Therapy is only one of many interventions that can help people with mental health problems return to the workplace. But Dr Rob Hampton highlights evidence from the Fit for Work pilot programmes on how non-clinical approaches can be effective.
Stress and mental health conditions form the major cause of long-term absence – and the figures are rising, according to a number of business surveys. It is estimated that, each year, one worker in six in England and Wales is affected by a mental health problem. Stress-related issues are now the most common reason for long-term sickness absence in the UK and are a particular problem in the public sector where mental ill health accounted for nearly 4.6 million of the 7.9 million days that were lost to work-related illness or injury in 2010/11.
Typically, GPs and employers will first consider counselling or other “talking therapies” for people who are off work with stress, anxiety or depression. The conventional wisdom is that such interventions will offer the best chance for a return to work. The experience from Leicestershire’s Fit for Work pilots, established in 2010 as part of the response to Dame Carol Black’s 2008 report Working for a healthier tomorrow, suggests that the obstacles for a return to work are usually a complex mix of practical and emotional problems. A return-to-work plan requires more attention to the human factors alongside, or even instead of, therapy that will not necessarily facilitate a return to work.
Over-medicalisation of mental health problems
The problem for GPs managing this complexity is that their time, sphere of influence and referral routes are rarely adequate to address issues at work or in a patient’s personal life. The problems become medicalised because pharmaceuticals and talking therapies are the most obvious options available to them. Most GPs recognise this over-medicalisation. Indeed, more than 70% say that on occasion they “are compelled” to sign notes for people for “other than medical reasons” but the demand for a “solution” from an increasing number of patients leaves GPs feeling powerless to intervene in any other way than by some form of “therapy”.
Is the fit note part of the problem? The main issue here is that the fit note still encourages the medicalisation of problems that may in fact be due to personal or workplace issues rather than a true mental health disorder. Organisations that have access to employment support or occupational health services often continue the medical model by seeking clinical opinions or talking therapies aimed at resolution of symptoms rather than addressing the actual problem.
My experience is that most GPs do not recognise the importance of their wording on the fit note – it acts as the main vehicle of communication for most employers to consider their approach to the management of sickness absence. Despite the new structure of the fit note, many GPs still feel that they are being asked to make a judgment on ability to carry out work duties, with little knowledge of the work environment or opportunities for adaptations.
Fit for Work pilots: a biopsychosocial approach
The Fit for Work Service (FFWS) pilots were intended to provide support that, in the words of the Black report, would be “based on case-managed, multidisciplinary support for patients in the early stages of sickness absence, with the aim of making access to work-related health support available to all”.
In addition to personal case management, clinical care is provided by the occupational health nurse advisers and the GP.“
The FFWS receives referrals only from GPs who are encouraged to do so, or patients at risk of long-term sickness absence. GPs have adopted the musculoskeletal flags approach (Burton and Kendall, 2009) for all their cases, including those with mental health problems. This model of assessment has been popular with non-clinical case managers because it allows them to deconstruct complex problems into personal, workplace and context obstacles to a person’s return to work and shifts the emphasis of assessment and intervention towards actions that facilitate recovery and return to participation. These are explored at the initial consultation and are agreed with the client in a jointly signed-off action plan.
Subsequent support is tailored to the individual’s needs. In addition to personal case management, clinical care is provided by the occupational health nurse advisers and the GP. The Leicestershire FFWS provides quick access to services, including musculoskeletal therapies, psychological therapies, debt management advice, legal advice, career counselling, and employer liaison and mediation. Liaison with employers is a vital component to most cases and dialogue is managed through consent forms.
The FFWS GP signs all fit notes throughout the person’s time with the service and writes a discharge summary with a copy of the final fit note on discharge.
Mental health: who needs therapy?
Experience shows that local GP colleagues welcome an impartial service that can deconstruct the complexity of mental health problems towards a targeted intervention. In the first two years of the pilot the service has received more than 1,200 referrals from GPs; 130 (87%) of the 145 GP practices in Leicestershire have referred patients, with 70 practices (48%) having referred five or more. Fully 96% of GP survey respondents agreed or strongly agreed that “FFWS has benefited my patients”; 63% of referred patients have mental health problems and 28% musculoskeletal problems; 68% of people return to or stay at work, with a further 10% to 12% being “work ready” or actively seeking alternative employment.
One of the most powerful messages from the pilot is that 78% of people who return to work cite “non-medical interventions”, such as mediation/negotiation, personal support and help with new employment as those that made the most difference. Healthcare interventions were cited by 22%, while only 7% cited mental health therapy as the most important intervention to aid return to work.
The message from the FFWS client feedback during case management is clear: although mental health problems account for the majority of long-term sickness absence, traditional mental health therapies are less effective towards a vocational outcome than other more practical or human forms of support.
All occupational health providers have an ethical duty to be independent and impartial. No data has been collected to back up this observation but several cases suggest that the employee’s perception of FFWS independence from an employer was helpful towards a negotiated solution. The fact that the route of referral for vocational rehabilitation was through a GP to a service that was tangibly independent of the employer seems to have given the Leicestershire FFWS an advantage to succeed where existing OH intervention had failed.
The Leicestershire pilot is thought to be the only independent service to have taken on responsibility for sickness certification – and has signed more than 2,000 certificates so far. It has been working with two local universities to perform a qualitative and statistical comparison of the way it uses fit notes compared with a local practice.
This analysis is nearing completion but early indications are that it uses the “may be fit” option five to six times more often than a typical GP surgery, a figure that rises significantly after the first note. Of all the notes issued, 90% include information within the text box available.
The case managers report that the fit note as a vehicle for communication, to facilitate dialogue between employers and employees, has helped their work enormously and overcome the inertia in disciplinary or grievance procedures at the root of so much mental health absence.
Improving communications between the workplace and GP
Fit notes will be here for the foreseeable future and, whatever their legal status or intended purpose, their de facto use suggests that they are regarded as the most influential transaction between mainstream healthcare and the workplace during sickness absence.
The Council for Work and Health (CFWH), set up in 2008 to provide an authoritative and representative unified voice on health and wellbeing issues, cited improved communication between employers and GPs as one of its first three key objectives.
The Leicestershire FFWS is thought to be the only independent service to have taken on responsibility for sickness certification.”
The Fit for Work team has been commissioned by the council to perform a study to assess the usability and effectiveness of a “standardised letter” developed by the CFWH. The letter provides a structure for an employer receiving a not-fit note to propose adaptations or adjustments that may facilitate an earlier return to work. The Institute of Occupational Safety and Health has sponsored this study with its development fund.
The plan is to train HR or line managers how to use the letter, trial it over six months and ask them to record structured data on its usefulness, usability and effectiveness as a method to encourage an earlier return to work. Semi-structured interviews are to be conducted with a sample of stakeholders to see whether the letter encourages dialogue between employers, employees and their GPs.
This project aims to guide the evolution of fit note use by developing standards, examples and guidelines to support best practice between employers and GPs and reduce unnecessary absence from work.
There is evidence emerging that a bespoke case-managed return-to-work service can provide help to people who are absent from work with stress and other common mental health problems. Conflict resolution and personalised support are the key interventions towards a successful outcome.
The pilot supports the idea that de-medicalising long-term sickness absence is appropriate for the majority of people receiving fit notes for more than six weeks and supports the proposal in the recent “Sickness absence review” commissioned by the Department for Work and Pensions that an independent advisory service to assess sickness absence at four weeks would be a more appropriate guide to rehabilitation than the health intervention routes typically chosen by GPs and employers until now.
Dr Rob Hampton is a GP in Wigston, Leicestershire, and clinical lead for the Leicestershire Fit for Work Service.
Black, C (2008). “Working for a healthier tomorrow”. London: The Stationery Office.
Kendall N, Burton K (2009). “Tackling musculoskeletal problems – a guide for clinic and workplace identifying obstacles using the psychosocial flags framework”. London: The Stationery Office.
Case study 1: Phased return to work after 11-month absence
A woman in her 50s working for a large retail chain had been off work for 11 months with anxiety and depression. There was no history of mental ill health.
She was taking antidepressants and had been receiving therapy through her GP for six months when her therapist asked the GP to refer the case to the Leicestershire Fit for Work Service.
The case manager used the Kendall and Burton flags system to identify the issues affecting a return to work as follows:
Case study 2: Support and encouragement proved crucial
A woman in her 50s working as a clerical officer in the public sector had been off work for nine months with stress-related symptoms and low mood.
She had been seen twice by her employer’s occupational health department and was advised to stay off work, but no action plan for a return to work was put in place. She had attended two talking-therapy sessions but declined any more before requesting referral by her GP.
The issues affecting a return to work were as follows:
One year on, this client is still at work and confident of remaining so. She reports that the offer of support and encouragement was more helpful than therapy. The key factor aiding the return was the involvement of the FFWS case manager who helped her to negotiate redeployment.