affect health and can affect an employee's ability to work.
CARE is a voluntary service that operates by providing employees with key information and advice to help them cope and function, promoting their own recovery or adapting to their personal or work situation. Specially trained advisers offer confidential, practical information and guidance to support employees based on an early intervention biopsychosocial approach, which looks at all circumstances and not just the disease as a medical model.
The adviser will keep in touch with the employee at regular intervals and provide continued support to help them back to health and back to work.
The service has been running since November 2011 and early feedback from employees is positive, with 96% feeling that their views and opinions were listened to and 70% indicating that the advice they had received from CARE had helped them.
BCU has recently been presented with the silver-level Corporate Health Standard Award and the positivity of the CARE service as a resource for employees was reflected in the feedback received.
CARE has now been running for six months and early indications are that the service is having a positive impact on short-term sickness absence.
From January to March 2012, there were 1,249 fewer sickness absence episodes compared to the same months in 2011. This equates to a mean reduction of 0.4% in the actual sickness absence rate over this time and a productivity cost saving of £193,954.80. The impact on long-term absence is yet to be assessed and statistical data will continue to be collected over the next 12 months to identify the long-term benefits of the CARE service to employees and its impact on BCU as a whole.
Bangor University health and safety services
The occupational health practitioner organised a focus group to understand the experience of staff returning from long-term sick leave. The following feedback from the focus group was shared with local GPs:
- "The phased return to work from my operation involved starting work at the normal time and finishing early, slowly increasing both hours and days of work every week for three weeks. This helped to overcome tiredness and allowed me time to readjust to being at work and the workload involved."
- "Amended duties were so helpful. Acute anxiety is a deeply dreadful feeling that stops all enjoyment of life and places a burden on those I work with and loved ones at home. The GP advised amended duties and the occupational health nurse then conducted a workplace stress impact assessment. The outcome matched my workload and responsibilities to a level I can cope with. The support I have received at work has had a positive effect on the quality of my life both at work and at home."
- "Altered hours helped me to cope with recently diagnosed epilepsy. I have fits at night and there are mornings when the consequence makes me feel unwell. My GP suggested having a discussion with my manager about altered hours. This has resulted in the department realising why there are days when I cannot come into work on time. As a result of this discussion, rather than take the whole day off as sick leave, I arrive later than the normal start of my shift. I very much enjoy my job and being able to continue at work gives me great peace of mind, a structure to my day and a much needed income."
- "Workplace adjustments were arranged after a pre-return-to-work assessment, with the occupational health practitioner ensured that changes were made in advance of the return-to-work day. These included: altering the height and improving the leverage of door handles; reducing the resistance needed to open corridor (fire) doors; lowering and increasing the amount of shelving that I can use at waist height; exchanging four-door filing cabinets with lower three-draw cabinets; and modifying lecture room audio-visual equipment to ensure everything is within a range of convenient reach. Without these adjustments, I would not have been able to make an earlier return to work. Now that I am back at work, the adjustments are preventing my health condition from being aggravated."
Feedback to GPs that summarised the extent of medical advice
GPs who attended the meeting received copies of graphs and tables that reviewed the trends in medical advice that fitness-for-work medical statements had followed over the past year. Not everyone returns to work with medical advice to support their return. GPs' advice on fitness-for-work statements is only of value if the person needs additional support to overcome barriers that would prevent them from coming back earlier, or when the health and safety of others needs to be considered, for example when determining fitness for driving.
The impact of the fitness-for-work medical statement needs to extend beyond an understanding of how people are being supported back from sick leave."
Data from Bangor University revealed that between April 2011 and April 2012, 141 staff returned from long-term sickness absence (ie more than 20 days). Of this number, 65 staff (46%) received medical advice to support an earlier return to work and 76 people (54%) did not. Those that did not receive medical advice were asked if the GP had discussed the options for an earlier return to work with them. The response revealed that: a significant number of people (41%) did not want any support to assist their earlier return to work; 30% did not recall having a discussion about an early return to work with their GP; and 29% did not respond to follow-up contact asking for feedback about their GPs' advice.
For staff who did receive medical advice to support an earlier return to work, trends were detected in the type of advice in relation to specific illnesses:
- Amended duties and a phased return to work were the main recommendations for people who were recovering from psychological conditions.
- Adapting the workplace is the most common type of advice for those returning from musculoskeletal conditions.
- Amended duties and altered hours are commonly recommended to help people who are recovering from cardiovascular conditions return to work.
- Those recovering from tumours were advised to discuss a phased return or altered hours at work.
- A mixture of altered hours, workplace adaptations and amended duties has been advised to help deal with the medical management of unstable diabetics and cases of epilepsy.
These findings were similar to those reported in a survey that was conducted two months after the introduction of the fitness-for-work medical statement, coordinated by Hyland (2010).
To understand the impact of medical advice for an early return to work on individuals, the findings of a survey conducted by the occupational health practitioner at Bangor University revealed that:
- no member of staff suffered a relapse or came to any harm at work;
- 54% said they began to feel better through being back at work;
- 32% said they did not feel any different from being at work compared with how they were at home; and
- 4% commented on the return-to-work process being more strenuous than they had expected it to be.
Preventing sickness absence from extending into the sixth month and beyond is known to reduce the 80% chance of individuals then being off work for five years (Waddell and Burton, 2006). For this reason, the impact of the fitness-for-work medical statement needs to extend beyond an understanding of how people are being supported back from sick leave and identify whether or not the duration of sick leave is actually shorter.
As the number of people that suffered from specific illness types at Bangor University is low, a difficulty exists in calculating any statistically significant difference between the duration of absence under the fitness-for-work system and absences under the sick note system. Nevertheless, an exception is where differences have been identified in the return-to-work patterns for staff suffering psychological illness (see table below).
Impact of fitness-for-work statements
The impact of fit notes on the duration of sick leave for psychological illness at Bangor University.
Number of sick leave absences due to psychological illness
Staff returning to work in fewer than 20 days
Staff returning to work between 20 and 54 days
Staff returning to work after 54 days
|2009/2010 = 57 ||40.4% ||40.4% ||19.2%|
|2010/2011 = 46 ||67.4% ||23.9% ||8.7%|
The finding for psychological reasons of absence reveals that the use of fitness-for-work medical statements coincided with more than 67% of staff suffering from psychological illness returning to work in fewer than 20 days, compared with just over 40% in the previous year.
The percentage who then returned after 20 days was proportionally distributed. Differences in the returned-to-work patterns were significantly improved when staff benefited from the fit-for-work process (chi-square test = 7.60, distribution frequency = 2, p = 0.022). The duration of sick leave for psychological illness has been significantly reduced.
Despite limited statistical significance, the trends and effect of GP advice given through the fitness-for-work statement suggests that people are returning from sick leave with greater ease (and are therefore more productive), in a shorter time (reducing the impact of absenteeism) and with greater success (measured by people not requiring further time off work for the same illness within weeks).
Areas of improvement that were identified by GPs
GPs are looking forward to the introduction of a computer-generated fitness-for-work statement that is compatible with their software systems, as this will help communication with other GPs about the advice given to patients. The use of software will also support clinical audit.
GPs shared with HR colleagues their unease about being asked to supply a medical certificate when people are unable to work six days or fewer. This seems to be a common part of HR absence management policies, not solely in North-West Wales, and needs to be addressed by the wider HR community.
GPs are more confident that the right level of workplace support is in place for their patients for a successful return to work from sickness absence."
The impact of ill health among part-time staff was also discussed at the meeting. It is common practice when people are only employed to work fewer than 20 hours for the individual to have a second and even a third job. On occasion, staff have been issued a medical statement saying they are unfit for work and receive sick pay from their public-sector job, then continue to work elsewhere.
While GPs may hold the view that this could be a form of altered hours that helps a person's recovery, contracts of employment prevent the practice of staff submitting a medical statement stating they are unfit for work and then work elsewhere. When it is known that this is happening, it invariably leads to disciplinary action and dismissal.
The meeting in Wales enabled local GPs and occupational health nurses to discuss issues that would normally be restricted to members of these separate professional groups. By crossing "organisational" barriers, GPs were genuinely interested to hear of the health interventions provided by local occupational health nurses, who, in turn, felt that the discussion fostered a closer relationship with the source of medical advice to refrain from, or return to, work.
GPs are more confident that the right level of workplace support is in place for their patients for a successful return to work from sickness absence. The OH team and the GPs have agreed to meet again.
Bangor University. "Pathways to health".
Black C (2008). "Working for a healthier tomorrow". Executive summary: early interventions.
Chamberlain L (2012). "Fit notes have made no difference to sickness absence". Personnel Today, 14 May 2012.
HSE guidance for employers - sickness absence (2004). Health and Safety Executive.
Hyland S (2010). "Occupational health of central England survey". Occupational Health, December.
Paton N (2012). "Employers to play a crucial role in the success of the fit note". Occupational Health, June.
Waddell G, Burton K (2006). "Is work good for your health and well-being?" The Stationery Office.
Shirley Jones BSc (Hons), OHND, RGN, is senior occupational health adviser at Gwynedd & Ynys Mon Council; Joe Patton MSc, BSc (Hons) OHND, RGN, RMN is an occupational health nurse practitioner at Bangor University; and Debbie Twigdon-Williams BSc (Hons) RSCPHN-OH is occupational health specialist practitioner and CARE team leader at Betsi Cadwaladr University Health Board.