A day assessing ability to work

09.00

My first medical (in a private surgery I hire) is a follow-up from a large goods vehicle (LGV) medical carried out by Sally, an occupational health nurse. She is one of three self-employed nurses who have used me as their occupational physician for the past four years to carry out assessments for paying companies. Occupational health is a small world and most nurses will find a physician or two to assess the more complex cases, usually involving long-term sickness absence and the potential for ill-health retirement (IHR) or an employment contract being terminated. I usually book hour-long appointments for each patient.

Setting up a client base can be difficult. Some GPs work with local NHS occupational health departments, but pay is low. There are several national occupational health agencies always on the lookout for suitable GPs. In my experience, this work is less rewarding and the income is less than half what you can realise by building up a local network of customers where the employers pay directly for assessments.

With this first patient, a 53-year-old man, Sally was concerned that he was on a variety of medication typically used for people with cardiovascular disease, something he had initially denied. He had refused consent for her to access his GP records, but eventually a story unfolds, which his employer doesn’t know, of a probable TIA a few months before. He has no residual disability, has not attended follow-up appointments and is in denial. I have to advise that he now cannot hold an LGV licence for more than a year and outline the steps towards renewal. Fortunately, Sally has anticipated this outcome. As he is a valued employee of a supportive employer, he gets an offer of warehouse work until his licence can be renewed. He is disappointed, but accepting.

10.00

My next appointment is for a 56-year-old teaching assistant referred for an IHR assessment by their school. I have a wealth of background information including a GP summary and a number of clinic letters describing a range of normal investigations. She has a variety of musculoskeletal symptoms typical of fibromyalgia. However, it is clear that the overwhelming problem is her weight, with a BMI over 47. All her symptoms, including the MRC grade 4 breathlessness, for which no cause had been found, are down to morbid obesity (or obesity class 3). This important detail was, surprisingly, not mentioned in any of the accompanying letters.

This is the third such case in the past year. The first time I came across this, after much deliberation with the trustees of the pension fund, I signed the IHR certificate. We had to agree that obesity class 3 is regarded as a clinical entity, likely to cause symptoms that impair day-to-day health and wellbeing. So after advising the patient, she was grateful that I would support her IHR application, but clearly disgruntled that obesity would feature as the main clinical problem.

11.00

My final hour is spent on paper case reviews, with advisory reports for employers. The first relates to a man with bipolar disorder who has recurrent sickness absence from an IT role. He is non-adherent to mental health medication and causing problems with colleagues. The behaviour described is suggestive of hypomania. My opinion includes advice that while all the evidence demonstrates normal mental capacity to refuse his medication, it is appropriate for the employer to exclude him from the workplace if his behaviour is causing distress. An intellectually challenging case, but I will be well rewarded by the employers and these dilemmas certainly keep the grey matter going.

I find the pace of work a welcome relief compared with the 10-minute appointments and rushed visits in primary care.

12.30

I have lunch at the surgery while providing feedback to Sally about the reports, which will probably take another three to four hours to write up this weekend. Then I walk the mile or so to the next surgery for my first appointment as a ‘normal’ GP at afternoon surgery.