Reviewing the fit note

Six months after its implementation, how does the fit note fit into the workplace? Joe Paton and Emma Riches report on survey results from Bangor University.

Bangor University has carried out a review of the impact of the new Statement of Fitness for Work (fit note) in the first six months since its introduction (6 April to 6 October 2010). The review revealed that the new style of medical advice was helping people to return from sick leave with greater ease (therefore making them more productive), in a shorter time (reducing the impact of sickness absenteeism) and with greater success, measured by people not requiring a further episode of sick leave within weeks of returning to work.

The Department for Work and Pensions (DWP) recommended that occupational health professionals should evaluate the impact of the new fit note.

Bangor University briefed employees and managers to change the perception that people should not return to work before they are 100% fit. Staff were given guidance on the action to take to relay their doctor’s advice to managers. Seven briefing sessions were held for managers, lasting 45 minutes each with examples about how the advice from GPs can be best managed, illustrated by examples provided in the DWP employers’ guide. Since 6 April, the university has received only two old-style sick notes.

Advice and support levels

Between 1 April and 30 September 2010, 46 staff received medical advice to take long-term sick leave (more than 20 days). The fit-for-work statement has not been in place for a sufficient length of time to ascertain its impact on the duration of sick leave. However, when medical advice to support a return to work was not given, the people concerned were off longer than those who did receive specific medical advice to support a return to work.

The occupational health practitioner sent a questionnaire to the 19 people in this group, asking them to share their experience of the new system; 12 responses were received (63%). The results showed that when the duration of amended duties extended beyond four weeks, staff indicated they feared a return to full duties would cause their health to deteriorate. This perception suggests that prolonged periods of adjustments may be counter-productive.

Every respondent stated that the medical advice had resulted in an easier return to work than with the previous certificate and most said GP and manager support had enabled them to return to work earlier.

All staff confirmed their medical advice resulted in a discussion between either themselves and their manager or the OH practitioner. This is a significant finding.

In 2007, the OH practitioner conducted an audit under the old sick note system. Of 119 individuals who should have received a return-to-work discussion with their manager, only 75 people (63%) did. When interviews took place there was no evidence the discussion resulted in periods of re-adjustment. The process had focused on managing attendance at work.

When comparing the findings from 2007 with the outcome of this review, it is clear that the fit note has succeeded in setting the scene for a discussion to agree and implement a successful return-to-work plan.

The 22 people who did not receive medical advice had discussed with their GPs the options of a phased return, altered hours, amended duties or workplace adaptations, but responded that they did not want any help to return to work.

Return-to-work advice

The seven people whose absence was longer than 28 days reported that their GP did not discuss the benefits of returning to work supported by adjustments with them.

Many said they would have appreciated return-to-work medical advice. One of those individuals came back to work while still signed off and was put on a phased return with temporary restrictions on manual handling and stair usage. The individual then resumed normal duties when the fit note expired.

GP comments

When medical advice has been received, managers are pleased to facilitate an earlier return to work. Managers asked for GPs to write comments in the free text section about the functional effect of the person’s condition to enable them to provide work within the limits of the person’s functional ability. Twelve GPs responded to the questionnaire, confirming the new system created an opportunity to encourage people back to health through work. Only one GP felt that the university did not respond favourably to the advice that had been given.

100% fit for work

A number of staff representatives hold the view that people need to be 100% fit to return to work. The basis for those concerns is that co-workers are said to undertake tasks that the returnee is restricted from doing. The point needs to be made that co-workers will probably be undertaking more of the tasks of an absent colleague.

A small number of staff representatives expressed a view that GPs are not sufficiently informed about the work people undertake to give occupational advice. In such cases, OH needs to explain that the GPs “suggest there may be benefit from” adjustments, and the advice will at least bring the manager and employee together to discuss what can be done.

Other staff representatives expressed a view that advice from GPs to support a return to work is more likely to be supporting health, whereas advice from the OH practitioner to return may be perceived to be supporting a reduction in absenteeism.

Return to work

This review confirms that when medical advice has been given, it is well directed and has been effectively managed. The employee is returning to work with greater ease. There is a consensus among employers and managers that many returned to work earlier than they would have done otherwise following the medical advice given in the Statement of Fitness for Work. This quality of discussion could not occur under the former sick note system.

There were cases when no medical advice was given to support a return to work. In many of these instances, the GP did discuss with the employee if a supportive return would be beneficial and this was felt not to be the case. Managers are happy that they receive medical advice only if the person returning to work needs additional support.

In a minority of cases, medical advice to support a return to work had not been discussed. This occurred among those who were off work for longer than 56 days. Those same employees commented that they would have appreciated medical advice for a supported return. They drifted into longer-term absence and the comparison with those who were supported suggests this was a missed opportunity to improve their health through an earlier return.

By sharing the impact of the Fitness for Work statement with the GPs, managers, HR, staff representatives and health and safety professionals it is hoped that these findings can form the basis of a wider discussion to build on the progress made over the first six months to explore how improvements can be made.

Joe Patton, MSc, BSc (Hons) OHND, RGN, RMN, is an occupational health nurse practitioner, and Emma Riches a health and safety assistant at Bangor University.

OH nurse survey shows progress of fit note

Two months after the implementation of the new fit note a questionnaire-based survey of occupational health nurses attending the Central England Occupational Health Group (CEOHG) Annual Study Day in June 2010 was carried out to explore the role occupational health nurses play and their views on the fit note.

Of the 52 OH nurses who participated, 31 (60%) were aware of the proposed changes at or before January 2009, a further 20 (38%) by December 2009, but one (2%) became aware only in April 2010.

Thirty-one (60%) had been involved in planning for the introduction of the new note and preparation and development of guidance for line managers and HR. Forty-four (85.6%) had read the published guidance for GPs, the same number read the employers’ guidance and 49 (94%)had read the guidance for occupational health professionals.

Despite some initial concerns, the majority, 34 (65%) reported no change to their OH workload and had not seen either an increase or decrease in referral numbers, both of which had been voiced as concerns before the introduction of the new system. In contrast, three (5%) reported a decrease and 12 (23%) an increase in workload. Seventeen (33%) reported that about 25% of notes that they were aware of said “maybe fit for some work”, rather than “unfit”, and six (11%) reported the number to be as high as 50%.

Early trends observed included phased returns being recommended for employees with mental health problems, reduced hours for people with cardiovascular ill health and workplace adaptations for employees with musculoskeletal disorders. Respondents also reported seeing examples of multiple recommendations involving several adaptations.

In terms of beliefs, 17 (33%) agreed and 14 (27%) disagreed that the new note was likely to encourage an early return to work. Sixteen (31%) reported that they thought the note had improved their communications, 22 (42%) felt it had improved opportunities for them internally in the business, but only seven (13%) felt they had developed more contacts as a result.

The findings of this survey, undertaken soon after the introduction of the fit note, suggest that in some cases OH nurses missed a valuable opportunity to raise their profile and demonstrate their value and contribution to business.

Although the majority (98%) of respondents were aware of the pending introduction of the fit note, a smaller proportion (60%) of OH nurses were involved in the initial planning and development of guidance for their own organisations before its implementation.

One possible explanation is that some OH nurses may have considered the fit note to be an organisational rather than a health initiative, and if they became too involved with the logistics of implementation this could only lead to conflict between OH and the employee/employer when advising on fitness for work.

Alternatively, they may have believed that getting involved in the implementation of the fit note would mean managers could refer cases to occupational health and increase OH workload when only simple adjustments were required. However, the study showed that initial concerns about an increase in workload did not appear to be a major issue.

There are likely to be further opportunities for OH nurses to raise their profile by getting more involved with the development of wider guidance for employers on the rehabilitation of employees, particularly those with mental health and musculoskeletal disorders and the issues facing older workers.

Sian Hyland is chair of the Central England Occupational Health Group.

Nerys Williams is principal occupational physician at the Department for Work and Pensions.

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