RADICAL CHANGES IN SICKNESS ABSENCE MANAGEMENT
The government’s response1 in January this year to the Sickness Absence Review by Dame Carol Black and David Frost,2 which was published in November 2011, will radically change the way sickness absence will be managed in future. In Great Britain, from 2014, an independent, State-funded Health and Work Assessment and Advisory Service will see those who have been off work for 4 weeks and provide assessment, advice to employees, employers, and GPs, signposting to interventions, case management, and follow-up.
GPS’ ROLE IN FITNESS FOR WORK
Most GPs will welcome these changes. Previous research3 has already shown that GPs support the idea of an independent assessment service and would be happy to engage with one. Currently, many GPs, employees, and employers struggle to access necessary and appropriate expert advice that can improve sickness absence management. The new Service will produce reports for all three parties.
In recent years, GPs have become increasingly aware of the strong evidence of the positive benefits for physical and mental health and wellbeing of good work and the damage caused by unemployment and prolonged sickness absence.4–8 Many have attended the Royal College of General Practitioners’ national education programme about health and work,9 which is designed to increase GPs’ knowledge, skills, confidence, and effectiveness in dealing with clinical issues relating to work and health. Many too have made use of the Healthy Working UK website (http://www.healthyworkinguk.co.uk/), which provides doctors and other healthcare professionals access to information, guidance, and training on the management of health and work. Guidance on the fit note, for GPs, employers, and employees, has been published;10 the GP guide is intended to help family doctors make best use of the fit note to support their patients.
Most GPs are only too aware that the longer someone is off sick or out of work, the harder it is to get back to work. Worklessness comes at great personal, financial, and social cost, not only impairing individuals’ health but leading to loss of worth and self-confidence, poorer social integration, poverty, and damage to families and their health and wellbeing.4, 6
A FIT FOR WORK SERVICE
It is good news that the government response1 goes beyond the recommendation of the Sickness Absence Review2 that there should be an assessment and advisory service, and recognises the importance of intervention, case management, and follow-up. However, the response is as yet somewhat vague about how the necessary interventions will be funded and delivered. GPs are often frustrated about delays in access to NHS services such as physiotherapy and cognitive behavioural therapy that their patients need. Without timely intervention, unnecessarily prolonged sickness absence and long-term worklessness can result. It is essential that there are further discussions with interested parties, including the representatives of GPs, about how to ensure the right interventions are delivered at the right time. That includes placing obligations on employers to implement the Service’s recommendations on workplace adjustments whenever possible.
The government response is also vague about how GPs will refer patients to the new Service. While the report implies that the fit note itself will trigger referrals, at a time of rising GP workload, GPs will want the referral system to be simple and streamlined, without requirements for detailed referral letters or questioning of patients about their employers’ occupational health arrangements. Although the responsibility for issuing any subsequent fit notes will not always rest with GPs, there needs to be clarity about where responsibility lies.
The new Service is to be staffed by 300–740 occupational health professionals and 5–10 physicians specialising in occupational health or vocational rehabilitation. Additionally, it is estimated that the Service will generate demand for 240–1300 healthcare professionals to provide interventions.1 Given that occupational health professionals are already in short supply and many are towards the end of their careers, it is important that the new Service can find the workforce it needs without detriment to other occupational health provision. One uncertainty is whether and how the Fit for Work Service pilots6 may migrate into the new Service.
SERVICE QUALITY AND BENEFITS
The quality and standards of the Service must be monitored to ensure it is delivering the necessary benefits. Another work-focused government-implemented assessment, the Work Capability Assessment,11 has caused widespread concern. Professor Harrington’s independent reviews of the implementation of the Work Capability Assessment demonstrate the importance of assessments being fit for purpose. It is imperative that the new Service is quality-controlled and that its assessments are fair, valid, effective and trusted.
The economic modelling in the government report is inevitably hypothetical, but suggests that the Assessment and Advisory Service will generate net benefits in terms of increased tax and National Insurance revenues, reduced expenditure on benefits and sickness absence payments, and increased economic output. It is predicted that the Service will cost £20–£85 million per year, but will generate yearly net benefits to employers of £65–£80 million and to government of £105–£225 million, and will increase economic output by £450–£900 million annually. These figures need to be considered against the background of the current costs of sickness absence: £15 billion to the economy, £9 billion to employers, £4 billion to individuals, and £2 billion to the government. The economic modelling assumes that the Service will reduce average sickness absence duration by 20–40%. (Given that the median duration of sickness absence for those reaching the 4-week point is 42 working days, such a reduction would yield 8 to 17 extra working days on average.)1 While the report rejects the Black–Frost recommendation of tax relief on medical treatment or vocational rehabilitation, the government intends to retain tax relief on Employee Assistance Programmes and announced in the 2013 budget that it would introduce tax relief on interventions recommended by the Assessment and Advisory Service.12
THE NEED FOR BETTER DATA
The report emphasises the importance of data in monitoring progress. Analysis of information from the rollout of electronic fit notes and from the new Assessment and Advisory Service will help, as will monitoring progress on the Health, Work and Wellbeing initiative using such indicators as reducing the proportion of people out of work due to ill-health and improving access to appropriate and timely health service support.13 However, more needs to be done, in terms of mainstreaming employment through all relevant health policy frameworks; collecting data on employment outcomes; and, in England, incentivising attitudinal change and data collection through the Commissioning Outcomes Framework. Whether patients stay in or return to work is an important indicator of clinical success.1,7,8
CONCLUSION
In summary, the government response will have a major impact on how sickness absence is managed in Great Britain, in particular through the introduction of the new Assessment and Advisory Service next year. However, there are still some issues to be resolved in respect of referrals, interventions, workforce, quality monitoring, and data collection. GPs and other stakeholders will be keen to work with the Department for Work and Pensions to ensure the new processes not only lead to cultural change but produce benefits for employers, taxpayers, the economy, health care professionals and most importantly for the future of those employees and patients at risk of long-term worklessness.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2013