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Competency 2 – Good Clinical Care:Be willing to seek advice and to change own views and to accept a patient can disagree with advice.

Objective: to understand and manage the legal and ethical implications of advice on suitability for work

ATTITUDES:

Be willing to seek advice and to change own views and to accept a patient can disagree with advice.

Decision making is a core clinical skill that can be very complex. It is not always possible to be aware of all the necessary information regarding various conditions and it is important to recognise one’s own limitations and seek further advice from appropriate bodies.

Recognise the need to take unpalatable or difficult decisions about ‘fitness for work’ issues.

On considering an individual’s fitness for work there will be times when you may disagree with the patient’s opinion of their capabilities. This can be very challenging and requires honest discussion and recognition of the implication of decisions made to both the individual and the doctor.

Be willing to accept that a diagnostic label does not reflect functional capacity.

It is important to individually assess a person in terms of their functional capacity; not all diabetics or epileptics are the same. Consider two individuals with epilepsy, one well controlled on medication who had their last fit 10 years ago, another who is poorly controlled with regular monthly fits. Both have the same diagnosis (epilepsy), but would have different working restrictions.

The above attitudes can be demonstrated by considering the following scenario:

Ms Y is a nurse working in a general medical ward of a NHS Trust hospital. She presents complaining that she is stressed, anxious and depressed as a result of her work. She has already had a week off for this reason (self certified), but says that if she had a further week away from work she would be better able to cope. Although unhappy at work, she is confident that she remains quite safe in the performance of her nursing duties. The GP’s assessment is that that she is not clinically depressed.

The type of information the GP should collect to help in the decision making process is outlined below:

1. Occupational information

a) Job Title:

Registered General Nurse

b) Occupational Tasks

  • General nursing duties
  • Some lifting and carrying
  • Frequent positional changes
  • General patient care
  • Drug administration
  • Interaction with the public
  • Interaction with patients
  • Interaction with colleagues and management
  • Writing
  • Record keeping

2. Occupational satisfaction/concerns

Ms Y believes she is being treated unfairly at work. For example, she says that with regard to the duty roster her nurse colleagues were given first choice of hours, whereas she was told what hours she was doing. She says she thinks the nursing supervisor is showing favouritism to others. Ms Y says she feels she lacks understanding and support from both nursing colleagues and from management. She says she feels used and abused. She has already taken 7 days (self-certified) off work but says she can’t face going back into the workplace and wants further time off work.

3. Functional limitations in her job

Whether the claimant is incapable by reason of some specific disease or bodily or mental disablement of doing work which he could reasonably be expected to do in the course of the relevant occupation. Is there a medical condition? If so, does it constitute ‘mental disablement’? If so, does it cause the patient to be incapable of performing work tasks?

The GP then must make an evidence based approach as how to best manage the nurse. The options available are outlined below:

  • Current Best Practice
    Ms Y presents with a management issue which she is attempting to medicalise for understandable reasons. She feels a lack of control about what is happening to her. Her doctor should explain that while the problem she presents with is not a medical one requiring a medical solution it does require some action on the part of her employer. She should discuss the issue with her line manager/trade union/work counsellor. Withdrawing from the workplace on the grounds of ‘ill health’ will not resolve the underlying issues.
  • Alternative Solution
    Any alternative to the above approach should be carefully considered. If the doctor does decide to complete a Med 3, care should be taken with the wording of the diagnosis e.g. the term ‘stress’ should be avoided, as should any attribution of symptoms exclusively to workplace stressors unless there is very clear evidence to support this. If a Med 3 advising the need to refrain from work can be clinically justified it should be issued with a strictly time-limited prognosis. At any point the issuing doctor may be asked to provide further information on the patient’s condition to a DWP medical officer.
    In electing this alternative course of action, the doctor should be aware that absence from work, whether justified or not, is associated with a considerable number of negative outcomes.

With reference to the above scenario:

  • Completing a Med 3 risks medicalising distress and unhappiness resulting from events at work, at home and everyday life
  • Interpersonal problems related to work are not solved by withdrawing
  • Risks to the patient include loss of social contact, confidence and job skills
  • Increased absence from the workplace leads to increased likelihood of not returning to work in the longer term
  • Increased work for the doctor as workless patients are likely to attend the GP more frequently
  • Although a doctor needs to consider social and management issues, he/she does not necessarily need to manage them personally and does not need to invoke use of the Med 3 as a solution. For example, issuing a Med 3 in the above situation, no matter how well meaning the doctor may be, could result in a far worse outcome for the patient than tackling the real issues
  • For the patient, there is the possibility of increased resentment from colleagues at work who have to cover her absence
  • Prolonged worklessness may also affect the patient’s family. A compromise position may be to issue Ms Y with a Med 3 advising a further few days off work as part of an agreement that during that time she will seek resolution of the problem by contacting her employer

ASSESSING FITNESS FOR A PARTICULAR JOB
Factors to be considered include:

The precise requirements of the job

  • Perception, mobility, strength endurance
  • Obtain job description from employer as well as asking the employee what the job entails
  • Inspecting the worksite

The individual’s abilities in the working environment

  • Reviewing physical condition on actual performance
  • Reviewing mental condition on actual performance
  • Considering trial of employment with feedback from all involved

The nature of any hazards (risk of harm occurring)

  • Harm from exposure in the workplace; asthma (bakers, laboratory technicians), dermatitis (hairdressers, builders)
  • Harm from demands of the job; heart attack (situations where there is an imbalance between demands of a job and a person’s ability to cope), back strain (static movements, repetitive twisting, bending).
  • Harm from infections; food handling (salmonella, campylobacter), surgical procedures (blood borne viruses)
  • Harm from situations; accidents (slips and trips)

The probability of harm occurring (the actual risk in the workplace)

  • Permanent or temporary
  • Major or minor

Who is at risk

  • Employee
  • Work colleagues
  • Public

Degree of risk: rely on facts available by means of

  • Obtaining relevant details from employee
  • Review documentation; accident reports, exposure records
  • Walk through; observing working practices
  • Identify frequency and duration of hazard exposure
  • Technical data if available; reports from hygienist or ergonomists (competency 6)
  • Research; checking sources of information
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