Question

Ruth is a 38-year old lady with facial pain. She is has been taking regular analgesia. She works in a clerical role but the pain has meant she has had difficulty concentrating and so felt she couldn't manage the pressure at work. She has now been off sick for 2 months. Ruth's pain has now improved and she wants to return to work in a limited role. Can I do this with the new fit note as she is not yet fully fit?

Response

Dear Dr GP

There is now growing evidence that in many cases work can be a positive influence on both physical and mental health and can be therapeutic and reverse some of the adverse health effects associated with episodes of Worklessness. (Is work good for your health and wellbeing? Waddell and Burton 2008) Long-term absence can result in job loss, long-term dependency on state benefits, poor self-esteem and loss of self-confidence. The negative effects of unemployment are reversible on re-entry to work. During the first one to six months of sickness absence interventions are most effective. Once an individual has been off work for 4 to 12 weeks there is a 10-40% chance of them still being off work after one year. Once someone has been off work for between 6 and 12 months there is a 90% chance of them never returning to any form of work in the foreseeable future. It would therefore be important for Ruth to be able to return to work. In most cases individuals do not need to be 100% fit to be able to return to work.

It would be advisable to explore with Ruth in more depth about her actual role before making a decision about her return to work and the advice you give her. Simple questions you might want to consider include:

• What is your job?
• What sorts of task do you need to do day-to-day?
• What are the main barriers to you getting back to work (either at work or at home)?
• What would help you stay in work? / What might help you return to work?
• Which bits of your job do you feel are possible, which bits difficult or impossible, and why?
• Are there any other jobs in your workplace that you might be able to undertake on a temporary basis?
• Can your work be changed to help you get back?
• How confident are you about being able to return to work?

Following discussion with Ruth about her actual role, suggestions could be put to her employer on adjustments to help support her return to work. These could include working reduced hours, reduced workload, a graduated return to full hours/workload over a few weeks, additional support, time off to attend for treatment/investigations or not driving/using machinery. Home working could also be suggested, which alleviates the transport issue.

GPs can still use a fit note to sign somebody off work but the new note allows you to write what your patient can do rather than what they can?t do. It will allow you to liaise with your patients? employers and provide advice that you feel might allow them to stay in or return to work. These simple changes to the workplace are often known as workplace modifications or adjustments.

So if you think Ruth would be able to return to some work then you could fill in the fit note stating that she 'may be fit for some work' and suggest some workplace modifications via the boxes and comments section on the note. I would also suggest you advise Ruth to discuss her situation with her line manager or occupational health if it is available at the workplace.

If you feel she would be unable to return to work just yet I would advise signposting very clearly that her condition is likely to be self limiting and that she should be able to return to work in the near future.

You may want to look at the Health e Working programme on the e learning for health website (http://www.e-lfh.org.uk/projects/healtheworking/index.html) Session 2 on fitness for work has some further guidance and useful advice on fitness for work and assessing the effect of someone's health on their ability to work.

There is also a decision aid that provides quick simple advice on assessing someone's fitness for work on the new Healthy Working UK site (www.healthyworkinguk.co.uk/decisionaid)
You can either look at this on line or download it to your computer.

Question

Ruth is a 38-year old lady with facial pain. She is has been taking regular analgesia. She works in a clerical ...

Question

Rebecca, a 30-year old pregnant female.
Length of sickness absence: 3+ months

Rebecca has severe widespread eczema which has become worse in recent weeks - variously infected etc - she needs to apply emollients ++ and attends the dermatology outpatient ward. She has been advised that she should start her maternity leave when she is 32 weeks pregnant and no longer be on sick leave. I am not clear that her eczema is caused by the pregnancy as she has had if for years and has managed marvellously with it. Is this appropriate advice for her employer to be giving her?

Response

Dear Dr GP

Rebecca is pregnant, and been absent from work for 3 months due to eczema. She has been advised by her employer that she has to commence maternity leave when 32 weeks pregnant. Employers can make staff commence maternity leave, if they have a sickness absence relating to pregnancy, within 4 weeks of the Expected Date of Delivery. If Rebecca will be 32 weeks at this time, then their advice would be incorrect. The government-run Directgov is a single point of access to services and information regarding employment and rights. You could signpost Rebecca towards this service and gain further insight into her rights regarding her future employment. Directgov can be found at www.direct.gov.uk and pregnancy information found under "parents-maternity leave". The Equality and Human Rights Commission will also be able to advice Rebecca on the best way forward. Found at www.equalityhumanrights.com.

If you believe that the health condition may not be pregnancy related, due to past history, you could write to the employer outlining your views. You could also consider if Rebecca could return to work with adjustments/restrictions in place-you could discuss her role and see if there is any aspect of it she could still perform. Her employer should be willing make adjustments to her role such as changing/reducing work hours, or finding alternative work, to suit the health condition. 3 months sickness absence is likely to be detrimental to Rebecca's wellbeing, and also to her employer, it may benefit all if Rebecca could return to work in some capacity.

Question

Rebecca, a 30-year old pregnant female.
Length of sickness absence: 3+ months

Rebe...

Question

Mr Jones suffers with low back pain. Three weeks ago he developed an exacerbation of his symptoms following some gardening at home. He has been signed off work for two weeks with lower back pain. He works in a factory; his duties include fork lift driving and some heavy lifting. He has been back to see me this week and his back is definitely improving. He still has somewhat restricted movements. He has no acute pain but complains of a dull ache on some movements I have enquired if there were lighter duties he could do in work, which there are but he feels he is not ready to go back to work yet.

In my opinion he would probably be able to return to some form of work However, please could you advise what duties would be suitable for Chris and what he should avoid doing in work. Could you also advice whether you think Chris should go back to work or continue having sickness certificates for a while longer.

Response

Dear Dr

There is a reasonable evidence base published by the RCGP and the Faculty of Occupational Medicine about the management of low back pain.

I am making the assumption in my response that you believe this is simple low back pain and that there are no "Red Flag" symptoms or signs.

There is good evidence that staying active and returning to normal activities as soon as possible leads to faster recovery. Similarly the longer people are off work the more difficult it is to rehabilitate.

Useful questions to help understand the nature of his work and any barriers to returning to work include:

• What is your job?
• What sorts of tasks do you need to do day-to-day?
• What are the main barriers to you getting back to work (either at work or at home)?
• What would help you stay in work? / What might help you return to work?
• Which bits of your job do you feel are possible, which bits difficult or impossible, and why?
• Are there any other jobs in your workplace that you might be able to undertake on a temporary basis?
• Can your work be changed to help you get back?
• How confident are you about being able to return to work?

It would also be important to explore any other social factors that may be influencing your patients attitude to return to work such as family, financial or other work related issues such as his relationship with his line manager, or changes to the workplace.

There are a number of resources that might help you in your decision-making.

You may want to look at the Health e Working programme on the e learning for health website http://www.e-lfh.org.uk/projects/healtheworking/index.html. Session 2 on fitness for work has some further guidance and useful advice on fitness for work and assessing the effect of someone's health on their ability to work.

There is also a decision aid that provides quick simple advice on assessing someone's fitness for work on the new Healthy Working UK site (www.healthyworkinguk.co.uk/decisionaid)
You can either look at this on line or download it to your computer.

There is also a decision aid specifically for low back pain and a number of leaflets and guidances that you might also find useful.

If you still feel your patient could manage some work you might then consider writing a fit note stating that they may be fit for some work and suggest some workplace modifications via the boxes and comments section on the note. I would also suggest you advise your patient to discuss his situation with their line manager or occupational health if it is available at his workplace.

If you feel he would be unable to return to work just yet I would advise signposting very clearly that his condition is likely to be self limiting and that he should be able to return to work in the near future.

I would recommend The Back Book published by the Stationery Office for patients (ISBN 011 702 0788)

Question

Mr Jones suffers with low back pain. Three weeks ago he developed an exacerbation of his symptoms following some ga...

Question

David, a 34-year old male factory warehouse worker
Length of sickness absence: 1-2 weeks

During the first week of August David was heavy lifting at work and had sudden back pain radiating down legs. He still has pain but does have good lumbar mobility. The MRI showed 3 prolapsed discs, the orthopaedic surgeon said that he should not be working. He has been made redundant as a result. The patient is now awaiting neurosurgical opinion but since he has no red flag symptoms and reasonable mobility, I doubt that they will see him soon and they may not offer surgery.

Response

Dear Dr

If David is looking for new employment, he should refrain from any job that may exacerbate his symptoms. Lifting loads over a 5kg weight and confined space work or static roles should also be avoided at this time. However, if his daily activities are not greatly impaired it may be feasible for David to return to some work.

Guiding David towards a Disability Employment Advisor who can be found at the Job Centre Plus offices would be to his benefit. They can provide specialist support on employment issues. They can refer patients into services, which are specifically designed to help people with disabilities to find or return to work, using elements such as:

• Job search and job-matching
• Pre-employment training
• Work placements
• Access to work

This is available for employed, self employed or unemployed people. It is also available for people who are limited in their ability due to health reasons but who may not fall within the scope of the DDA (2005).

If you would like to learn more about supporting your patient who is out of work long term session 4 of the Healthy e Working e learning programme on long term worklessness (http://www.e-lfh.org.uk/projects/healtheworking/index.html) may be of interest to you.

There are a number of useful guidances and leaflets for patients on the Healthy Working UK website (www.healthyworkinguk.co.uk/websiteleaflets/main) and link to local and national support agencies that you may want to signpost your patient to.

If David would like to see how he can help manage his condition he could contact the Expert Patient Programme (http://www.expertpatients.co.uk/)- the programme reviews self management of health conditions and is aimed at keeping people in work. Although aimed at long term conditions, it could still be invaluable

Question

David, a 34-year old male factory warehouse worker
Length of sickness absence: 1-2 weeks

Question

Debra, a 39-year old residential home carer is awaiting further treatment for sarcoma and is being investigated for possible metastases.
Length of sickness absence: Over 3 months

Her employer sought a medical report about whether she was unfit for her job and would / could be better served by leaving the post and signing on for sickness benefits. Debra consulted with me to inform my report. I felt that it was not in her best interest for her employment to be terminated on sickness grounds while potentially curative Rx was still being planned (due now). I suggested in my report that she should remain unfit for work for a further three months and then review the situation in three months.

The employer has written again and requested I review the report, as Debra is at present unable to do her full job. I believe there may have been some excessive pressure on Debra to consider resigning, and the employer is finding it hard to cope with one member of staff out long term in a smallish residential home. I still believe Debra should wait before resigning, and see the outcome of her surgery and she wishes to do this. I am therefore consulting with you about whether we should amend the original advice, given that her fitness for work has not essentially changed?

Response

Dear Dr GP

Debra's treatment is on-going and the prognosis as yet not defined. Once this is completed then more specific advice could be given by yourself as to the tasks she would be able to undertake at work. In the long term, having a job to return to, would be a benefit to Debra, and probably reduce the likelihood of social exclusion and psychological stress/depression that unemployment can bring. So trying to support her to remain in work for as long as possible is probably in her best interest.

Debra is likely to fall within the scope of the Disability Discrimination Act (2005) due to the nature of the health condition. The DDA is determined by the activities of daily living NOT their ability to work. However, people with HIV, cancer and multiple sclerosis, and people who are registered blind, are automatically covered by the DDA, from the point of diagnosis (and not just when they become unwell).

Her employer therefore has a duty of care to make reasonable adjustments to the workplace to help accommodate her health needs. These could entail allocation of part of her role to someone else or transferring her to another role or adjusting her hours or tasks. In a small organisation this may not be practical but the decision would have to be made by the employer. GPs can give an opinion whether they believe someone is likely or not likely to fall within the scope of the DDA but a tribunal will make the decision as to whether someone falls within the scope of the DDA not the GP, occupational health physician or the employer.

The Disability Employment advisor (DEA) can be found at the Job Centre Plus offices. They can provide specialist support on employment issues. They can refer patients into services, which are specifically designed to help people with disabilities to find or return to work, using elements such as:

• Job search and job-matching
• Pre-employment training
• Work placements
• Access to work

The 'Access to Work' scheme might pay towards a number of areas to support patients to remain in work such as

• equipment needed at work
• adapting premises
• a support worker
• the cost of getting to and from work if your patient cannot use trains or buses
for a communicator at job interviews

This is available for employed, self employed or unemployed people.

If you would like to learn more about the DDA you may want to review the e learning programme Healthy e Working session 3, on the e learning for health website (http://www.e-lfh.org.uk/projects/healtheworking/index.html) There are a number of useful guidance?s and leaflets for patients on the Healthy Working UK website (www.healthyworkinguk.co.uk/websiteleaflets/man)

Question

Debra, a 39-year old residential home carer is awaiting further treatment for sarcoma and is being investigated f...