Sick of Fit Notes?

1. Sick of Fit Notes? Dr Emma Lackey GP and The Department of Justice (Medically Qualified Member of First Tier Social Entitlement Chamber) Dr Jan Sturman GP and Medical Disability Analyst for ATOS

2. Disclaimer! • Although I do work for the Department of Justice, this presentation is my own and is not done on their behalf – opinions and mistakes are my own…

3. What we are covering today…. • Employment and Support Allowance (ESA) • Is work good for you? • Fit notes • ESA work capability assessment and ATOS • ESA appeals process • ESA and JSA – monetary issues • Disability Living Allowance (DLA) – brief summary

4. Employment and Support Allowance • Ethos of it ESA: Intended to provide income replacement for people who are unable to work because of illness or disability. • Commenced 27 October 2008 • Replaces Incapacity Benefit, severe disablement allowance and income support paid on the grounds of incapacity (migration period).

5. What we are covering today…. • Employment and Support Allowance (ESA) • Is work good for you? • Fit notes • ESA work capability assessment and ATOS • ESA appeals process • ESA and JSA – monetary issues • Disability Living Allowance (DLA)

6. Is work good for you or not? • Asked by the Department of Work and Pensions in 2005 as part of their Health, Work and Well-being Strategy. • Independent Review commissioned – done by Waddell and Burton. • 246 pages later the question was answered in a green paper….

7. Drum Roll • Work IS generally good for health and wellbeing. Waddell and Burton (2006) “Is work good for your health and well being?” Proposals were laid out in a white paper written by DWP, DH and health and safety executive

8. Benefits of work…… • Generally the most important means of obtaining adequate economic resources (i.e. we do it for the money) • Work provides psychosocial needs, identity, social roles and social status. Waddell and Burton (2006)

9. But

10. And it’s a big but….. • There were several provisos……

11. Work has to be safe • Physically

17. Provisos • Various psychosocial aspects of work can also be hazardous and pose a risk to health.

18. Provisos • Findings were a group effect – a minority of people may experience contrary health effects from work. • Beneficial health effects do depend on the nature and quality of work (i.e. work should be safe and accommodating) • Waddell and Burton (2006)

19. Unemployment

20. Unemployment (even when a health selection effect is considered) • Higher mortality • Poorer general health, longstanding illness • Poorer mental health, psychological distress, minor psychological/psychiatric morbidity • Higher medical consultation, medication consumption and higher hospital admission rates • Longer off, less chance of getting back to work • Strong evidence from Waddell and Burton (2006)

21. Re-employment • Improved self esteem • Improved general and mental health • Reduced psychological distress and minor psychiatric morbidity • Waddell and Burton (2006)

22. City and Guilds Career Happiness Index 2012 Happiest workers were gardeners and florists (87%) (65%doctors were happy)! Happiest working age was over 56

23. Work for sick and disabled people • Is therapeutic, promotes recovery and rehabilitation • Leads to better health outcomes • Minimizes harmful physical, mental and social effects of long-term sick absence • Reduces risk of long term incapacity • Promotes participation in society and independence • Reduces poverty and improves quality of life and well-being • Waddell and Burton (2006)

24. Take home message number 1 • Overall, the beneficial effects of work outweigh the risks of work, and are greater than the harmful effects of long-term unemployment or prolonged sickness absence. • Work is generally good for health and well-being.

25. What we are covering today…. • Employment and Support Allowance (ESA) • Is work good for you? • Fit notes – introduced 6th April 2010 • ESA work capability assessment and ATOS • ESA appeals process • ESA and JSA – monetary issues • Disability Living Allowance (DLA)

26. How long can you put on a fit note? • During the first 6 months of sickness this can be up to a maximum of 3 months. After the first six 6 months of incapacity a statement can be issued for any clinically appropriate period up to ‘an indefinite period.’

27. Can I issue a statement from a telephone consult or without any patient contact? • Yes you record the date on which you undertake or undertook: • A face to face consultation • A telephone consultation. • The consideration of a written report from another doctor or registered healthcare professional

28. Can they be backdated? • A statement of fitness to work can only be issued for a backdated period when it is based on a previous assessment. • An assessment is defined as the date you either had a face to face consult, a telephone consult or considered a report from another doctor or registered healthcare professional. You can issue a statement after this but not before.

29. Backdating continued…. • The DWP recognise there are some situations where your patient may ask for medical evidence to cover a backdated period for which there has not been a previous assessment. For example if they did not get a med 3 at hospital discharge or a previous consult with another GP. • In these situations you cannot issue a Med 3 for the back dated period. However in order to be helpful for your patient you may wish to, either in the comments box or in a separate letter, provide advice that the patient was not fit for work for an earlier period. You should ensure you have the appropriate information and evidence to justify this advice – generally via a report or patient record. Employers and DWP can accept this advice as strong evidence for fitness to work for social security and Statutory sick pay purposes. • BB

30. Can I issue duplicate statements to a patient with 2 part time jobs? • No. You can only issue a duplicate Med 3 if the original statement has been lost. You should clearly mark it “Duplicate”. Advise people with more than one employer to submit the statement to their main employer, who can note the details of the advice you have given. They can then present the statement to their second employer.

31. “The job centre told me I need/must have one…” • What the Jobcentre may have said, “To be eligible for ESA you need a sick note.” • Or if the patient tells the job centre they have a health problem affecting work, the response may be “you would need a fit note from your GP regarding that.” • Sometimes I think things change in translation. • The decision re issuing the statement is a statutory obligation of the doctor (and only a registered medical practitioner).

32. I miss the RM7 can I still use it? • The RM7 has been withdrawn from use. It was really a request for an independent medical assessment of a patient and the idea is now that the ATOS work capability assessment is done much earlier (at 3 months), so one is done anyway now.

33. Can I put a white lie in the diagnosis box? • The diagnosis should be as accurate as possible unless you consider that providing a precise diagnosis would be harmful to your patient’s wellbeing or compromise your patient’s position with their employer. A less precise diagnosis is the done thing.

34. Why is there nowhere to put, “This patient is fit for work’?

35. To show you….

36. Declaring ‘fit for work…’ • From 6th April 2010 certification changed and the box ‘need not refrain from work’ disappeared. • It generated a common myth that some patient or employers felt it was needed this as a statement. In the cases where one is required (e.g. for LGV/PCV drivers) there is an existing procedure. • If an employer feels they require such advice they can get it a GP or occy health specialist via a private arrangement…

37. What should I put in the bit about may be suitable for work if…..

38. May be suitable for work if…. • Try not to be too prescriptive…. • E.g. – ‘cannot sit for long periods’ is better than ‘should be provided with a better chair’ • In travel related anxiety ‘avoiding travel in peak hours’ is better than ‘should work between 10am and 4 pm.’ • Consider recommending an occupational health assessment. • If the employer cannot provide the conditions (phased return amended hours etc) they can use the statement as you had advised ‘not fit for work.’ • Recent HR study showed that between 38-70% had noted GPs did not comment

39. What about new electronic fit notes? • Roll out begins in July 2012 and should be complete by early 2013 (?) • No changes – just that it will print electronically – but handwritten notes will still be available (e.g. for home visits) • Electronic notes will not be available for hospital doctors. • Audit use (anonymised)

40. What we are covering today…. • Employment and Support Allowance (ESA) • Is work good for you? • Fit notes • ESA work capability assessment and ATOS • ESA appeals process • ESA and JSA – monetary issues • Disability Living Allowance (DLA)

41. ESA – how do you get it? • Fit note (med3) as not fit for work from GP (Assessment phase covers first 13 weeks) • Then fill in an ESA50 form from job centre • Then called for a Work Capability Assessment. • Decision maker at the Department for Work and Pensions informs client of outcome. • Right to appeal goes to the Department of Justice. • Appeal is done either as a review of paperwork or with the client present.

42. Work Capability Assessment • Performed by Atos • Newcastle carried out at Arden House

43. Special conditions • Terminally ill • Some chemotherapy • carrying or having had contact with certain diseases covered by public health regulations • Hospital in-patients (including residential detox) • Pregnancy - conditions apply

44. How can this be done without medical records? • Impairment • Disability

45. Impairment and disability Johnny Peacock (UK) winning Gold, 100m Paralympics 2012

46. Impairment and Disability • Impairment • Any loss or abnormality of physiological or anatomical structure or function (objective) • Disability • Any restriction or lack of ability to perform an activity • Pain and disability are subjective • A disability examination is very different from a diagnostic examination

47. Work Capability Assessment • ESA50 form and GP correspondence letters in file • List conditions – duration, history, specialists, treatments, current symptoms and frequency • Drug and alcohol issues • Medication and side effects • Social history - cohabitants and accommodation type • Occupational history and reason for leaving and current work / study • Typical day

48. Examination • Demonstration • Observed behaviour

49. Work capability Assessment (continued) • Choice of descriptors • Justification • Non functional descriptors • Support group justification • Personal statement summary • Prognosis

50. Descriptors • 17 descriptors in total – see handout • You need 15 points to receive ESA (take the highest points in each descriptor) • Caution advised – you need to read them very carefully and those applying them have specialised (extensive) training - for example • Descriptor 2 • Application when drunk • Going out accompanied – necessity or choice? • Beyond reasonable doubt or balance of probability • Non functional descriptors - Regulation 29