Consultation skills - Assessing fitness to work

Encouraging an early return to work can improve a patient's physical well-being.

Discuss the impact of the illness on function at work (Photograph: JH Lancy)
Discuss the impact of the illness on function at work (Photograph: JH Lancy)

Employment is good for physical and mental health.1 'Worklessness' is a term used to describe not being in paid employment and not actively seeking employment.

A report in 2008 estimated that annual costs of sickness absence and worklessness associated with ill health exceed £100 billion per year.2 Encouraging an early return to work, which can include phased returns and work modifications, improves physical and psychological recovery.

The longer a patient is off work, the lower their chances of getting back to work. Long periods out of work are associated with poor mental and physical health, increased use of health services, poverty and social exclusion.

The benefits of work
The beneficial effects of work generally outweigh the risks, improving physical and mental health and well-being and reducing poverty and social exclusion.

Long periods out of work can cause or contribute to a two- to threefold increased risk of poor general health, a twoto threefold increased risk of mental health problems and 20 per cent excess mortality.1

Children in workless households have increased prevalence of recurrent health conditions and psychiatric disorders and are more likely to experience worklessness themselves during adult life

The new 'fit note'
The old medical statement was designed in 1948 when the workplace was different. The Department of Work and Pensions designed a new 'fit note', introduced in April 2010, to enable better fitness for work advice.

Visit out fit note resource centre

The new note should improve communication between GPs, patients and employers. A pilot of the new fit note showed that GPs were less likely to advise patients to refrain from work, more patients were considered fit for some work and GPs provided more written fitness for work advice.3 It is intended that an electronic format of the fit note will be introduced.

Changes to sickness certification

  • The forms Med 3 and Med 5 are now combined.
  • Telephone consultations are now acceptable for assessment.
  • GPs can now advise that patients 'may be fit for work' and provide advice about a phased return to work, amended duties or altered hours.
  • There is now more space for comments with tick box suggestions.
  • During the first six months of sickness absence the statement can be issued for no longer than three months
  • Introduction of employment and support allowance (ESA) means you do not need to fill out a Med 4 form.
  • Forms RM7 and Med 6 are no longer needed as most patients making a new claim to ESA undergo a medical assessment within a short period after making the claim to benefit.

Points to consider when completing the fit note

  • Patients can self certify for up to one week.
  • The date of assessment is date of consultation, date of telephone call or date when report from another registered healthcare professional was considered.
  • The description of the condition should be as accurate as possible unless it would be harmful to the patient's well-being or compromise the patient's position with their employer.
  • Consider whether the patient is 'not fit for work' or 'may be fit for work taking account of the following advice'.
  • If the patient may be fit for work, use the four tick boxes and the comment box for advising both the employee and employer.
  • For patients who may be fit for work, discuss with the patient the impact of the illness on function at work.
  • Decide whether you will need to assess your patient's fitness for work again at the end of the statement period.

Where to go for advice
The Department of Work and Pensions Guide for GPs and other doctors on statement of fitness for work provides helpful advice on how to complete a fit note and includes some useful case studies.

It is also possible for GPs to access telephone advice from occupational health nurses in a pilot project, which is running until March 2011.

The advice line number for England is 0800 022 4233, for Scotland is 0800 019 2211 and for Wales is 0800 107 0900.

Questions to ask the patient
  • When do you see yourself going back to work?
  • What needs to change for you to go back? (Need to find out what the obstacles to returning to work are and how they can be overcome.)
  • How important is it for you to get back to (or be in) work? What is it about your work that is important to you?
  • How confident do you feel about returning to work? (Both importance and confidence are needed to assess readiness to return to work.)

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: Earn More Credits

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Give a talk to your colleagues on fit notes and make them aware of the facts to improve motivation, questions to ask the patient and the resources available.
  • Look at the last 10 fit notes you have written. Have you recorded the patient's occupation, a discussion about return to work with a likely date and how long they have been off work for so far?
  • Design a protocol or template for your practice on what information should be recorded when someone attends for a fit note.

References
1. Waddell G, Burton AK. Is work good for your health and well-being? London: TSO, 2006.

2. Black C. Working for a healthier tomorrow. London: TSO, 2008.

3. Sallis A, Birkin R, Munir F. Working towards a 'fit note': an experimental vignette survery of GPs. Br J Gen Pract 2010; 60: 245-50.

  • Dr Carter is a locum GP in West Yorkshire

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