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Competency 2 – Good Clinical Care: Understand the process of rehabilitation

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 ‘fit 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:

  • 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 up to 28 weeks of statutory sick pay.
  • Employment and Support Allowance (ESA). This is offers financial support to those unable to work. It can also be claimed by those unable to claim SSP from their employers such as those who are  self-employed or unemployed.

For the first 7 days of any illness an employed claimant completes a ‘self-certificate’ or SC2. 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.

Know when and how certificates should be issued

Fit note: guidance for patients and employees

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).

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:

  • The forms must be completed in ink or electronically printed, signed by a doctor or medical practitioner who is responsible for the clinical care of that patient
  • the form is issued only once. Replacements must be marked as duplicates
  • certificates are used for Social Security purposes and
  • the forms must be kept secure by practitioners to prevent misuse and fraud.
  • the forms must contain the patient’s name, date of examination, as accurate a diagnosis as possible—unless the completing medical practitioner thinks that a precise diagnosis will damage the wellbeing of the patient or damage their position with their employer—date of issue, address and signature of the doctor or medical practitioner.

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
The fit note has options that initially are: you are not fit for work; or you may be fit for work taking account of the following advice.

There are then tick boxes for the advice which are:

  • A phased return to work: This is a gradual increase in work duties or hours
  • Altered hours: which is changing the work times or total hours
  • Amended duties: This is changing the work duties
  • Workplace adaptations: which is changing aspects of the workplace

The Fit note also has an area for comments from the signing practitioner. This box must be completed if “may be fit for work” has been ticked and may be useful to complete if “not fit for work” has been indicated

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

Equality and Human Rights Commission

Disability Rights

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 recently diagnosed diabetes 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 comments section of the fit note; 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.

ActThe Equality Act 2010, which now emcompasses disability discrimination

https://www.gov.uk/browse/disabilities

There are some medical conditions which may be covered by the disability component of the Equality Act (EA). Under this act an employer is legally required to consider ‘reasonable adjustments’ to the workplace. In order to qualify under the EA 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 such things as:

  • 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 EA. Some are listed below:

Jobcentre Plus www.jobcentreplus.gov.uk

Work Coaches found in Jobcentre Plus

Access to work, a scheme available through Jobcentre Plus