Sicknote pilots put to the test

 When the idea that OH professionals might take over sickness certification from GPs was first mooted last year, the reaction from many in the profession was sceptical, to say the least. Worries about workload, competency, cost, confidentiality and conflict (with patients, GPs and employers) predominated.

OH, it was argued, had enough on its plate already without taking on this extra burden. Yet there were those who recognised that, were it to be embraced, OH could actually benefit from the increased profile and responsibility that would come with having a role in the certification process.
After months of preparation, and some delays, year-long pilots examining how OH nurse-based sickness certification might work in practice are due to kick off this month.

The test sites – a mixture of larger and smaller employers – will use a variety of certification models (see box on page 17), which will then be evaluated by academics from Warwick University.

The intention is to be at a point by April 2006 where enough progress will have been made for GPs to begin to give up their responsibility for sickness certification – long seen by family doctors as onerous and not a particularly good use of their time.

It should be stressed, of course, that there is no question of a shutter coming down on GP certification at this point. Even if some element of responsibility is handed over, GPs will retain medical responsibility for patients on their lists.

As part of the preparation for the launch of the pilots, a series of Sickness Certification Pilot Project courses were run in November and December for the OH practitioners involved.

The two-day courses were led by project leader Dr Barbara Kneale, chief medical officer for Peugeot; Gail Cotton, head of OH services for the Leicestershire Fire & Rescue Service; and OH consultant Cynthia Atwell. A psychologist and OH physician were also present.

The key message to come out of the training, stresses Kneale, is that OH practitioners need not have anything to fear from sickness certification. “It helped raise the confidence of the OH advisers in the skills and knowledge that they possess,” she explains.

Certainly, for those taking part, the courses were a valuable confidence boost ahead of the launch. OH nurse Karl Brookes was one of 20 or so practitioners who attended the November course. OH practitioners from many sectors, including engineering, office based and call centres, were represented, and from all parts of the country, particularly the Midlands, Manchester and London.

Brookes is an OH consultant to London Taxis International, one of the companies taking part in the pilot, which employs 300 people in Coventry. The company will be using its existing in-house OH operation to provide a certification function, with employees going to see OH in the first instance rather than their GP.

“It was about sharing common and potential problems within the peer group that people will be facing when the scheme is introduced,” explains Brookes.

The course also made it clear that, while practitioners may come from different backgrounds, they all have core protocols they can draw on and follow.

Leicestershire’s Cotton says that the core of the training was the recognition that while OH practitioners might be taking on a new responsibility, the way they do it should not differ from what they are doing already. Indeed, it is hoped it will be at the core of making the pilots a success, she suggests.

OH practitioners running the pilots will simply be providing a functional assessment of an employee, not making a medical diagnosis, she stresses. “It is not assessing illness, but fitness to work. It is simply doing a functional assessment – is this person OK to go back to work?
“It’s about tying up loose ends and ensuring people felt they were working consistently,” she says.

“The course was not there to teach delegates anything new. Sickness certification is not something to be freaked out about, but something new and terribly exciting,” she enthuses.

Before the course, some of those involved had been approaching the pilots with a degree of trepidation, Brookes concedes. One particular worry was the issue of potential conflict and confrontation. What, in essence, should be the right response when an employee is questioning your expertise either to sign them off, or back into, work?

“OH practitioners will need to be quite firm in their opinion and encourage the employee that it is in their best interest, and that they are acting as their advocate as well,” he explains.

The course also stressed the need for action to be taken in a consistent way, integrated with GPs and other providers. “GPs need to be aware of what we are doing. They need to be able to say, this man is employed by this company, which uses this service and has a rehabilitation plan,” explains Brookes.

Along with general confidence building, the course looked in depth at some of the different types of disorder commonly presented and, through the use of case studies, examined how practitioners might respond. What checklist should they be following and what boxes needed to be ticked, for instance?

Other areas included when to feed into HR when something moved into the realm of a disciplinary issue and looking at medico-legal issues. “It was very clearly about deciding what our objectives are and what our professional response would be,” says Brookes.

“A lot of people wanted to know what they should do if someone presented with a certain condition – what would be the right thing to say? So it was just about wanting to confirm some grey areas,” he explains.

“It really made us feel more confident that our professional judgement was on the right lines. It is very comforting to know that you have professional backing,” he adds.

The networking potential of the course was equally as important as the nuts and bolts advice and support, agrees Cotton.

Through contact on the course and subsequently via e-mail and phone, those involved now have a network they can call on to provide professional advice and supervision, reflect on successes, problems or lessons, she explains.

The fact that practitioners will be following clear protocols and consistent, evidence-based guidelines was hugely reassuring, argues OH adviser Anthea Turnbull, who also attended the November course.

Turnbull works with Cotton at Leicestershire Fire & Rescue Service, and will be closely involved in one of the pilots with a local bus company, using the model of a visiting OH practitioner. “It is about realising that this is very structured. There is going to be consistency and familiarity in your way of working and it is going to be evidence-based,” she says.

A variety of speakers during the course explored issues around musculoskeletal problems and the psychological impact of sickness absence on the individual, employer and society.

Participants were also able to meet the research team and discuss individual roles within the study.

Where the pilots will particularly help, Turnbull believes, is in giving OH access to people who may have gone off sick with relatively minor ailments and, so, get them back to work more quickly.

“It will enhance our role because we are actually going to be dealing with these common illnesses on a regular basis. We will be seeing a lot of people who would otherwise have gone to their GP and been signed off for things such as coughs, colds and flu.”

There the sicknote system has been falling down, both sides now recognise, is that a harassed GP presented with a patient claiming, say, work-related stress, has five minutes at most to make a diagnosis with little or no idea about their work or workplace.

“The nurses involved are all people who know the employee and the work they do, they know the detail of the job and its requirements. They simply tend to underestimate their own abilities,” says Brookes.

Employers, too, were rapidly recognising that fast-track interventions in rehabilitation and determining fitness for work, alongside active engagement of OH experts, rather than ‘the antiquated legacy of awaiting receipt of the obligatory medical certificate’ was the way forward, he adds.

This does not, of course, mean that the pilots will be looking to step OH practitioners into GPs’ shoes, nor should OH professionals want to go down this route, suggests Turnbull.

“If there is anything major we will, of course, refer them back to the GP. We will also be working much more closely with GPs. At the moment, we have little to do with GPs, there is not much interaction other than report writing,” she explains.

Indeed, with OH professionals becoming the first port of call for many employees, they may have a role in encouraging people who might otherwise have sat at home waiting to see their GP.

If improved communication with primary care is a long-term result of the pilots, all to the good, suggests Kneale.

OH practitioners are not being asked to judge whether someone is sick or well – that will remain the GP’s job – but simply whether they are fit to work, she stresses.

“I do not feel OH professionals communicate with GPs often enough, to be honest. OH is often under-utilised. This is all about helping them to reach their potential,” she explains.

How the pilots will work

Around 20 firms around the country are now set to take part in the sicknote certification pilots.

The pilots are a key part of a deal struck between the Department of Health and GPs as part of their agreement of a new contract for family doctors.

They were initially due to start early last year, then in April, then October and now, finally, will get under way this January – with the last delay simply the result of so many organisations being interested in taking part.

The pilots will be looking simply at the practicalities of offering alternatives to GP certification, its costs, lessons, popularity and impact on employers, employees, GPs and OH practitioners.

Four different models are set to be evaluated over the pilot period:

  • Using an in-house OH department to act as a first port of call for sick employees and draw up fitness-to-work reports for line managers.
  • Employees are issued with information booklets and ‘credit cards’ outlining who to contact, and how. Local GPs will be targeted through an advertising campaign informing them that employees at the firms involved are taking part
  • Access to a nurse-based call centre that logs absentees and offers basic medical advice to both employer and employee
  • Access to a visiting OH service, where advisers can be booked in person
  • Access to an OH practitioner working from a GP practice.
  • Key points covered by the course

    Confidence building: OH has nothing to fear from sickness certification and is often the best placed practitioner to be making the decision on whether an employee is fit to be at work
  • Conflict management: tips on how to manage disputes over the fitness to work assessment, as well as medico-legal issues
  • Networking: building up a support and advice network of other practitioners involved in the pilots
  • When to feed the decision-making process into HR
  • Building up and facilitating communi-cation with primary care, and recog-nising when to refer
  • How to respond to specific common ailments and workplace illnesses, including musculoskeletal disorders
  • How to respond to the psychological impact of sickness absence
  • The need for a completely consistent, evidence-based approach.

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