‘Fit for work’ option removed from fit notes

Tony - With regard to your last paragraph you sum up very nicely why an EMPLOYEE should have concerns of bias with in house OH. What you have just explained is that if an employee takes their employer to tribunal for perceived disability discrimination, if they had an OH advisor at their company they were more likely to loose their case!

I think that says it all! What can you possibly say now that is going to convince me that having OH is benefiting employees?

If you remember I was NOT talking about getting people BACK to work which I agree there are SOME that will take a little convincing, but about those that WANT to return or indeed continue in their role but are stopped from doing so. Presumably these are the ones that account for some of those tribunals you looked up!

Carole

Professionals who are governed by independent professional bodies are expected to behave professionally. Doctors, lawyers, and accountants to name but a few all come under this umbrella of expectations.

Doctors working as occupational physicians are expected to follow the ethical guidelines produced by the Faculty of Occupational Medicine. They should all be impartial. Employees may perceive bias from in-house services, but if external contractors are still paid by the company, what is the difference? If the employee is allowed to 'shop around' until they find an OHP who will give them the report they want, is this fair and reasonable?

The reason why many employees feel that their OH service is biased is because all their treating physicians act as the patient advocate, and may well give advice that is incorrect because they do not actually know what goes on in the company. The OHP is the first doctor who has actually explained the situation to them fully; I often ask employees if their GP explained to them that by signing them off sick again they could lose their job. The answer is always no. I tell them that they would actually be safe working, that I can recommend adjustments and they can then avoid losing their job by returning to work.

There are significant advantages to an in-house OH service who will know much more about the work, and about what adjustments can be made. Yes, they do meet with managers and this has advantages, doctors get to know the company, they can give more timely advice, follow up cases to ensure the adjustments are working, and more important get to know the managers so they understand which managers are likely to be supportive, which are weak, which are dogmatic and which have hidden agendas. I have often gone to higher management to discuss problems with line manager styles, something that is difficult to do as an exernal provider.

If I told you that in most cases the only advantage to having an external provider was that you would get a cheaper service, would you still prefer it?

When NICE recommend independent, properly trained and impartial advisers, they mean OHAs and OHPs rather than the line manager or union rep., and NICE are happy for them to be in-house or contractors.

The only completely independent service is the DWP who do medical assessments for benefits. They are currently the ones under fire for 'doing what the government has ordered them to do'.

You must also remember that whoever sees the employee will usually do so at management request, following a referral from management. This referral will ask specific questions which the OHP will answer. If you wish to call this manipulation, do so, but I don't attempt to answer all 1001 questions that could be asked when spending five minutes writing my report, because that is all I have in my forty minute appointment time. I am also well aware that while I make recommendations, it is up to management to decide whether these can be implemented or not. I may well recommend a redeployment, but if no such role is available then the employee will not be redeployed.

I have conducted a major review of tribunal decisions on disability, and of note, where the employer had an in-house OH service and the case went against the employer, it generally turned out that the employer had ignored the in-house OH advice. Where the employer had taken advice from doctors who were not OH trained, they were more likely to lose in tribunals and more likely not to get advice on adjustments. The message is that the problem lies with the employer not with OH.

But what happens Tony when there is in house OH, where the employees can quite understandably feel there could be bias as the OH employee is also seemingly meeting with managers and everyone having their wages paid by the company?

What happens if the Employee WANTS to return to work or do a specific role (not including here H&S issues) but OH sides with the company and says they cannot and the employee sees this as an excuse to get rid of them?

Isn't it true that NICE have just issued Guidelines that say that independent, properly trained and impartial people should be involved with the employee whilst they are off sick and in the process of bringing them back into the work place for RTW?

Sometimes it isn't about getting people back to work from long term sick it is about companies who would really rather not have that employee back to work because having to make reasonable adjustments is all a bit of a bother and really they would rather have somebody fit and well. They use OH inappropriately by asking them questions about the employee which are very ambiguous and a report can then quickly be manipulated and used inappropriately by the company against an employee. I know this happens as I have seen it many times. It puts OH in a difficult position but where salaries are all being paid from the same pot one wonders were loyalties are, especially when money is tight and there are threats on jobs.

My personal feeling is that if there is to be an OH service it should be mandatory for it to be totally independent from the Company to ensure the integrity for both parties. Therefore that does not mean setting up a company and then selling off your previously owned OH department into it and subcontracting the work back to the company! If anything allow an employee to chose an OHT/P - at the end of the day does it matter as long as the outcome is transparent which at the moment for many employees sadly it is not. Sorry Tony!

Fiona

I do admire your optimism, and I would like to see more specialist OH practitioners. There are actually many 'OH practitioners' in the UK, but most are not specialists and many GPs practising OH have had no specific OH training.

There are several 'missing links' here, but perhaps the most important is the link between those practising OH but without training or with limited training, and specialists. This can lead to wide variations in quality of delivery, and this is not always helpful to employers, employees or perceptions of OH. The new Occupational Heath Service Standards for Accreditation published by the Faculty of Occupational Medicine last month aims to correct this by requiring doctors practising occupational medicine to either be specialists, or to have access to an accredited specialist in order to meet the standards.

The link with GPs is an interesting one. I don't often meet with obstruction from GPs, and usually have good support from them when I get in contact with them. The apparent lack of co-operation is usually generated by employees exaggerating or making up stories. If a patient says to a GP 'my company doctor is forcing me to go back on the production line and lift very heavy boxes' the GP will believe them. He will not know that I have actually advised a return to part time hours doing some paperwork.

This leads on to the main problem, the perception that doctors can somehow reduce sickness absence. Employees go off sick because they want to, and they can. There is nothing we can do as doctors to force them to return. We can advise that they are fit, but in many cases I advise that they will not be harmed by work, I would have expected them to return to work by now, but they say they are in pain or are too tired, and refuse. That is essentially a management matter to provide appropriate motivation. The best forms of motivation I see are stopping company sick pay and the final written warning for attendance. These are not 'fit notes' or medical reports, but management tools.

There is a lot more that we do in OH besides helping reduce sickness absence directly. We help keep the workforce fit and healthy, and we help with advice on adjustments to enable those with impairments to work more effectively. We also advise when adjustments are not needed. Having the 'disability label' can be harmful; I recently advised a young employee with a history of anxiety that if adjustments were always made for him, there would be a number of career opportunities he could not follow. He would be better off learning to cope with his anxiety so he could in turn handle higher pressure at work. After six months trying this approach he was very grateful for my advice and support, and is working successfully and confidently without any adjustments. The same applies to many with simple back pain; encouraging them to work normally enables them to get fitter and therefore get better.

We can also act as intermediaries when issues such as work stress arise, helping identify problems, and helping to find solutions to improve satisfaction, efficiency and health in the workplace.

Tony - I agree wholeheartedly that Occupational Health Practitioners must practice with neutralilty, independance and evidence base.
Firstly businesses must have access to Occ Health. The relationship between the practitioner and the managers requires cultivating . It is about OH understanding the business culture- each business has its own unique culture..
Secondly - if this country is to achieve a reduction in sickness absence there must be, in my opinion, active co operation between General Practitioners and OH Practitioners.
There is very little reference made to the role of OH in the press or media when it highlights the governments drive to reduce national disabliity benefit claims and helping the nation back to work!
There are too few OH Practitioners in the UK at the present time.

Tony
Without exception the OH practitioners I know are neutral, independent, well-informed and entirely honourable. Some things would be easier for them if they were not.

Occasionally, as a body, the OH professions support notions which are culturally convenient as opposed to evidence-based. But not to do so could make a difficult job impossible; you have to speak the same language as those you deal with, at least at first. But that’s for another thread.

What is evident is that a large number of people who could be at work, are not, and some who should not be, still are. The system isn’t working for everyone. The numbers involved are very large.

Rather than fix the entire system, I would focus on mental health and bodily pain as the key issues. Perhaps the powers-that-be have already grasped this? There are signs of an awakening in the story behind the new Fitter Note.

But someone still needs to facilitate the interfaces between all the stakeholders, case by case, as well as at the lofty Political level. If someone would develop and demonstrate a successful practical solution at the coal face it would make fixing ‘the system’ rather easier.

OH specialists are not as numerous as they should be to be the entire answer.

Andrew

Occupational health practitioners are ethically obliged to be neutral, independent and to give advice based on evidence.

They are not always perceived as being so, and that is the problem.

Treating doctors are expected to be the patient advocate, so the occupational physician may be the first doctor who has 'told the truth' about the condition, based on evidence, rather than saying what the patient wants them to say. This can lead to significant conflict.

Employers often complain that the occupational physician or nurse is too supportive of the employee, because the employer has not got the answer they want.

I have no doubt that whoever was chosen to be 'neutral' could fall victim to subjective accusations of bias, particularly if the payment for services always had to come from the employer. A taxpayer funded service would still be accused of bias, following 'government dictat' rather than evidence.

I think we are stuck with what we have got. It does usually work well, and the Fit Note shouldn't make things any worse but could make them better.

Tony

Tony and Carole

Well said.

So far the variables that significant persons and perhaps intermediaries must grapple with are:

Caused by work.
Made worse by work.
More noticeable while at work.
Makes work less manageable.
Cannot cope with work.

Illness with no diagnosis.
Diagnosis with no illness.
Diagnosis with illness.

Beliefs. (yellow flags and blue flags)

Effect of medication (helpful and unhelpful).
Effect of therapy (helpful and unhelpful).
Effect of the absence of therapy or medication.

Effect of policy (black flags).




One expected effect of these variables in any combination is uncertainty in:

communications
prognosis,
proportionate actions,
recidivism,
compliance,

The Fitter Note could add to or reduce the uncertainties. It is unclear to me if the effect on uncertainty can be predicted in general or in specific cases.

One effect of uncertainty [an effect which is repeated very often] or even just the effect of realising there is uncertainty, is greater activity for private and public insurances. Time will tell if insurers of both kinds are driven to adding to existing intermediation services.

Mental and pain problems are so very common and so very uncertain with respect to the above list. Surely there is someone or group of someones who can lead from a position of recognised neutrality?

Carole

You have raised some very pertinent issues.

Most employers don't bother with GPs at all, they ask their employees how they are and what they can do, alow them back to work as soon as they want to return adjust the duties if necessary. In 99% of cases this is all that is needed. Employers that don't do this either don't have the confidence to do so, or suspect that there are other agendas and think the GP will identify these.

Most GPs (or around 60% in surveys) simply do what the patient asks.

This is not all about insurance. The Association of British Insurers do not require GPs to sign patients back to work.

Many GPs are perfectly capable of understanding what patients do at work, and many are also able to advise on fitness and work, but occupational physicians are trained differently to think differently, asking different questions, approaching issues from a different perspective so that in many cases the advice can be very different. For example, patients usually ask their GPs how to avoid getting symptoms, so GPs are used to advising them to avoid activities that may be completely harmless but that might cause them symptoms. Occupational physicians focus much more on what might harm them. If they will not be harmed, then they can choose to do the activity if they want even if it causes symptoms.

Currently GPs are completely unaccountable for their sick notes. That is why they are happy to issue them to whoever asks for one. Most are completely unaware that the cost to employers of their sick notes each year comes to around £300,000 in pay alone while the cost to the NHS of their prescriptions comes to around £100,000. The new system will go electronic later this year, so that for the first time we can find out which GPs write too many sick notes, and address this with them.

In most cases of illness, the GP bases the diagnosis and assessment of disability entirely on what the patient tells them. The only way the GP can tell the patient is 'stringing them along' is if the GP happens to bump into them on the golf course or in Tesco doing something they said they could not do.

The 'Fit Note' does represent a significant change. It certainly has the potential to save significantly more than it cost. I certainly hope it does.

Tony

Tony if there is no requirement for a GP to sign an employee fit from a period of sickness absence, then why bother with them at all? If as you say it is simply between the employer and employee the GP does not need any involvement because whatever he says now is going to be disregarded.

Whats the point for instance in them bothering with "maybe fit for some duties" as that is a get out of jail statement if ever I have heard one. Lets face it this is all about insurance. Employers dont think GP's are educated enough to advise if their patient is well to return to their job because they are not supposed to know enough about their patients job to judge. Employers think that employees can hide behind some GP's if they want extended sick leave and OH want their foot in the door so are creating a job for themselves by acting as the middleman.

This new "note" will be no better than the last one and will be just as confusing. Personally I cannot understand why a GP who should know their patient given they have been monitoring them over a period of time whilst dishing out their "sick notes", cannot ask them what their job consists of and what they would be doing in the course of a day. They are not unintelligent people and I am sure they should be able to judge if their patient is well enough to either return to work or return with reduced duties for a period of time. A responsible employer SHOULD then take that advice and use it in their employees best interest given they have a duty of care towards them. Is that not common sense or what??

If a patient goes to their GP and asks to return to RTW I am sure the GP will use their common sense as they will if the patient turns up trying to string it along. GP's do have to be able to account for why patients are being signed off for long periods.

When it comes down to more specific duties such as has been mentioned above then of course those employers will already have systems in place to make sure that employees are fully safe, that goes without saying.

I dont know how many millions this "review" has cost tax payers but frankly its another example of gross miss-management of our money. What a b----- waste of time.

Andrew

One of the most significant problems facing us today is inappropriate beliefs about 'illness'. Many people feel ill because they have symptoms, and believe that in order to recover from these they need rest.

The most obvious example of this is simple back pain. Over 95% of cases of back pain are 'simple back pain', a situation where symptoms of pain are felt because of poor use of the back not because of any significant underlying disease process. Doctors have in the past been confused when they find signs of 'wear and tear' on X-rays and MRI scans, but there is no evidence that these findings are the cause of the symptoms.

The worst possible 'treatment' for this is rest, because this leads to worse posture, stiffness and a loss of fitness. The best treatment is normal activity. Most importantly, simple back pain is not 'caused' by activity, but activity can make people aware of their symptoms.

Many patients I see say 'I have been injured' or attribute their back pain to activities at work. They expect a change from work to 'reduce the risk' while in practice, in most cases they need more activity not less if they are to improve the fitness of their back. Some expect compensation. Many awards of compensation are entirely unjustified on medical grounds.

There are many other conditions that are similar; many chronic pain conditions result from inactivity not injury, and many people who rest in order to recover from surgery just become unfit and therefore prolong the recovery period. Unfortunately in many cases this is not a message they want to hear or accept.

In many cases the symptoms are more obvious because the individual is unhappy at work, and is using 'back pain' as an opportunity to avoid issues they are unhappy with, sometimes unknowingly and sometimes knowingly.

Overall, issuing a sick note in these circumstances is actually harmful. If, however, I suggest to many of these patients that a return to work will help them recover, I am greeted by a torrent of abuse or worse. It is also important to realise that a gradual return to work will be more helpful in most cases than an immediate return to full hours and duties, but this gradual work should not be unnecessarily prolonged.

So while I agree that the solution may be to find an intermediary, the individuals with the symptoms must also approach the intermediary with an open mind, and crucially they must want to get better. And by that, I mean they must really want to get better, not just say they want to get better. I would of course suggest that OH should be that intermediary as we have the expertise and understanding to identify those who could return to work from those who should not.

Increasingly patients who are unhappy with work simply resort to a sick note for 'depression'. Again, in many cases coming in to work will help them recover. A label of 'depression' for what is an entirely normal reaction to pressures is not always helpful because it suggests that doctors will cure them. All the evidence shows that in mild to moderate depression antidepressant medication is no better than placebo; the solution lies in most cases with the individual who needs to adapt their situation or adapt to the pressures in order to cope. There is a risk that by caring 'too much' we make the matter worse.

These are major social issues that do need to be understood if we are to use 'fit notes' better, and if we are to manage employees who have symptoms better.

Tony

Between the lines, there is something of value in what Nigel says. He clearly has a caring stance. Caring is essential. But caring is not enough.

It might be possible for the person with illness and those who manage them to spontaneously recognise the real problems for themselves, but my feeling is that usually this is too much to expect. There is too much temptation to play at personal politics and to hold to inaccurate models of what's going on.

The challenge in complex cases is to find an intermediary who can express themselves well and have a keen grasp of the distinction between illness and diagnosis. The latter is key to overcoming the conceptual barriers to making progress. Action has to be soon after the divergence between illness and diagnosis become apparent. Delay is very risky indeed.

Why would you care any less for someone who is ill but has no diagnosis than someone who is ill and has a diagnosis?

Phylosophical and/or semantic argument regarding the less than certain period somewhere between illness and restored fitness or functionality avoiding the acknowledgement of a transitional period loosly defined as 'in recovery' or "rehab" that should ideally include a progressive potential return to a status as near too or improved upon where you was before you were sort of not well.

Shouldn't be rocket science but is a question of the less tangible and voluntary elements of 'goodwill' or 'positive regard' held between the two parties, employer and employee, in terms of relationship management and open'ish communications founded on a degree of trust & reconcilliation.

If one os convinced that employee is or was ill just to skive off or even spite them and the employee feels they are being treated like a bit of tick-box managed kit with an inconsiderate self-inflicted soft or hardware problem rather than a valued resource or even a person never the twain shall meet.

Just a problem of seeing problems everywhere rather than opportunities.

On the "Fitter Note"
Where is the honest broker?
Argument:
Illness does not imply having a diagnosis, having a diagnosis does not imply illness.
Most of the time the distinction is irrelevant; illness and healing follow parallel paths. When healing ends, so does illness.
There are those for whom illness continues long after healing has completed.
There are those who have illness with no medical cause.
The latter groups added together are a significant body of people for whom "is fit for work" will always be uncertain and the medical gatekeeper will be tempted to keep relationship options open by stating "is not fit for work".
For this group though, 'may be fit for some work' could be just the lifeline that is needed to help recue the ill person. But taking helpful steps on this requires a leap of understanding from HR and supervisors which it seems is not commonplace. Added to this, Unions will be deeply suspicious. FAR easier then just to read "may be fit for some work" as "unfit for work".
On its own, the new 'fitter note' will struggle to make the real difference that is hoped for.
Intermediation of some sort would seem to be the logical next step. Who will provide it? Who will pay?
For mental and pain issues perhaps charities such as MIND and BackCare could provide or guide the honest broker or provide access to the honest broker? There are many illnesses with specific charities working in that field. Perhaps charities are seen as sufficiently neutral to allow effective dialogues to take place?

Leaving out the 'fit for work' option was done for a very important reason. Some employers persist in believing that an employee can only return from a period of sickness absence if a doctor has 'signed them fit'. There is no requirement for this and it wastes a great deal of GP time and causes unnecessary delays in returning to work.

By removing this from the 'fit note' it is hoped that employers will begin to understand that it is the employer who decides someone is fit for their job, not their GP who is unlikely to understand what the job involves. Furthermore, as almost nobody is '100% fit', expecting people to wait until they reach this state of perfection is a considerable waste of talent and money, and for disabled people it is probably discriminatory.

In the very few cases where a medical assessment is needed, for example for HGV drivers, merchant seamen, pilots etc, then special arrangements are needed and the employers will be well aware of these.

I suspect the introduction of the 'fit note' will cause significant difficulties for those employers who have very misplaced beliefs about sickness absence, fitness and the abilities of doctors to distinguish between patients who say they are ill and patients who are ill. It should help employers who are prepared to be flexible, and employees who want to work.

Tony

Does this mean we'll have to stop calling them 'fit notes' and start calling them 'may be fit notes' instead?

if's and should's.....in a perfect world many things "would" work as planned!

We all know that employers who see an opportunity to replace a "wounded" with a perfectly well employee often try to take that road despite what they know they SHOULD be doing. This could very well be too much effort for some.