Absence essentials: fitness for work advice and certification

Consultant occupational physician Dr Nerys Williams separates fact from fiction in the controversy surrounding sickness certificates, and explains the roles of GPs and the benefits system in employees' absences from work.

Issues surrounding sickness certification and absence from work due to illness have recently made the headlines of the major newspapers. GPs have come in for criticism for the ease with which they give medical statements (also known as Med 3s or "sick notes") to their patients.

In turn, some GPs have expressed their dissatisfaction about what they see as a role in "policing" attendance management programmes and in spending their time seeing patients only for a short-term sick note when they are under no obligation to supply one, but the patient's employer has requested it.

Often, employers complain that employees are being signed off for little or no reason, but GPs argue that their role is to be a patient advocate and not the employer's occupational health adviser. All sides need to understand the roles that each should play, and the roles of other participants, if there is to be the best outcome for the patient/employee.

Short-term ill health and certification

In the UK, the first seven days of absence are self-certified by the individual employee completing a form SC2 (or form SC1 if they are self-employed).

Not all employers fund the first few days of sickness absence. Indeed, there is a trend for organisations not to pay for the first few days of absence as a method of controlling short-term unexpected non-attendances. It remains to be seen if this is effective in either the short or long term - both regarding its impact on short-term absences and on the number and frequency of longer (>7 days) absences.

Generally, GPs do not have a duty to provide a sick note or confirm sickness leading to less than eight days' absence, although they are often requested to do so by either the employer or the employee. If they do decide that they are in a position to confirm illness, perhaps because the patient consulted them, then they may provide a private note and charge accordingly. However, their NHS terms of service do not require them to provide the employee (or, indirectly, the employer) with such a note or certificate.

From the eighth day, a medical statement, more commonly called a certificate, is required to support a claim to Statutory Sick Pay and equivalent employer benefits. This can only be signed by a registered medical practitioner (a doctor) and is an official document. GPs are required, under their conditions of service, to provide such statements to patients or their representatives, free of charge.

Funding for this role is included in the overall remuneration that GPs receive from the NHS. The medical statement contains advice from the doctor to the patient, but is often used by the patient to verify their absence and to claim sick pay. However, the employer is entitled to seek their own medical evidence, even though the majority of organisations rely on the statement issued by the employee's doctor.

Alternatives to GPs

While the majority of sick notes are signed by GPs, guidance from the Department for Work and Pensions and the Department of Health to hospital doctors has reminded them that they are responsible for issuing statements where they have clinical care of the patient. For example, this would follow routine surgery or when patients are seen frequently for chronic disease care. Sickness certification by hospital doctors is encouraged as one way to reduce the workload of GPs.

A number of other initiatives are taking place in the field of certification, including the Department of Health's NHS Modernisation Agency pilots to look at certification by occupational health practitioners (see Have sick notes had their day?).

Research has also been carried out on the views of other groups of professionals regarding their capability to issue certificates and will shortly be published. Many osteopaths and chiropractors already issue patients with guidance on their capabilities and workability through "notes", but these do not have the same legal standing for statutory sick pay purposes as the doctor's statement. Again, further pilots are likely to look more closely at the issue of professional groups who may be involved in certification.

Longer-term ill health

In the case of longer-term absences from work, the GP will see the patient regularly for treatment including advice on their fitness for work. With the increasing role of the practice nurse in screening and in chronic disease management, it is likely that the patient will consult the nurse as well.

This is the time when, ideally, enquiries are made about the individual's functional capacity - that is, what they can do rather than what they cannot, and about the nature of the tasks normally undertaken by the patient at work.

If it appears that the barrier to a return to work involves a small part of the job then, with the patient's permission, the GP or the practice nurse may contact the patient's employer or the occupational health department to suggest alternative or adapted duties. Recommendations to the employer can also be documented by the doctor on the Med 3 statement.

A flexible attitude by the patient's employer to requests for modified or adapted work can facilitate an earlier return than would normally be expected, and establish a good working relationship with local GPs.

GPs can use the clinical consultation as an opportunity to reinforce positive messages about work and health, and to manage patient expectations about a return to their job.

If patients are hesitant about returning to work, then the GP may encourage them to seek the advice of the employer's occupational health (OH) adviser or line manager. Another useful contact, who is accessible to the GP, the OH adviser and the patient, is the Disability Employment Adviser (DEA), based at the local Jobcentre Plus.

Both OH adviser and DEA can assess the individual and their work and make recommendations as to adaptations and modifications, which may allow the person to return to work. The DEA can also obtain funding, such as the Access to Work scheme, which can help provide adaptations to the workplace and to work activity to allow a person with a disability to return to work. DEAs can also organise an employment assessment to identify suitable work or training needs and arrange for referral to an occupational psychologist for help with workplace problems such as phobias and lack of confidence.

Incapacity benefit

Usually after six months' absence from work, sometimes earlier, the individual may apply for state incapacity benefit. This is a taxable but non-means-tested benefit. The claimant will then be called for a Personal Capability Assessment (PCA) by the Department for Work and Pensions Medical Services.

Only about 70% of people are actually medically examined, and many severe and permanent conditions, such as blindness, mean that a person is exempt from the assessment. Following the PCA, feedback on the outcome is always given to the GP. If the individual's disabilities are significant enough and they satisfy the test, then the award of benefit is made by "Decision Makers" acting on behalf of the Secretary of State. These are lay people who base their decisions on advice provided by doctors experienced in disability assessment.

The award of incapacity benefit means that the person is not expected to actively search for work, but it does not mean the person is incapable of all work or permanently incapable of any work. Many people on incapacity benefit subsequently re-enter the job market, but the longer they claim benefit the less likely they are to subsequently be employed.

Employment potential

From a potential working population of 28 million people in the UK, there are around 2.7 million people of working age currently claiming incapacity benefit and not in employment. The most common medical conditions preventing work are anxiety and depression and musculoskeletal disorders, usually of the back.

Surveys have shown that many people claiming benefit want to get back to work but the chances of them doing so reduce the longer they claim. They lose confidence, their skills become outdated and they may even develop additional mental health problems. What people need is help and competent advice on what their capabilities are and what they can do with support from employers.

The fact that an individual is claiming incapacity benefit when they apply for a job does not mean they are unemployable or unfit for all work. Far from it, often minor adjustments (or even none at all) are all that is needed. Under the Disability Discrimination Act 1995, employers are required to make reasonable adjustments to the work and workplace to allow people with disabilities, as defined under the Act, to work safely and be offered the same opportunities as other employees. As of 1 October 2004, the scope of the act has extended to employers of small numbers of workers and to certain occupational groups who were previously exempt.

What constitutes reasonable adjustments is a matter for the legal system and for employment tribunals, but examples of how work could be adapted, regardless of whether the individual meets the definition of "disabled" under the Act or not, are illustrated below.

A 23-year-old supermarket checkout operator developed chronic back pain following an accident at her gym. She found that her symptoms were aggravated by pulling heavy bags of pet food and bedding across the electronic scanner. Opportunities for possible adaptations may involve her employer arranging for her to work only on "hand basket" tills, on the customer service desk or on "meet and greet" duties.

A 64-year-old legal secretary with chronic osteoarthritis of the thumbs finds it difficult to undertake word processing for more than 20 minutes without increased pain. A simple cost- effective adaptation would be for her employer to provide her with voice recognition software to reduce her use of the keyboard.

A 32-year-old IT consultant with long-standing multiple sclerosis develops a tremor, which makes keyboard use more difficult. A reasonable adaptation may be for his employer to provide a grid to place over the keyboard to allow him to avoid touching neighbouring keys when typing.

Why is work so important to health?

Work is important for health. But not any work; it must be the right type of work for the individual. That is, work that gives control over tasks and manages demands and is satisfying.

There is also a growing body of evidence of the negative effects of being out of work. Studies have reported increased consumption of tobacco¹, of alcohol² and increased sexual risk-taking behaviour³. It is estimated that the non-working population suffers twice the rate of depression and three times the rate of anxiety than the general population⁴. And after being on sick leave for six months, the risks of developing depression - even if that was not the initial reason for their absence - increases (source: Department for Work and Pensions personal communication).

Even after adjustments for social class, poverty, age and pre-existing morbidity, unemployment continues to be associated with greater levels of ill health. Studies have reported increased obesity⁵ and reduced activity⁶. There are also additional barriers for people with mental health problems to get and retain work, as shown by the results of the Labour Force Survey in 2003. This found that 21% of people with a mental health disability were in employment, compared with 50% of people with disabilities generally and 75% of the non-disabled working age population.

But it is not just mental health problems that are more common in those without work - cardiovascular morbidity and mortality also increase with unemployment⁷. Yet, encouragingly, when employment rates increase, reductions in mortality at the community level are seen very quickly. Certainly this is "food for thought" for those with corporate social responsibilities.

¹Wilson, S H and Walker, G M (1993) "Unemployment and health: a review", Public Health, vol. 107, no.3, pp.153-162.

²Janlert, U and Hammarstrom, A (1992) "Alcohol consumption among unemployed youths: results from a prospective study", British Journal of Addiction, vol. 87, no.5, pp.703-714.

³Janlert, U and Hammarstrom, A (1997) "Unemployment and sexual risk-taking among adolescents", Scandinavian Journal of Social Medicine, vol. 25, no.4, pp.266-270.

⁴Ytterdahl, T and Fugelli, P (2000) "Health and quality of life among long-term unemployed", Tidsskrift for den Norske Laegeforening, vol. 120, no.11, pp.1,308-1,311.

⁵Morris, J K, Cook, D G and Shaper, A G (1992) "Non-employment and changes in smoking, drinking and body weight", British Medical Journal, vol. 304, no.6, 826, pp.536-541.

⁶Underlid, K (1996) "Activity during unemployment and mental health", Scandinavian Journal of Psychology, vol. 37, no.3, pp.269-281.

⁷Brenner, M H (2002) "Employment and Public Health: Final Report to the European Commission", vol. 1, European Commission Directorate General, Employment, Industrial Relations and Social Affairs.

This article was written by Dr Nerys Williams, a consultant occupational physician and a medical policy adviser at the Department for Work and Pensions; email: nerys.williams@virgin.net.