Dr Mark O’Connor gives his view on how GP federations can transform the role of GPs by supporting employees as they go back to work.
GPs are sometimes seen by HR and occupational health (OH) professionals as a barrier to getting employees back to work after sickness absence. O’Connor leads a team of 20 GPs working from four practices in North Somerset, who are trying to break the mould.
Example case study
Maria smells of booze again and, of late, is looking a little dishevelled. You are the HR manager and have been asked to investigate. She is a senior analyst who has been employed with the firm for 10 years and is leading on a new IT project for a major client. Your heart sinks a little because you know Maria is a real talent and is therefore important to the business, but is also known for her quirky character and challenging personality. A senior colleague has told you that the project is way behind and that Maria has stopped responding to emails. Over a friendly coffee, Maria admits she feels overworked, that her GP thinks she might need some time off work because she is stressed and that she is considering starting antidepressant medication. You ask for more details but Maria gets upset when you suggest asking for a formal report. She breaks into tears and leaves abruptly, saying: “Sometimes I think it would better if I wasn’t here at all.” The next day you receive a fit note that says “depression – may be fit for work” with a tick against the box for “amended duties” with a duration of three months. However, Maria does not respond to your calls and her manager is keen to start disciplinary proceedings.
At this point you would be forgiven for taking a slug of your own favourite tipple and booking to see a GP yourself. Maybe you are lucky and are one of the tiny number of companies that use an in-house OH service or have an independent OH company to which you can pass the whole messy medical bit. More than likely, however, at this point you are thinking this is going to be a long haul. With a heavy heart you will write to Maria’s GP for a report. You have little confidence that a report will be prepared with any urgency by a GP who you assume will be an advocate for Maria. You now expect an expensive report with many useless clichés and platitudes, as you have negative thoughts about the whole process, alongside an opinion that sits on the fence.
As an occupational physician, I have watched for 20 years as HR as a discipline has grappled frequently with the sort of problem Maria presents. I have been impressed with the professional approach, care and desire of HR managers to support employees with complex problems and have shared their frustrations with the slowness with which medical information and opinion is brought to help the situation.
Who are Work Doctors?
In North Somerset there is a group of GPs that is working hard to make sure that the above problem does not present itself. They have called themselves Work Doctors and their mission is as bold as it is simply stated: let’s get Maria sorted this week. It is a team of 20 GPs, led by myself, working from four practices under the Work Doctors name.
If HR contacts us on Monday, we see Maria on Tuesday, a report is with HR on Wednesday and we can chat about the nuances on Thursday and, well, Friday is up to you because the case is pretty much solved by then.
It is also proving popular with local and national businesses that appreciate the relationship skills we bring to complex cases, and are also impressed by the timescales.
So how do we do it? Well, we have to thank the bankers. Since 2008 there has, as a result of the economic crisis, been a move to reduce the resources of the NHS. General practices are increasingly looking to federate to survive by sharing back-office staff, pooling talents and building infrastructure resources. That is what Work Doctors has done.
Formation of the LAWCY group
My GP partners and I have joined with 20 GPs from three other practices to provide NHS services, research and teaching as a federation called the LAWCY group (LAWCY – an acronym formed from the names of the practices involved: Long Ashton, Wrington, Clevedon and Yeo Vale). It has also, crucially for Maria and other employees like her, given us the opportunity to pool our OH-trained doctors, nurses and building resources into an OH company.
So, what makes us different? Well, frankly, we are fed up with the stereotypical image of the unhelpful GP who patrols that space between employer and employees, whose sole aim is to keep employees out of the toxic work environment, painted by the one-sided account he has heard from “she who must be believed”, ie his patient. Like all stereotypes, there was once a grain of truth in this view of GPs but nowadays most GPs understand that work is good for mental and physical health. They want to help employees back into the workplace. They would love the time to be able to engage with HR teams and produce in-depth reports but they simply do not have it. The structure of UK general practice with small teams of GPs in partnership is under threat of extinction to an unprecedented degree. GPs in traditional practices are busy just dealing with the demands of appointment requests that make the A&E crisis look like accommodating an extra guest for Sunday lunch.
The LAWCY federation of GPs, the first in North Somerset and Bristol, has created a “super-practice” in direct response to this existential threat. Yet each branch remains a local community presence with stable staffing that even Dr Finlay, the ancient fictional TV doctor, would have recognised and been proud to work in. We have created time, and we want to use it to get patients back into work.
Employers may be thinking: well this is fine but what happens to employees not registered with the GP practices in the federation, but with struggling GPs in other practices? Work Doctors can take on these too. In fact, the employees in our current client base exceed our registered lists and yet still comply with our mission statement to see all within a week.
So, what happens to employees for whom we do not hold the medical record? Between the four federated practices we have nearly 50,000 patients registered for NHS services. With a national average of five consultations per patient per year, that is more than 175,000 consultations a year. So, even if Maria is not one of our own patients, we understand at a deep level the subtleties of her treatment and the natural history of her condition. The same is true for any employee referred to us with any condition. We can organise support and advice and our reports can outline a detailed framework of action for HR professionals often without needing to involve Maria’s GP at all. That is how we achieve our mission of a same-week solution.
It is a radical, some say audacious, approach to case management, but as Henry Ford said: “If you always do what you always did, you’ll always get what you always got.”
Of course, sometimes we might need to find out more information, but the fact that we are all GPs, as well as trained in OH, reassures employees and is enough to get a detailed roadmap and time frame of a return to work. This means that HR can plan appropriately and make adjustments from our initial report.
The word “clinical” comes from the Greek “to be at the bedside”. Many other companies offering OH services would struggle to convincingly call themselves clinicians as they neither treat nor prescribe for any group of patients, nor do they take responsibility for diagnosis. We are steeped in it, with many thousands of real clinical interactions weekly. Appraised, revalidated, checked by the Care Quality Commission as up to date in the management of any condition that it is possible to be presented with in modern general practice.
We do not need to sit on the fence and produce a bland report six weeks late that drives a case backwards. We understand all the medical, surgical, gynaecological and psychiatric issues that are affecting employees because we deal with them every day. We are not afraid to advise employees either on the treatment they have received or how to navigate the complexity of the NHS and prepare for their own future GP consultations and maximise their effectiveness.
Are we in danger of breaching established ethical lines that state OH services should refrain from treatment advice? Well, we are back to Henry Ford again; we are walking that line, certainly, but employees and employers are on the tightrope with us and it is working. Employees that we see are getting back into work quickly and safely which is good for them, their company and the country.
Apart from the big multinational OH companies such as Atos and Serco, the majority of OH provision, where it exists, is in small firms often led and run by nurses. We have worked closely with OH nurses all around the country, incorporating them as associates and delivering services using our IT infrastructure to the same standards. We have really benefited from this close association with skilled OH nurses who, for too long, have worked in isolated silos. We now have OH nurses using our local facilities, seeing employees and contributing to training and development of our GPs as part of their ongoing training and preparation for their professional OH qualification examinations.
We have a dedicated online appointments system which means that HR professionals can simply log on from their own office, book a free slot that week and know that a report will be emailed to them within 24 hours. In a similar vein, we have automated the medical assessment for pre-employment and pre-placement. What is often a paper chase lasting many weeks with filing, storage and retrieval problems now takes place within minutes. You get a direct line to the doctor to discuss the reports and so does the employee. We will even visit onsite and facilitate a meeting, if needed.
General practice has always been recognised as being 15 years ahead of the hospital sector with respect to IT infrastructure. It stems from being responsible for buying it and therefore being an intelligent customer. We have used that history and have a common online OH medical record system called SecureNotes. It is simple, reliable and means that wherever the patient is followed up, the doctor or nurse has the complete record.
OH medicine has its roots deep in the history of general practice, long before the NHS was a germ of an idea of NHS founder Aneurin Bevan. Pre-NHS, GPs were local factory doctors who performed simple medicals for local businesses. Its academic base and research has grown and the legal framework now places burdens on both employer and OH company to provide to exacting standards. This is all as it should be and to be applauded. But let’s not forget Maria, and the many thousands of employees who develop the full panoply of medical, surgical and social conditions that blight their ability to enjoy a full life and contribute to the workplace.
So how did we solve the problem of Maria? Well, we were told about her on the Monday. I saw her on Tuesday. I told her I was a doctor that treated many thousands of patents like her. She could trust me. Clichéd but true, nevertheless, and it resonates with employees and opens up the conversation to get to the heart of the problem. I told her I know her employer and line managers and that I have visited her workplace and know what it is like. She agreed that my report could be released on Wednesday and, because I understood the clinical issues and trusted her, we agreed we did not need to burden her own GP with a report request. Maria is in treatment now, is off the booze, has finished counselling and did manage to complete the IT project after we all agreed that a three-day week for two months working solely on this project would be reasonable. It worked.
So, after talking to her manager on Thursday and agreeing the changes, I sent my invoice in on Friday. You guessed it, to be paid in 60 days. Some things never change.