Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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SICK NOTE CULTURE
- MUKHLIS MADLOM (19 March 2008)
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To work or not to work – not if I can have a sick note!
- David G Samuel (19 March 2008)
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Just what is needed
- Jacques A Loeb (20 March 2008)
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Incapacity - a big problem not a simple one
- Peter A West (20 March 2008)
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Discrimination on ill heath
- Elizabeth Howard (20 March 2008)
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Should GPs issue 'fit notes' for people with mental illness?
- Fareez Rana (20 March 2008)
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Sick certificates
- George Y Caldwell, Singapore 259858 (21 March 2008)
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Incapacity, work and benefits
- Miles J Stanger (21 March 2008)
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The route to incapacity benefit
- Peter G Davies (22 March 2008)
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Receiving Incapacity Benefit does not equate with being unable to work.
- Richard D Colman (22 March 2008)
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Breaking Back of UK
- Christine Salter (23 March 2008)
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Overhaul the 'sick note' procedure
- Aban KADVA (23 March 2008)
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Occupational medicalisation.
- William G Pickering (25 March 2008)
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MUKHLIS MADLOM, CONSULTANT PAEDIATRICIAN DONCASTER ROYAL INFIRMARY
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This is long over due. GPs are in difficult position when they are faced with their own patients as they have to maintain good working relationship. In addition, as generalists, GPs do not have the expertise to make detailed assessment of the conditions that lead to long term sickness. GPs should be able to authorise short sickness leaves but once this becomes chronic or recurrent, say over three weeks, the patient should be referred to an independent multidisciplinary panel for me detailed assessment. Such assessment should look at what the patient can do as well as what they can't do. This is likely to relieve the GPs from this sort of activity and enable them to focus on other services. This should be welcomed by primary care. Competing interests: None declared |
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David G Samuel, Final year medical student CF48 2AS
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I feel that the government proposals to overall the sick note culture in the UK is doomed to fail if they are not prepared to invest and maintain large companies that help those with disability into work. I also feel the proposals put GP’s in a very difficult situation where they must act as a gatekeeper for the government in controlling the benefits claimants across the UK. It is also extremely hard for them to have to write reports on their patients knowing their patients are likely to be annoyed at seeing that many of them are deemed “fit to work” and basically seen as trying to pull a fast one to claim benefits! I have been saddened to read of the plight of the Remploy factory workers in recent weeks and months. At a time where the government is leading a drive to encourage more disabled people back into employment it seems outrageous that companies such as Remploy are not being supported financially and are facing closure. The Remploy factories have a long tradition of promoting an inclusive working environment for those with disabilities and have helped many people across the UK to work despite their physical and mental ailments. I have benefited immensely over the years form the expert work of the Remploy factory at Aberdare, South Wales who produced a specially made Orthotic boot for my disability. It has allowed me to lead a “super normal” life and I also know it was made by several employees who have major disabilities themselves. I urge the government to reconsider their actions and ensure that more jobs are not lost that directly help those with long term illnesses back into employment and subsequently reduce the number of incapacity benefits. You cannot expect people to return to work if the suitable environments that were once in existence are being closed as many disabled people find it difficult or prohibitive to be able to carry out employment in the normal working sector. I am currently undertaking my final undergraduate attachment at a local GP surgery. A large proportion of my patients are “on the sick” or in receipt of benefits and many report being unable to return to work as their employees cannot make the adaptations needed to make their working environment suitable. Unless companies are pressurised by government watchdogs to cater for their employees needs and ensure occupational health services are in place the reliance on MED 3 forms will continue. Keep up the good work Remploy - you are a champion of champions for all disabled people across the UK and I am forever in your debt! David Gwynfor Samuel 5th year medical student – Cardiff University 6 Caeracca Villas Pant Merthyr Tydfil CF48 2AS 01685 375178 07890 696291 welshsledge@hotmail.com Competing interests: None declared |
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Jacques A Loeb, Retired surgeon l6j 4x3
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Just what is needed: another layer of paper shufflers J A Loeb MB BS FRCS FRCSC FACS REFUGEE FORM NHS 1959 Competing interests: None declared |
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Peter A West, Senior Research Associate York Health Economics Consortium, University of York, currently seconded to a government agency.
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Sickness absence and incapacity are very serious problems for society. But big cost figures, up to £100 billion, can paint a misleading picture. For example, if we spent £50 billion solving the problem, would the economy grow by £50 billion? Not likely. The economy is limited by lots of factors including skills, labour available in different markets, migration, willingness to relocate, house prices and, crucially, the demand for goods and services. Recently, immigration has filled many jobs that UK workers either do not want or are reluctant to take (e.g. because a group of young migrants may be prepared to live in accommodation in W London that is not suitable for a family now living in the North West of England). It is therefore convenient to turn days not working into money but a gross over-simplification to give the impression that this is a real measure of the cost to the economy. Suppose the credit crunch produces a recession. Many migrants who lose their jobs may just go back home where they can be employed or be unemployed more cheaply. This is more likely if they cannot get benefits. So the economy, rightly or wrongly, has a balancing item in it now. If we try to get lots of people off incapacity benefit at a time of recession, we may just change their benefits, not their working status. This does not mean that we should not try but we need to understand the complexity of the problem. For those who cannot find work, unemployment benefit is less supportive than incapacity benefit. It is a logical move for unemployed people to seek additional benefits and as a result, they may become used to not working. On the other hand, if we squeeze incapacity claims we may simply find that we increase poverty and not employment in some areas. Then we might find the government paying out alternative benefits instead. Overall, headline-grabbing claims that we are losing the equivalent of the Portuguese economy give a misleading impression. There are a lot of people on sickness benefits but also a lot of reasons. Competing interests: None declared |
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Elizabeth Howard, Locum GP Romford
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I have had the misfortunate of ill- health , I now work as a locum GP and do medicals for incapacity benefit. As a GP I try to treat agressively and minimise sick leave especially for mental heath conditions as I know the patient's best chance of employment is, if possible, to keep the job they have. As a doctor for incapacity benefit I see people tied not only by their disability but by the compounding depressive effects of long term sickness. Some of these are undertreated - and we are not allowed to advise them on how to get better- just to re-visit their GP. As an ex-ill person , I see the chasm into which these people fall when they no longer qualify for incapacity benefit. A few will get jobs, but many are held back by real and percieved discrimination against ill- health in the workplace. Being ill destroys your confidence, having an unpredictable condition affects your reliability. Any disability, especially mental health, can slow you down / reduce your productivity. In a high demand competitive business environment you are just not 'cost- efficient'. Job application forms ask what medication the person is on, giving some people the impression that you have to be 'off medication' before you can get a job. After a couple of years off there is a gap in your CV. With all these worries how can a person compete in todays job market. I agree with thinking twice before you sign people off for long periods , and sicknotes should not automatically be issued without a plan for management to get the person better and working. Making inacapcity benefit harder to get just puts more people into the chasm - from which a few strong willed ones will climb out. Well notes - can't see that happening. Active management with job advisors physio, good co-ordinated care now theres an idea - but not new, just not universally available. Competing interests: None declared |
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Fareez Rana, Staff Grade Psychiatrist Oxfordshire and Buckinghamshire Mental Health NHS Trust, Harlow House, High Wycombe, HP13 6AA
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Mental illness is one of the commonest reasons for ‘sick notes’. Mental illness imposes heavy costs on economy (about 2% of GDP- Mental Health: Britain’s biggest social problem, Executive summary by Richard Layers, Jan 2005) and on the family. Significant cost is due to lost out put as highlighted in the report by The Sainsbury Centre for Mental Health ‘Economic and Social Costs of Mental Illness’ (2003). This shows that the costs of mental health problems in England comprise: £12.5 billion for care provided by the NHS, local authorities, privately funded services, family and friends; £23.1 billion in lost output in the economy caused by people being unable to work (paid and unpaid); £41.8 billion in the human costs of reduced quality of life, and loss of life. Returning to work can be therapeutic for a person recovering from mental illness. It improves self esteem, self worth, provides social support and stability. I am all for reforms aimed at helping people return to work after falling ill. But I have my concerns about people being given ‘fit notes’ on recovery from mental illness. Giving ‘fit notes’ is different to giving sick notes in that it places a huge responsibility on the patient, it can cause emotional and financial stress causing relapse of mental illness and further delay in returning to work. I have seen a number of my patients going back to work with encouragement from Mental Health service and the GP. And I have seen a number of patients who got worse if they felt pressured to go back to work. I also have concerns about General Practictioners having to give ‘fit notes’ for those with mental health problems. Firstly, a lot of GPs have not had training in psychiatry. Secondly, not many GPs are able to do thorough assessment in the limited time they have. I think we need to take a flexible approach when people are returning to work especially while recovering from mental illness. Have we thought about the emotional costs of this already vulnerable group of patients? I think there is scope for improvement in the current practices rather than changing them so drastically. Better support systems, improved understanding among employers and improvement in benefits policies for people to go back to work without losing benefits drastically, will go a long way in helping individuals to return to work. Competing interests: None declared |
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George Y Caldwell, general practitioner 31 Balmoral Park, #18-33, Singapore 259858
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A Doctor will issue the First Certificate for THREE days or ONE week as he sees fit. Extension of this must be approved by an independent Medical Board to avoid any threatening action by the patient. In fact there need be no benefit paid for those first three days which will be held and added to any later absence from work when the full benefit shall be paid. Many patients, certainly in rural districts, do not wish to be "off" for a whole week. They have work to do and want to do it. Competing interests: None declared |
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Miles J Stanger, Occupational Physician Oxford
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To add to the debate on the huge increase in Incapacity Benefit claimants, I would make the following points on the factors behind this and then suggest some remedies. Incapacity Benefit,IB, should not be seen as a payment for being unable to carry out any work at all due to illness. Instead it is seen by most claimants as a form of income support and as a gateway benefit to other state support such as Housing and Council Tax benefits. This package can typically amount to over £700 each month. It is easy to claim and requires only a medical certificate to allow payment by direct Bank transfer. No further evidence is initially required and there is no need to sign on at regular intervals. There are powerful incentives to continuing the claim as Benefit levels increase after one year and returning to paid work may involve a drop in income or at best a small increase as all benefits are lost. It is extremely difficult for a GP to refuse a sicknote FMed3 request for IB and to be impartial when giving advice. Certificates for Incapacity benefit are NOT statements of incapacity for all work but really just confirmation that the patient has consulted a Doctor and requested a certificate for IB. In my experience more than 90% of IB claimants are able to do some type of work , and in fact many do so unofficially. From this, the single most important way to help those on IB and new claimants is to take GPs out of the requirement to provide long term certification and payment should not be dependent on them. A GP may be asked to provide an initial certificate to a patient, so that they can access the system, but payment should only be made after assessment by an independent Doctor and confirmation that the claimant is unable to work in any way at all. The patient should then be regularly assessed before further payments are made. Assesments should be funtionnal and if some type of work is possible then further help and advice about finding work can be given. Other considerations are secondary but may be important. I have concerns about IB increasing after 12 months as this may contribute to long term claims. The linkage to other benefits may also need to be addressed to reduce the 'poverty trap' . But fundamentally the most impotant measure is to remove the link between GP certification and benefit payments. Competing interests: None declared |
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Peter G Davies, GP Principal Keighley Road Surgery, Illingworth, Halifax. HX2 9LL
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I welcome reform of the incapacity benefit system. The need has been obvious for some time now. (1) As Jenkinson (2) pointed out no-one is totally unfit to work. The real question is if work is available for them, and if employers will support them to do it. He used the example of his own broken ankle- which the surgery staff worked around compared with the same injury in a builder where the employer would simply have laid the builder off until recovered. For the last twenty years or so incapacity has been used as a cover for unemployment. This has allowed our governments to claim low unemployment, when in fact people have simply been shifted from "unemployed" to "sick." It is time this pretence was stopped, and the incapacity definition refined so that those fully incapacitated are treated well, and those who could get back to work get help to achieve this. 1. Malik, S (2005) A Very British sickness New Statesman 10.1.2005 p27-29 2. Jenkinson, S (2003) A brief history of time off work British Journal of General Practice 53;417 Competing interests: None declared |
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Richard D Colman, Occupational Physician N Yorks
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I echo many of the comments made by fellow Occupational physician Dr Stanger There is much misunderstanding about the meaning of being in receipt of Incapacity Benefit. What it means is that the recipient has accumulated enough points via a screening test to be awarded the benefit. However many with sufficient points for the benefit do and are capable of working. Receipt of the benefits denotes the accumulated degree of disability that society via the government is prepared to pay as compensation. I repeat it is not an objective test of capability to work. Unfortunately the bar was set too low and people misinterpret its significance. This was a badly advised political decision. Re-educating the public and putting things right will take time and money. Competing interests: None declared |
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Christine Salter, RN, CRRN, Manager Acute Rehab Phelps County Regional Medical Center, 65401
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Workers soliciting GPs for sick notes should be required to submit to rigorous testing. Too many people in the UK are off work, collecting compensation from either their employer or the Government (the workers!). This mentality is breaking the back of the Government, leading us toward recession. A stop should be put to giving sick notes to anyone who is, indeed, able to work. Competing interests: None declared |
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Aban KADVA, Consultant Essexrivers Healthcare NHS Trust
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It is aobut time that the professionals look at this entire process and aim for a fair and appropriate system to support those deserving of time off sick and deter the injudicious use of this facility. There should be more accountability. Competing interests: None declared |
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William G Pickering, Doctor NE3
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Occupational medicalisation. The two recent BMJ items on disability assessment and GP sick notes touch on ticklish and expensive issues, both exacerbated by UK state medicine [1,2]. As one contributor courageously puts it, claimants “have an incapacity if they say they do” [3]. Precisely. Their word has been the only requirement for generations of disbelieving but complaisant GPs to sign many off work. [Note, in passing, the connection between the profligacy of prescribing certain drugs (eg. psychotropics, NSAIs) and the relaxed dispensation of sick notes. For a quiet life, both ruses ward off patient hostility, and show their doctor ‘understands’. The cost to patients, companies and taxpayers meanwhile, stacks up — in more ways than one.] The proposed removal of the issue of ‘unfitness for work’ to other theatres with different actors, ie. to the “occupational health” stage, actually occurs all the time right now, both privately and also at state expense. It can be lucrative for OH doctors though they are possessed neither of refined tools to objectively assess validity of claim, nor clairvoyance [4]. Disputatious issues at work, hating the job for example, are quite often medicalised toward ‘stress’, or this pain or that. But, coerced by the fear of litigation, many companies, state services and local authorities cravenly duck primary management decisions themselves, and refer ‘medicalised’ matters to OH [4]. They risk doctors’ expensive prevarications, but at least their boxes are ticked. The considerable and obvious disabilities that the self-employed and many employees unpredictably overcome to continue work, should caution all (including a government bent on another ‘new initiative’), about the considerable limitations of medical perception. Management / health resources know their employees better than any remote doctor. Management and medic must therefore surely confer head to head. The current use of letters for communication, though easier, can preclude candour, insight and understanding – the very items essential to rapidly disentangle and resolve work and health matters. William G Pickering. 24.3.08 wgpi@hotmail.com References: 1. Jos Verbeek and Frank van Dijk. Assessing the ability to work BMJ 2008; 336: 519-520. 2. Caroline White. Report calls for shake up in management of sick notes. BMJ, Mar 2008; 336: 631 3. Anthony N Williams. How helpful is disability label? BMJ, Mar 2008; 336: 630 ; doi:10.1136/bmj.39520.537778.3A 4. William G. Pickering. Occupational communication. http://bmj.com/cgi/eletters/336/7643/519#192008, 12 Mar 2008 Competing interests: None declared |
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