last updated:24/01/2012 @ 3:06 pm
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Competency 2 – Good Clinical Care: Fitness for work

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

KNOWLEDGE:

Know the basis of the UK sickness certification scheme

A certificate commonly referred to as a ‘sick note’ is a medical statement that records the advice given by the doctor to the patient regarding their ability to perform their own or usual type of occupation.

It is an official legal document that may be used by a patient as evidence to support a claim for:

    1. Statutory sick pay (SSP). This is claimed by employed individuals who are aged between 16-65 years and have met certain conditions (such as time in employment and hours of work each week). They are entitled to 28 weeks of statutory sick pay.
    2. Incapacity benefit (IB). This is claimed by individuals who do not fulfil the criteria for SSP i.e.: self employed, unemployed, employed individuals who are not entitled to SSP.

For the first 7 days of any illness a claimant completes a ‘self certificate’ form SC1 (self employed/unemployed) or SC2 (employees).

An employee only requires a medical certificate from their doctor after the first 7 days of absence. If one is requested within the first 7 days, a doctor can provide a private medical certificate for which there is a charge.

For individuals who are not entitled to SSP (i.e. the self employed and unemployed), they may fill in an initial SC1 for the first 7 days of incapacity and then follow it with a certificate. This will allow them to apply for incapacity benefit.

Know when and how certificates should be issued

DWP Desk aids for certifying medical practitioners

DWP example certificates & report forms

DWP guide to issuing Med 3 or Med 5

DWP Medical Training Pack – Advising Patients of Working Age – Trainers notes

Social security regulations state that only a registered medical practitioner can issue statements of a person’s incapacity for work. Hence a certificate may be filled in by a GP or hospital doctor for periods of incapacity to work likely to be more than 7 days. The duty to provide a certificate note rests with the doctor who has clinical responsibility for the patient at the time. Hospitals are required to provide all certificates for social security and Statutory Sick Pay purposes for both in-patients and outpatients who are incapable of work (see below). There are different types of certificates each one is used under certain circumstances.

The most commonly used certificates are:

Med3 Statement of incapacity for work.
Med4 Statement used for patients undergoing a Personal Capability Assessment, usually provided after 28 weeks of incapacity.
Med5 Special statement of incapacity for work. This is issued retrospectively.

Key points

It is important when advising a patient about fitness for work to consider:

  • The nature of the patient’s medical condition
  • Appropriate clinical guidelines e.g. clinical guidelines for acute low back pain.
  • Clinical management of the condition including patient’s expectation and patient’s best interest regarding fitness for work.
  • The patient’s functional limitations. Especially in relation to their condition and duties in work.
  • Reasonable adjustments, i.e. could the patient continue to work with slight alterations/exemptions to some duties. Some medical conditions legally require employers to make reasonable adjustments.

There are rules that govern the completion of certificates

1. The forms must be completed in ink, signed by a doctor or medical practitioner who is responsible for the clinical care of that patient
2. the form is issued only once. Replacements must be marked as duplicates
3. certificates are used for Social Security purposes and
4. the forms must be kept secure by practitioners to prevent misuse and fraud.
5. the forms must contain the patient’s name, date of examination, an accurate diagnosis (terms such as “bereavement” or “pregnancy” are not acceptable), date of issue, address and signature of the doctor or medical practitioner.

The Med3 (“sick note”) can also be used to provide advice about any restrictions and functional ability without the need to necessarily certify the patient as being unfit for all work. The doctor can enter recommendations in the box at the bottom of the form to guide the employer on suitable adjustments which could help a person at work.

Certification should be viewed as important as writing a prescription.

When used appropriately, certification of a period of time away from work and then a considered return with adjustments if needed, can support a patient’s recovery and rehabilitation. Return to work is one of the key clinical outcomes of successful clinical treatment.

The Details
“Med 3” forms are the most frequently used statement and require the doctor or medical practitioner to see the patient on either the day of issue or the day before. The Med3 should be issued on discharge from hospital where a hospital doctor advises a patient to refrain from work, and the doctor was attending and having clinical responsibility for the patient at the time the advice was given. In such cases the Med3 should be issued for an appropriate forward period. Examples were certificates should be issued by hospital doctors include when a patient has had surgery and in ongoing cancer treatment were it is likely that the patient will be attending the hospital weekly or fortnightly for chemotherapy.

Responsibility for issuing further certificates rests with the doctor who assumes clinical responsibility for treating the incapacitating condition. In the majority of cases this is the GP but as in the example above, it maybe an oncologist.

Open and Closed Certificates
On Med 3 forms there is a section that asks about the length of absence. This can be completed in two ways; the first way is termed an open certificate; “for” section whereby no date to return to work is provided, but a period of incapacity of up to 6 months can be issued. e.g. 1 month. The second way is termed a closed certificate; “until” section whereby a date to return to work up to 2 weeks after issue is completed. e.g. 13/9/2006.

If the patient requests a certificate to cover them for a period that is greater than one day prior to the date of issue and the GP or practitioner has supporting documentation from other medical practitioners who have seen or examined the patient, then a Med5 form may be used for ‘back dated’ periods of absence.

Understand the impact of certification on work

Waddell G and Burton AK, Concepts of Rehabilitation for the Management of Common Health Complaints. 2004, London: TSO.

Waddell G and Burton AK, Is work good for your health and well being? 2006, London: TSO.

Concepts Of Rehabilitation For The Management Of Common Health Problems: Evidence Base (Appendices)

It is important to consider carefully whether advising a patient to abstain from work is the most appropriate clinical management. A doctor’s advice is important in shaping patients’ and employers’ beliefs about work and health and can influence a patient’s ability to return to work.

Inappropriate certification can lead to a risk in:

  • Delay in clinical recovery
  • ‘Medicalisation’ of a problem
  • Dependency on the doctor
  • Patient’s future employment status

There is now strong evidence base that work is generally good for physical and mental health and well-being. Worklessness is associated with poorer physical and mental health. Work can be therapeutic and reverses adverse effects of unemployment in the majority of healthy people of working age as well as disabled individuals. However it is important to take into account the nature and quality of work and its social context; jobs should be safe and accommodating. On overall balance the benefits of working outweigh its risks and the harmful effects of long-term unemployment or prolonged sickness absence.

Understand the process of rehabilitation in the context of return to work and the support services available

  1. Disability Rights Commission
  2. Rehabilitation: an integral part of clinical practice by A. Frank & M. Chamberlain. Occupational Medicine vol 56 no.5:289-290.

Rehabilitation in occupational health terms relates to returning an individual to some type of work or social inclusion. If an individual is in work this might mean seeking suitable alterations to their job or redeployment. This could include temporary or permanent alterations depending on the medical condition and the job they do.

For example a shift worker who has recently been diagnosed with diabetes and started on medication wants to return to work after a spell of absence. In order to ensure adequate management of his diabetes it is important to take regular meals and medication at the correct and regular times. This is difficult to achieve with a recently diagnosed diabetic on shift work, as their meal times/activity levels are variable depending on what shift they are on, so one recommendation that would be advisable as part of a rehabilitation programme would be to abstain from shift work for a period of time until reviewed by their practitioner and their diabetes has been adequately controlled.

Rehabilitation has traditionally been a separate, second stage process carried out after medical treatment has no more to offer. However, research shows that obstacles to recovery are often predominantly psychosocial in nature rather than just relating to pathology. Rehabilitation must therefore focus on identifying and overcoming the numerous factors that prevent an individual from recovery and returning to work. Rehabilitation needs to be considered early on in the management of a patient and not as an add-on process at the end of a period of treatment.

It is not always essential for an individual to be 100% fit to be able to return to work. It is important to consider work-related factors, employer attitudes, process and practice.

Returning to work in any capacity can be very therapeutic and an essential part of rehabilitation. Therefore consider the nature of the medical condition and functional limitations, when suggesting work adjustments to enable an early return to work.

Consider carrying out the following:

  • Contacting the employer with employee’s consent.
  • Contacting the occupational health advisor of company (if present) with employees consent.
  • Writing on the remarks section of the medical statements (Med3); this could include possible suggested adjustments or changes to working practices.
  • Prescribing graduated work and/or transitional arrangements; change in working hours, change in shift, change in duties. Most recommendations are temporary and can enable an earlier return to work with positive outcomes for both employer and employee.

The Disability Discrimination Act

http://www.direct.gov.uk/DisabledPeople/fs/en

There are some medical conditions which may be covered by The Disability Discrimination Act (DDA). Under this act an employer is legally required to consider ‘reasonable adjustments’ to the workplace. In order to qualify under the DDA the individual must have ‘a mental or physical impairment that has an adverse effect on their ability to carry out normal daily activities, and that the adverse effect is substantial and long-term’.

Reasonable workplace adjustments in such situations include:

  • Considering contact with employer provided employee consents
  • Adjustments to premises
  • Changes to equipment
  • Reduction or flexible hours
  • Gradual reintroduction to the work place
  • Transfer to a different job
  • Time off for treatment.
  • Additional support for example another employee is assigned as a buddy who can supervise and support an individual retuning to work

There are many support services available for people who are deemed to be protected under the DDA. Some are listed below:

Jobcentre Plus www.jobcentreplus.gov.uk

Disability Employment Advisors found in jobcentre plus

Access to work, and Pathways to work are examples of available schemes at jobcentre plus.

Shaw Trust

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