As a newly qualified GP, I found discussing fitness to work in consultations a real challenge. I was concerned that not signing a fit note for a patient would lead to conflict and risk a breakdown in the doctor-patient relationship. Just as I would not sign a prescription for a medication that I felt would harm the patient, I didn't want to sign fit notes that could cause harm to a patient's wellbeing. So when an opportunity arose at the Leicester Fit for Work (FFW) service I felt this was an ideal way to gain experience in this field.
Since its inception in April 2010, the Leicester FFW service has received 850 referrals from 80% of GP practices in Leicestershire and signed over 1,500 fit notes. Of the clients referred to our service, 77% returned to or remain at work.
Leicester is one of six Department for Work and Pensions pilots that were set up following Dame Carol Black's review of the health of Britain's working-age population, Working for a healthier tomorrow.
Our team helps the employed and self-employed get back into work and also helps those who are at risk of prolonged sickness absence to remain in work. Some 22% of clients cited healthcare interventions as the most important, including physiotherapy, psychotherapy and in-house occupational health assessments.
The service aims to improve the health of the working population by:
• the demedicalisation of the management of sickness absence through non-medical interventions
• providing rapid healthcare interventions where appropriate
• providing quick access to occupational health assessments
• acting as a one-stop shop for health, work and wellbeing issues.
Following my experience with FFW, I now feel able to educate patients on the potential problems associated with long- term sickness and – with their best interests at heart – advise them on alternative pathways to manage their problems. GPs are so often pressed for time during consultations, and offering good-quality occupational health support without services such as FFW would be a challenge.
When commenting upon the independent assessment service (IAS) proposed by the Government's sickness absence review, GPC deputy chair Dr Richard Vautrey said: ‘If what is being described is a proper occupational health assessment at an earlier stage in the patient's illness then that would be helpful. But if it turns out to be a punitive process to try and save money without the best interests of the patient at the heart of the process, then it will fail.'
At the Leicester FFW service, we provide independent occupational health assessments with rapid medical and non-medical interventions. We believe that we have been providing a service that fits the brief of a successful IAS, and to give an idea of our casework, below are three clinical case studies based on our service aims.
Case study 1
Demedicalisation of sickness absence
A 45-year-old check-out worker was referred to the Leicester FFW service by her GP for assistance in returning to work.
Her working hours and duties had been changed without consultation. Conflict with her manager resulted and she subsequently developed stress-related symptoms. She was previously fit and well, and when she first presented there was no evidence of depression or generalised anxiety disorder.
After consulting her GP she was signed off as not fit to work for four months, despite the GP's best efforts to encourage the patient to communicate with her employer about the changes.
By the end of this period she was demonstrating significant depressive symptoms and the GP referred her for further assistance.
Her allocated case manager at FFW identified the conflict with management as the main barrier to returning to work, rather than her medical diagnosis. The case manager arranged and mediated a meeting between the manager and the patient. A successful return to work with amended duties and working hours resulted.
There is evidence to suggest that long-term sickness absence is associated with higher rates of anxiety and depression. We encourage patients to focus on what they can do rather than reinforcing any beliefs that they are unable to work at all. We aim to give people a greater sense of control over their working life and promote resilience to cope with work stresses.
Attending FFW empowered this lady to negotiate her shift pattern and work duties, and her self confidence improved as a result.
Case study 2
A 30-year-old hotel cleaner was referred to our service by her GP for assistance in managing her back pain.
The GP felt a course of physiotherapy would help resolve her symptoms and facilitate a return to work, but there was a several-week wait for NHS physiotherapy. She had had a long period of sick leave the year before for similar symptoms, and the GP was keen to avoid a similar situation again.
She was assessed by a case manager and an occupational health nurse, and referred for private physiotherapy funded by our service. Following four sessions of physiotherapy, her symptoms had settled and she felt confident to return to work. A full return to work was achieved within four weeks.
Delays in NHS treatments such as physiotherapy and psychotherapy can make the management of sickness absence extremely challenging. The rapid intervention with physiotherapy, in tandem with one-to-one case manager support, resulted in symptom control and a full return to work. If this woman had waited for NHS physiotherapy sessions, a successful return to work was unlikely to have been achieved as quickly.
Case study 3
Specialist occupational health assessment
A 37-year-old patient was referred by her GP for an assessment regarding her fitness to work. She had a background of rheumatoid arthritis and ankylosing spondylitis, and was struggling with widespread aches and pains. Rheumatology had assessed her and felt that her rheumatic conditions were quiescent.
Blood tests looking for other causes of fatigue were all normal. She had told her GP she felt she was unlikely to be able to continue at work for much longer. She worked for a small company as an events co-ordinator and did not have access to an occupational health department.
She was assessed by a case manager, who completed a pain-detect score and referred her on for a clinical assessment by one of our occupational health doctors. She received a diagnosis of fibromyalgia and was started on low-dose amitriptyline. Her symptoms have subsided and she remains in work without needing to have any workplace adaptations.
Interestingly, there is a higher incidence of fibromyalgia in people with rheumatoid arthritis than in the general population. Our experience is that the supportive explanation of the diagnosis of fibromyalgia and treatment with tricyclic antidepressants can significantly help symptoms and facilitate a return to work.
Dr James Cowling is a GP in Lutterworth, Leicestershire