UNIVERSITY OF LIVERPOOL
SUPPORTING HEALTH PROFESSIONALS
[THE CREATION OF A SICKNESS ABSENCE AND A RETURN TO WORK WEB PORTAL ] REPORT WRITTEN BY
ANNE-MARIE MARTINDALE WITH PROF. MARK GABBAY, DR. SUZANNE EDWARDS AND DR. ANNE RANNARD 2/15/2012
This report charts the progress of the Fit for Work research team’s goal to explore health professionals attitudes and needs were surrounding sickness certification and its surrounding issues and to provide an additional and one-stop shop type supportive tool. 1
The Fit for Work Team THE FIT FOR WORK TEAM IS BASED AT THE UNIVERSITY OF LIVERPOOL’S HEALTH SERVICES RESEARCH DEPARTMENT. THE TEAM CONDUCTS RESEARCH, PUBLISHES AND LECTURES ON SICKNESS, HEALTH AND EMPLOYMENT RELATED ISSUES.
THE TEAM ROLES FOR THIS PROJECT HAVE BEEN ANNE-MARIE MARTINDALE LEAD RESEARCHER ANNE RANNARD
RESEARCHER
PAULA BYRNE
RESEARCHER
SUZANNE EDWARDS
CO-GRANT HOLDER AND CO-PRINCIPAL INVESTIGATOR
MARK GABBAY
CO-GRANT HOLDER AND CO-PRINCIPAL INVESTIGATOR
QUERIES TO ANNE-MARIE MARTINDALE
HEALTH SERVICES RESEARCH FIRST FLOOR WATERHOUSE BUILDING BROWNLOW HILL UNIVERSITY OF LIVERPOOL L69 3GL
0151 794 5595 AMMARTIN@LIV.AC.UK
2
Contents The Fit for Work Team
2
Introduction
4
The need for the research project: Policy background
4
Methods
5
Results of the secondary research: literature reviews
7
The causes of work related ill-health
7
Sickness certification research
8
GP behaviours and attitudes
8
Patients experiences of the sickness certification process
9
GP thoughts on the recently introduced Fit Note
9
GP attitudes to continuing professional development (CDP) and transferring new learning
10
Summary of literature review findings
11
Results of the primary research
11
Overview
11
Translation of research themes into areas of the website.
12
The process- how the website took shape
14
The end product- the web portal
15
Introduction The project was funded by MerseyBeat, (a collaboration between Liverpool PCT, local NHS Trusts, local authorities and Universities) as a pilot project, which fitted into their Health and Work research stream. Initial Aims and objectives Aim
To develop an educational DVD/webcast for GPs to assist them with their management of sickness certification consultations.
Objectives:
To develop a learning package summarising content with links to relevant websites, of best evidence about managing sickness absence in Primary Care. (To include a series of vignettes to illustrate ways of managing consultations around sickness absence and return to work to be filmed and recorded onto DVD/webcast as an educational tool for GPs).
To pilot the DVD in Liverpool practices, conduct focus groups with GPs to evaluate the package
including its utility and impact and to refine the content of package and finalize production. The aim and objectives have shifted since the project’s inception as we have become more aware of the needs of Health professionals who support patients to manage their sickness absence related issues. The learning package became a one-stop shop web portal, to enable health professionals (GPs and nurses) to access a range of professional, medical, welfare and patient advocacy resources and organisations. The site was designed with the input of health professionals, to be used in two ways, firstly, during a consultation with patients, and secondly, outside of the consultation to explore issues of professional development. The report will chart the stages of the research culminating with the launch of the site.
The need for the research project: Policy background During its third term in Office, New Labour increasingly turned its attention towards the causes and costs of sickness absence for the individual, the State and society. The focus was on long-term sick leave, which carried greater resource implications. For employers these included sick pay, staff replacement and occupational health support costs. For the State, costs were likely to be accrued when people passed from long-term sicknesses absence within work, through to benefit assessments 4
and associated benefit costs. In a DWP Pathways to work training day it was noted that a person is more likely to die or retire if they have been on incapacity benefit for two years or more (DWP, web page, 2006). The government sought to change this position, initially by carrying out a review of work, welfare and sickness management related policies.
The publication of the Black review into work, sickness and welfare consolidated what was largely already known and set out a vision statement of DWP intent. Policies would be directed towards keeping people in work and providing them with the necessary tools and support to keep them there. Those that were found not able to work would be supported using enhanced welfare provision. Occupational health was expected to play a more substantial role, to support people to stay in work. Likewise, GPs are set to play a more pivotal role. Successive policy documents have emphasised a phased return to work, with the employee taking part in some work if possible, (rather than none) utilising either state or employer based occupational support. At the same time, there has been a shift in the sickness certification system to reflect this policy development. The Med3 Sick Note certifying absence from work for periods between 1-26 weeks was replaced by the Fit Note which enables a ‘partially fit’ for work option (April 2010).
It was anticipated that this research proposal- to
develop an educational tool for GPs, would support them by consolidating sickness management resources, act as a consultation aid, to facilitate negotiations with patients about health and work and certification and provide avenues to professional development in this daily aspect of the GP role.
Methods Firstly, as stated previously, a series of literature reviews were carried out to give a comprehensive understanding of the shifting policy agenda and the salient sickness certification related issues for GPs and patients. The first stage of the primary research involved designing, recruiting to and carrying out six focus groups, with GPs and others interested in the sickness certification process. Of the six, two focus groups were carried out with GPs. Recruitment to the second GP focus group took over six months. Many surgeries and GPs did not feel able to participate, citing other commitments and a lack of payment for participation as reasons for non-take up. Part way through the project health professionals based within the North-West Strategic Health Authority expressed an interest in becoming involved with the project. This led to the Team being commissioned to undertake research with nurses, to find out about their sickness and employment related needs. Though they don’t currently certify sickness, it was felt that nurses would find the web portal useful in supporting patients to manage their ongoing conditions and the impact of work on chronic diseases and vice versa. Two focus groups took place with nurses, one in Manchester, one in Liverpool. 5
One focus group took place with human resources officials, who frequently came into contact with sick and Fit Notes. A final group was conducted with union representatives who had experience of supporting employees in sickness absence related matters. Most of these groups had two facilitators present, one to take notes and both to interject when necessary, or to probe, or keep the conversation moving. All groups were recorded and the resulting data was transcribed for analysis. The second part of the primary research involved setting up a group of GPs, at different stages of their careers, to help us to translate the research findings into a useful web portal. This action learning approach was used to test the research team’s ideas actively alongside a group of professional endusers. In this way we used this approach- which the PCT was very keen on exploring, to actively engage the clinicians in developing the work with the researchers to integrate knowledge translation as part of the ongoing project development rather than after completion. Owing to the late start of the nursing aspect of the work we incorporated questions about working conditions and website usage into the focus groups. We also contacted nurses individually to ask them to complete the on-line evaluation of the draft portal.
Table 1. Summary of research and evaluation methods Literature reviews
National sickness absence data
Secondary Research
National policy changes to welfare, sickness and employment GP sickness certification behaviour, including the views of patients Knowledge transfer GP attitudes to CPD Focus Groups
In Kendal, with academic GPs at a Conference With GPs from a Liverpool practice
Primary Research
A group of Union Representatives local to Liverpool A group of HR officials from small, medium and large employers with sites in the Liverpool area. Focus group with practice nurses in Manchester Focus group with practice nurses in Liverpool
Primary Research
Discussions with
Oct 2010- face to face- via questionnaire and semi-structured
group of GPs about
group interview
6
web design and
Sent out individually and asked for comments Jan 2011-May (GPs
content
and nurses)
Emailed local GP
Draft website, with on-line evaluation questionnaire and open-
consortia, regional
ended space for comments was sent out between September-
research networks
October 2011.
Evaluation
and local GP and nurse organisations to request evaluation participation
Results of the secondary research: literature reviews The following themes were explored during a light touch review, to familiarise ourselves with the key issues
current GP attitudes and behaviours to sickness certification
comments on the proposed policy changes i.e. the Fit for Work Note and GP greater
involvement
GP attitudes to continuing professional development (CPD), and knowledge transfer, to
explore the circumstances in which the portal might be received.
The results are expressed as a series of mini findings. These were used to inform the development of the focus group questions.
The causes of work related ill-health Using 2872 case studies from GPs on their database, the THOR-GP research group (2008) concluded that musculoskeletal disorders were the most frequently reported diagnosis, but that mental ill-health was responsible for most work related sickness, accounting for over half of the total days lost. With mental health diagnosis raising by 13% a year O’Neil wanted to assess whether the diagnoses were valid. He anonymized 100 previously reported cases and sent them to 5 occupational health workers and 5 psychiatrists (2008). He found little evidence of systematic differences in diagnosis used between the two groups. Perhaps the stigma surrounding mental health diagnoses is rescinding, or employers are demanding more specific absence reasons? In a further editorial, the THOR-GP team found that larger proportions of mental ill-health were reported by people in education, health and social care, and financial intermediation. Where-as, a higher proportion of musculoskeletal disorders 7
were reported by workers in the construction industry and work related diseases, mostly skin based, were reported by people in the hair and beauty sector. Consequently, they called for an industry specific
approach
to
sickness
certification,
rather
than
a
blanket
approach
(2008).
Research is needed not only on the type of certification, but also on rehabilitation, particularly on the lack of communication between GPs and occupational health professionals and how to improve it. Through his Delphi study, Beaumont found that delays in such communication could lead to delays in patient care. Stating that training alone wouldn’t be sufficient, his research participants called for closer collaborative working.
Sickness certification research GP behaviours and attitudes Gabbay & Shiels (2004) used carbonised MED3 & 5 certificates from 44 GPs to examine the sickness certification processes in 13,127 certificates. They found that that diagnosis was the most important factor affecting length of sickness certificate, followed by deprivation, age and sex. Most of the variance remained unexplained, but that the certifying GP was not a large factor on the length of absence. A study completed by Bollag in Switzerland published in the same year confirmed these findings. Neither the age, nor gender of the GP had an impact on the certification process. Regarding the patient’s ability to influence certification outcomes, Campbell and Ogden found that GPs rated patients with psychological problems more ill, had more sympathy with them and gave out sick notes because they felt they were unfit for work (2005). Where-as those with physical conditions received less sympathy and received a sick note to maintain a relationship with them. In terms of certification length, Agius et.al. (2006) found that the main factors most associated with the development of long-term incapacity included: social deprivation; increasing age and diagnosis. Shiels and Gabbay added gender to this list of risk factors for longer absence (2006). Whilst, a Norwegian study of GPs found predictions of return to work were more accurate for short-term absence than long-term (Wahlström and Alexanderson, 2004). Mia Von Korring researched Swedish GPs difficulties with the sickness certification process. She found that many GPs described feelings of fatigue and a lack of pride in their work with sickness certification tasks. They believed they were contributing to unnecessary sickness absence and the medicalisation of patients non-medical problems. Many GPs felt a lack of competence in dealing with patient’s physical or mental pain, where symptoms were hard to diagnose. Debbie Cohen completed similar research in South Wales for the DWP (2003) during the ‘Fit for Work’ consultation period. Four major themes emerged
8
1)
Role legitimacy- GPs had uncertainty about whether their role was clearly defined enough,
lack of training was a strong theme, there was a consensus that scarcity of occupational health training lead newly qualified GPs to believe that the subject was not of high importance. 2)
Negotiation- consensus negotiation with patients around sickness certification was difficult,
due to uncertainty of patients expectations, managing the agenda and making decisions, polite tug of war, if left unsaid till end. 3)
Managing the patient- GPs had to ask about social and psychological factors to put the
certificate in context, time management and some practice processes compromised the quality of GP decision making. 4)
Managing systems- there was a consensus that GPs needed to understand the evidence
around
work
and
health
to
support
their
clinical
decision
making.
Knowing about the systems available to support patients, the facts about ill health and employment and the social and economic issues/personal consequences of being out of work gave GPs increased feelings of confidence during the consultation. However, these might not alter the final consultation outcome.
Patients experiences of the sickness certification process Campbell and Ogden found that the issuing of sickness certificates was not found to be based on family circumstances or by patients making demands (2005). O’Brien (2008) interviewed 19 patients who had recently received a sick note from their GP in 12 practices in south Wales. She found that patients wanted the same from a certification consultation as they did from other consultations (despite GPs seeing them differently). Patient’s valued continuity of care, time and comprehensive discussion and wanted to discuss being off in the context of their illness, work and home life. She cited Wessely, who found that some patients wanted to take an active role in the sickness certification process, while others needed more guidance from their GPs. O’Brien concludes that policy makers need to consider the impact to patients of continuity of care and adequate consultation time with GPs, and that this maybe challenging in light of recent Governmental policy shifts (White Paper Healthy lives, healthy people 2010).
GP thoughts on the recently introduced Fit Note Overall, concern has been expressed that GPs might have to make return to work decisions, involving a work place assessment that they are not trained to complete, as they are not occupational health professionals. It is felt that some GPs are out of touch with current employment legislation and that many will require both a cultural and attitudinal shift, particularly when faced with patients with 9
mental health complaints. One GP concluded that it was time to demedicalise sickness absence and to expand self-certification. This seems unlikely to occur in the present policy climate, unless workers will be asked if they can do some work, and phase in their own return to work.
GP attitudes to continuing professional development (CDP) and transferring new learning Davis (1999) found insufficient clinical evidence to prove that CPD had a significant effect on practice. In 2003 Little & Hayes examined GPs perceptions of post-graduate education approved meetings and professional development plans using 921 questionnaires in 3 health authorities. They concluded that changes in practice after meetings mostly related to clinical relevance and the perceived impact/interest factor of the lecturer. From her 2005 research with 43 GPs in Holland Hobma concluded that an appreciation of training and participation are dependent on the topic studied. CPD requires resources, educational support materials, skilled support staff and investment time, adding that investment time and credits must be clearly stated. In 2007 the THOR-GP team assessed the needs of occupational health GPs registered with them, 213 or 73% responded. They were shocked to find that only 22% used the THOR website for CPD. 66% reported the use of occupational medicine journals for CDP, 27% said they attended occupational medicine meetings, whilst 12% used in house training. When asked about the use of other e-learning resources 47% reported using doctors net (a website) or British Medical Journal (BMJ) learning. Those who used other e-sources were more likely to use the THOR website. A lack of GP time was the most frequently given reason for the low THOR website use. The team promised to make it more accessible and to add more refinements. They concurred with Hobma’s findings, that protected time would be needed to train and develop skills, however, it might not be available. Even if web-based learning is completed, it is not certain that it will influence behaviour. Curran and Fleet found limited research demonstrating performance change in clinical practices. No studies reported that web based CME continuing medical education was effective in influencing patient or health outcomes (2004). Having taken account of the political agenda, GP feelings towards the sickness certification process and training and skills development, it is important to examine how this new policy information may be translated and received. Boissel found that GPs experienced difficulties translating research papers into altered prescribing behaviours (2004). This was explained through various means, including: GPs being critical of studies and having limited time; inadequate statistics training; a lack of conceptual tools to read the research and an inability to assess the quality of study. He suggested an 8 step solution, with on-line resources available for all GPs, hosted and maintained by the government or a professional organisation. Exploring where GPs find additional information from, Dawes and Sampson 10
found that most referred to readily available printed matter and personal libraries- as it saved time and money, and also consulted colleagues if this did not work. A lack of time was the most common reason for not researching more information on a topic.
Summary of literature review findings In summary, we have found that GPs do not necessarily regard sickness certification as a highly significant part of their role, in spite of its regular occurrence. Some reportedly found the practice ‘cumbersome’ and difficult to manage, in terms of the expectations of patients. Consequently, GPs do not always consider the ‘certification consultation’ as worthy of a whole appointment. However, this may be in contrast to patient views, who value the chance to discuss the context of their illness. These differences have lead some practitioners to confess a lack of confidence when certifying sickness absence, particularly when lacking knowledge about new policies or patient support organisations. Inversely, GPs report feeling confident about the procedure when they know about the consequences of being out of work for the patient, systems of available support and facts about ill health (Nilsen, 2011). Translating new sickness certification and DWP policies into practice will require more initial GP training and a raise in the status of the field. Existing GPs can be trained via CPD, through meetings, web sources or training events. It is possible to infer that the effectiveness of CDP to change prescribing practices is limited. Even when GPs say they are interested in taking part in web-based training, their activity is low (22% of existing THOR website users used it for CPD, Debbie Cohen found that the most GPs only visited the Healthy Working Wales website once, during its first year). The RCGP has been providing a web-based educational tool and resource as well as half-day training, developed in collaboration with academics and occupational health practitioners which has been rolled out across the UK. (It anticipated approximately 1,400 GPs taking part). Even with a well designed educational tool, i.e. a one stop-shop sickness certification web portal, GPs might still not engage with it for a variety of reasons as described above, but this project was not to explore these factors.
Results of the primary research Overview The results of the literature review fed into the development of the focus group themes. The six focus groups were completed over a 7 month period. The first GP focus group was completed at a conference for academic GPs and included recent and more experienced GPs from across the NorthWest. As it was conducted away from their own surgery GPs may have been more relaxed and open. The second focus group was completed in a Liverpool surgery during a lunch time. There was a feeling 11
amongst the researchers that more junior colleagues were reluctant to speak. There may be merit in providing future separate forums for GPs depending on experience and seniority. The first nursing focus group was conducted in Manchester and contained nurses from various practices across the region. The second was completed in Liverpool at a pre-existing practice nurse meeting. A framework analysis approach was used. Transcripts were supplied to each team member and they were asked to consider the key themes arising from each of the focus groups. This analytical process led to the development of a number of themes which explored the thoughts, behaviours, values and tensions embedded within the process of sickness certification. This research has been designed to highlight areas of concern, complexities and tensions as a result of the wider sickness certification process. It is not intended to speak authoritatively for a statistically significant body of health professionals. The web portal is intended as a starting place, to enable professionals to explore concerns relevant to themselves and their patients.
Translation of research themes into areas of the website. The GPs we spoke to alluded to the fact that sickness certification was a regular aspect of their role. However, they had received little initial or subsequent training, many worked in isolation, had little feedback, didn’t feel entirely confident and felt that their role as State welfare ‘gatekeeper’ challenged their relationship of trust with their patients. After analysis, it was possible to reduce GP and nurse knowledge requirements down to three broad areas: professional needs; awareness of shifting certification policies and information to signpost to patients, either inside or outside of the consultation. The following requests or issues were raised by health professionals during the focus groups
to provide short summaries of recent policies, or provide links to sites that do,
to acknowledge the tensions which can arise or underpin the Sickness Absence (SA)
consultation,
to acknowledge the significance of the Fit Note and provide a detailed breakdown on its
legality, uses/abuses and potential for opening up dialogue and assisting negotiation with a patient,
to provide a short visual map, or other, of the uses and significance of the fit note beyond the
consultation i.e. employers, unions, disciplinary...
to provide sites/links to access Occupational Health (OH) training or OH information for
patients, 12

to

to provide GPs with a list of referral agencies dealing with health, employment and return to
work 
provide
(which
tables
on
can
average
be
time
off
work
printed
periods
to
for
set
give
conditions
out)
to provide academic papers on sickness absence and return to work, which prove the case for
returning.
13
The process- how the website took shape The three broad areas and bullet points provided a framework, from which to focus discussions about what a website would look like. As part of the focus groups GPs and nurses had been asked about which medium they would prefer to receive the in formation. As they wanted something close to hand during a consultation, a website was suggested, as it could be accessed by all at any hour of the day, either at home or in the practi ce. This was something GPs stated they were used to doing currently. A CD-ROM was not welcomed and some GPs said they wouldn’t use it, partly because it required constant updating. Having paper copies of all the information was thought to be too impractical and would be unsustainable during surgery hours. Diagram 1 An initial conceptual map of the research findings prior to web production.
We recruited a group of 5 local GPs at various stages in their career. All had at least one academic role, i.e. research or teaching and provided them with a similar diagram to the one above. The first part of the meeting involved the GPs answering an open ended questionnaire and providing their comments on the proposed categories for the website. During the second part of the meeting the researchers opened up a discussion on the results. We continued to engage with group, as individuals, asking for their feedback of subsequent conceptual versions until a draft website was produced. An on-line evaluation questionnaire was also published and the pilot site was advertised widely through various regional and local medical professional organisation and links. In spite of this and the extended length of time given to respond the results of the evaluation were very poor. Less than ten GPs and nurses responded. Those that would use the site thought they would do for aspects of it and not in its entirety, for example, the guides to the length of time someone might be off work for with a named condition, or the section dealing with armed forces or ex armed forces personal. The comments were used to amend a final draft and a final version has been produced and is now live and the process of being promoted and regularly updated.
The end product- the web portal
http://www.merseyprimarycare.org/gp-resources/outside-the-consultation/guidance-on-recoveryperiods-for-conditions.aspx The site contains two key areas for health professionals, one for GPs and one for nurses. Each profession has two choices upon entering, either to go for the ‘inside the consultation’, or ‘outside the consultation’ section. In each section the user is presented with a clearly labelled list of themed headings. Each of these contains a list of hyperlinks to a range of professional, governmental and advocacy sites. It will be checked for link breakages regularly and updated.