Could the use of independent and impartial doctors in signing sickness certificates benefit the management of sickness absence in the UK? IOSH conference speaker Dr Robert Hampton believes so.
“The medical sickness certificate is one of the most powerful and potentially dangerous treatments in the GP armamentarium.” These are the words of Professor Waddell at a 2006 British Medical Association (BMA) conference on work, health and well-being when introducing the influential evidence review, Is work good for your health and well-being?1
Professor Waddell’s powerful statement makes sense given the overwhelming evidence that avoidable worklessness is at least as dangerous as smoking in terms of mortality and morbidity. As a ‘jobbing GP’, who also has a part-time occupational medicine practice, I’ve developed a fascination for the myths and misconceptions that have grown up around sickness certification.
The average GP will write around 600 Med 3s (now known as the fit note) each year. The old sick notes were unpopular with GPs, occupational-health professionals and employers. Indeed, organisations representing employers have repeatedly cited the sick note as the greatest obstacle to managing absence.
Alternatives have been piloted, including telephone follow-ups or personal contact with OH professionals, but attempts to engage absent workers have met resistance from trades unions and suspicion from many employees. Consequently, the practice of GPs signing notes to cover absence is here to stay.
Going on the Lloyd George
The changed format of the new fit note replaces the old sick note, a hardy beast that had remained pretty much unchanged since 1911, when introduced as part of Lloyd George’s National Insurance Act. This gave all workers the right to sick pay of 10 shillings a week for up to 26 weeks of sickness. The official sick note, written by family doctors, was the proof of illness. Several commentators at the time predicted an increase in malingering and idleness among workers, and the phrase “going on the Lloyd George” persisted for decades as an ancestor to the current concept of ‘throwing a sickie’.
The format of the old sick note could only be changed by Parliament, so remained unchanged for 99 years! In her review of the health of the working-age population, Dame Carol Black realised that the note itself was not fit for purpose and proposed a new ‘fit note’.2 The idea was to encourage everyone involved in managing absence to consider what the employee could do at work rather than making an all-or-nothing judgment.
The consultation to finalise the format of the fit note included representation from medical, business, trade-union, patient and disability groups. The final format, which was approved by Parliament to go live in April last year, included the following significant changes:
All in favour?
Some 10 months into its use, the fit note has stimulated debate among all the groups who participated in its design.
GPs have generally responded favourably. At primary-care meetings and presentations, I have had the opportunity to ask about 200 GPs, by a show of hands, how they view the new note. Overwhelmingly, they see it as either a positive change (about 75 per cent) or neutral (25 per cent). Not one hand has been raised to defend the old note when I’ve conducted such a poll.
The reaction from employers’ groups, particularly HR managers, has been divided, with about 50 per cent seeing it as a positive change, 25 per cent neutral, but one in four feeling that it has made the management of sickness absence more difficult. Commonly cited problems are that the GP doesn’t understand the particular issues at their workplace, the ‘may be fit’ option has been ticked without enough, or sometimes any supportive information, and the information provided has been unhelpful. I have actually seen a fit note with the advice to ‘sack the line manager’ as the suggested adaptation!
An analysis on the use and impact of the fit note by DWP is planned in the coming months. Early data from a variety of sources suggest that GPs are choosing the ‘may be fit’ option in 10-20 per cent of certificates. Subjective feedback from around 100 employers to a sounding board chaired by Dame Carol Black would seem to indicate that it has stimulated dialogue between employers and GPs, as well as an increase in occupational-health referrals.
Stubborn myths
Many myths have built up around the Med 3, whether in its current or previous form, and the new note does not seem to have had an effect on changing these so far. Frequently-encountered myths are:
Other than as documentary evidence for an employee to receive statutory sick pay, the note has no such mandate. In any other scenario, it is an advisory opinion to the person receiving it. The reality is that any number of payroll, management and insurance requirements have built up around this piece of paper over the years so that it has become a de-facto requirement for most organisations.
This has never been the case. It should simply be regarded as one component to consider when managing the absent worker. Where the ‘may be fit’ option has been chosen, the employer should consider whether a return to work is feasible. If not, the note reverts to a sick note. Where the person is signed as unfit to work, it is rare for employers not to follow the GP’s advice, unless an occupational-health assessment has supported such action.
Nothing in the field of health and well-being at work creates more frustration among GPs than this misguided request. The usual reason given is ‘to cover the employer’ for insurance purposes. Legal experts in this field tell us that there has never been successful litigation against an employer for allowing someone to return to work when their note runs out, or indeed, before the note expires. The new note has removed the tick box to indicate that the person is now fit for work, but the requests still come in and waste valuable time for patient and GP alike.
So what can we expect for the future? The intended ‘revolution’ that the new fit note was to bring about in the way sickness absence is managed in the UK seems to have started, albeit slowly. I believe that two developments will radically change the current status quo in the future.
The e-Fit note
For several years I have been puzzled as to why I have to fish around for the pad of sick/fit notes when just about every other administrative task that supports patient care can be performed on a computer. GPs have embraced IT in the UK and can record, prescribe, refer, advise, and even educate themselves during the consultation but, when completing the fit note, it’s back to pen and paper.
That may be about to change, however, as a note generated from the GP computer and given to the patient (as with prescriptions) is planned for later this year. UK primary care is regarded as one of the most intensely scrutinised area of health provision in the world, yet the opposite is true of how GPs sign sickness certification. The opportunity that e-fit notes will offer the Government, the general public and GPs to scrutinise their use will inevitably lead to changes in practice.
Other professionals signing fit notes
Only doctors can sign fit notes and, traditionally, this is the patient’s own GP. But many believe that other health professionals, such as nurses, physiotherapists, or occupational therapists should be able to sign notes in future. Although this is unlikely to happen for some time, the current guidelines do not prevent a doctor, working in an impartial role rather than that of advocacy, from signing the notes.
Fit for Work Service Pilot
Leicestershire is running one of the 11 Fit for Work Service Pilots in the UK funded by the DWP. Our pilot is unique in only seeing clients referred by their GP.
We have been operating since April last year to provide personalised case-managed support for the employed population of Leicester City and Leicestershire County, to get them back to work more quickly when they are signed off sick by their GP. The core team consists of case managers, an OH nurse and a part-time GP, who provide assessment and one-to-one flexible and personalised support. We have developed a network of support services, such as musculoskeletal therapies; psychological therapy; debt, legal and housing advice; and drug and alcohol support. So far, we have successfully returned 72 per cent of referred people back to work. The success rate rises to 92 per cent of those referred with a stress-related disorder.
A unique aspect of this service that has contributed to its success is that we sign all the fit notes for the clients for the duration of their time with the service. Fit notes are signed at a weekly multidisciplinary meeting, which allows the team to adopt an impartial approach to signing notes. We have signed several hundred so far, with the ‘may be fit’ option chosen 50 per cent of the time. As far as we know, this is the first time that a GP has systematically signed notes in a different capacity to that of an advocacy role. There is no legal or ethical reason why independent doctors, particularly occupational physicians, could not sign notes in future.
Most GPs report having been intimidated into signing sickness certification on several occasions. There is a growing body of opinion, supported by our pilot, that certification signed by an impartial doctor could improve the overall management of people at risk of long-term sickness absence. If more widely practised, this could benefit the successful management of sickness absence and, ultimately, the health of the working-age population in the UK.
References
1 Waddell, G and Burton, K (2006): ‘Is work good for your health and well-being? The Stationery Office – www.dwp.gov.uk/docs/hwwb-is-work-good-for-you.pdf
2 Black, C (2008): ‘Working for a healthier tomorrow – Dame Carol Black’s review of the health of Britain’s working-age population’, The Stationery Office – www.dwp.gov.uk/docs/hwwb-working-for-a-healthier-tomorrow.pdf
Dr Robert Hampton is a GP, occupational physician and clinical lead for the LCL Fit for Work Service, and will be participating in a panel discussion on the fit note at the IOSH conference on Tuesday, 15 March – www.ioshconference.co.uk
In this episode of the Safety & Health Podcast, ‘Burnout, stress and being human’, Heather Beach is joined by Stacy Thomson to discuss burnout, perfectionism and how to deal with burnout as an individual, as management and as an organisation.
We provide an insight on how to tackle burnout and why mental health is such a taboo subject, particularly in the workplace.
