BMA and CBI at odds over role of GPs in return-to-work efforts

Sarah Silcox reports on recent debate over government proposals to make GP services more relevant to the needs of working people and better able to facilitate returns to work.

The Department of Health has issued new guidance for general practitioners¹ on advising patients about work. Pressure has been mounting on GPs from a variety of quarters to “up their game” in respect of treating patients of working age. The employers’ body, the CBI, has criticised the family doctor service as being “outdated and rigid” and placing an unnecessary burden on employees and employers; and the mental health foundation, the Sainsbury Centre, produced research suggesting that the “road to long-term unemployment for people with depression begins in the GP surgery with the writing of a sick note”. At the same time, the conclusions of Lord Darzi’s interim report on the NHS to the prime minister² highlighted the need for GP services to become more accessible to working people.

In defence of its members, the British Medical Association said that GPs already work extremely hard to benefit local people, and that most patients were satisfied with the services on offer.

Lord McKenzie, minister for health and work, launched the new guidance for GPs in September at a BMA conference on the role of work in the maintenance of good health. In his speech to the conference, the minister highlighted DWP-sponsored research by Doctors.net showing that 64% of GPs are not aware of the independent review evidence published in 2006 showing that “good work is good for health”³. The Doctors.net research also found that only 40% of GPs feel confident about dealing with patient issues concerning returning to work. However, it did suggest that GPs are receptive to change – over half think their sickness certification practice would change if they had better skills to deal with work-retention issues; and almost 90% feel that having evidence on the value of work to health would affect the way they practise.

Department of Health guidance

The new guidance starts from the premise that work is an integral part of life and meets a range of financial and psychosocial needs. It presents the evidence that unemployment is bad for health, and argues that GPs have a duty to discuss with patients whether staying off work is the most appropriate way to manage their health problem. GPs need to consider the risks of sickness absence and whether these might outweigh the benefits, the guidance argues.

The guidance focuses on the mild-to-moderate conditions that make up the bulk of a GP’s workload – mental health, cardio-respiratory and musculoskeletal disorders. It outlines the health-related, psychological and occupational obstacles to recovery, including “poor absence management” by the employer, and litigation. Myths surrounding these common health problems are tackled – for example, the mistaken belief among employees, and employers, that there should be no return to work before individuals are 100% fit. The leaflet suggests that work is therapeutic and an essential part of recovery, and that GPs should encourage patients to return to work when possible, even if still experiencing some symptoms. GPs can make an important contribution to a return-to-work plan and the patient’s employer “can be an ally”.

GP awareness-raising measures

The guidance for GPs is part of a series of Department of Health initiatives to support and educate health professionals on the health risks of unemployment and the consequences of sickness certification. A pilot education programme on health and work, developed and delivered by the Royal College of General Practitioners, was recently run in six of the college’s faculty areas. An early evaluation suggests that this workshop training improved GPs’ confidence in dealing with fitness-for-work issues, and the Department of Health is currently considering a roll-out. The General Medical Council is working on developing a set of key messages on health and work to be included in medical student training, and the Academy of Medical Royal Colleges is working on a similar initiative. The Department of Health has also commissioned an online training module to support doctors in difficult consultations with patients about work. A revised Fmed3 form is due in 2008, Lord McKenzie told the BMA conference.

“Tension” in the GP role

The government’s initiative to inform GPs about the benefits of work to health is an important step to help prevent people, in particular those with mental health problems, from getting caught in a “spiral of unemployment, poverty and ill health”, according to the Sainsbury Centre for Mental Health. The centre’s director of employment, Bob Grove, comments that unemployment is as bad for your health as smoking or obesity, “yet every year, thousands of people with depression and other mental health problems are signed off sick for long periods and end up losing their job.”

Dr Alan Cohen, the Sainsbury Centre’s primary care adviser and a practising GP, said: “Issuing a sick note is as serious a task as making a prescription. Like a prescription, it can help some people over a tough time, but it can also have potentially devastating side effects. GPs need to bear these in mind when they issue a sick note. They need to keep in touch with patients on sick notes and to support them in their journey back to work.” Grove adds that it is vital that GPs and other NHS staff are aware of the impact that long-term absence from work has on job retention, and the Sainsbury Centre calls on health workers to “offer appropriate support to people who have a medical certificate to return to work”.

A new briefing paper⁴ from the Sainsbury Centre calls for GPs to be encouraged “through their contract” to provide work-focused help for people signed off sick with depression, including the timely provision of psychological therapies such as cognitive behavioural therapy and referral to employment advisers where appropriate. The best approach, the centre recommends, is for GPs to arrange appropriate therapy, assess fitness for work, communicate with employers and Jobcentre Plus, and help develop a return-to-work plan.

GPs generally accept responsibility for the possible side effects of medications when they issue a prescription, and should also consider the possible adverse consequences of providing a sick note, the briefing suggests. However, reforms are needed to create the levers for change in the way GPs work, including changes to the GP contract. The centre suggests that the incentive scheme for GPs should be altered to reward them for taking action in the case of patients whose employment is at risk as a consequence of mental ill health. However, this requires central government to commit to policies that recognise that employment for people with mental health problems is a high public health priority. A change in culture in general practice is also required, and could be difficult, it suggests, as GPs may believe there is conflict between their role as patient advocate and providing advice on fitness for work.

The need to improve GP services for people of working age was one of the interim conclusions of Lord Darzi’s review of the NHS; and the way GP services are currently organised was criticised by the CBI. They said that restricted opening hours, difficulty in booking forward appointments and the limited range of services on offer in many surgeries result in millions of working days being lost unnecessarily. A CBI report⁵ argues that it should be easier for employees to switch GPs and they should be able to register at more than one practice. More widespread availability of walk-in centres and over-the-counter advice from pharmacists would also help ensure working people had access to timely healthcare wherever they live and work.

The CBI called on the Department of Health to incentivise GPs to deliver services that best meet the needs of working age people – and pressed for the extension of polyclinics and practice-based commissioning.

GP funding should follow the patient more fluidly to expose poor providers, the CBI argues, and primary care trusts should create the conditions in which providers from the public and private sectors can compete.

1. Advising patients about work: an evidence-based approach for general practitioners and other healthcare professionals, Department of Health, September 2007.

2. Our NHS, our future, NHS next stage review, interim report, October 2007 (external website).

3. See “Is work good for your health and well-being?” Gordon Waddell and A Kim Burton, OHR 124, November/December 2006, pp.30–31.

4. Work and wellbeing: developing primary mental health care services, (external website) Briefing 34, Sainsbury Centre for Mental Health, September 2007. (See SCMH website.)

5. Just what the patient ordered: better GP services , (external website) CBI, September 2007.