Category Archives: Blog

Do Fit Notes always Fit the Problem?

Do Fit notes always Fit the Problem?


Minister Matt Hancock recently launched the NHS Long Term Plan that highlighted our need to address the high rates of employment sickness absence due to musculoskeltal (MSK) problems and/or mental ill health.


Let’s look at some stats: 9 to 10 million GP Fit Notes are signed annuallyin England alone. A colossal number, likely to be taking an inordinate amount of precious GP time, particularly when 80% of these are used by employees as evidence of their illness for their employer as required by HR policies. 93% of GP Fit notes say that the person is not fit for work. Surely it’s time for another approach that chimes with the upcoming changes in GP Surgeries?


Work related problems are mainly identified in GP surgeries which are already taking the strain of high patient demand with a shrinking workforce. So it is great news that the NHS Long Term Plan sets out to expand the multi disciplinary team (MDT) workforce in GP surgeries to help meet demand. Ambitious pilots using allied health professionals (AHPs) like occupational therapists, paramedics and physiotherapists have shown safe, cost effective results that patients and families welcome. Seeing an AHP as a First Contact Practitioner from your GP surgery is going to become more the norm.


Which leads me back to my question….do Fit Notes always fit the problem? So, if you were off work, would you use a confidential work clinic based in your GP surgery? You may be surprised to learn that a growing number of patients are doing just this and using newly opened clinics in Southampton and South Pembrokeshire. Occupational Therapy Led Vocational Clinics are for people who are in employment and struggling with MSK and/or mental health problems. A safe space where they can talk through what work difficulties they face and how these may be resolved. Everybody gets an AHP Health and Work Report which can be shared with the employer with advice about how work modifications could keep the person in work.


  • Does the patient get individualised work and symptom management advice? Yes
  • Does the employer get more detailed, accurate info about how to support staff? Yes
  • Can the employer use the AHP Health and Work Report as evidence for statutory sick pay? Yes.
  • Does it cut down on GP time writing GP fit notes? Yes but …


… embed this new approach, we need employers to understand that there are alternatives to the traditional GP Fit Note. If they and the employee want to use alternative evidence than the GP fit note, this is available now and the legislation allows it.


So the question for employers may be ….would you prefer a detailed report saying how someone can stay at work by an AHP or a GP fit note just saying they are not fit for work? The answer will depend on the clinical situation of course, but the AHP Health and Work Report can provide the clear instructions that employers often crave.


Full results of the Occupational Therapy Led Vocational Clinics will be available in March 2020. These Clinics are one of 19 initiatives across the UK selected to receive funding from the Work and Health Challenge Fund.




Genevieve Smyth

Professional Adviser

Royal College of Occupational Therapists


Preparing for a Wellbeing Programme – A case study from Defence

Martin Short, Head of Wellbeing, Diversity and Inclusion. MoD Business Unit

In July 2018, following an 18-month secondment to the What Works Centre for Wellbeing, I returned to the Ministry of Defence (MoD) to design a wellbeing programme for a large MoD business unit of some 5000 staff spread over a number of different locations.

The organisation had never had a centrally coordinated wellbeing programme so, while I had considerable freedom of action, there were three big challenges to overcome before we could move forward.

The first challenge was that, as an organisation, we had no common understanding of what ‘wellbeing’ actually meant – or why it was important to both individuals and organisations. The second was that our wellbeing-related data was low grade and unsuitable for taking an evidence-based approach. Finally, while many staff were doing great work at local level, they worked in isolation and we had no joined up wellbeing community.

To tackle these challenges I designed a ‘start-up’ phase made up of three core activities which we called – Educate, Measure and Connect.


It is impossible to hold meaningful conversations about any topic if it means different things to different people, so I spent four months visiting every site and delivering over thirty ‘Wellbeing Awareness Briefs’. It didn’t matter so much what our wellbeing concept was, but it was important that we shared the same one. These one-hour presentations covered:

  • Wellbeing: What it is and why it matters to both individuals AND organisations.
  • What we know about Wellbeing across the life course and the factors that exert influence.
  • Wellbeing in the Workplace – the role of individuals, managers and leaders. This general approach is illustrated well in theACAS  Mental Health at Work Framework.


The annual Civil Service People Survey gives some insights into wellbeing but lacks detail, so we augmented it with data from another survey tool – a workplace wellbeing diagnostic tool developed by the What Works Centre for Wellbeing. This higher resolution data allowed us to diagnose where our main workplace wellbeing issues lay and also created a benchmark from which we could measure our progress as we started to take action.

One of the most interesting findings came from a graphic that we called the ‘Heatmap’. This plotted how far our different sites were from the organisational average for each of the five ‘drivers’ of workplace wellbeing measured by the tool. As can be seen from the heatmap below, not one of our sites has the same wellbeing experience – and the military and civilian experience is often profoundly different – even at the same site. This suggested that, for our organisation at least, a ‘one size fits all’ strategy would probably be ineffective. It also led us to the conclusion that the best model for our needs involved a light central structure which measures, monitors and advises, with evidence-informed action being delegated to local leadership and wellbeing networks.


The final preparatory activity was termed ‘Connect’. While I knew there were many staff doing great work at local level (Mental Health First Aiders, Mindfulness groups, Peer Support Groups, Sports Clubs etc.) we had no central visibility of what was actually happening locally. The Connect activity was simply a gathering together of information about what wellbeing and mental health related initiatives were happening and where.

What did we achieve?

Our three preliminary activities have allowed us to do a number of things:

  • Develop a shared understanding of what wellbeing means to us as an organisation – so our future conversations are better informed and make sense to staff.
  • Diagnose our main wellbeing challenges and establish a data benchmark from which we can measure progress when we run the survey again.
  • Complete an audit of the wellbeing-related resources we already have and identify and connect our pan-organisation wellbeing network.
  • Helped us understand the significant impact of local issues on staff wellbeing, thus guiding us towards appropriate governance structures.

The next phase will be the analysis of those issues that we wish to address at organisation level, followed by the generation of local action plans to address the needs identified at our different sites. At present we are planning to re-run the survey in late 2020 to check our progress.

The views and opinions expressed are those of the author and do not necessarily reflect the official policy or position of the Civil Service or the Ministry of Defence.

The SOM has a wellbeing special interest group. To view the slides from the most recent meeting, please click on the links below:An Evidence-based Approach to Understanding Workplace Wellbeing Challenges Supporting healthy high performance`

The Right Kind of Incentive Can Help People to Stay Active

Hans Pung is the President of Rand Europe. Marco Hafner is a senior economist at RAND Europe

Having the motivation to keep exercising regularly can be challenging for many of us. The benefits of regular physical activity are widely recognised yet about one third of the world’s adult population is not meeting the minimum weekly level of physical activity as recommended by the World Health Organisation. Weekly exercise can result in a lower risk of some diseases such as cardiovascular disease, diabetes and cancer, as well as maintain a healthy body weight and mental health. So the question is: what will motivate people to keepheading out the door, whether it’s for a swim or to the gym, for some much-needed activity?


Existing evidence suggests that incentive programmes can have a positive impact on people’s healthy behaviours, and in particular on physical activity, but the type of incentive matters. A recent RAND Europe report has highlighted the impact a particular “loss-framed” financial incentive scheme has had on people’s activity levels. Think of a loss-framed incentive as more of the proverbial “stick,” as opposed to the alternative gain-framed method or “carrot” reward for healthy behaviour. The stick in our study being people having to pay higher or lower monthly amounts for a smartwatch, depending on how physically active they were.


In the study researchers reviewed the data of more than 400,000 people, across the US, UK and South Africa, who had signed up to the Vitality Active Rewards programme run by multi-national health insurer Discovery. Members were rewarded for healthy behaviour with “Vitality points” which they could then use towards benefits – the carrot – such as movie tickets or free hot drinks. Members on the Vitality Active Rewards programme could also take up the Apple Watch benefit. This allowed members to buy the smartwatch and fitness tracker at a discounted price. Monthly repayments would then vary according to their level of activity during the previous month. If people exercised regularly and tracked their activity to earn enough points they would not have to pay any further costs.


Analysis of the data showed that those people who took up the Vitality Active Rewards with Apple Watch benefit increased their physical activity by about 34 per cent per month, compared to those who only participated in the Vitality Activity Rewards points programme. This meant that on average, people were exercising nearly five days extra every month. Also, the type of activity was recorded as advanced, meaning that not only did people exercise more while on the programme, they also exercised more intensely.


Notably, the study also looked at whether the increased physical activity levels persisted over time. Members on the Apple Watch scheme had two years to pay off the watch and researchers found that the levels of raised activity were sustained throughout the 24 month period. So it would suggest that people needed the extra push from a loss-framed incentive to stay motivated and maintain a positive behaviour change, over and above the rewards offered on the Vitality Activity Rewards points scheme. Offering members the opportunity to update their smartwatch every two years and continue the repayment process may also help them to stay active.


Previous studies contributing to this area of research have been done before, but never on so large a scale. Neither have they covered such a wide subject area. People who took part in the scheme varied widely in their fitness levels and the RAND Europe study showed that the benefit also incentivised those that initially tended to be more inactive, such as obese individuals, to become more active. Granted, fewer people in this at-risk group took up the benefit, however for those that did, they also showed a significant increase in activity levels.


While by no means a magic bullet, the combination of modern technology and the loss-framed incentive would seem to make a significant impact on people’s motivation, helping them to huff and puff their way to the desired amount of activity every week. This effect is important to consider when designing fitness and wellbeing programmes, whether it be for a health insurance company, employer or local GP. Finding ways to encourage healthy behaviour is vital and this might be the type of motivation people need to make it a way of life.


Hans Pung is the President of Rand Europe. Marco Hafner is a senior economist at RAND Europe and lead author on the “Incentives and physical activity” study.

Cancer recovery and return to work: An integrated approach

Cancer recovery and return to work: An integrated approach.

By Julie Denning, PhD. CPsychol, Managing Director at Working To Wellbeing.


In 2014 there were 360,000 new cancer diagnoses with a predicted rise to 422,000 by 2022. Data suggests around 60% of people survive cancer (Seifart & Scmielau 2017).

As increasing numbers of people are living with and beyond cancer, it is time to start addressing their needs on a larger and more inclusive scale.   Whilst advances in medical interventions are staggering, support for the sequelae of those treatments is often lacking.

People in our service often report a “black hole” post treatment or as if they are falling off a cliff.  They may still have links to their oncology or surgical team but still experience physical and psychological difficulties.  They also may be unsure about what to do about work. Indeed post treatment, many people do not return to work because of emotional difficulties and many report that physical difficulties are an obstacle to return.

Mood and physical issues

Early intervention support should be provided to help people have a smooth recovery post cancer diagnosis.  Evidence has shown that people benefit from vocational rehabilitation support.  This can come in the form of supporting the engagement in exercise and activity throughout treatment and afterwards.  Just providing reassurance that it is OK to exercise can be enough to get people moving and becoming active again.   We know that people often need a graded exercise programme to increase strength and stamina and also to enable functional activity and recovery.

People also need to have the opportunity to talk about the impact their diagnosis has had and to express their feelings about their situation with someone who is outside their social sphere so that they can have the ability to talk without guilt or worry.  As an example, I once called a patient for a review and found out that he was in hospital again.  I said I would call back another time, but he was insistent we have the call.  He wanted to talk through how he was feeling with me rather than upsetting and worrying his wife when she arrived later that day to visit him.

Furthermore, it is important to discuss people’s fear of recurrence and changes to their ‘normal’ lifestyle.  Early conversations mean that worries don’t balloon into panic and generalized anxiety. It is important to note too, that people won’t necessarily need CBT as an intervention, they may just need the opportunity to talk and process what has happened to them.

An integrated service model that provides both physical and mental health support is key. By ‘joining the dots’, such a model helps people to focus on their recovery, improve their functioning and when ready, rehabilitate back into work.

Practical considerations for return to work and employer support

It is important to understand the impact of symptoms in relation to returning to work.  Clinicians have a vital role to understand this so they can help someone return to everyday functioning. Employers need to adhere to the Equality Act and make reasonable adjustments to support their returning employee, so it is important that they also understand how someone’s symptoms may impact on them returning to work.

For example, if someone is experiencing fatigue this may affect their concentration, focus, communication and mental processing.  Neuropathy in one’s hands or feet can affect dexterity for typing and writing and difficulties in walking.  Anxiety and/or low mood can impact on concentration, productivity can cause a lack of focus, relationship difficulties and lethargy.  Pain can result in difficulty sitting for long periods at a desk.

Knowing what their colleague is going through post cancer diagnosis and treatment can help employers to best support them. Indeed, they have a crucial role to play.  Often this comes down to a line manager level, but having helpful, proactive policies in place at an organisational level and creating a culture of support for return is essential.  If employers see that work is a key part of recovery for someone and clinicians see work as a health outcome, then there would be greater impetus to create a supportive work environment.

3rdSector engagement

The third sector is noticeably engaging in the work conversation.  Macmillan is spearheading the way forward not only with their plethora of information booklets and online information but also more recently with their work support service helpline where people can be offered advice as to return to work planning. Anthony Nolan have gone a step further and provides a brief intervention service supporting patients post-transplant with their work plans as well as providing emotional support and guidance as to exercise and activity.

Conclusions: more VR needed, more integrated support

In conclusion, support is urgently needed for a growing body of people who are living with and beyond cancer.  They may have been cured or told they are in remission, but their story continues as they are often facing other challenges, both physically, emotionally and vocationally.

Their needs must be met and their voice must be heard.

We must ensure that they have access to early intervention services to meet their physical and mental health needs so that they are able, when ready, to return to the workplace.  Providing early integrated vocational rehabilitation services must move higher up the agenda at both a government, clinical and employer level.





Collaboration is key

Collaboration is key

Dr Justin Varney, MBBS MSc FFPH HonFOM

Collaboration not competition is fundamental for the future and this is absolutely the case in the sphere of occupational health.

The occupational health profession is diverse and varied with professionals coming from many different parts of medicine, nursing, the allied health professions, psychology, occupational hygiene, health and safety and ergonomics.

Each of the professional groups however is small and, perhaps with the exception of health and safety professionals, have limited visibility and voice within their ‘parent specialism’.  As professionals they work in, and across, the public, private and voluntary sector. They often have portfolio careers that patchwork together clinical practice in different settings, industries and sectors, all working to enable individuals to remain in, or return to work in ways that work for them and their health conditions.

As the public sector faces an ageing population who are living longer with increasingly complex needs there is an understandable focus on shifting training resource into areas of acute pressure like general practice and geriatrics rather than into occupational health training. Although there is a strong case that reducing training capacity in the professionals will ultimately be a false economy, something to discuss in another blog!

Over the last fifty years there has been a fundamental shift in the nature of work and the change continues to accelerate and deepen in its implications for individuals and for occupational health.

Digital and technological breakthrough has seen many employees moved away from the high occupational risk exposures of front line heavy manufacturing processes to technical, hospitality or administrative roles. Patterns of musculoskeletal disease may well shift from lower limb and lower spinal issues to upper limb and upper spine issues linked to the way we use our computers and phones rather than the way we lift and twist.

This sits alongside the shift to mandatory manual handling training and office health and safety instruction which has increased both employer and employee understanding of health and safety as well as the strengthening through case law and legislative reform of the punative risks associated with organisational negligence and accountability.

Finally the global nature of business also provides a new dimension of occupational health with 4 out of 5 jobs in the top 40 economies linked to directly to global supply chains and business networks. Both recreational and occupational travel creates new vectors for disease communication as well as new dimensions of cross-cultural occupational health practice.

The landscape of occupational health has never been more complex and that is why collaboration is key to the future of occupational health practice. It is only by working together across professional and sectoral boundaries that as partners in the Council of Health and Work that we can make the leaps and bounds that are needed to respond to, and position for, the changing and evolving future of work and health.



PHE Health and Work Clinical Champion

Dr Rob Hampton, PHE Health and Work Clinical Champion


One of the recommendations from the Improving Lives Command Paper published in November 2017 was the introduction of a Medical Champion for Work as a Health Outcome. In our conversations with patients, healthcare practitioners are used to asking questions about the lifestyle factors that underpin health such as diet, exercise, alcohol and smoking.


But there’s another important question that we need to consider: ‘How is work?’ This role aims to support colleagues in understanding the importance of work as a health outcome with guidance around having those conversations.


Good work[1]is good for us. It isn’t just about gaining economic benefit but more to do with social connections, physical activity and intellectual challenge. There is clear evidence to show that good work helps us to be healthier and happier[2].


Conversely being out of work increases our patients’ risk of ill-health. Long-term unemployment increases the risk of limiting illness and worsening mental health and the longer we’re out of work; the more likely it is to impact on our health[3]. Working can be considered a health outcome in itself, reflecting how well we are supporting individuals to adapt to or recover from their health challenges.


In general practice we have an opportunity to use our trusted relationships with the people we care for to help them maximize the health benefits of being in work.


This could mean preventing our patients from falling out of work, or for those who aren’t working because of a disability, medical condition or injury, helping them return at a time that’s right for them and their health.


It can all start with a conversation.


There’s so much we can do to help people stay in and return to work, from providing key information or boosting a patient’s confidence through to helping with pain management or coping with stress.


For example, clinicians can signpost to resources that charities have developed to help our patients, and their employers, to maintain good work and good health. Conditions covered by these resources include people with cancer, musculoskeletal pain, mental health problems and heart disease.


And crucially, we can make an impact even when our time with patients is limited.


As a Work and Health Clinical Champion I meet GP’s all over the country and I highlight the following key actions:


  • Starting conversations about work– asking patients about their work is clinically useful in itself, but it can also open up an opportunity to talk about how important work is to them, how confident they are and whether their health is proving to be a barrier.
  • Discussing reasonable adjustments– employers have a legal duty to consider reasonable adjustments but many people haven’t considered this as an option. We can raise awareness of opportunities that could be offered by an employer for instance flexibility around hours or changes to the working environment.
  • Signposting or making referrals– There will be options emerging in your area that may include NHS or community provision, services linked to local job centers or information online. Social prescribing is emerging as a great referral route for such employment support



Work from the Improving Lives paper, is already under way to help one million people with long term physical and mental health conditions stay-in or return-to the workforce. This is an ambitious plan to change the landscape and move vocational rehabilitation closer to mainstream healthcare.


Ultimately we need to ensure that people are supported by employers that are committed to creating healthier workplaces and the right health and wellbeing support for their staff. We also want everyone to understand the importance of work as a health outcome and feel supported by a health system which promotes an understanding of good work and good health. 


[1]M. Marmot, 2010. Fair Society Healthy Lives, The Marmot Review.



How to achieve better employee health and wellbeing in UK plc. Christian van Stolk, Vice President of RAND Europe

How to achieve better employee health and wellbeing in UK PLC

Imagine an employer who loses about 30 days of productive time per employee due to IT problems. It’s likely an executive would have tough discussions with the IT suppliers or the responsible manager within the organisation. Consequences would happen if the problem persisted.

Now, imagine an employer who loses about 30 days in productivity on account of an employee coming to work in suboptimal health. In most cases there are few, if any, consequences .Most employers find it much more difficult to act and many small-to-medium sized organisations do nothing at all.

Britain’s Healthiest Workplace is an annual survey of employers and their employees sponsored by Vitality Health). Last year’s survey shows that on average UK employers lose these 30 days per employee per year due to absenteeism and presenteeism (being in suboptimal health while at work).

About 28 days out of this 30 day lost per employee can be attributed to employees coming to work when in suboptimal health and being less productive. According to our analysismental health appears to be the main factor, explaining about 30 per cent of presenteeism. Mental health problems are often compounded by lack of sleep, financial concerns, caring responsibilities and issues in the workplace, such as lack of control over what one does at work or poor relationships.

There is also a significant link between mental health and musculoskeletal conditions. When looking at demographics, it is clear that the young have much higher productivity loss and poorer mental health compared to other age groups. The same goes for those employees on relatively low pay. Overall, these trends seem to be getting worse over the years that the survey has been conducted, contributing to rising productivity loss in the workplace.

Many larger employers have a range of programmes and interventions that aim to improve the health and wellbeing of their employees. However, there is a disconnect between what employers tell us is happening within the workplace and the experience of employees recorded in the surveys.

About  50 per cent of employees have access to the programmes according to employers. From the employee survey, we know that only 22 per cent are aware of the employer programme with only about one-third of this data set participating in the programme. This is a missed opportunity. Our work on the data suggests that almost 75 per cent of employees perceive a health and wellbeing benefit from participation. Analysis of employees responding to the survey over the years also finds that employees who participate or even start involvement in any employer programme improve on a wider set of outcomes: cardiovascular health; mental health; perceptions of bullying; and productivity targets. Many of those participating are also not in the at-risk groups such as the young or those on lower incomes.

A number of factors seem to be associated with higher participation in programmes and better health and wellbeing outcomes: allowing employees time during working hours to participate; senior leadership and line manager support; and external and internal reporting on human capital. These all point to the importance of senior management showing leadership – from participation in the programmes through setting health and wellbeing as a strategic priority, and finally, monitoring progress over time. The more enlightened employers understand the prize. Happier and healthier employees are important from a corporate social responsibility point of view, but promoting employee health and wellbeing also makes complete business sense.

Christian van Stolk is a Vice President of RAND Europe. RAND Europe is a not-for- profit research organisation that conducts the Britain’s Healthiest Workplace surveys annually.