RCGP policy debate: From sick notes to fit notes

RCGP chairman Professor Steve Field has organised a series of breakfast meetings, bringing together GPs and policy makers to discuss hot topics for all UK practices. GP was at the table to exclusively report the first debate.

The panel included (l-r): Professor Steve Field, Dr Bill Gunnyeon, Dr Alan Cohen, Dr John Chisholm and Dame Carol Black
The panel included (l-r): Professor Steve Field, Dr Bill Gunnyeon, Dr Alan Cohen, Dr John Chisholm and Dame Carol Black

The introduction of the new Med 3 form, the so-called 'fit note', is about to push the relationship between work and health to the top of the primary care agenda.

From 6 April, GPs will have the option to state that a patient 'may be fit for work', and advise on ways that they could be helped to return sooner.

The Department for Work and Pensions has redesigned the form as part of its plan to drive a major cultural change in the UK, extolling the health benefits of being in work.

And in response, the RCGP has been running a national educational programme to advise practices on work and health issues, with 1,000 GPs already signed up.

College chairman Professor Steve Field brought together some of the main players from the government and general practice to highlight key issues.

Why does the system need to be changed?

Dr Bill Gunnyeon
There was a concern about what GPs did when they gave advice to patients about whether they should work or not with a health condition.

There was a recognition that a lot of people ended up becoming long-term sick and as a consequence running the risk of losing their job, finding themselves out of work, being dependent on state benefits, and facing a real challenge to get back into work.

GPs were often blamed for this but my concern was that we never properly equipped GPs to give the advice.

The medical statement, the so-called sick note, did not actually help matters because it only really gave GPs two options - fit for work or not fit for work - and did not encourage any discussion between the GP and patient about whether there might be things that could be done to help them return a bit earlier rather than drifting in to long-term absence

Dame Carol Black
Just like smoking, work is a social determinant of health. We doctors and nurses would try to be positive about getting patients to stop smoking but none of us have thought of work as a social determinant of health.

There has been nothing in our training until recently that would have made us think that way. So there is a widespread educational need.

Few of us, when we see a patient, think 'can we keep them in, or return them to, their functional status?' That is part of how they feel - their dignity, their self-esteem.

We may only be changing the structure of a form but ultimately it's about enabling people to live a better and fuller life.

In the wider context of society and life, it's a crucially important step and we all need to work to make it meaningful.

Is a GP the right person to give this advice?

Dr Bill Gunnyeon
One of the things that concerns GPs is that they are not occupational health experts and they don't know the details of the patient's job and workplace.

But we are not actually asking GPs to make recommendations about the specific nature of the patient's job.

What we are asking them about is the functional impact of the patient's condition and anything they think of a general nature that might help the patient return to work.

It is then for the employer to decide whether they can make those adjustments or not.

If they cannot return to work, then the certificate they have from the GP enables them to not return to work. There is no need for them to go back to the GP for another statement. The employer has effectively taken responsibility.

How are the Med 3 form changes going to affect the work of GPs?

Dr John Chisholm
There is a lot of good news in this change for GPs. For a long time the sick note has not been fit for purpose for GPs or for patients, or employers, and we are now moving to something much more useful in that it will enable GPs to do more for their patients through giving better quality advice to them and their employers.

It's also emphasising what patients can do and not just what they can't do.

Dr Alan Cohen
What's really important as a GP when seeing patients is that it's never just about diabetes or just about pain or just about depression, it's about all the other bits as well.

And what I like about this excellent initiative is that for the first time we are beginning to approach something in a way that is outside of the silo approach.

It's a whole person approach, where employment is seen as being as important as their depression or their diabetes.

And for that reason it's going to change the way that GPs work and improve the outcomes for their patients. It's a major change that's going to be very important.

Dr Bill Gunnyeon
One of the objectives is to make life easier for GPs and the new form allows the GP to indicate whether they will need to see the patient again.

So there will no longer be this idea that somehow everybody has to go back to the GP be signed fit to go back to work, which has never been a requirement anyway, it's just something that's grown up.

So the aim is to facilitate an early intervention?

Dr John Chisholm
It's an enormous frustration for GPs to know what their patient needs but to be unable to get it in a timely way, and it particularly applies in the two commonest areas of work absence - mental health issues and musculoskeletal problems.

We know that the longer people stay off work, the less likely it is that they will get back to work in a timely way or sometimes ever. So early intervention will be helpful.

Dame Carol Black
What I felt was that there were no pathways of care that a GP could access quickly in these situations. If they saw someone with a heart problem, they would have a pathway of care that could be followed.

It's about early intervention in to whatever the problems are, whether it's physiotherapy you need, or debt advice or family help. It's no good just saying work is good for you.

What are the challenges ahead, once the new form is introduced?

Dr Bill Gunnyeon
There is a big challenge about changing public perceptions about work and health, and the importance of work generally, so that people actually recognise that you do not need to be 100 per cent fit to work and that being at work actually has a lot of benefits, while being out of work can have a detrimental effect on your health.

We are talking about a fairly significant culture change here, that is going to take time.

Employers are another big challenge. The guidance for employers is critical because it's one thing getting GPs to give better quality advice to patients but it's all going to fall down if employers don't look at that advice and try to do something with it.

How will we know whether it makes a difference?

Dr John Chisholm
Some of the outcomes of this change are quite hard to monitor in terms of improving dialogue and support, and will not happen overnight.

But hopefully in a year or two, things will be quite a lot better in terms of supporting people in work or helping them back into work.

We also want to place GPs in a position regarding occupational health that they already hold in relation to any other specialty. This is a good news story and part of a gradual cultural change for which I think the fit note will be a catalyst.

Dr Alan Cohen
And rather than it being a chore to sign sick notes, we now have a clinical intervention. Signing the sick note is now part of a set of therapeutic interventions.

Dr Bill Gunnyeon
It's certainly not my view that this is something that government wants to audit. It's very much my view that it's for GPs to look at, now that we are giving them the opportunity to audit the advice they are giving to patients, and I would certainly welcome that.

But it's not something I would like to see driven from the centre because that sends the wrong message. What we are trying to do is help GPs give better advice and improve outcomes for patients.

I do not want to turn this back in to something that's about monitoring GPs because that is certainly not what has driven it.

And what should be the priorities now for the profession's leaders?

Professor Steve Field
We need to make sure that some of these issues that are clearly beneficial for patients are picked up if there is a change of government, and if commissioning moves to GPs rather than PCTs.

One of the problems has been inconsistencies across the country, and clearly some areas have not been commissioning the sort of services that GPs can access quickly enough.

We hope that having more GP involvement will mean better services for patients but we must make sure that we have consistency.

This is a key area because if we can keep people in work, and keep people healthy, it will reduce the workload for GPs. So it's actually a win-win situation for everybody.

The Panel

Dr Bill Gunnyeon Director of health, work and wellbeing, and chief medical adviser, Department for Work and Pensions

Professor Dame Carol Black National director for health and work

Dr Alan Cohen GP and national primary care adviser for Improving Access to Psychological Therapies

Dr John Chisholm RCGP council member and former GPC chairman

Professor Steve Field Chairman of RCGP council.


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