Health and Work in General Practice Dr Elfrieda Power.

Health and Work in General Practice

Dr Elfrieda Power

Patient perception of the role of GP’s

• 91% believe that GP’s should have a say on how long you should have off work due to ill health

• 61% believe that GP’s should advise you not to go to work

• 96% believe that GP’s should help you access treatment and therapy to help you manage at work

Worklessness

• “A state which includes not being in paid employment and not actively seeking employment”

• 66% of all sickness is due to minor self-limiting conditions

• 99% return to work quickly but..

Worklessness

• On average 1 million report sick each week• After 6 months 3,000 are still not back at work• Five years on 2,500 of them will be claiming

Incapacity Benefit• 2.7 million people claim IB each year which equate

to 1 in 13 of the working age population• Window of opportunity 1-6 months

– Worker off for 4-12 wks - 10-40% chance of being off work at 1 year

– Worker off 6-12 months - 90% chance of never returning to work

Worklessness

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Benefits of work

• For most adults of working age, there is strong evidence that work:– Promotes recovery and aids rehabilitation– Improves physical and mental health and well-

being– Reduces social exclusion and poverty– The beneficial effects of work generally outweigh

any risks of work

Benefits of work

• There is strong evidence that long periods out of work can cause or contribute to:– Higher consultation, medical consumption and

hospital admission rates– 2-3 times increased risk of poor health– 2-3 times increased risk of mental health problems– 20% excess mortality– Impact on children in workless households

• Sickness certification is a major clinical intervention with potentially serious long-term consequences

• 2/3 sickness absence, long-term incapacity and ill-health recruitment is now due to ‘common health problems’ (mild-moderate mental health, musculoskeletal problems and cardio-respiratory problems) Much of this should be preventable

• Common health problems can often be accommodated at work, if necessary with appropriate adjustments

• Planning and supporting return to work, in partnership with patients, are important parts of clinical management

A Functional Assessment

• Diagnosis is not important• Think about impact of health on work

– HOW IS THIS AFFECTING YOU?

• Think about impact of work on health– WHAT DOES THAT INVOLVE?

• A fit note not a sick note– Combines MED3 and MED5– A form of communication to employer– Should be advisory– NOT a legal document

Effects of work on health• Demands of job

– physical, intellectual

• Environment – shop-floor/office RF, dust, chemicals, noise etc

• Temporal – shiftwork, early start

• Travel – commute, between sites, overseas

• Organisational – lone working, customers

• Layout – ergonomic aspects, workstation and equipment

Effects of health on work• Stamina

– work fulltime, physical demands Mobility• Mobility

– Walking, bending, stooping• Agility

– Dexterity, posture, co-ordination• Rational

– Mental state, mood• Treatment

– Side effects, duration• Intellectual

– Cognitive abilities• Essential for job

– Food handlers, driving• Sensory aspects

– Safety, self and others

FIT NOTE• Common workplace modifications:

– Consider lowering patient targets– Suggest a workplace assessment– Need to change activity regularly– Altered pattern of work - shifts/tasks/content– Advise referral to an occupational physician– Reduced hours– Phased return– Training– Mobility and transport– Are you able to arrange physio?

ENCOURAGE PATIENT TO KEEP IN TOUCH WITH WORK

• The doctor who has the immediate care issues the fit notes, eg secondary care responsible if recent surgery etc.

• The doctor is not required to sign the patient back to work - they can go back when ever they feel ready

• If you think condition could be work related eg asbestosis, dermatitis - refer early to specialist

• Tribunals decide if someone has a disability so do not make that decision

• Consider return to work mid-week• Avoid medicalising non-medical issues (eg stress)• If work related issues write “patient states that there are factors

related to work-based issues’• If bullying - empower patient to take to higher manager• If employers ignore your suggestions - ask them to write to you

and consult DWP website - EMPLOYERS RESPONSIBILITY• A sick note is NOT a legal document - a form of communication

between employee and employer• Negatives of sick notes: Patient needs to be aware that legally

they can legally be dismissed if they have too much time off work

• Medically recognised diagnosis

• If tick, have to qualify

• Prognosis - refer to websites

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Changing behavior

• Motivational interviewing– Shift style, remove ambivalence, empower

individuals

– “How important is it for you to get back to work?

– “So how confident do you feel about getting back to work?”

• Grade 1-10• How would you approach this?

What if well and functioning?

Please doc can I have a sick note?– “you’re putting me in a difficult situation - my role is

to do a medical assessment but I can’t find anything wrong, you’re asking me to commit fraud”

– “I you’re unhappy I suggest you d/w employer– “Evidence shows that it is better for your health to

go back to work and that is what I believe is best for you, I would be doing a disservice if I signed the note”

Employment and Support Allowance

• ESA was developed to ensure that individuals would get the benefit and support they need to help them return to work, where possible.

• ESA is intended to be a combined benefit bringing together the rules from Incapacity Benefit (IB) and Income Support (IS).

• For both elements of ESA a person must have limited capacity for work. This is determined initially by a medical certificate from a GP (MED3) but then the Work Capability Assessment (WCA) which should be completed by week 13 of the claim.

ESA• Assessment Phase

– Lasts for up to 13 weeks.– During this phase the rate of benefit is based on Jobseekers Allowance

(60.50/wk) although additional premiums may also be payable.– A Work Focus interview (WFI) takes place after 8 wks.

• Main phase– Starts once limited capacity for work has been established by meeting

the WCA threshold.– A work related activity component becomes payable (24.00)

conditional on complying with the work-related activity regime. This is paid in addition to the Assessment phase allowance (84.50/wk) equivalent to the long-term rate of Incapacity Benefit.

ESW

• Support Component– All cases are looked at by an approved HCP at the outset.– They identify individuals with the most severe limitations, will

contact the GP/others for further evidence which may allow the individual to go straight to the support group without having to attend a WFI.

– They do not to comply with work related activity regime and are entitled to an extra 29.00 and disability premium (12.60) so total 102.10/wk.

Work Capability Assessment

• Assesses entitlement to ESA• A medical assessment that has been developed to

ensure it accurately reflects limited capability for work (ie looking at what they can and cannot do in a modern labour market and working envirnoment)

• Based on the effects of a persons condition, not the condition itself.

• Also a Work Focussed Health Related Assessment looking at the support a person may need.

• GP’s are an important part of the process - individuals may ask GP’s to provide info and this is taken into account

WCA Statistics

5% Assessed by the WCA as suitable for the ESA Support group

11% Suitable for ESA Work Related Activity Group

36% Assessed as fit for work

48% ESA before completing the assessment or the assessment is still in progress

If a patient appeals the decision - GP should continue to write fit notes

• Working for health website– www.workingforhealth.gov.uk/Carol-Blacks-Review

• Resources for GP’s– www.healthyworkinguk.co.uk

• Occupational health adviceline for GPs– 0800 022 4233– www.health4work.nhs.uk/

• Department of Work and Pensions– www.dwp/govuk/healthandwork

• Practical advice on Recovery times– www.rcseng.ac.uk/patient information/return-to-work

• Work and Health leaflets– www.tsoshop.co.uk/gempdf