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 …

…..to 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.

#OTVoc.

#WHChallengeFund

Genevieve Smyth

Professional Adviser

Royal College of Occupational Therapists

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.

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.

3^rdSector 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.