Fit notes: occupational health is key to their success

OH will have a major role to play if the government’s new ‘fit note’ scheme is to work properly.

GPs will need specialist occupational health (OH) advice filling in the new ‘fit note’ if it is to achieve the government’s objective of helping people back to work earlier, according to Dr Tony Stevens, president of the Society of Occupational Medicine (SOM).

He believes the government is “on the right track” with its draft new medical statement, adding that the new style form will make GPs more accountable and give them the flexibility to aid patients’ return to work. But he adds that doctors and employers will need support and training to make the new system work, otherwise it could create rather than remove barriers to rehabilitation.

Stevens was giving Occupational Health the SOM’s initial response to a government consultation1 seeking views on draft regulations implementing a new-style medical statement from April next year.

The Social Security (Medical Evidence) and Statutory Sick Pay (Medical Evidence) Amendment Regulations 2010 will change the format of the current medical statement to allow doctors to record whether a patient “may be fit for some work now” – an additional option to the existing ones of “fit” or “not fit for work”.

The regulations will also remove two medical forms (4 and 5) to simplify the process for both GPs and employers. GPs will also be able to issue computer-generated statements, although these will still need to be printed out by the medical practice, and will not be electronically transferable immediately as was originally mooted.

Doctors will be able to specify whether patients need to consult the GP when a statement expires before returning to work, and the government is also considering removing the option for them to issue “fit for work” statements altogether, effectively ending the practice of employers requiring such a document before allowing an employee back to work.

The government’s primary objectives in moving towards a fit note culture are to get people back to work after illness or injury faster and to encourage workers to discuss their return to work, including any adaptations or adjustments required, with employers.

The government – along with many OH professionals and employers – believes the current format does not give sufficient emphasis to how or whether an individual’s condition can be accommodated at work, and the emphasis in the new fit note is firmly on what an individual can do, rather than on what they are prevented from doing.

New options for GPs

In addition to the new option for a GP to state that a patient “may be fit for some work now”, family doctors will also be able to indicate on the form if the patient may benefit from a phased return to work, altered hours, amended duties or workplace adaptations. However, there is no obligation on the employer to implement any changes or adaptations suggested, and the appearance of the “may be fit” wording on a statement must still be considered as constituting evidence that the patient should refrain from work for sick pay purposes. It is still up to the employer to consider all circumstances before accepting that the employee is either capable or incapable of work.

An evaluation of a pilot of the new Med 3 statement, involving more than 500 GPs, concludes that it will achieve its objective – some patients under the new system returned to work faster after a period of sickness absence than those covered by the old system. For example, GPs using the new certificate in the pilot were less likely to advise patients to stop working compared with GPs using the current Form Med 3.

Although some patients who would have been classed as “fit” under the old system moved into the “may be fit” category, a far larger number moved from “unfit” into the “may be fit” group. The consultation document concludes that this also means the new form could increase the numbers of employees discussing return to work on modified duties with employers.

An impact assessment produced for the consultation shows that, even with the most conservative estimate of an additional 3% of patients returning to work under the revised statement system, the increase in output to the economy would be around £332.9m over the period 2009-10 to 2018-19, rising to £1,109.6m if 10% of individuals return to work early.

The assessment also suggests that the new statement could have a disproportionate, positive effect on people with mental health problems, including stress, anxiety and depression, the single most important cause of non-manual workers’ long-term sickness absence.

Can GPs give OH advice?

GPs using the “may be fit” wording on the new statement will have to provide general details of the functional effect of the individual’s condition. For example, they might state that an individual with moderate back pain is unable to lift heavy objects, and should be given the opportunity to change position or take regular breaks.

However, the consultation document recognises that GPs are not OH experts, and that any such advice should only be generic.

Brendan Barber, TUC general secretary, sounds a note of caution at this level of GP involvement, and is concerned that workers might be “bypassed” if the new fit note becomes a tool for dialogue between the doctor and employer.

“Workers may feel they are being forced back to work. The most effective way of encouraging workers back to work is through access to proper occupational health support,” he says.

The TUC is also concerned that some people may be forced back to work before they are ready.

“There are many circumstances where an early return can prevent the worker making a full recovery, or even lead to a relapse. Most employers won’t have the expertise to give workers the support they need for an early return and this could make matters worse”, Barber adds.

GPs and employers need support

GPs are under great time pressure and will need training and support, and access to specialist OH advice, to make the new system work, according to the SOM’s Stevens. He is worried that, if clumsily applied, it could have the opposite to its intended effect, and employers could find it unhelpful.

A GP’s decision to tick one of the boxes of suggested workplace measures (for example, a phased return) will need to be evidence-based to be effective, which will require them to seek specialist advice, from the patient’s in-house OH team, or the planned fit for work service, for example.

The SOM believes employers will also need more advice, for example, on how to interpret the new note containing suggestions for a phased return. Otherwise employers could feel the GP’s recommendations are a barrier, particularly if they are already anxious about the applicability of disability legislation, Stevens adds.

Charlotte Bray, OH consultant at AON, agrees the new system will place added responsibility on line managers and human resources professionals to apply any medical recommendations contained in the statement in the workplace. There will be no requirement on them to take notice of the GP’s suggestions (unless the patient is covered by disability legislation), so clear training and guidance will be required to encourage them to do so.

Ben Willmott, senior public policy adviser at the Chartered Institute of Personnel and Development (CIPD), recognises that resource issues will continue to affect an employer’s willingness or ability to accept any workplace changes suggested in the new fit note, and that some small and medium-sized employers in particular will have concerns about allowing an employee operating at less than 100% capacity back to work.

But, he adds, the fit note change is part of a gradual education process, and employers need to understand that any short-term costs in terms of adaptations at work are balanced by the long-term gains from getting an employee back to work.

Willmott accepts this is a challenging area for employers, adding that the CIPD is working with the British Occupational Health Research Foundation on research looking at how line managers support individuals’ return to work.

Widening access to OH

Bray argues that the role of OH will be critical to the new system’s success – bridging the gap between the surgery and the office. There is plenty of evidence that an OH intervention helps people get back efficiently, making widening access a priority, she argues.

The Association of Occupational Health Nurse Practitioners (AOHNP) agrees, and will be pressing for an OH referral or assessment to be added to the specified list of employer actions that GPs can suggest in the new statement.

AOHNP president Jeremy Smith told Occupational Health: “We feel it is imperative that the option to recommend an OH assessment should be added to the revised statement list. Although this may be a challenge for employers and GPs, it will encourage development of more accessible OH services (for example, helplines) and help facilitate a supported and faster return to work, where appropriate”.

Raising awareness of OH as a solution by including it on every fit note will fuel demand, leading to more trained and more efficient, effective services, “which can only be of benefit to UK employers and their employees”, Smith adds.

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